Hospital, Emergency Department, and Home Health Use in Older Adults with Sensory Impairment

Hearing, vision, and dual (combined hearing and vision) sensory impairments (HI, VI, and DSI) are common in older adults and associated with adverse health outcomes. However, it is not clear how sensory impairments impact healthcare utilization in older adults. This study aims to examine hospital, emergency department (ED), and home health care use amongst adults 65 and older diagnosed with HI, VI, and DSI in an urban academic health system. This secondary analysis (N=45,000) used a limited data subset of older adult primary care patients’ EHR data from a parent study examining medical complexity, healthcare use, and social vulnerability. Using logistic regression and controlling for participant demographics and comorbidities, results show HI, VI, and DSI increase the likelihood of having an ED visit (OR 1.29, p<.0001; OR 1.28, p=0.0011; OR 1.50, p=.0328, respectively) and a home health episode (hearing OR 1.41, p<.0001; vision OR 1.42, p=.0002) compared to those without sensory impairment (SI). No significant difference was found in hospital use and home health use for DSI. This is the first known study to examine ED use for older adults with VI and DSI, and home health use for older adults with SI in the US. Findings suggest older adults with SI have greater utilization and dependence on healthcare services. Older adults with SI may benefit from outpatient assessments and interventions to mitigate risks of ED use. Findings also support research into the drivers of healthcare use amongst this population, financial implications, and intervention development to prevent avoidable healthcare use.

Acute and chronic toxicity of ethyl chloride insufflation in two patients

Objective: Inhalant abuse has been a source of increasing concern because of its easy accessibility and affordability. Anecdotal reports have previously described ethyl chloride as a potential cause of altered mental state and neurologic symptoms. Its use has been thought to be found most often in adolescents and among men who have sex with men. Common acute symptoms include confusion, dizziness, headache, nausea, and fatigue. We describe two cases of adult patients who presented to one general hospital emergency department with ethyl chloride toxicity. The first presented with acute delirium; the second with a picture of chronic neurological symptomatology. It is important that clinicians become familiar with ethyl chloride intoxication because of its prevalence and potential to present with varying acute and chronic symptomatology.

Reducing Thoracic and Lumbar Radiographs in an Urban Emergency Department Through a Clinical Champion Led Quality Improvement Intervention

Background: Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number. Methods: A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months. Results: The percent of appropriately ordered radiographs increased from 5.8% to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frameConclusion: A multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

Trends in consultations for schizophrenia and non-affective psychoses in Italian emergency departments during and after the 2020 COVID-19 lockdown

Aims To analyse the hospital emergency department (HED) consultations for schizophrenia-spectrum disorders in nine Italian hospitals during the 2020 lockdown and post-lockdown periods, compared to the equivalent periods in 2019. Methods Characteristics of consultations, patients, and drug prescriptions were analysed. Joinpoint models were used to identify changes in the weekly trend of consultations. Results During the 2020 lockdown the overall number of HED consultations for schizophrenia decreased by 40.7% and after the lockdown by 12.2% compared with 2019. No difference was found in the proportion of consultations that led to GHPU admissions or compulsory admissions. Suicidality rates did not differ across the two years, with the exception of ideations and plans (+5.9%) during the post-lockdown period. We found an increase in benzodiazepine prescriptions in 2020 during the lockdown and post-lockdown periods (+10.6% and +20.8%, respectively), and a decrease of prescriptions for short-acting sedative agents in the post-lockdown period (-7.9%). An increase in the weekly trend of consultations occurred from March 11-17 (week 11) to June 26-June 30 (week 26). As a result, the initial gap in the number of consultations between the two years cancelled out at the end of June. Conclusions HED consultation rate for schizophrenia-spectrum disorders declined consistent with that of other psychiatric disorders. In the post-lockdown period the growth of suicidal ideation/planning and increase in the prescriptions of anxiolytic-sedating drugs may foreshadow that for some schizophrenia patients the exit from the lockdown period is not liberating, but rather a source of agitation or perturbation.