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STUDY OBJECTIVE Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation. METHODS We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression. RESULTS Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time. CONCLUSIONS ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.

BACKGROUND Symptom checkers (SCs) are diagnostic decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnosis and triage advice and assist users in seeking the appropriate level of care. Little evidence is available on their diagnostic and triage accuracy with direct use by patients for urgent conditions. OBJECTIVE To determine the diagnostic and triage accuracy and usability of a symptom checker in use by for patients presenting to an emergency department METHODS We recruited a convenience sample of English-speaking patients presenting for care in an urban emergency department. Each consenting patient used a leading SC from Ada Health prior to ED evaluation. Diagnostic accuracy was evaluated, comparing (1) the SC’s diagnoses and (2) those of 3 independent emergency physicians viewing the patient-entered symptom data, to (3) the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. Patients completed a usability survey based on the Technology Acceptance Model. RESULTS Forty participants (80% of those approached, mean age 40.1 years (range 18 – 76); 65% female, 68% White, 48% Hispanic or Latino, completed the SC assessment and usability survey. Sensitivity for at least one of the ED final diagnoses by Ada (based on it’s top 5 diagnoses) was 70.0% (95% CI 54% – 86%) close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated Ada triage decisions as 62% fully agree, and 24% safe but too cautious. It was rated unsafe and too risky in 22% by at least one physician, 14% by two and 5% by all 3, although none of the under-triaged patients suffered an adverse event in the ED. Some cases only had symptoms recorded for their ED diagnosis, limiting analysis. Usability was rated highly, participants agreed or strongly agreed a mean of 84.6% with the 7 TAM usability questions, although “satisfaction” and “enjoyment” were rated low. CONCLUSIONS This study provides preliminary evidence that a SC can provide acceptable usability and diagnostic accuracy for patients with a variety of urgent conditions. 14% of SC triage recommendations were deemed unsafe and too risky by at least 2 physicians based on the symptoms recorded. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments.

Author(s): Goldberg, Elizabeth M.; Hasegawa, Kohei; Lawrence, Alexis; Kline, Jeffrey A.; Camargo, Jr, Carlos A. | Abstract: Introduction: Coinfection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) and another virus may influence the clinical trajectory of emergency department (ED) patients. However, little empirical data exists on the clinical outcomes of coinfection with SARS-CoV-2 Methods: In this retrospective cohort analysis, we included adults presenting to the ED with confirmed, symptomatic coronavirus 2019 who also underwent testing for additional viral pathogens within 24 hours. To investigate the association between coinfection status with each of the outcomes, we performed logistic regression. Results: Of 6,913 ED patients, 5.7% had coinfection. Coinfected individuals were less likely to experience index visit or 30-day hospitalization (odds ratio [OR] 0.57; 95% confidence interval [CI], 0.36-0.90 and OR 0.39; 95% CI, 0.25–0.62, respectively). Conclusion: Coinfection is relatively uncommon in symptomatic ED patients with SARS-CoV-2 and the clinical short- and long-term outcomes are more favorable in coinfected individuals.

Background Emergency department (ED) visits for opioid-related overdoses continue to rise across the United States, particularly among Black, Latinx, and American Indian/Alaskan Native communities. A minority of people with opioid use disorder (OUD) engages in formal addiction treatment and there are racial disparities in treatment access. ED visits for opioid overdose are crucial opportunities to link individuals with OUD to harm reduction and treatment services. However, we know little about whether racial inequities exist in ED treatment after opioid overdose. Methods This observational, cross-sectional study examined differences in services provided to overdose patients who were discharged after an ED visit for opioid overdose by patient race-ethnicity. Primary outcomes included provision of take-home naloxone, ED-based behavioral counseling, and linkage to treatment. Race-ethnicity differences in post-overdose ED services were evaluated using chi-square analyses, and multivariable logistic regression analyses were conducted to examine associations of race-ethnicity with receiving post-overdose services, controlling for other institutional-, provider-, and patient-level factors. Results From September 2017 to February 2020, 734 patients were discharged from the ED for an opioid-related overdose. Most patients were White non-Latinx (70.0%), 8.9% were Black non-Latinx, 3.3% were Other race non-Latinx, and 18.0% were Latinx. Take-home naloxone was the most frequent intervention provided to patients while behavioral counseling was the lowest across all race-ethnicity categories. There were no statistically significant differences in provision of take-home naloxone and treatment referral based on patient race-ethnicity. However, a lower proportion of discharged Black non-Latinx patients received behavioral counseling compared to patients of other race-ethnicities, and the odds of receiving behavioral counseling was significantly higher for White non-Latinx (OR: 1.75; 95% CI: 1.00, 3.06); Latinx (OR: 2.06; 95% CI: 1.05, 4.06); and Other race non-Latinx (OR: 3.29; 95% CI: 1.18, 9.15) patients compared to Black non-Latinx patients. Conclusion Black non-Latinx patients discharged from the ED for an opioid-related overdose were less likely to receive behavioral counseling compared to non-Black patients. Possible reasons for this decreased provision of behavioral counseling include provider bias, patient mistrust of the medical and behavioral health care systems, and limited provider training in addiction medicine and motivational interviewing. These inequities add to the known racial disparities in ED patient care. Further research should elucidate barriers to behavioral counseling within ED settings and factors contributing to racial inequities in post-overdose emergency care.

Author(s): Napoli, Anthony; Ali, Shihab; Lawrence, Alexis; Baird, Janette | Abstract: Introduction: Boarding of patients in the emergency department (ED) is associated with decreased ED efficiency. The provider-in-triage (PIT) model has been shown to improve ED throughput, but it is unclear how these improvements are affected by boarding. We sought to assess the effects of boarding on ED throughput and whether implementation of a PIT model mitigated those effects.Methods: We performed a multi-site retrospective review of 955 days of ED operations data at a tertiary care academic ED (AED) and a high-volume community ED (CED) before and after implementation of PIT. Key outcome variables were door to provider time (D2P), total length of stay of discharged patients (LOSD), and boarding time (admit request to ED departure [A2D]).Results: Implementation of PIT was associated with a decrease in median D2P by 22 minutes or 43% at the AED (p l 0.01), and 18 minutes (31%) at the CED (p l 0.01). LOSD also decreased by 19 minutes (5.9%) at the AED and 8 minutes (3.3%) at the CED (pl0.01). After adjusting for variations in daily census, the effect of boarding (A2D) on D2P and LOSD was unchanged, despite the implementation of PIT. At the AED, 7.7 minutes of boarding increased median D2P by one additional minute (p l 0.01), and every four minutes of boarding increased median LOSD by one minute (p l 0.01). At the CED, 7.1 minutes of boarding added one additional minute to D2P (p l 0.01), and 4.8 minutes of boarding added one minute to median LOSD (p l 0.01).Conclusion: In this retrospective, observational multicenter study, ED operational efficiency was improved with the implementation of a PIT model but worsened with boarding. The PIT model was unable to mitigate any of the effects of boarding. This suggests that PIT is associated with increased efficiency of ED intake and throughput, but boarding continues to have the same effect on ED efficiency regardless of upstream efficiency measures that may be designed to minimize its impact.