Objective: To examine changes in the rate of seeing patients between 1990 and 2004 and to see whether performance might be related to patient age, using data held on the patient administration system. Method: Data collected in 1990 were compared with those collected in 2004. Age related data were examined for the following parameters: the number of patients arriving by ambulance; the time taken to process the attendance; the number of investigations; the number of emergency admissions; and the length of inpatient stay. Results: Emergency department (ED) performance has fallen markedly since 1990. Between 1990 and 2004, there was a 54% increase in total patients with a disproportionate 198% increase in patients aged more than 70 years, including a 671% increase in those aged more than 90 years. The time taken to manage patients increased with age. In 2004, there was a marked rise in investigation rates, and the probability of having investigations increased with age. In 2004, older patients (aged more than 70 years) were 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less). Their average length of stay was 6.9 times longer. Younger patients were 3.3 times more numerous than older patients but older patients occupied 9.8 times more emergency bed days. Conclusions: Pressure on emergency care is associated with a disproportionate increase in the number of elderly patients and with an increased tendency to investigate them. Population ageing is of central importance in planning health services.

Naltrexone is a long acting opioid receptor antagonist used in controlled opioid withdrawal drug programmes. When taken by an opioid dependent patient an acute withdrawal reaction will be precipitated. The case is presented where a known opioid drug misuser inadvertently ingested naltrexone in conjunction with heroin resulting in severe agitation, requiring heavy sedation followed by general anaesthesia to enable investigation and management of his clinical condition. N altrexone is a long acting opioid receptor antagonist used in drug rehabilitation programmes to maintain opioid abstinence. However, when consumed in conjunction with an opioid substance, prolonged opioid withdrawal will be precipitated resulting in unpredictable and life threatening medical consequences. We present a case where a known drug misuser consumed naltrexone in conjunction with heroin. CASE REPORTA 39 year old man presented to the accident and emergency department having taken up to three, 50 mg tablets of naltrexone and having smoked an unknown quantity of heroin. He was known to be an injecting drug user and to suffer from epilepsy. No other recreational drugs, alcohol, or prescribed medications were known to have been consumed. On arrival he was extremely agitated being restrained by four police officers. He was confused, sweating, with episodes of profuse projectile diarrhoea and vomiting. Glasgow Coma Scale was 12 (spontaneous eye opening, localising to pain, and using inappropriate speech). Pupils were dilated but reactive to light. Heart rate was regular at 180 beats/minute and respiratory rate 40 breaths/minute. Blood pressure, oxygen saturation, blood glucose, and temperature were normal. There was no evidence of head injury and no history of seizure. Urea, electrolytes, full blood count, and arterial blood gas measurements were normal. Initial attempts at sedation using a combination of titrated intravenous midazolam and droperidol were unsuccessful. After receiving a total of 20 mg midazolam and 15 mg droperidol he continued to be confused, agitated, and increasingly violent. An urgent CT head scan was arranged to exclude any intracranial pathology. To expedite this he was anaesthetised and ventilated. Rapid sequence induction of anaesthesia was carried out using 200 mg propofol, and 100 mg suxamethonium. Anaesthesia was maintained with a propofol infusion and incremental paralysis with atracurium.CT of his brain was normal. A lumbar puncture was performed while the patient was still anaesthetised. This showed no abnormality. The patient was extubated four hours after induction and transferred to the medical high dependency unit for observation. Further episodes of agitation occurred overnight requiring additional sedation with intravenous midazolam. The following morning he took his own discharge. Retrospectively urine toxicology screen confirmed the presence of cannabinoids, benzodiazepines, and opioids.

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resulting in 920 cases, 738 hospitalizations, and 30 deaths. To support the Michigan Department of Health and Human Services' efforts to increase hepatitis A vaccination rates among highrisk individuals, our multicenter health system implemented an electronic medical record (EMR)-based vaccination intervention across its nine emergency departments (ED). The primary objective of this retrospective cohort and survey analysis was to quantitatively determine whether this intervention was successful in increasing vaccination rates. The secondary objective was to qualitatively assess the attitudes towards, and barriers to use of, the computerized vaccine reminder system.Methods: All patients 18 years or older who arrived to any of the nine EDs between August 2018 and January 2020 were screened using an electronic nursing questionnaire embedded in the EMR (Epic). If a patient was determined to be high-risk based on the questionnaire (homeless, incarceration history, illicit drug use, liver disease, or a man who has sex with men), an electronic best practice advisory (BPA) would trigger and give the patient's physician the option to order the hepatitis A vaccine. If consented, patients would receive a one-time dose of the hepatitis A vaccine in the ED. We also administered a survey to physicians and nurses to evaluate perceptions and barriers to use of the EMR intervention.Results: During the pre-intervention period from August 2016 to July 2018, 885,344 patients visited the EDs. 49 vaccines were ordered (5.5 per 100,000 patients) and 34 were administered (3.8 per 100,000 patients). During the intervention period from August 2018 to January 2020, 774,034 patients visited the EDs and 574,865 (74.3%) were screened. Of those screened, 11,016 patients were found to be high-risk and triggered the BPA. Among this group of patients, 1,929 vaccines were ordered (249 per 100,000 patients) and 883 were administered (114 per 100,000 patients). We also found that during the intervention period, an additional 565 vaccines were ordered and 322 vaccines were administered without a BPA prompt. Nurses consistently screened 70-80% of patients per month. Physicians were initially more compliant with the BPA's use (301 vaccines in September 2018), but compliance declined over time (67 vaccines in January 2020) (Graph 1). Surveys revealed that two major barriers to consistent BPA use by physicians was lack of time and the perception that vaccinations are low-priority in the ED.Conclusion: EMR screening tools and BPAs can be utilized in the ED as an effective strategy to vaccinate high-risk individuals. This may be translatable to outbreaks of other vaccine-preventable illnesses like influenza, measles, or SARS-CoV-2. Providing recurrent education about the importance of public health initiatives and eligibility criteria for vaccine administration are needed to sustain compliance. It is essential to frequently audit and provide feedback to physicians on their compliance, and address their concerns about barriers to use. 263 UNderstanding EQUi...

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