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Academic
Emergency
Medicine
A GLOBAL JOURNAL OF EMERGENCY CARE

Vol.31 No. 8
August 2024
ISSN 1069-6563
 15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14528 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Academic Emergency Medicine
CONTENTS

Volume 31 · Number 8 · August 2024 · www.aemj.org

ORIGINAL ARTICLE
Estimating the size and scope of the academic emergency physician workforce
Cameron J. Gettel, Carlos A. Camargo, Christopher L. Bennett et al. 732

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study
Jennifer A. Hoffmann, Camille P. Carter, Cody S. Olsen et al. 739

Early versus late advanced airway management for adult patients with out-of-hospital cardiac arrest:
A time-dependent propensity score–matched analysis
Shunsuke Amagasa, Shintaro Iwamoto, Masahiro Kashiura et al. 755

Perspectives from persons living with dementia and their caregivers on emergency department visits,
care transitions, and outpatient follow-up: A qualitative study
Megan C. McHugh, Kayla M. Muschong, Sara M. Bradley et al. 767

Full-dose challenge of moderate, severe, and unknown beta-lactam allergies in the emergency department
Adam M. Anderson, Stephanie Coallier, Reid E. Mitchell et al. 777

Prospective validity evidence for the abbreviated emergency medicine Copenhagen Burnout Inventory
Earl J. Reisdorff, Mary M. Johnston, Michelle D. Lall et al. 782

SYSTEMATIC REVIEW
Interventions to improve emergency department throughput and care delivery indicators: A systematic
review and meta-analysis
Elias Youssef, Roshanak Benabbas, Brittany Choe et al. 789

CONSENSUS CONFERENCE
2023 Society for Academic Emergency Medicine Consensus Conference on Precision Emergency Medicine:
Development of a policy-relevant, patient-centered research agenda
Matthew Strehlow, Michael A. Gisondi, Holly Caretta-Weyer et al. 805

RESEARCH LETTER
Reporting of sex and gender demographics among research studies
Michael Gottlieb, Rachel Chang, Miranda Viars et al. 817

Eligibility of emergency department patients for public benefit programs

Joseph Harrison, Grace McDermott, Erica L. Dixon et al. 820

Eligibility for anticoagulation initiation in atrial fibrillation: Agreement between emergency physician and
medical record review
Darshana Seeburruth, X. Catherine Tong, Christopher Kirwan et al. 824
 15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14528 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Academic Emergency Medicine
CONTENTS

Volume 31 · Number 8 · August 2024 · www.aemj.org

Atypical symptoms in emergency department patients with urosepsis challenge current urinary tract infection
management guidelines
Brett Biebelberg, Iain E. Kehoe, Hui Zheng et al. 828

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Metformin for Type 2 diabetes mellitus
Blair J. MacDonald, Ricky D. Turgeon, James McCormack et al. 832

INVITED COMMENTARY
Academic emergency medicine: Common practice or underdeveloped?
Alexander T. Janke, Robert W. Neumar 835

LETTER TO THE EDITOR

Asymptomatic bacteriuria or symptomatic urinary tract infection? That is the question
Alejandro Smithson 837

REPLY
Response to: “Asymptomatic bacteriuria or symptomatic urinary tract infection? That is the question”
Brett Biebelberg, Iain E. Kehoe, Michael R. Filbin et al. 838

REFLECTION ARTICLE
The shape of war
Zhaohui Su 840

The long and winding road

Tommaso Lupia 841
 15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14528 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Academic Emergency Medicine
Official Journal of the Society for Academic Emergency Medicine | saem.org

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Received: 2 February 2024 | Revised: 26 March 2024 | Accepted: 11 April 2024

DOI: 10.1111/acem.14931

ORIGINAL ARTICLE

Estimating the size and scope of the academic emergency

physician workforce

Cameron J. Gettel MD, MHS1,2 | Carlos A. Camargo Jr. MD, DrPH3 |

Christopher L. Bennett MD, MSc, MA4 | D. Mark Courtney MD5 | Amy H. Kaji MD, PhD6 |
7 8 9
Gregory J. Fermann MD | Fiona E. Gallahue MD | Lewis S. Nelson MD, MBA |
Carleigh F. Hebbard MD, PhD10 | Craig Rothenberg MPH1 | Ali S. Raja MD, DBA, MPH3 |
Arjun K. Venkatesh MD, MBA, MHS1,2
1
Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
2
Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
3
Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
4
Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
5
Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
6
Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Torrance, California, USA
7
Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
8
Department of Emergency Medicine, The University of Washington, Seattle, Washington, USA
9
Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
10
Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA

Correspondence
Cameron J. Gettel, Department of Abstract
Emergency Medicine, Yale School of
Background: Academic emergency medicine (EM) is foundational to the EM specialty
Medicine, New Haven, CT 06520, USA.
Email: [email protected] through the development of new knowledge and clinical training of resident physi-
cians. Despite recent increased attention to the future of the EM workforce, no evalu-
Funding information
National Institute of Allergy and Infectious ations have specifically characterized the U.S. academic EM workforce. We sought to
Diseases, Grant/Award Number:
estimate the national proportion of emergency physicians (EPs) identified as academic
L30AI178800; MTEC Medical Technology
Enterprise Consortium; CA Office of and the proportion of emergency department (ED) visits that take place at academic
Traffic and Safety; National Academy
sites.
of Medicine of the National Academy
of Sciences, Grant/Award Number: Methods: We performed a cross-­sectional analysis of EPs and EDs using data from
SCON-­10000824; National Center for
the American Hospital Association, the Centers for Medicare & Medicaid Services,
Advancing Translational Sciences, Grant/
Award Number: KL2TR003143; National and Doximity's Residency Navigator. EPs were identified as “academic” if they were
Institute on Aging, Grant/Award Number:
affiliated with at least one facility determined to be academic, defined as EDs officially
R03AG073988
designated by the Accreditation Council for Graduate Medical Education (ACGME) as
clinical training sites at accredited EM residency programs. Our primary outcomes

Dr. Gettel is partly supported by the National Institute on Aging (NIA) of the National Institutes of Health (NIH; R03AG073988) and the National Academy of Medicine of the National
Academy of Sciences under award number SCON-­10000824. Dr. Bennett reports support from the National Center for Advancing Translational Science (NCATS; KL2TR003143) and
the National Institute of Allergy and Infectious Diseases (NIAID; L30AI178800) of the NIH. Dr. Kaji is partly supported by the MTEC Medical Technology Enterprise Consortium and the
CA Office of Traffic and Safety (OTS). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation
or approval of the manuscript.

See related article on page 835

Supervising Editor: Jesse M. Pines

732 | © 2024 Society for Academic Emergency Medicine. wileyonlinelibrary.com/journal/acem Acad Emerg Med. 2024;31:732–738.
 |

15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14931 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GETTEL et al. 733

were to estimate the national proportion of EPs identified as academic and the pro-
portion of ED visits performed at academic sites.
Results: Our analytic sample included 26,937 EPs practicing clinically across 4920
EDs and providing care during 130,471,386 ED visits. Among EPs, 11,720 (43.5%)
were identified as academic, and among EDs, 635 (12.9%) were identified as academic
sites, including 585 adult/general sites, 45 pediatric-­specific sites, and 10 sites affili-
ated with the Department of Veterans Affairs. In 2021, academic EDs provided care
for 42,794,106 ED visits or 32.8% of all ED visits nationally.
Conclusions: Approximately four in 10 EPs practice in at least one clinical training
site affiliated with an ACGME-­accredited EM residency program, and approximately
one in three ED visits nationally occur in these academic EDs. We encourage further
work using alternative definitions of an academic EPs and EDs, along with longitudinal
research to identify trends in the workforce's composition.

KEYWORDS
academic, emergency department, emergency physician, workforce

I NTRO D U C TI O N particular attention to the role that academic EM plays in the train-
ing of future EPs.
Academic medicine drives health care forward by generating new However, limitations exist in defining academic status within EM.
knowledge through research, educating residency and fellowship It is unclear whether the definition should be based on being a funded
trainees, and providing complex clinical care. To date, estimation investigator, teaching residents, working clinically in a residency-­
of the scope of academic medical practice in the United States has affiliated training site, or some combination of these factors and/or
revealed various disparate estimates ranging from approximately others. A stringent research-­oriented definition of ‘academic’ may
400 teaching hospitals reported by the Association of American include only NIH funded investigators and exclude researchers with
Medical College's (AAMC) Council of Teaching Hospitals (COTH) only foundation or industry support. A strictly education-­oriented
to over 1000 teaching hospitals defined by the American Hospital definition may define “academic” as any physician considered core
Association (AHA) survey.1,2 At the physician level, estimates from faculty within an EM residency program and actively involved in
the AAMC suggest that approximately 20% of recent trainee gradu- trainee teaching. With no agreed-­upon definition, nor currently
ates across all specialties are hired into academic roles, in that they available estimates, we sought to estimate the national proportion
currently hold a full-­time faculty position at a U.S. medical degree of academic EPs, defined as those having a clinical affiliation with an
(MD)-­granting school.3 Estimation of the scope of academic emer- AAMC COTH where EM residents clinically train, and the proportion
gency physicians (EPs) is of importance, given the required balance of ED visits that take place at these academic sites. This work will
in prioritization across all academic missions (e.g., clinical practice, describe the role of academic EPs and EDs within larger conversa-
research, education) and several ongoing pressures, including in- tions about the EM workforce and serve as the first to characterize
creasing emergency department (ED) visit volumes, growth of resi- academic status using one definition within existing national data.
dency training programs, and stagnating federal funding for principal
investigators within the specialty.
Over the past two decades, the clinical scope of academic med- M E TH O D S
icine, including academic EPs, has expanded. The consolidation of
health systems and the expansion of clinical teaching sites of gradu- Study design and data sets
ate medical education training programs have resulted in a broader
spectrum of physicians identifying as academic across more het- We performed an observational cohort study of EPs and EDs using
erogeneous settings. However, EM workforce studies to date have four data sources. First, the AHA's annual survey database is a pro-
primarily assessed its entirety—EPs, non–EM-­trained physicians prietary data set compiling yearly results of an AHA-­directed nation-
practicing in the ED setting, and nonphysician practitioners—and wide survey of all U.S. hospitals as well as data from the U.S. Census
have not uniquely characterized the academic EM workforce.4–7 In Bureau and hospital accrediting bodies. Commercially available on
response, the Society for Academic Emergency Medicine (SAEM) an annual basis, we used the 2021 AHA database as it contains hun-
established its workforce committee in May 2022, in part to in- dreds of data elements, including ED visit volume collected directly
crease the understanding of the future EM workforce needs, with from >6000 U.S. hospitals.8 Second, we used the 2021 Centers
 |

15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14931 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
734 ACADEMIC EMERGENCY PHYSICIAN WORKFORCE

for Medicare & Medicaid Services (CMS) Provider Utilization and

Payment Data from the Physician and Other Practitioners Public
Use File (PUF). This data set provides information on services and
procedures provided to traditional Medicare (fee-­for-­service) Part
B beneficiaries, organized by National Provider Identifier (NPI) or
Healthcare Common Procedure Coding System (HCPCS) code.9
Third, we used the Medicare facility affiliation data, publicly re-
ported in CMS's Provider Data Catalog, providing information on
NPI and the CMS Certification Number (CCN) for facilities where an
individual clinician provides services.10 Finally, we used Doximity's
Residency Navigator, the most comprehensive residency program
directory available providing up-­to-­date information regarding
program size, clinical training sites, and alumni, among others,11
which has been used in other EM literature.12 This site provides
information regarding clinical training sites at accredited EM resi-
dency programs officially designated by the Accreditation Council
for Graduate Medical Education (ACGME). This study was deemed
exempt by the lead author's institutional review board and fol-
lowed the Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) guidelines.13

Data management

We first determined the academic status of all facility CCNs within

the AHA database by manually linking facility names and addresses
using Doximity's Residency Navigator. A facility in the AHA data-
base was identified as academic if residents from an EM residency
F I G U R E 1 Analytic sample flow diagram. Spread of clinical sites
program performed clinical rotations at the site. Based on data from
and training duration for two examples EM residency programs. (A)
Doximity's Residency Navigator,11 the clinical training sites of two
Example residency program that provides clinical training at one
example programs are shown in Figure 1. site. (B) Example residency program that provides clinical training
at six different clinical sites. ABEM, American Board of Emergency
Medicine; CMS, Centers for Medicare & Medicaid Services; DOB,
Developing the analytic cohort date of birth; NPP, nonphysician practitioner.

Clinicians in the Medicare PUF were identified as EPs based on the Doximity Residency Navigator to determine the academic status of
“Rndrng_Prvdr_Type,” which was derived from the specialty code EPs. An EP was identified as academic if they were affiliated with at
on the associated claim. Those with addresses registered to the 50 least one facility determined to be academic, defined as a site where
states and Washington, DC, were considered for inclusion, with the EM residents clinically train.
state of the provider identified as reported within the National Plan
& Provider Enumeration System. Based on HCPCS codes 99281 to
99285, included EPs were required to cumulatively perform ≥50 Outcomes and data analyses
ED visits in 2021, identical to thresholds in previous EM workforce
analyses,14–16 to qualify for inclusion. We identified 54,396 clinicians Our primary outcomes were the national proportion of EPs identi-
in the Medicare PUF, inclusive of non–EM-­trained physicians prac- fied as academic and the national proportion of ED visits performed
ticing in the ED setting and nonphysician practitioners, who received at academic sites. For each of these outcomes, the numerator was
at least 50 reimbursements for ED-­based clinical care; this included the number identified as academic, and the denominator was the
37,986 EPs. Linked by NPI, we then merged to the Medicare facility number total (academic and nonacademic) identified in the analytic
affiliation data to obtain affiliated facility CCNs of practicing clini- cohort. We additionally determined state-­level proportions of aca-
cians. This resulted in 33,826 EM clinicians, including 26,937 EPs, demic versus nonacademic EPs. We used descriptive statistics and
with complete Medicare data from both sources with at least one performed data management and analyses using Stata (Version 16,
affiliated facility CCN. Linked by facility CCN, we then merged to the StataCorp) and R software (Version 4.0.2, R Foundation) for data
AHA database of facilities with academic status identified within the visualization.
 |

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GETTEL et al. 735

R E S U LT S sites, and 10 sites affiliated with the Department of Veterans Affairs.

Academic EDs were responsible for care during 42,794,106 (32.8%)
In 2021, the Medicare and AHA data sets identified 37,986 EPs ED visits nationally (Figure S2). Stratified by ED visit volume, 180
practicing clinically across 4920 EDs and providing care during (59.8%) of the 301 EDs with a visit volume greater than 80,000 an-
130,471,386 ED visits. nually were identified as academic, in comparison to just 36 (1.3%)
of the 2720 EDs with a visit volume less than 20,000 annually
(Figure 3).
Estimation of academic EPs

Among EPs, 26,937 had complete data regarding their clinical prac- DISCUSSION
tice facility CCNs; the excluded group (n = 11,049) was similar to
those with complete data in several key characteristics (Table S1). To our knowledge, this study is the first to characterize the size and
Of the included sample, 11,720 (43.5%) EPs were identified as aca- scope of academic EM and academic EPs in the United States. Our
demic, having at least one clinical affiliation with a site where EM study had three main findings. First, analyzed at the level of the in-
residents clinically train (Figure S1). In comparison to male EPs, a dividual physician, over 40% of EPs may be considered academic, as
greater proportion of female EPs were considered academic (40.6% defined by affiliation with an ED that serves as a clinical training site
vs. 50.5%, respectively). The largest number of academic EPs prac- within an EM residency program. Second, although only approxi-
ticed in New York, California, Pennsylvania, Michigan, and Ohio. A mately 13% of EDs are considered academically affiliated, they man-
greater proportion (13.1%) of EPs without an academic affiliation aged one in three ED visits. Third, considerable geographic variation
practice in rural designations compared to those with an academic exists in the distribution of academic EPs, with greater penetration in
affiliation (3.5%). On average, nonacademic EPs, compared to aca- states in New England, Mid-­Atlantic, and Midwest regions. Together,
demic EPs, annually provided care during a greater number of ED these findings are the first of their kind and identify that academic
visits to Medicare beneficiaries (331 vs. 278, respectively; Table 1). EM comprises a considerable proportion of U.S. emergency care.
Considerable geographic variability existed in the proportion These findings suggest that academic EM is not a niche subdivi-
of EPs determined to be academic. Six states had at least 60% of sion within the broader EM landscape and that the size and scope of
EPs determined to be academic, including Rhode Island (133 of 187, the academic EP workforce is much larger and broader than histor-
71.1%), Delaware (65 of 94, 69.1%), the District of Columbia (74 of ically reported.17 Resultantly, there may be less of a distinction be-
108, 68.5%), Massachusetts (573 of 905, 63.3%), Ohio (744 of 1230, tween EM practice in academic sites and in the community, as many
60.5%), and New York (1166 of 1941, 60.1%; Figure 2). EPs practicing at nonacademic sites also practice clinically and are
affiliated with sites training EM residents. There are important impli-
cations of the potential widespread reach of academic EM, regarding
Estimation of academic EDs knowledge translation from research to bedside and a more diverse
clinical training experience for EM resident physicians. Importantly,
The 282 EM residency programs with training site data in the this effort may allow for longitudinal trend analyses regarding the
Doximity Residency Navigator had a mean (±SD) of 3.8 (±1.8) af- academic EP workforce composition as well as a usable definition of
filiated training sites, with a maximum of 15. Identified as academic academic EM for future investigations.
sites, the EM residency programs had affiliations with 635 (12.9%) Our study adopted a specific criterion to categorize EPs as ac-
unique EDs, including 585 adult/general sites, 45 pediatric-­specific ademic, focusing on their involvement in the clinical training of EM

TA B L E 1 Characteristics of EPs with

Academic affiliation
and without an academic affiliation.
Yes (n = 11,720) No (n = 15,217)

Gender
Male 7735 (40.6) 11,310 (59.4)
Female 3985 (50.5) 3907 (49.5)
Most common states of 1. New York—1166 (10.0) 1. California—1373 (9.0%)
practice 2. California—1029 (8.8) 2. Texas—1148 (7.5)
3. Pennsylvania—918 (7.8) 3. Florida—908 (6.0)
4. Michigan—871 (7.4) 4. New York—775 (5.1)
5. Ohio—744 (6.4) 5. Illinois—727 (4.8)
Rural practice 410 (3.5) 1995 (13.1)
Number of ED visits 278 (±166) 331 (±184)

Note: Data are reported as n (%) or mean (±SD).

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736 ACADEMIC EMERGENCY PHYSICIAN WORKFORCE

F I G U R E 2 Proportion of EPs identified

as academic by state.

Residency Review Committee or funded investigator status from

the NIH RePORTER would likely reveal a more limited scope of
academic EP practice. Prior data from the AAMC suggests that
13.0% of individuals that completed EM residency training from
2013 to 2022 currently hold a full-­t ime faculty appointment at a
U.S. MD-­granting school. Furthermore, 2022 AAMC data suggest
that 6648 EM physicians were full-­t ime faculty at a U.S. medical
school.19
At first glance, our estimates, therefore, may seem a bit higher
than anticipated. However, with only 150 MD-­granting schools
in the United States and nearly 300 EM residency programs, it is
assured that many EPs considered academic would not have been
F I G U R E 3 Proportion of EDs identified as academic. captured by the AAMC statistics, which furthermore neglected
those considered part-­time faculty. Additionally, each of the EM res-
resident physicians. Our estimate of 43.5% of EPs identified as aca- idency programs have several (some as high as 15) training sites, with
demic did not include the 11,049 EPs without facility affiliation data each EP affiliated with those sites identified as academic, as they
within the Medicare data. Using available clinician characteristics, are likely to be engaged in the training of EM resident physicians.
we identified that the included sample and those with missing fa- Corroborating our findings, as a hypothetical calculation, assuming
cility affiliation data were very similar with regards to gender, state each of the 282 EM residency programs has 55 affiliated faculty, this
of practice, and rurality (Table S1). While imperfect, this may reflect would result in 15,510 academic EPs, with an estimate similar to our
that the data were nearly missing at random, supporting the estimate findings. A random search of EM residency programs revealed 56
of 43.5% for academic EPs, and if prorated, then the full sample of full-­time faculty, 50 full-­time faculty, and 16 part-­time and 40 full-­
37,986 EPs would be estimated to include 16,523 (43.5%) identified time faculty for the first three EM residency program sites searched,
as academic. If, instead, we were to assume that all EPs with missing providing face validity to our findings. Finally, in the 2015–2016
facility affiliation data were nonacademic (missing not at random), academic year, data from the Academy of Academic Administrator
then our results would suggest that 11,720 (30.9%) of the 37,986 of Emergency Medicine and the Association of Academic Chairs
EPs were academic. The latter scenario represents the most con- of Emergency Medicine suggested that 97 survey-­responding ED
servative (lowest) estimate, with the real value likely somewhere in clinical sites affiliated with an EM residency program accounted for
the middle or more toward the upper end of the range given that the nearly 7 million ED visits. 20 If extrapolated to the more than 600
data are more likely missing at random. clinical sites identified in our analyses, these findings support our na-
Our definition of academic practice—at least one clinical affil- tional estimate of academic facilities accounting for approximately
iation with a site where EM residents clinically train—is just one 42 million ED visits.
of several definitions that could be used and is distinct from defi-
nitions operationalized by others using different data sets from
sources such as the American Medical Association, the ACGME, LI M ITATI O N S
6,18
and the SAEM. While this was a clinically oriented definition,
the number of EPs defined as academic may change if other defi- The present analysis has several limitations. First, as mentioned
nitions such as ones that are teaching oriented or grants oriented previously, there is no universally accepted definition for aca-
are used. Further investigation using core faculty data from the demic status, with the outcomes identified dependent on our
 |

15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14931 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GETTEL et al. 737

clinical, educationally oriented definition. This may be percieived Gettel, Craig Rothenberg: statistical expertise. Cameron J. Gettel:
as a deprioritization of the research aspect of academic. Second, acquisition of funding.
EPs solely providing pediatric care would not have been included
as the inclusion requirement was for providing at least 50 ser- AC K N OW L E D G M E N T S
vices to Medicare Part B enrollees. Pediatric EDs may have been The authors thank all members of the SAEM Workforce Committee
included if at least one EP treating Medicare patients was also af- for their engagement, feedback, and expertise during formative dis-
filiated with that pediatric ED; an example might be an EP primar- cussions within early stages of this work.
ily seeing adult patients at an academic ED that does occasional
clinical shifts at the affiliated children's hospital ED. Third, it was C O N F L I C T O F I N T E R E S T S TAT E M E N T
not possible to identify the primary clinical site of the EP within CJG, CAC, CLB, DMC, AHK, GJF, FEG, LSN, CFH, ASR, and AKV are
the Medicare facility affiliation data; an EP may have practiced members of the Society for Academic Emergency Medicine's (SAEM)
a very small amount at the facility training EM residents. Fourth, Workforce Committee. ASR currently serves on the SAEM Board of
we relied on AHA data with provided facility CCNs to link to EPs. Directors.
It is possible the AHA survey design was not fully inclusive of all
ED visits as in other data sources such as the National Hospital ORCID
Ambulatory Medical Care Survey (NHAMCS) or the National Cameron J. Gettel https://orcid.org/0000-0002-6249-1023
Emergency Department Inventory (NEDI)-­USA database, 21 due to D. Mark Courtney https://orcid.org/0000-0002-0905-465X
differences in underlying methods. Fifth, the Doximity Residency Amy H. Kaji https://orcid.org/0000-0003-4588-7939
Navigator does not describe what type of clinical rotation was Arjun K. Venkatesh https://orcid.org/0000-0002-8248-0567
performed at a clinical site, such as ED, intensive care unit (ICU),
or specialty service rotation. However, based on our institutional REFERENCES
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D. Mark Courtney, Arjun K. Venkatesh: study concept and design. 9. Medicare Physician & Other Practitioners. Centers for Medicare &
Cameron J. Gettel: acquisition of the data. Cameron J. Gettel, Carlos Medicaid Services. Accessed October 27, 2023. https://​data.​cms.​
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13. von Elm E, Altman DG, Egger M, et al. The Strengthening the 20. Reznek MA, Scheulen JJ, Harbertson CA, Kotkowski KA, Kelen GD,
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provides what care? An analysis of clinical focus among the national Additional supporting information can be found online in the
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17. Physician Specialty Data Report. Association of American Medical
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18. Bennett CL, Ling AY, Agrawal P, et al. How we compare: Society for
How to cite this article: Gettel CJ, Camargo CA Jr., Bennett
Academic Emergency Medicine faculty membership demographics.
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19. Faculty Roster: U.S. Medical School Faculty. Association of emergency physician workforce. Acad Emerg Med.
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www.​aamc.​org/​data-­​repor​t s/​f acul​t y-­​insti​tutio​ns/​report/​f acul​t y-­​
roste​r-­​us-­​medic​al-­​schoo​l-­​faculty
Received: 18 October 2023 | Revised: 20 December 2023 | Accepted: 12 March 2024

DOI: 10.1111/acem.14910

ORIGINAL ARTICLE

Pediatric mental health emergency department visits from

2017 to 2022: A multicenter study

Jennifer A. Hoffmann MD, MS1 | Camille P. Carter BS2 | Cody S. Olsen MS2 |
David Ashby DO, MS3 | Kamali L. Bouvay MD4 | Susan J. Duffy MD5,6 |
James M. Chamberlain MD7 | Sofia S. Chaudhary MD8 | Nicolaus W. Glomb MD, MPH9 |
Jacqueline Grupp-­Phelan MD, MPH9 | Maya Haasz MD10 | Erin P. O'Donnell MD11 |
Mohsen Saidinejad MD, MS, MBA12 | Bashar S. Shihabuddin MD, MS13 |
14 15 16
Leah Tzimenatos MD | Neil G. Uspal MD | Joseph J. Zorc MD, MSCE |
Lawrence J. Cook PhD2 | Elizabeth R. Alpern MD, MSCE1 | on behalf of the PECARN
Registry Study Group

Correspondence
Jennifer A. Hoffmann, MD, MS, Division Abstract
of Emergency Medicine, Department
Background: The COVID-­19 pandemic adversely affected children's mental health
of Pediatrics, Ann & Robert H. Lurie
Children's Hospital of Chicago, 225 E. (MH) and changed patterns of MH emergency department (ED) utilization. Our objec-
Chicago Ave., Chicago, IL 60611, USA.
tive was to assess how pediatric MH ED visits during the COVID-­19 pandemic dif-
Email: [email protected]
fered from expected prepandemic trends.
Funding information
Methods: We retrospectively studied MH ED visits by children 5 to <18 years old at
Health Resources and Services
Administration nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research
Network Registry from 2017 to 2022. We described visit length by time period: pre-
pandemic (January 2017–February 2020), early pandemic (March 2020–December
2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit
rates from prepandemic data using multivariable Poisson regression models. We cal-
culated rate ratios (RRs) of observed to expected visits per 30 days during each pan-
demic time period, overall and by sociodemographic and clinical characteristics.
Results: We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for
7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pan-
demic visits. During the early pandemic, observed visits per 30 days decreased rela-
tive to expected rates (RR 0.80, 95% confidence interval [CI] 0.78–0.84), were similar
to expected rates during the midpandemic (RR 1.01, 95% CI 0.96–1.07), and then de-
creased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86–0.98).

Presented at the Pediatric Academic Societies Meeting, Washington, DC, April 29, 2023; and at the Society for Academic Emergency Medicine Annual Meeting, Austin, TX, May 19,
2023.

Supervising Editor: Mark R. Zonfrillo

For affiliations refer to page 752.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.

Acad Emerg Med. 2024;31:739–754.  wileyonlinelibrary.com/journal/acem | 739

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740 PEDIATRIC MENTAL HEALTH ED VISITS, 2017–2022

During the late pandemic, visit rates were higher than expected for females (RR 1.10,
95% CI 1.02–1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38–2.75), schizophre-
nia spectrum disorders (RR 1.55, 95% CI 1.10–2.59), and substance-­related and addic-
tive disorders (RR 1.50, 95% CI 1.18–2.05).
Conclusions: During the late pandemic, pediatric MH ED visits decreased below
expected rates; however, visits by females and for specific conditions remained el-
evated, indicating a need for increased attention to these groups. Prolonged ED visit
lengths may reflect inadequate availability of MH services.

I NTRO D U C TI O N boarding (prolonged stays while awaiting disposition) increased during

the pandemic based on a survey of hospitalists and a national study of
One in six U.S. children has a mental health (MH) condition,1,2 and sui- commercial insurance claims,20,21 but all-­payer multicenter health record
3
cide is the second leading cause of death among adolescents. While data on MH ED visit length during the pandemic have not been reported.
MH conditions were common prior to the COVID-­19 pandemic, the Moreover, studies of pandemic-­related changes to admission rates for
pandemic presented additional physical, psychological, and economic ED MH visits have been limited to single centers or commercially in-
stressors that adversely affected child and adolescent MH.4 Children sured children,17,21 and no multicenter studies have evaluated changes
experienced increased uncertainty and changing routines, transi- to return MH ED visit rates among children during the pandemic.
tions to virtual schooling, loss of access to established MH services, To address these knowledge gaps, we used data from nine EDs
and increased family financial stressors.5,6 As the prevalence rates of participating in the Pediatric Emergency Care Applied Research
clinically elevated anxiety and depression symptoms among children Network (PECARN) Registry to assess how pediatric MH ED visits
increased,7 leading pediatric professional organizations declared a na- during COVID-­19 pandemic differed from expected prepandemic
8
tional emergency regarding youth MH, which was followed shortly trends, overall and by sociodemographic and clinical characteristics.
thereafter by a special advisory report from the U.S. Surgeon General.9
When a child experiences a MH crisis, the emergency department
(ED) serves as a critical access point for risk assessment and connection M E TH O D S
10
to MH services. MH ED visits by children were already increasing prior
to the COVID-­19 pandemic,11 and patterns of MH ED utilization have Study design and data sources
changed considerably since its onset.12 Surveillance data from the Centers
for Disease Control and Prevention (CDC) show increased pediatric MH We conducted a retrospective cross-­sectional study using data from
ED visit rates during the first months of the pandemic as well as specific nine EDs participating in the PECARN Registry from 2017 to 2022.22
increases in adolescent female ED visits for suspected suicide attempts in The PECARN Registry comprises electronic health record (EHR) data
2021.12,13 According to CDC data, ED visits increased among adolescent from every pediatric ED encounter at participating institutions, harmo-
females in January 2022 compared with 2019 for anxiety, trauma and nized into a deidentified, central repository.22 Variables include demo-
stressor-­related disorders, eating disorders, tic disorders, and obsessive graphics, laboratory and radiology results; International Classification of
compulsive disorder.14 In fall 2022, adolescent MH ED visits decreased Diseases, 10th Revision, Clinical Modification (ICD-­10-­CM) diagnoses;
below 2019 prepandemic levels, but ED visits remained elevated above and disposition. Participating hospitals included seven quaternary chil-
prepandemic levels for specific conditions, including eating disorders (for dren's hospital EDs and two affiliated secondary community hospital
15
both sexes) and suicide-­related behaviors (among females). EDs. U.S. Census regions of participating hospitals were: five Midwest,
Important gaps in CDC surveillance data must be filled to develop three West, and one Northeast. This study follows the Strengthening
a comprehensive understanding of pediatric MH presentations during the Reporting of Observational Studies in Epidemiology (STROBE) re-
the pandemic. Although the CDC has described national trends in MH porting guidelines.23 The study was approved by the institutional re-
ED visits, racial and ethnic differences in pandemic-­related changes to view boards of all study sites and the University of Utah Emergency
MH ED visits were not described. Studies examining how MH ED vis- Medical Services for Children Data Center.
its changed across racial and ethnic groups have been limited to single
health systems or have focused on adults populations.16–19 Additionally,
to our knowledge, no multicenter studies have evaluated pandemic-­ Encounter identification
related changes to MH visits by children with chronic medical condi-
tions, children with developmental delay or intellectual disability, or We identified ED visits by children 5 to <18 years old with any ICD-­
children with varying levels of neighborhood opportunity. Also, MH ED 10-­CM diagnosis code for a MH condition, defined by the validated
 |

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HOFFMANN et al. 741

Child and Adolescent Mental Health Disorders Classification System 2022–December 31, 2022). The primary outcome was MH ED visits
24
(CAMHD-­C S). We assessed frequencies of CAMHD-­C S MH di- per 30 days for each of the time periods.
agnosis groups among the identified visits and retained visits con-
taining the nine most frequent MH diagnosis groups, to exclude
MH diagnoses unlikely to represent the reason for the ED visit (e.g., Statistical analysis
specific learning disorders, communication disorders). Although less
common reasons for ED visits, we also included diagnoses of eating We described sociodemographic and clinical characteristics of pre-
disorders, bipolar and related disorders, and schizophrenia spectrum pandemic MH visits using percentages. For each characteristic, we
disorders based on prior literature indicating high illness severity or calculated the difference in percentages and 95% confidence inter-
14,25,26
pandemic-­related changes in presentations. vals (CIs) between the prepandemic time period and the early, mid,
and late pandemic time periods.
We calculated observed 30-­day MH visit rates for each time period.
Study measures To estimate expected 30-­day visit rates during the early, mid, and late
pandemic time periods, we fit multivariable Poisson regression models to
Demographic characteristics included patient age; sex; insurance visit data from the prepandemic time period. A Pearson scale parameter
type (private, public, other/self-­pay); composite race and ethnicity; was used to account for overdispersion. Poisson models were chosen in
and zip-­code level Child Opportunity Index (COI) 2.0. The COI 2.0 is favor of negative binomial models due to better model fit estimated by
a composite measure of neighborhood-­based opportunities for chil- log likelihood statistics.39 Models included the number of months since
dren including education, health and environment, and social and January 2017 to account for temporal trends. A more complex temporal
economic factors. 27,28 We analyzed COI in quintiles (very low, low, effect, such as an autoregressive trend, was not considered due to an in-
moderate, high, very high). 29,30 Race and ethnicity were categorized sufficient number of pre-­pandemic observations. Covariates additionally
by ethnicity (Hispanic or non-­Hispanic) and then by race within the included month and site to account for seasonal and geographic trends.
non-­Hispanic group. Due to limited sample sizes, non-­Hispanic racial The dependent variable was the rate of MH visits per 30 days. We esti-
categories were analyzed as Black, White, and other non-­Hispanic mated 95% CIs for the 30-­day MH visit rates in each time period. Rate
(including American Indian or Alaska Native, Asian, Native Hawaiian ratios (RRs) and 95% CIs of observed to expected visits were calculated
or other Pacific Islander, multiple races, and other). Race and ethnic- by treating the number of observed visits as a fixed parameter and cal-
ity were included in analyses due to differential COVID-­19 pandemic culating the ratio between observed visits and the estimated visit rate
experiences and previously described differences in MH ED utiliza- and 95% confidence limits. All analyses were repeated for each level of
tion by racial and ethnic group.16,31,32 the following characteristics: age, sex, race and ethnicity, primary payer,
Clinical characteristics included CAMHD-­C S MH diagnosis COI, and MH diagnosis group. Models for each characteristic included
group, representing the reason for ED presentation24; comorbid de- the same covariates as the overall model, with the addition of the char-
velopmental delay or intellectual disability, defined by CAMDH-­C S acteristic of interest and an interaction with the number of months since
diagnosis groups24; intentional self-­harm injury, based on external 2017. The interaction term allowed modeling of temporal trends for each
33,34
cause-­of-­injury diagnosis codes ; prior year MH ED visits; pres- level of the characteristic, resulting in better fitting models. RRs and 95%
ence of a medical complex chronic condition documented during the CIs of observed to expected visits during the postpandemic period were
current or prior year using previously validated reference criteria35; calculated for each level of the characteristic.
measures of ED resource utilization; clinical disposition (admitted/ Estimated visit rates and 95% CIs were plotted alongside ob-
observation/died, transferred, discharged, other); and return MH ED served visit rates for each calendar month for all MH visits and by
visits within 7 and 30 days. Visits could be assigned to more than age group, sex, race and ethnicity, COI, and MH diagnosis group. We
one MH diagnosis group, if corresponding diagnostic codes were plotted ED length of stay percentiles by year.
present. 24 Deaths were categorized together with admission/obser- We used a significance level of 0.05 to determine statistical sig-
vation due to the small number of deaths (n = 8) in the study sample. nificance. No adjustments were made for multiple comparisons. We
Measures of ED resource utilization included triage acuity defined performed all analyses using SAS/STAT software version 9.4 (SAS
by Emergency Severity Index (ESI)36; ED length of stay (<6, 6 to <12, Institute Inc.).
12 to <24, ≥24 h); performance of laboratory testing37; performance
of neuroimaging; and administration of psychotropic medications.38
We defined psychotropic medications as anticonvulsants, antide- R E S U LT S
pressants, antihistamines, antipsychotics, benzodiazepines, stimu-
lants, and other psychotropic agents.38 Study population characteristics
The primary exposure of interest was time period, defined
as prepandemic (January 1, 2017–February 29, 2020), early pan- There were 175,979 MH ED visits by children during the study period
demic (March 1, 2020–December 31 2020), midpandemic (January (70.4% by adolescents 12 to <18 years old, 52.4% by females, 51.8%
1, 2021–December 31, 2021), and late pandemic (January 1, by non-­Hispanic White children; Table 1). We excluded 2628 (1.5%)
 | 742

TA B L E 1 Sociodemographic characteristics of pediatric MH ED visits by pandemic time period.

Difference in percentage of MH visits (95% CI)

Percentage of MH visits, Prepandemic vs.

Overall, 2017–2022 prepandemic, Jan 2017–Feb 2020 Prepandemic vs. early pandemic, Mar midpandemic, 2021 Prepandemic vs. late pandemic,
(n = 175,979), n (%) (n = 93,902) 2020–Dec 2020 (n = 20,451) (n = 31,978) 2022 (n = 29,648)

Age (years)
5 to <12 52,056 (29.6) 31.6 −3.4 (−4.0 to −2.7) −4.8 (−5.3 to −4.2) −4.5 (−5.1 to −3.9)
12 to <18 123,923 (70.4) 68.4 3.4 (2.7 to 4.0) 4.8 (4.2 to 5.3) 4.5 (3.9 to 5.1)
Sex
Male 83,813 (47.6) 50.3 −3.9 (−4.7 to −3.2) −6.9 (−7.5 to −6.3) −5.5 (−6.2 to −4.9)
Female 92,151 (52.4) 49.7 3.9 (3.1 to 4.6) 6.9 (6.3 to 7.5) 5.5 (4.9 to 6.2)
Unknown 15 (0.0) 0.0 0.0 (−0.0 to 0.0) 0.0 (−0.0 to 0.0) 0.0 (−0.0 to 0.0)
Race and ethnicity
Hispanic 26,849 (15.3) 14.7 0.5 (−0.0 to 1.0) 1.6 (1.1 to 2.1) 1.4 (0.9 to 1.9)
Black 40,909 (23.2) 24.0 −0.3 (−0.9 to 0.4) −2.9 (−3.4 to −2.3) −1.4 (−1.9 to −0.9)
non-­Hispanic
White 91,196 (51.8) 52.2 −1.0 (−1.7 to −0.2) 0.0 (−0.6 to 0.7) −1.5 (−2.2 to −0.9)
non-­Hispanic
Other 14,566 (8.3) 7.9 0.6 (0.2 to 1.0) 0.8 (0.5 to 1.2) 1.0 (0.6 to 1.4)
non-­Hispanic
Unknown 2459 (1.4) 1.2 0.1 (−0.0 to 0.3) 0.4 (0.2 to 0.5) 0.5 (0.4 to 0.7)
Primary payer
Private 74,749 (42.5) 41.5 2.1 (1.4 to 2.9) 3.3 (2.7 to 3.9) 1.0 (0.3 to 1.6)
Public 97,557 (55.4) 56.0 −1.5 (−2.2 to −0.7) −2.3 (−3.0 to −1.7) 0.0 (−0.6 to 0.6)
Other 3673 (2.1) 2.5 −0.6 (−0.8 to −0.4) −1.0 (−1.1 to −0.8) −1.0 (−1.2 to −0.8)
COI
Very Low 44,251 (25.1) 25.9 −0.5 (−1.1 to 0.2) −2.4 (−2.9 to −1.8) −1.3 (−1.9 to −0.8)
Low 28,603 (16.3) 16.7 −1.6 (−2.1 to −1.0) −1.1 (−1.6 to −0.7) −0.6 (−1.1 to −0.1)
Moderate 32,422 (18.4) 18.6 −0.8 (−1.3 to −0.2) −0.2 (−0.7 to 0.3) −0.0 (−0.5 to 0.5)
High 27,461 (15.6) 15.1 1.2 (0.6 to 1.7) 1.3 (0.8 to 1.7) 0.9 (0.4 to 1.3)
Very high 43,074 (24.5) 23.7 1.6 (1.0 to 2.3) 2.5 (1.9 to 3.1) 1.1 (0.5 to 1.6)
Unknown 168 (0.1) 0.1 −0.0 (−0.1 to −0.0) −0.1 (−0.1 to −0.0) 0.0 (−0.0 to 0.0)

Abbreviations: COI, Child Opportunity Index; MH, mental health.

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HOFFMANN et al. 743

encounters due to missing data. There were 93,902 prepandemic visits, 12 to <18 years were lower than expected during the early pandemic
20,451 early pandemic visits (March 2020–December 2020), 31,978 (RR 0.87, 95% CI 0.83–0.91), higher than expected during the mid-
midpandemic visits (in 2021), and 29,648 late pandemic visits (in 2022). pandemic (RR 1.13, 95% CI 1.07–1.20), and then were similar to ex-
Characteristics of MH ED visits differed by pandemic time period pected levels during the late pandemic (RR 1.03, 95% CI 0.96–1.12;
(Table 2). The percentage of MH ED visits by children with developmen- Figure 3). MH ED visits per 30 days by males were lower than ex-
tal delay or intellectual disability increased from 4.6% to 5.2% during pected across pandemic time periods, while visits by females were
the early pandemic (percent difference 0.6% [0.3% to 1.0%]), followed lower than expected during the early pandemic (RR 0.90, 95% CI
by a decline to 4.1% during the late pandemic (percent difference −0.5% 0.86–0.95) and higher than expected during the midpandemic (RR
[−0.7% to −0.2]%). The percentage of MH ED visits by children with 1.22, 95% CI 1.15–1.30) and late pandemic (RR 1.10, 95% CI 1.02–
complex chronic conditions increased from 18.5% prepandemic to 1.20). During the early pandemic, MH ED visits per 30 days were
21.5% during the early pandemic (percent difference 3.0% [2.4% to lower than expected for Hispanic, Black non-­Hispanic, and White
3.7%]) and remained elevated at 19.1% in the late pandemic (percent non-­Hispanic children. Across all racial and ethnic groups, observed
difference 0.6% [0.1% to 1.2%]). The proportion of MH ED visits with rates were similar to expected rates based on prepandemic trends
psychotropic medication administered increased from 14.2% prepan- during the mid-­ and late pandemic. During the early pandemic,
demic to 21.5% during the late pandemic (percent difference 7.3% MH ED visits per 30 days were lower than expected across insur-
[6.8% to 7.8%]). Of MH ED visits, 1.3% had psychotropic medications ance payers and COI quintiles, while observed rates were similar to
administered via the intramuscular route (Supplemental Table S1). expected rates during the mid and late pandemic, with the excep-
Median ED length of stay increased from 4.4 h (interquartile range tion of visits by other payers which remained lower than expected
[IQR] 3.0–6.6 h] prepandemic to 5.7 h (IQR 3.7–9.6 h) during the late (Figure 4).
pandemic (Figure 1). Visit length ≥12 hours occurred in 7.3% prepan-
demic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late
pandemic visits. Visit length ≥24 h occurred in 1.7% prepandemic, Observed versus expected MH ED visits by
2.5% early pandemic, 5.9% midpandemic, and 7.5% late pandemic diagnosis group
visits. The percentage of visits resulting in discharge home decreased
from 53.5% prepandemic to 51.5% early pandemic (percent differ- Across all MH diagnosis groups, MH ED visits per 30 days were
ence −2.0% [−2.8% to −1.3%]) and 51.1% in the late pandemic (per- either lower than expected or did not differ significantly from ex-
cent difference −2.4% [−3.0% to −1.7%]). There was no significant pected during the early pandemic. During the midpandemic, MH
difference in MH return ED visits within 7 days, while returns within ED visits per 30 days increased more than expected for depressive
30 days increased from 9.8% prepandemic to 10.8% in the early pan- disorders (RR 1.17, 95% CI 1.02–1.37), anxiety disorders (RR 1.15,
demic (percent difference 1.0% [0.6% to 1.5%]), but did not differ sig- 95% CI 1.00–1.36), substance-­related and addictive disorders (RR
nificantly from prepandemic rates during the late pandemic. 1.28, 95% CI 1.06–1.61), feeding and eating disorders (RR 1.50, 95%
CI 1.17–2.09), bipolar and related disorders (RR 1.73, 95% CI 1.38–
2.32), and schizophrenia spectrum and other psychotic disorders (RR
Observed versus expected MH ED visits by pandemic 1.57, 95% CI 1.20–2.26). Of these, only substance-­related and ad-
time period dictive disorders, bipolar and related disorders, and schizophrenia
spectrum and other psychotic disorders remained elevated beyond
Before pandemic onset, 2407 MH ED visits occurred per 30 days. expected rates during the late pandemic (RR 1.50, 95% CI 1.18–2.05;
During the early pandemic, MH ED visits decreased to 1976 per RR 1.83, 95% CI 1.38–2.75; and RR 1.55, 95% CI 1.10–2.59, respec-
30 days, which was below expected rates based on extrapolated tively). MH ED visits per 30 days were lower than expected for au-
prepandemic trends, with an observed to expected RR of 0.80 (95% tism spectrum disorder across all pandemic time periods. Figure 5
CI 0.78–0.84). During the midpandemic, in 2021, MH ED visits in- displays observed versus expected MH ED visits by month for each
creased to 2585 per 30 days, which did not differ significantly from MH diagnosis group.
expected rates based on prepandemic trends (RR 1.01, 95% CI 0.96–
1.07). During the late pandemic, MH ED visits decreased to 2391
per 30 days, below expected rates based on prepandemic trends (RR DISCUSSION
0.92, 95% CI 0.86–0.98; Table 3, Supplemental Table S2, Figure 2).
Within a multicenter pediatric ED data registry, MH ED visits by
children decreased below expected rates during the early COVID-­19
Observed versus expected MH ED visits by pandemic, were similar to expected rates during the midpandemic,
sociodemographic characteristics and decreased below expected rates during the late pandemic.
Trends differed by age and sex, with more visits than expected
MH ED visits per 30 days by children 5 to <12 years old were lower among adolescents during the midpandemic and with increased vis-
than expected across pandemic time periods, while visits by children its by females during the mid-­ and late pandemic. No differences
 TA B L E 2 Clinical characteristics of pediatric MH ED visits by pandemic time period.
| 744

Difference in percentage of MH visits (95% CI)

Percentage of MH visits, Prepandemic vs. early Prepandemic vs.

Overall, 2017–2022 prepandemic, Jan 2017–Feb pandemic, Mar 2020–Dec midpandemic, 2021 Prepandemic vs. late pandemic,
(n = 175,979), n (%) 2020 (n = 93,902) 2020 (n = 20,451) (n = 31,978) 2022 (n = 29,648)

MH diagnosis group
Depressive disorders 67,575 (38.4) 38.1 −0.9 (−1.6 to −0.2) 1.0 (0.4 to 1.6) 1.3 (0.7 to 1.9)
Suicide or self-­injury 60,948 (34.6) 32.4 1.8 (1.1 to 2.5) 4.9 (4.3 to 5.5) 6.9 (6.2 to 7.5)
Anxiety disorders 55,224 (31.4) 28.9 3.6 (2.9 to 4.3) 5.8 (5.2 to 6.4) 5.9 (5.3 to 6.5)
Attention deficit/hyperactivity 50,372 (28.6) 29.6 2.0 (1.3 to 2.7) −2.7 (−3.2 to −2.1) −4.1 (−4.6 to −3.5)
disorder
Trauma and stressor-­related 26,613 (15.1) 14.8 0.4 (−0.2 to 0.9) 0.2 (−0.2 to 0.7) 1.5 (1.0 to 2.0)
disorders
Autism spectrum disorder 26,145 (14.9) 14.3 1.4 (0.8 to 1.9) 1.3 (0.8 to 1.7) 1.1 (0.6 to 1.6)
Disruptive to impulse control and 21,645 (12.3) 14.1 −2.7 (−3.2 to −2.2) −4.0 (−4.4 to −3.6) −4.3 (−4.7 to −3.9)
conduct disorders
MH symptom 19,531 (11.1) 11.4 −1.6 (−2.0 to −1.1) −0.8 (−1.2 to −0.4) 0.1 (−0.3 to 0.5)
Substance-­related and addictive 11,449 (6.5) 6.2 0.7 (0.3 to 1.1) −0.0 (−0.4 to 0.3) 1.1 (0.8 to 1.5)
disorders
Feeding and eating disorders 6052 (3.4) 2.5 1.2 (0.9 to 1.5) 2.1 (1.8 to 2.4) 2.2 (2.0 to 2.5)
Bipolar and related disorders 4785 (2.7) 3.2 −0.9 (−1.2 to −0.7) −0.9 (−1.1 to −0.7) −1.1 (−1.3 to −0.9)
Schizophrenia spectrum and other 3191 (1.8) 1.8 0.1 (−0.1 to 0.3) 0.1 (−0.0 to 0.3) 0.1 (−0.1 to 0.3)
psychotic disorders
Intentional self-­harm injury 17,531 (10.0) 9.1 0.8 (0.4 to 1.3) 2.0 (1.6 to 2.4) 2.1 (1.7 to 2.5)
Developmental delay or intellectual 7934 (4.5) 4.6 0.6 (0.3 to 1.0) −0.4 (−0.6 to −0.1) −0.5 (−0.7 to −0.2)
disabilitya
Complex chronic condition 33,866 (19.2) 18.5 3.0 (2.4 to 3.7) 1.6 (1.1 to 2.1) 0.6 (0.1 to 1.2)
Triage category
ESI
1 1590 (0.9) 0.8 0.0 (−0.1 to 0.2) 0.1 (−0.0 to 0.2) 0.4 (0.2 to 0.5)
2 106,658 (60.6) 59.9 −2.6 (−3.4 to −1.9) 1.1 (0.5 to 1.7) 4.7 (4.1 to 5.3)
3 45,041 (25.6) 25.5 2.9 (2.2 to 3.6) 0.8 (0.2 to 1.4) −2.4 (−3.0 to −1.9)
4 20,208 (11.5) 12.1 0.1 (−0.4 to 0.6) −1.4 (−1.8 to −1.0) −2.1 (−2.5 to −1.7)
5 1451 (0.8) 1.1 −0.4 (−0.6 to −0.3) −0.5 (−0.6 to −0.4) −0.7 (−0.8 to −0.6)
Unknown 1031 (0.6) 0.6 −0.0 (−0.1 to 0.1) −0.1 (−0.1 to 0.0) 0.2 (0.1 to 0.3)
Laboratory test performed 83,517 (47.5) 42.4 11.1 (10.4 to 11.9) 10.8 (10.2 to 11.4) 10.4 (9.8 to 11.1)
PEDIATRIC MENTAL HEALTH ED VISITS, 2017–2022

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 HOFFMANN et al.

TA B L E 2 (Continued)

Difference in percentage of MH visits (95% CI)

Percentage of MH visits, Prepandemic vs. early Prepandemic vs.

Overall, 2017–2022 prepandemic, Jan 2017–Feb pandemic, Mar 2020–Dec midpandemic, 2021 Prepandemic vs. late pandemic,
(n = 175,979), n (%) 2020 (n = 93,902) 2020 (n = 20,451) (n = 31,978) 2022 (n = 29,648)

Neuroimaging performed 6290 (3.6) 3.2 0.7 (0.4 to 1.0) 0.7 (0.4 to 0.9) 1.3 (1.0 to 1.5)
Psychotropic medication administered
Any route 29,653 (16.9) 14.2 2.7 (2.2 to 3.3) 5.9 (5.4 to 6.4) 7.3 (6.8 to 7.8)
Intramuscular route 2257 (1.3) 1.1 0.3 (0.1 to 0.4) 0.6 (0.4 to 0.7) 0.3 (0.1 to 0.4)
ED length of stay (h)
<6 113,401 (64.4) 69.6 −1.8 (−2.5 to −1.1) −12 (−13 to −11) −16 (−17 to −16)
6 to <12 43,472 (24.7) 23.0 0.7 (0.1 to 1.4) 4.5 (3.9 to 5.0) 4.6 (4.0 to 5.2)
12 to <24 12,892 (7.3) 5.7 0.2 (−0.2 to 0.6) 3.5 (3.1 to 3.8) 6.1 (5.7 to 6.4)
24+ 6160 (3.5) 1.7 0.9 (0.6 to 1.1) 4.2 (3.9 to 4.5) 5.8 (5.5 to 6.1)
Unknown 54 (0.0) 0.1 −0.1 (−0.1 to −0.0) −0.1 (−0.1 to −0.0) −0.1 (−0.1 to −0.0)
ED disposition
Admitted/observation/diedb 68,992 (39.2) 38.5 2.0 (1.2 to 2.7) −0.2 (−0.8 to 0.4) 3.1 (2.5 to 3.7)
Discharged 92,887 (52.8) 53.5 −2.0 (−2.8 to −1.3) −0.3 (−0.9 to 0.3) −2.4 (−3.0 to −1.7)
Transferred 12,897 (7.3) 7.3 0.3 (−0.1 to 0.7) 0.8 (0.4 to 1.1) −1.0 (−1.3 to −0.7)
Other/unknown 1203 (0.7) 0.7 −0.3 (−0.4 to −0.2) −0.3 (−0.4 to −0.2) 0.3 (0.1 to 0.4)
MH visit within the prior yearc 46,620 (31.8) 31.7 1.0 (0.2 to 1.7) −0.7 (−1.3 to −0.0) 0.4 (−0.2 to 1.0)
d
MH return visit within 7 days 6183 (3.6) 3.4 0.5 (0.2 to 0.8) 0.2 (−0.0 to 0.5) 0.1 (−0.2 to 0.3)
d
MH return visit within 30 days 17,578 (10.1) 9.8 1.0 (0.6 to 1.5) 0.8 (0.4 to 1.1) 0.4 (0.0 to 0.9)

Abbreviations: ESI, Emergency Severity Index; MH, mental health.

a
Visits with a developmental delay/intellectual disability code in addition to a code from one of the selected MH diagnosis groups specified above.
b
There were eight visits overall with a disposition of death (January 2017–February 2020, n = 4; March 2020–December 2020, n = 1; January 2021–December 2021, n = 1; January 2022–December 2022,
n = 2).
c
Visits from 2017 (n = 29,454) excluded from “MH visit in prior year” measure due to not having a full year of data prior to 2017 visits to determine whether a prior visit occurred.
d
Visits from December 2022 (n = 2275) excluded from “RETURN VISIT” measures due to not having a full month of data post December 2022 visits to determine if a return visit occurred.
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15532712, 2024, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acem.14910 by Shifa Tameer-e-Millat, Wiley Online Library on [26/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
746 PEDIATRIC MENTAL HEALTH ED VISITS, 2017–2022

F I G U R E 1 Length of stay percentiles

for pediatric MH ED Visits, 2017–2022.
Median (IQR) ED length of stay increased
from 4.3 (3.0–6.4) h in 2017 to 5.7 (3.7–
9.6) h in 2022. The 90th percentile length
of stay increased from 9.4 h in 2017 to
20.7 h in 2022. The 95th percentile length
of stay increased from 13.1 h in 2017 to
28.2 h in 2022. MH, mental health.

were noted from expected rates by race and ethnicity during the compared to White children,16 we found no differences from expected
mid-­ and late pandemic. However, trends differed by MH diagno- trends in MH ED visits by race and ethnicity during the mid-­ and late
sis group, with more visits than expected during the late pandemic pandemic. Although more disadvantaged neighborhoods in the United
for substance-­related and addictive disorders, bipolar disorders, and States experienced a higher COVID-­19 disease burden,45 we found no
schizophrenia spectrum disorders. Visit lengths increased substan- differences from expected pediatric MH ED visits during the mid-­and
tially, with nearly one in five MH ED visits exceeding 12 h during the late pandemic across child opportunity index quintiles.
late pandemic. Visit trends also differed by diagnosis, with increases in ED vis-
The COVID-­19 pandemic had a multifaceted impact on children's its for depression, anxiety, and eating disorders during the midpan-
access to MH services and MH outcomes. Children who transitioned to demic, which receded during the late pandemic. CDC surveillance
virtual schooling lost access to school-­based MH services, while other data similarly demonstrated increased ED visits for depression and
children experienced grief from losing loved ones to COVID-­19.5,6 eating disorders (particularly among adolescent females) in 2021
During the early pandemic, rates of clinically elevated depression and compared with 2019.14 Our findings are also consistent with mul-
anxiety symptoms among children increased.7 Despite these changes, ticenter studies demonstrating increased outpatient visits and hos-
we found MH ED visits initially decreased during the early pandemic. pitalizations for eating disorders among adolescents from 2020 to
This may be due, in part, to family perceptions of risk and avoidance of 2021. 25,46,47 Our more recent data from 2022 indicate eventual sta-
40
health care facilities, with more families seeking MH treatment via bilization relative to expected rates.
41
telehealth. Moreover, prior work has shown that the proportional Concerningly, we identified more ED visits than expected
decline of MH ED visits was not as great as the decline in medical ED for substance use disorders, bipolar disorder, and schizophrenia
visits during the early pandemic.42 Subsequent rises in ED visits for spectrum disorders that persisted through the late pandemic. In a
specific MH conditions as the pandemic progressed could be related study of U.S. children's hospitals, ED visits for substance use dis-
to delayed access to MH services and accumulation of pandemic-­ orders decreased during the early pandemic (fall 2020) compared
related stressors over time. to prior years.48 Consistent with our results, more recent CDC
We identified differences in MH ED visit trends by patient demo- surveillance data found increases in ED visits by adolescents for
graphics. MH ED visits by adolescents and females increased beyond drug overdoses, and for opioid-­involved overdoses specifically,
expected levels, which is consistent with CDC surveillance data of U.S. in Fall 2022 compared to the prepandemic period.15 Given these
14,15
pediatric ED visits. Pandemic-­related MH risks among adolescent increases, clinicians who work in EDs may consider implementing
girls were similarly identified in a large population-­based study of screening, brief interventions, and referrals for substance use dis-
outpatient MH service use in Canada.43 Because racial and ethnic mi- orders as well as initiation of medication-­assisted treatment for
nority groups disproportionately experienced adverse physical health opioid use disorders.49,50 Although less common in children, bipo-
outcomes related to COVID-­19, one might expect MH consequences lar disorder and schizophrenia are often high in severity; they rep-
to track similarly.31,44 While a single-­center study demonstrated resented the second and third most common and costly reasons
greater pandemic-­related reductions in MH ED visits among Black for pediatric MH hospitalizations prior to the pandemic. 26 Further
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HOFFMANN et al. 747

TA B L E 3 Observed versus expected pediatric MH ED visits per 30 days by pandemic time period.

RR of observed to expected visits (95% CI)

Observed 30 day visit rate, Jan Early pandemic, Mar

2017–Feb 2020 2020–Dec 2020 Midpandemic, 2021 Late pandemic, 2022

Total 2406.6 0.80 (0.78–0.84) 1.01 (0.96–1.07) 0.92 (0.86–0.98)

Age (years)
5 to <12 761.1 0.67 (0.63–0.72) 0.78 (0.72–0.86) 0.69 (0.62–0.79)
12 to <18 1645.5 0.87 (0.83–0.91) 1.13 (1.07–1.20) 1.03 (0.96–1.12)
Sex
Male 1209.4 0.71 (0.68–0.75) 0.83 (0.78–0.88) 0.76 (0.70–0.82)
Female 1197.3 0.90 (0.86–0.95) 1.22 (1.15–1.30) 1.10 (1.02–1.20)
Race and ethnicity
Hispanic 357.5 0.77 (0.66–0.92) 1.01 (0.82–1.31) 0.87 (0.67–1.24)
Black non-­Hispanic 585.9 0.81 (0.72–0.94) 0.93 (0.78–1.13) 0.91 (0.73–1.19)
White non-­Hispanic 1272.1 0.80 (0.74–0.88) 1.04 (0.93–1.19) 0.93 (0.80–1.11)
Other non-­Hispanic 191.1 0.83 (0.68–1.07) 1.05 (0.80–1.52) 0.94 (0.67–1.60)
Primary payer
Private 996.0 0.82 (0.76–0.88) 1.04 (0.94–1.15) 0.88 (0.77–1.01)
Public 1351.1 0.81 (0.76–0.87) 1.02 (0.94–1.12) 0.98 (0.88–1.11)
Other 59.5 0.49 (0.38–0.69) 0.46 (0.32–0.76) 0.35 (0.23–0.75)
COI
Very low 626.0 0.82 (0.74–0.91) 0.96 (0.85–1.12) 0.92 (0.78–1.13)
Low 403.8 0.75 (0.67–0.86) 0.98 (0.83–1.19) 0.93 (0.75–1.20)
Moderate 447.0 0.80 (0.71–0.91) 1.05 (0.90–1.26) 0.98 (0.80–1.25)
High 362.7 0.85 (0.75–0.98) 1.06 (0.90–1.30) 0.93 (0.75–1.23)
Very high 567.1 0.80 (0.73–0.90) 1.01 (0.89–1.19) 0.85 (0.71–1.05)
MH diagnosis groupa
Depressive disorders 915.5 0.85 (0.77–0.95) 1.17 (1.02–1.37) 1.12 (0.94–1.38)
Suicide or self-­injury 778.8 0.83 (0.75–0.92) 1.12 (0.99–1.30) 1.06 (0.90–1.30)
Anxiety disorders 693.0 0.87 (0.79–0.98) 1.15 (1.00–1.36) 1.03 (0.86–1.29)
Attention deficit/hyperactivity 712.7 0.83 (0.76–0.91) 0.88 (0.78–0.99) 0.74 (0.64–0.88)
disorder
Trauma and stressor-­related 356.1 0.87 (0.76–1.01) 1.10 (0.92–1.37) 1.10 (0.88–1.48)
disorders
Autism spectrum disorder 343.2 0.64 (0.58–0.72) 0.70 (0.61–0.82) 0.53 (0.44–0.66)
Disruptive–impulse control and 339.6 0.80 (0.70–0.93) 0.98 (0.83–1.21) 0.95 (0.77–1.27)
conduct disorders
MH symptom 275.3 0.77 (0.69–0.87) 1.08 (0.93–1.29) 1.13 (0.93–1.43)
Substance-­related and 149.7 1.05 (0.92–1.24) 1.28 (1.06–1.61) 1.50 (1.18–2.05)
addictive disorders
Feeding and eating disorders 61.3 1.04 (0.86–1.30) 1.50 (1.17–2.09) 1.30 (0.95–2.08)
Bipolar and related disorders 76.8 1.04 (0.88–1.28) 1.73 (1.38–2.32) 1.83 (1.38–2.75)
Schizophrenia spectrum and 42.5 1.10 (0.90–1.42) 1.57 (1.20–2.26) 1.55 (1.10–2.59)
other psychotic disorders

Abbreviation: COI, Child Opportunity Index; MH, mental health; RR, rate ratio.
a
MH diagnosis groups are not mutually exclusive.

work is needed to determine how children with these conditions Notably, we did not find higher than expected ED visits for sui-
were affected by the pandemic and how to prevent ED visits in cide or self-­injury, which contrasts with a CDC surveillance report
these populations. that found rising suicide attempt ED visits among adolescent females
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748 PEDIATRIC MENTAL HEALTH ED VISITS, 2017–2022

F I G U R E 2 Observed versus expected pediatric MH ED visits, 2018–2022. MH ED visits decreased significantly below expected visit
numbers from March to May 2020 and from August 2020 to February 2021. MH ED visits were significantly higher than expected from June
to July 2021. MH ED visits were significantly lower than expected from August to December 2022. MH, mental health.

F I G U R E 3 Observed versus expected pediatric MH ED visits by sociodemographic characteristics. Separate models were constructed for
each of the following sociodemographic characteristics: age, sex, and race and ethnicity. To account for seasonal, geographic, and temporal
trends, models adjusted for month, site, the number of months since January 2017, and the sociodemographic characteristic of interest and
its interaction with a temporal trend. MH, mental health.
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HOFFMANN et al. 749

F I G U R E 4 Observed versus expected pediatric MH ED visits by COI. To account for seasonal, geographic, and temporal trends, the
model adjusted for month, site, the number of months since January 2017, and the interaction of child opportunity index with a temporal
trend. COI, Child Opportunity Index; MH, mental health.

in 202113 as well as higher positivity rates on suicide risk screening prolonged boarding.57,58 MH boarding times represent low-­value care,
questions in a single ED after pandemic onset.51 Our results also with few children receiving psychiatric medication changes or psy-
differ from a systematic review and meta-­analysis that found good chotherapy.20,59 As length of stay increased, we also found that the
evidence for an increase in ED visits for attempted suicide by youth percentage of children discharged from the ED decreased during the
during the pandemic and modest evidence of an increase in ED visits pandemic, potentially indicating higher illness severity or more limited
52
for suicidal ideation. Since our analysis used prepandemic trends availability of community MH services.60
to predict expected ED visit rates, if ED visits were rising for a par- We identified that the proportion of MH ED visits with psy-
ticular condition (e.g., suicide and self-­injury) prior to the pandemic, chotropic medications administered increased as the pandemic
the observed versus expected ratio might be not be significant even progressed. Some instances of medication administration may rep-
as ED visit rates continued to increase. resent provision of home medications,61,62 which may be increas-
We found substantial increases in ED visit length over time, indi- ingly ordered in the ED as length of stay increases. Unfortunately,
cating an acceleration of prepandemic trends.53 These data are consis- medication errors are common among children experiencing MH
tent with a survey of hospitalists from 88 unique hospitals indicating ED boarding, with one study finding medication errors among 73%
rises in ED boarding of children awaiting psychiatric admission or of these visits, most commonly among antidepressants and anti-
transfer.20 Our results are also consistent with a cross-­sectional anal- psychotics.61 Such errors could be due to lack of familiarity of ED
ysis of national commercial health insurance claims, which demon- clinicians with psychotropic medication dosing, inadequate ED sys-
strated that prolonged boarding (defined as two or more midnights) tems to facilitate medication reconciliation, or hospital formularies
in the ED or medical unit for youth awaiting inpatient psychiatric ad- not carrying certain psychotropic medications.61 In our study, the
54
mission increased 76.4% between March 2019 and February 2022. proportion of MH ED visits with psychotropic medications given in-
Similarly, at one center, boarding times more than doubled from 2.1 tramuscularly did not change substantially over time. Some of these
to 4.6 days during the first pandemic year.55 Substantial increases in medications may have been administered for the management of
boarding may be due to a lack of sufficient MH services for children acute agitation.63 ED staff training in verbal deescalation techniques
56
in the community and higher levels of care. Unfortunately, children and deliberate practice via simulation may be considered as strate-
with specialized needs (e.g., autism spectrum disorder, develop- gies to reduce the need for pharmacologic interventions for acute
mental disorders, severe aggression) are at particularly high risk for agitation management.64–66
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750 PEDIATRIC MENTAL HEALTH ED VISITS, 2017–2022

F I G U R E 5 Observed versus expected pediatric MH ED visits by MH diagnosis group. Separate models were constructed for each MH
diagnosis group. To account for seasonal, geographic, and temporal trends, models adjusted for month, site, the number of months since
January 2017, and the interaction of MH diagnosis group with a temporal trend. MH, mental health.
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HOFFMANN et al. 751

The percentage of MH ED visits by children with developmental it was a MH or physical health diagnosis. Because we focused
delay or intellectual disability increased during the early pandemic, our analysis on common MH diagnoses seen in the ED setting,
followed by a decline during the late pandemic. The percentage of some MH conditions that present infrequently were not included.
MH ED visits by children with complex chronic medical conditions The indication for medication administration is not specified in
remained elevated throughout the pandemic. The disproportionate the database, so it was unclear which medications were given for
impact on these populations during the pandemic may have been acute agitation management, for other acute indications, or as
exacerbated by changing routines, loss of support networks, and de- home medications. Due to large sample sizes, some statistically
creased access to specialist input.67,68 During the pandemic, parents significant differences may not be clinically significant. We as-
of children with special educational needs and disabilities described sessed prepandemic trends over a relatively short (3-­year) time
that their children experienced increases in worry, low mood, and window. While we included two community hospital EDs, most
acting out, which parents sometimes attributed to their limited participating EDs were at children's hospitals, potentially limiting
understanding of pandemic-­related changes.68 In a survey of care- generalizability of results.
givers of children with disabilities, 31% reported worsening of the
child's functioning during the pandemic; stable or improved func-
tioning was associated with parent self-­efficacy and greater support CO N C LU S I O N S
in accessing schooling.69
Return MH ED visits remained high throughout the pandemic, Our study shows that mental health ED visits by children decreased
with approximately one in 10 children returning for MH reasons during the early COVID-­19 pandemic relative to expected levels
within 30 days. This rate is similar to a prepandemic study of based on prepandemic trends. Mental health ED visit rates were
Medicaid-­e nrolled youth seen in the ED for a MH condition and similar to expected rates during the midpandemic and then de-
discharged, of whom 12.8% had additional MH acute care use creased below expected rates during the late pandemic; however,
70
(an ED visit or hospitalization) within 30 days. Frequent return visits remained elevated beyond expected rates during the late pan-
ED visits could reflect inadequate access to or engagement in demic for females and for specific mental health diagnoses. ED visit
outpatient MH services,1 leading to worsening of mental illness. length progressively increased, with nearly one in five mental health
Alternatively, revisits could reflect referrals back to the ED from ED visits exceeding 12 h during the late pandemic. Our results have
70
outpatient MH professionals. In a study of MH revisits at U.S. relevance to policy considerations and the development of tailored
children's hospitals, diagnoses associated with behavior distur- interventions to improve youth mental health. Strengthening pre-
bance, including disruptive or impulse control disorders, neurode- vention and early intervention services should focus on groups that
velopmental disorders, and psychotic disorders, were associated experienced increases in mental health emergencies during the pan-
71
with revisits. demic. These findings may also inform mental health–related pre-
There are many opportunities available to improve emergency paredness efforts for future public health emergencies.
care for children experiencing MH crises. Delivery of evidence-­
based brief interventions in the ED may promote symptom reduc-
tion and facilitate connection to follow-­up care,72,73 allowing more STUDY AUTHORSHIP GROUP
children to be safely discharged home.74,75 Clinical pathways can
serve to standardize care processes, such as reducing unneces- Members of the PECARN Registry Study Group include Drs.
sary laboratory testing, and quality improvement initiatives can be Elizabeth Alpern, Lynn Babcock, Lalit Bajaj, David Brousseau,
76–78
focused on supporting children who are boarding. Ultimately, Jim Chamberlain, Bob Grundmeier, Prashant Mahajan, Bashar
reducing the number of children experiencing MH emergencies will Shihabuddin, Leah Tzimenatos, and Joe Zorc.
require investments in prevention and early intervention, including
integration of MH care into primary care settings and schools, in- AU T H O R C O N T R I B U T I O N S
creasing access to telehealth services, and expanding the MH clini- Jennifer A. Hoffmann provided substantial contributions to study
cian workforce.79–81 Additionally, emerging care models may provide conception and design, analysis and interpretation of data, and draft-
alternatives to ED-­based care, including mobile crisis evaluation, ing of the manuscript. Camille P. Carter, Cody S. Olsen, and Lawrence
psychiatric urgent care, and direct transport to freestanding psychi- J. Cook provided substantial contributions to study conception and
82
atric facilities. design, analysis and interpretation of data, and statistical expertise
and revised the article critically for important intellectual content.
Elizabeth R. Alpern provided substantial contributions to study con-
LI M ITATI O N S ception and design and analysis and interpretation of data and re-
vised the article critically for important intellectual content. David
Because the PECARN Registry is an EHR database, there is poten- Ashby, Kamali L. Bouvay, Susan J. Duffy, James M. Chamberlain,
tial for misclassification of ED visits. No specific marker is avail- Sofia S. Chaudhary, Nicolaus W. Glomb, Jacqueline Grupp-­Phelan,
able to establish the primary visit diagnosis, including whether Maya Haasz, Erin P. O'Donnell, Mohsen Saidinejad, Bashar S.
 |

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752 PEDIATRIC MENTAL HEALTH ED VISITS, 2017–2022

15
Division of Emergency Medicine, Department of Pediatrics, Seattle
Shihabuddin, Leah Tzimenatos, Neil G. Uspal, and Joseph J. Zorc pro- Children's Hospital, University of Washington, Seattle, Washington, USA
16
vided substantial contributions to analysis and interpretation of data Division of Emergency Medicine, Department of Pediatrics, Children's
and revised the article critically for important intellectual content. Hospital of Philadelphia, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania, USA
All authors provided final approval of the version to be published
and agree to be accountable for all aspects of the work in ensuring
that questions related to the accuracy or integrity of any part of the C O N F L I C T O F I N T E R E S T S TAT E M E N T
work are appropriately investigated and resolved. The authors declare no conflicts of interest.

F U N D I N G I N FO R M AT I O N ORCID
PECARN is supported by the Health Resources and Services Jennifer A. Hoffmann https://orcid.org/0000-0003-1653-363X
Administration (HRSA) of the U.S. Department of Health and Human Bashar S. Shihabuddin https://orcid.org/0000-0001-6903-5680
Services (HHS), in the Maternal and Child Health Bureau (MCHB),
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Received: 2 December 2023 | Revised: 7 February 2024 | Accepted: 6 March 2024

DOI: 10.1111/acem.14907

ORIGINAL ARTICLE

Early versus late advanced airway management for adult

patients with out-­of-­hospital cardiac arrest: A time-­dependent
propensity score–matched analysis

Shunsuke Amagasa MD, PhD1,2 | Shintaro Iwamoto MAS3 | Masahiro Kashiura MD2 |
Hideto Yasuda MD, PhD2 | Yuki Kishihara MD2 | Satoko Uematsu MD, PhD1 |
Takashi Moriya MD, PhD2

1
Department of Emergency and Transport
Medicine, National Center for Child Abstract
Health and Development, Tokyo, Japan
Objective: The objective was to investigate whether early advanced airway manage-
2
Department of Emergency and Critical
Care Medicine, Saitama Medical Center,
ment during the entire resuscitation period is associated with favorable neurological
Jichi Medical University, Saitama, Japan outcomes and survival in patients with out-­of-­hospital cardiac arrest (OHCA).
3
Department of Data Science, Clinical Methods: We performed a retrospective cohort study of patients with OHCA aged
Research Center, National Center for Child
Health and Development, Tokyo, Japan ≥18 years enrolled in OHCA registry in Japan who received advanced airway man-
agement during cardiac arrest between June 2014 and December 2020. To address
Correspondence
Shunsuke Amagasa, MD, PhD, resuscitation time bias, we performed risk set matching analyses in which patients
Department of Emergency and Transport who did and did not receive advanced airway management were matched at the same
Medicine, National Canter for Child
Health and Development, 2-­10-­1 Okura, time point (min) using the time-­dependent propensity score; further, we compared
Setagaya-­ku, Tokyo 157-­8535, Japan. early (≤10 min) and late (>10 min) advanced airway management. The primary and
Email: [email protected]
secondary outcome measures were favorable neurological outcomes using Cerebral
Performance Category scores and survival at 1 month after cardiac arrest.
Results: Of the 41,101 eligible patients, 21,446 patients received early advanced
airway management. Thus, risk set matching was performed with a total of 42,866
patients. In the main analysis, early advanced airway management was significantly
associated with favorable neurological outcomes (risk ratio [RR] 0.997, 95% con-
fidence interval [CI] 0.995–0.999) and survival (RR 0.990, 95% CI 0.986–0.994) at
1 month after cardiac arrest. In the sensitivity analysis with early advanced airway
management defined as ≤5 min and ≤20 min, the results were comparable.
Conclusions: Although early advanced airway management was statistically signifi-
cant for improved neurological outcomes and survival at 1 month after cardiac arrest,
the RR was very close to 1, indicating that the timing of advanced airway management
has minimal impact on clinical outcomes, and decisions should be made based on the
individual needs of the patient.

KEYWORDS
airway management, cardiopulmonary resuscitation, heart arrest, intubation

Supervising Editor: Aaron Robinson

Acad Emerg Med. 2024;31:755–766. wileyonlinelibrary.com/journal/acem © 2024 Society for Academic Emergency Medicine. | 755
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756 EARLY VS. LATE ADVANCED AIRWAY MANAGEMENT FOR OHCA

I NTRO D U C TI O N M E TH O D S

Out-­of-­h ospital cardiac arrest (OHCA) is a major public health Study design and setting
problem owing to its high mortality rate and serious sequelae.1–3
Improving the neurologic survival of patients with OHCA is an We conducted a retrospective examination of data for June 2014 to
important issue. Advanced airway management, encompassing December 2020 sourced from the JAAM-­OHCA Registry, a nation-
tracheal intubation, placement of a supraglottic device, and the wide, multicenter initiative in Japan that prospectively gathers both
use of esophageal obturators, represents an important resusci- prehospital and in-­hospital data of patients experiencing OHCA.
tation technique that provides a more reliable airway than bag– The registry encompasses all OHCA patients transported to affili-
4–6
mask ventilation. Several studies in the prehospital setting have ated medical centers.
reported that early advanced airway management improves the Ethical approval for the registry protocol was granted by the in-
probability of return of spontaneous circulation (ROSC) and neu- stitutional review board of each participating institution. Given the
rological outcomes.7–9 observational nature of the study and the assurance of data ano-
Resuscitation time bias, also known as immortal time bias, is nymity, the need for patient-­specific informed consent was waived.
a form of systematic error indicates during cardiopulmonary re- The study report was written in accordance with the Strengthening
suscitation (CPR), the group with a longer CPR duration is more the Reporting of Observational Studies in Epidemiology (STROBE)
likely to receive interventions such as advanced airway manage- guidelines.18
ment.10,11 If resuscitation time bias is not addressed, interven-
tions will be biased toward poor outcomes, as a longer duration
of arrest is associated with poorer outcomes. Therefore, resus- Management of OHCA in Japanese emergency
citation time bias may bias patients with late advanced airway medical services
management toward poorer outcomes. Resuscitation time bias
has been recently shown to be effectively addressed by risk set In Japan, local governments manage emergency medical ser-
matching with time-­d ependent propensity scores.12–16 While vices (EMS) systems under the oversight of the Japanese Fire
there have been studies using rigorous methods for in-­h ospital and Disaster Management Agency.19,20 The Japan Resuscitation
cardiac arrest,12,13 research on advanced airway management Council provides CPR training guidelines for all EMS staff, align-
in OHCA attempting to address resuscitation time bias is lim- ing with the International Liaison Committee on Resuscitation's
ited. Moreover, these studies have only examined the presence statement. 21,22 The EMS team is composed of three members,
or absence of advanced airway management in the prehospi- with at least one being a highly trained emergency medical tech-
14 16
tal setting, or they involved relatively small sample sizes. nician (EMT) skilled in prehospital care. The composition of EMS
Furthermore, evidence for the impact of early advanced airway teams, specifically the number of EMTs in each team, varies across
management on OHCA outcomes throughout the prehospital and regions based on the availability of certified EMTs. Emergency
in-­h ospital resuscitation periods is lacking, and a systematic re- personnel other than EMTs are trained in first aid. All EMTs have
view by the International Liaison Committee on Resuscitation's the ability to utilize upper airway tools such as laryngeal tubes
Advanced Life Support Task Force was unable to identify the op- (esophageal obturator) and laryngeal mask airways. However, only
timal timing of advanced airway management.17 EMTs with specific training and certification can perform tracheal
Determining the effectiveness of early advanced airway man- intubations, which is performed only when the patient has expe-
agement on survival and neurological intact survival is critical for rienced cardiac arrest. In Japan, there are 42,495 qualified EMTs,
appropriate application of resuscitation strategies in patients with with 29,389 working as EMTs (as of April 1, 2023). 23 Of the quali-
OHCA. The Japanese Association for Acute Medicine (JAAM) fied EMTs, 15,977 are certified to perform tracheal intubation.
OHCA Registry, a large data set with comprehensive resuscitation Certification as an EMT in the performance of tracheal intubation
time information including pre-­ and in-­hospital information, has the requires completion of a program approved by a regional medi-
potential to fill the current knowledge gap. cal control committee. This program consists of 62 sessions, with
To examine whether early advanced airway management in the each session lasting 50 min. In addition, the practical aspect of
total period of resuscitation is associated with favorable neurolog- the training requires the completion of more than 30 successful
ical outcomes and survival in adult patients with OHCA, we com- intubations in the operating room under the supervision of expe-
pared early and late advanced airway management using risk set rienced attending physicians. Legally, Japanese EMS personnel
matching with time-­dependent propensity scores and multivariate cannot cease on-­site resuscitation; every OHCA patient is taken to
analysis to address resuscitation time bias and prehospital and in-­ a medical facility unless resuscitation is unquestionably futile and
hospital confounders. has not commenced. In the context of EMS in Japan, a patient is
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AMAGASA et al. 757

considered nontransportable if he or she meets all of the following Weeks were divided into weekdays and weekend. The times of
six criteria: (1) a level of consciousness of Japan Coma Scale 300; emergency calls were categorized as 7:00–14:59 h, 15:00–22:59 h,
(2) complete absence of respiration; (3) no palpable pulse in the and 23:00–6:59 h. 25 Witness status was categorized as none, EMS
carotid arteries; (4) dilated pupils and no light reflex; (5) coldness personnel, and others. Bystander CPR was categorized as present,
and no temperature sensation; and (6) rigor mortis in the extremi- absent, and present including rescue breathing. The initially mon-
ties or livor mortis. itored cardiac rhythms were categorized as ventricular fibrillation,
pulseless ventricular tachycardia, pulseless electrical activity, asys-
tole, and others. The causes of cardiac arrest were classified as car-
Study population diogenic, respiratory, asphyxiation, traumatic, other intrinsic factors,
and other extrinsic factors. Prehospital advanced airway manage-
OHCA patients aged ≥ 18 years who were part of the JAAM-­OHCA ment was classified as laryngeal masks, esophageal obturators, and
Registry and received advanced airway management during cardiac endotracheal tubes.
arrest were included in this study. Exclusion criteria included cases
where time to advanced airway management was missing, 0 min,
≥60 min, or inconsistent (i.e., negative values) and cases where time-­ Data analysis
dependent variables or outcome data were missing.
Descriptive statistics were calculated for all the relevant variables.
Continuous data were presented as median and interquartile range
Measurements and definitions (IQR), whereas categorical variables were presented as counts and
percentages. Standardized differences between the two groups in
The JAAM-­OHCA Registry, which integrates prehospital and in-­ the initial cohort indicated differences in baseline characteristics.
hospital data, served as the source of the study data. Prehospital Risk set matching using a time-­d ependent propensity score
data were collected by the EMS personnel based on the Utstein-­ analysis was performed to examine the relationship between
style template.19 In-­hospital data, as well as evaluations of the eti- early advanced airway management and outcomes. A Fine–Gray
ology of cardiac arrest, were collected by the medical staff. The regression model, including time-­d ependent covariates, time-­
physician at the hospital to which the patient was transported de- independent covariates, and competing risk events, was used to
termined the etiology of the cardiac arrest based on the patient's calculate a propensity score that represented an estimated risk
history, clinical course, and examination findings. The JAAM-­OHCA score predicting the likelihood of early advanced airway manage-
Registry Committee combined these data. 20 ment. Similar methods have been used in previous cardiac arrest
The exposure was early advanced airway management versus treatment trials and have been shown to be effective in reducing
late advanced airway management during cardiac arrest. Advanced resuscitation time bias.14–16,26 Because this study aimed to eval-
airway management was defined as tracheal intubation, placement uate the effectiveness of early advanced airway management in
of a supraglottic device, or the use of an esophageal obturator. Early cardiac arrest, this Fine–Gray regression model considered ROSC
advanced airway management was defined as placement of an ad- before advanced airway management as a competing risk and in-
vanced airway within 10 min or less following the initial contact formative censoring. The time-­d ependent and time-­independent
between the patient and EMS. Based on a previous study8 and the covariates used to calculate time-­d ependent propensity scores
feasibility of advanced airway management in adult patients with are listed in Table 1. The time-­d ependent covariates included
OHCA, we determined a cutoff time of 10 min. To ensure that the the presence or absence of adrenaline administration, time from
10-­min criterion was appropriate, we also examined at the median EMS–patient contact to adrenaline administration, presence or
and distribution of the time to advanced airway management prior absence of shock delivery, and time from EMS–patient contact to
to the analysis. In cases where cardiac arrest was directly observed shock delivery. As in-­h ospital treatments (percutaneous coronary
by the EMS staff, the time intervals for advanced airway placement, intervention, extracorporeal membrane oxygenation, intra-­a ortic
adrenaline administration, and shock delivery were calculated from balloon pump, and target temperature management) could not be
the moment of witnessing the cardiac event rather than from the included in the propensity score, they were adjusted using mul-
initial EMS–patient contact. tivariate analysis after matching. These covariates were selected
The primary outcome was favorable neurological outcome based on their importance and medical relevance to the exposure
1 month after cardiac arrest, and the secondary outcome was and outcomes from the guidelines and previous studies.14–16,27–29
survival 1 month after cardiac arrest. A favorable neurological Each patient who underwent advanced airway manage-
outcome was defined as a Cerebral Performance Category (CPC) ment at any time between 1 and 59 min after EMS contact was
score of 1 or 2. 24 The CPC score encompasses five distinct out- matched by caliper matching to a patient undergoing resuscita-
comes: (1) good cerebral recovery, (2) moderate cerebral disability, tion who was at risk for advanced airway management and had
(3) severe cerebral disability, (4) coma or vegetative state, and (5) not yet received an advanced airway management during the
death or brain death. same time period (risk set matching). The caliper width for the
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758 EARLY VS. LATE ADVANCED AIRWAY MANAGEMENT FOR OHCA

TA B L E 1 Demographics and characteristics of original cohort.

Early advanced airway Late advanced airway

management management
Standardized
(n = 21,446) (n = 19,655) difference

Age (years) 77 (66–85) 74 (61–84) −0.187

Male 12,730 (59.4) 12,149 (61.8) 0.05
Day of week 0.011
Weekday 14,366 (67.0) 13,064 (66.5)
Weekend 7080 (33.0) 6591 (33.5)
Time of emergency call 0.038
7:00–14:59 8988 (41.9) 7947 (40.4)
15:00–22:59 8072 (37.6) 7417 (37.7)
23:00–6:59 4386 (20.5) 4291 (21.8)
Witness status 0.072
None 11,887 (55.4) 10,190 (51.8)
EMS personnel 1704 (7.9) 1686 (8.6)
Others 7855 (36.6) 7779 (39.6)
Bystander CPR 0.097
Presence 8496 (39.6) 7435 (37.8)
Absence 11,219 (52.3) 11,034 (56.1)
Presence including rescue breathing 1731 (8.1) 1186 (6.0)
Initial monitored cardiac rhythm 0.073
VF 1585 (7.4) 1765 (9.0)
Pulseless VT 26 (0.1) 44 (0.2)
PEA 5622 (26.2) 5306 (27.0)
Asystole 13,457 (62.7) 11,797 (60.0)
Other 756 (3.5) 743 (3.8)
Cause of cardiac arrest 0.252
Cardiogenic 11,789 (55.0) 10,160 (51.7)
Respiratory 1263 (5.9) 963 (4.9)
Asphyxiation 1323 (6.2) 1331 (6.8)
Traumatic 743 (3.5) 1739 (8.8)
Other intrinsic 4626 (21.6) 3523 (17.9)
Other extrinsic 1702 (7.9) 1940 (9.9)
Time from emergency call to start of CPR (min) 9 (7–11) 9 (7–12) 0.066
Time from the patient contact by EMS to arrival at the hospital (min) 24 (20–30) 24 (18–31) −0.01
Adrenaline administration before advanced airway management 649 (3.0) 1293 (6.6) 0.167
Time from the patient contact by EMS to adrenaline administration 6 (5–7) 8 (7–9) 1.04
before advanced airway management (min)
Shock delivery before advanced airway management 1721 (8.0) 2181 (11.1) 0.105
Time from the patient contact by EMS to shock delivery before 2 (1–3) 2 (1–3) 0.232
advanced airway management (min)
Prehospital advanced airway management 19,862 (92.6) 7088 (36.0) 1.46
Prehospital advanced airway management type 1.65
Laryngeal mask 2288 (10.7) 273 (1.4)
Esophageal obturator 14,835 (69.2) 4959 (25.2)
Endotracheal tube 3458 (16.1) 2016 (10.2)
Physician during emergency transport 1925 (9.0) 1409 (7.2) 0.066
Prehospital advanced life support by physician 2375 (11.1) 2202 (11.2) 0.004
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AMAGASA et al. 759

TA B L E 1 (Continued)

Early advanced airway Late advanced airway

management management
Standardized
(n = 21,446) (n = 19,655) difference

In-­hospital variables
Percutaneous coronary intervention 625 (2.9) 623 (3.2) 0.015
Extracorporeal membrane oxygenation 959 (4.5) 907 (4.6) 0.008
Intra-­aortic balloon pump 729 (3.4) 696 (3.5) 0.015
Target temperature management 1226 (5.7) 1268 (6.5) 0.031

Note: Data are reported as median (IQR) or n (%).

Abbreviations: CPR, cardiopulmonary resuscitation; EMS, emergency medicine service; IQR, interquartile range; PEA, pulseless electrical activity; VF,
ventricular fibrillation; VT, ventricular tachycardia.

caliper matching was set to 0.2. When configuring pairs through early advanced airway management as ≤5 min and ≤20 min using the
nearest neighbor matching, a specific caliper is set; if the width same methodology as the main analysis. These cutoffs were estab-
is less than or equal to the value calculated based on the caliper, lished based on a previous study7 and the quartile range of the time
the pair is configured. Narrowing the caliper width will enhance to advanced airway management. To evaluate only patients who re-
the alignment of characteristics between both groups for com- quire advanced airway management before arriving to the hospital,
parison but decreases the number of matched patients, leading we performed analyses that included only patients who underwent
to a loss of patients from the matching cohort. In the present prehospital advanced airway management.
study, the caliper width was determined based on recommen-
dations from statisticians in previous literature and studies that
employed similar methods.14–16,30,31 Since matching should not Subgroup analysis
be based on future events, patients who subsequently received
advanced airway management were also considered to be at risk Subgroup analyses of patients under 60 years of age and witnessed
for advanced airway management. Although the matched con- cases were performed because of the potential benefits of analyz-
trols were independent within the risk strata at each time point ing the age group with a better chance of improving outcomes and
(min), several patients in the control group overlapped within witnessed cases, in which the time since cardiac arrest is considered
the matched cohort across all combined strata. This issue was to be more consistent.7,8 In addition, because current international
addressed by adjusting the frequency weighting to indicate the guidelines advocate the use of two different algorithms depending
number of duplicates when analyzing the results. Risk set match- on the initial rhythm monitored, with separate suggestions for the
ing assumes that matched pairs are correlated at the same time timing of advanced airway management, we performed a subgroup
point. Therefore, a generalized estimating equation (GEE) was analysis of shockable and nonshockable rhythm cases.14 In addi-
used to analyze the results and estimate the risk ratio (RR) while tion, given the uncertainty surrounding optimal airway management
accounting for intrapair correlation. practices in OHCA—in terms of both the preferred device and the
To assess the effectiveness of the risk set matching, standardized ideal timing for device placement—we performed subgroup analyses
differences were calculated for each covariate. A well-­matched bal- for laryngeal mask, esophageal obturator, and tracheal intubation.
ance was defined as a balance with an absolute value of <0.20 and
the standardized difference.30 RRs between early and late advanced
airway management outcomes were estimated using GEE with a R E S U LT S
modified Poisson regression with robust variance. The correlation
matrix was considered as “exchangeable.” All tests were two-­t ailed Patients
and considered statistically significant if the 95% confidence interval
(CI) did not cross 1. Data were analyzed using the R software version A total of 60,348 patients with cardiac arrest were enrolled in the
4.1.3 (www.​r-­​proje​c t.​org). JAAM-­OHCA Registry (Figure 1). Among them, 59,107 patients were
aged ≥18 years. A total of 15,167 exclusions were made based on
the time to advanced airway management, with 7796 cases not re-
Sensitivity analysis ceiving advanced airway management and 5933 having missing data
for the time to advanced airway management. After cases that met
To assess whether changes in cutoff values alter the effect of early other exclusion criteria were excluded, 41,101 cases were included
advanced airway management, we performed analyses defining in the final analysis.
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760 EARLY VS. LATE ADVANCED AIRWAY MANAGEMENT FOR OHCA

Patient characteristics and for the sensitivity analysis, in which early advanced airway man-
agement was defined as ≤5 min and ≤20 min, are shown in Table 3. In
Among the 41,101 patients, 21,446 (52.2%) underwent early ad- the main analysis, early advanced airway management was signifi-
vanced airway management and 19,655 (47.8%) underwent late cantly associated with favorable neurological outcomes (RR 0.997
advanced airway management (Table 1). In comparison with late [95% CI 0.995–0.999]) and survival (RR 0.990 [95% CI 0.986–0.994])
advanced airway management, early advanced airway management at 1 month after cardiac arrest. In the sensitivity analysis with early
was less likely to be used in cases with traumatic causes (early ad- advanced airway management defined as ≤5 min, early advanced air-
vanced airway management 3.5%, late advanced airway manage- way management was significantly associated with favorable neuro-
ment 8.8%). logical outcome (RR 0.995 [95% CI 0.991–0.999]) and survival (RR
To address the concern that patients with missing advanced air- 0.991 [95% CI 0.985–0.998]) at 1 month after cardiac arrest. In the
way management time might bias the data, information from such sensitivity analysis with early advanced airway management defined
patients is presented in Table S1. Importantly, there were no note- as ≤20 min, no significant differences were observed for favorable
worthy characteristics that would introduce substantial bias in the neurological outcomes at 1 month after cardiac arrest (RR 0.999
excluded patient groups with missing advanced airway management [95% CI 0.997–1.001]), but early advanced airway management was
time. significantly associated with survival at 1 month after cardiac arrest
(RR 0.994 [95% CI 0.991–0.997]).

Main results
Sensitivity analysis
The demographics and traits of the time-­dependent propensity
score–matched cohort are presented in Table 2. After risk set match- In the sensitivity analysis, which only included patients with pre-
ing with a time-­dependent propensity score, 42,866 patients were hospital advanced airway management, no significant difference
matched. With this group, 27,518 patients were matched uniquely, was observed between early advanced airway management and
while 10,475 were matched multiple times. Except for the time favorable neurological outcome at 1 month after cardiac arrest
from EMS contact to the injection of adrenaline before advanced in all analyses. This includes scenarios defined as early advanced
airway management, for which only some patients were included, airway management ≤10 min (RR 0.998 [95% CI 0.995–1.001]),
the standardized difference was 0.20 for all variables, demonstrat- 5 min (RR 0.999 [95% CI 0.997–1.001]), or 20 min (RR 0.999 [95%
ing good balance after matching. CI 0.997–1.001]; see Table S2). Moreover, early advanced air-
The outcomes of the original and time-­dependent propensity way management was significantly associated with survival at
score–matched cohorts are shown in Table 3. Among the eligible pa- 1 month after cardiac arrest in all analyses. This correlation re-
tients, 1064 (2.6%) had a favorable neurological outcome and 2524 mained consistent whether early advanced airway management
(6.1%) survived at 1 month after cardiac arrest. was defined as ≤10 min (RR 0.990 [95% CI 0.985–0.995]), 5 min
The outcomes after risk set matching for the main analysis, in (RR 0.983 [95% CI 0.975–0.990]), or 20 min (RR 0.994 [95% CI
which early advanced airway management was defined as ≤10 min, 0.990–0.998]).

F I G U R E 1 Study flowchart. EMS,

emergency medical service; ROSC, return
of spontaneous circulation.
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AMAGASA et al. 761

TA B L E 2 Demographics and characteristics of the time-­dependent propensity score–matched cohort.

Early advanced airway Late advanced airway

management management

(n = 21,433) (n = 21,433) Standardized difference

Age (years) 77 (66–85) 77 (66–85) 0.006

Male 12,722 (59.4) 12,683 (59.2) 0.004
Day of week 0.004
Weekday 14,358 (67.0) 14,400 (67.2)
Weekend 7075 (33.0) 7033 (32.8)
Time of emergency call 0.007
7:00–14:59 8981 (41.9) 8948 (41.9)
15:00–22:59 8067 (37.6) 8067 (37.6)
23:00–6:59 4385 (20.5) 4449 (20.8)
Witness status 0.013
None 11,886 (55.5) 11,878 (55.4)
EMS personnel 1694 (7.9) 1767 (8.2)
Others 7853 (36.6) 7788 (36.3)
Bystander CPR 0.008
Presence 8494 (39.6) 8483 (39.6)
Absence 11,209 (52.3) 11,175 (52.1)
Presence including rescue breathing 1730 (8.1) 1767 (8.2)
Initial monitored cardiac rhythm 0.01
VF 1584 (7.4) 1546 (7.2)
Pulseless VT 26 (0.1) 23 (0.1)
PEA 5621 (26.2) 5671 (26.5)
Asystole 13,455 (62.8) 13,462 (62.8)
Other 747 (3.5) 732 (3.4)
Cause of cardiac arrest 0.013
Cardiogenic 11,786 (55.0) 11,872 (55.4)
Respiratory 1262 (5.9) 1280 (6.0)
Asphyxiation 1323 (6.2) 1341 (6.3)
Traumatic 743 (3.5) 716 (3.3)
Other intrinsic 4618 (21.5) 4568 (21.3)
Other extrinsic 1701 (7.9) 1656 (7.7)
Time from emergency call to start of CPR (min) 9 (7–11) 9 (7–11) 0.011
Time from the patient contact by EMS to arrival at the hospital 24 (20–30) 25 (20–30) 0.006
(min)
Adrenaline administration before advanced airway 649 (3.0) 565 (2.6) 0.024
management
Time from the patient contact by EMS to adrenaline 6 (5–7) 8 (6–9) 0.695
administration before advanced airway management (min)a
Shock delivery before advanced airway management 1721 (8.0) 1696 (7.9) 0.004
Time from the patient contact by EMS to shock delivery before 2 (1–3) 2 (1–3) 0.08
advanced airway management (min)a
Prehospital advanced airway management 19,849 (92.6) 19,849 (92.6) 0
Prehospital advanced airway management type 0.011
Laryngeal mask 2275 (10.6) 2212 (10.3)
Esophageal obturator 14,835 (69.2) 14,876 (69.4)

(Continues)
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762 EARLY VS. LATE ADVANCED AIRWAY MANAGEMENT FOR OHCA

TA B L E 2 (Continued)

Early advanced airway Late advanced airway

management management

(n = 21,433) (n = 21,433) Standardized difference

Endotracheal tube 3458 (16.1) 3492 (16.3)

Physician during emergency transport 1918 (8.9) 1977 (9.2) 0.01
Prehospital advanced life support by physician 2369 (11.1) 2420 (11.3) 0.008
In-­hospital variables
Percutaneous coronary intervention 624 (2.9) 564 (2.6) 0.017
Extracorporeal membrane oxygenation 958 (4.5) 922 (4.3) 0.008
Intra-­aortic balloon pump 728 (3.4) 703 (3.3) 0.006
Target temperature management 1226 (5.7) 1138 (5.3) 0.018

Note: Data are reported as median (IQR) or n (%).

Abbreviations: CPR, cardiopulmonary resuscitation; EMS, emergency medical services; IQR, interquartile range; PEA, pulseless electrical activity; VF,
ventricular fibrillation; VT, ventricular tachycardia.
a
Because the variable is only for patients who received that treatment, matching does not necessarily improve the balance.

TA B L E 3 Outcomes between early and late advanced airway management in risk-­set matching using time-­dependent propensity score.

No. of patients with outcome

Early advanced airway

management Late advanced airway management RR (95% CI)

Original cohort n = 21,446 n = 19,655

Favorable neurological outcome at 402 (1.9) 662 (3.4) NA

1 month after cardiac arrest
Survival at 1 month after cardiac arrest 1262 (6.4) 1262 (5.9) NA
Time-­dependent propensity score-­matched cohort
Early advanced airway management n = 21,433 n = 21,433
defined as ≤10 min
Favorable neurological outcome at 402 (1.9) 327 (1.5) 0.997 (0.995–0.999)
1 month after cardiac arrest
Survival at 1 month after cardiac arrest 1260 (5.9) 1014 (4.7) 0.990 (0.986–0.994)
Sensitivity analysis
Early advanced airway management n = 8716 n = 8716
defined as ≤5 min
Favorable neurological outcome at 188 (2.2) 139 (1.6) 0.995 (0.991–0.999)
1 month after cardiac arrest
Survival at 1 month after cardiac arrest 562 (6.4) 463 (5.3) 0.991 (0.985–0.998)
Early advanced airway management n = 31,243 n = 31,243
defined as ≤20 min
Favorable neurological outcome at 596 (1.9) 578 (1.9) 0.999 (0.997–1.001)
1 month after cardiac arrest
Survival at 1 month after cardiac arrest 1747 (5.6) 1497 (4.8) 0.994 (0.991–0.997)

Note: Data are reported as n (%).

Abbreviation: RR, risk ratio.

Subgroup analysis (Table 4). However, the RR was very close to 1 in all analyses, poten-
tially suggesting less clinical importance.
In the subgroup analyses of patients aged ≤60 years or >60 years, In a subgroup analysis focusing on different devices for advanced
with or without witness, and shockable rhythm or nonshockable airway management, laryngeal mask, esophageal obturator, and en-
rhythm, early advanced airway management was significantly as- dotracheal intubation had RRs very close to 1 in each analysis for
sociated with neurological outcomes or survival in some subgroups the association with favorable neurological outcome and survival at
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AMAGASA et al. 763

1 month after cardiac arrest, with no apparent differences observed it was significantly associated with survival at 1 month, but not with
across the devices (Table 5). favorable neurological outcome. However, the RR was very close to
1 in all analysis, indicating that timing of advanced airway manage-
ment has little effect on clinical outcomes and should be tailored to
DISCUSSION the individual needs of the patient.
In this study, early advanced airway management showed lit-
This study reviewed data from the JAAM-­OHCA Registry, which in- tle clinical association with the outcomes. In two observational
cludes prehospital and in-­hospital data and addressed resuscitation studies on adult OHCA patients who received prehospital ad-
time bias by sequential matching using time-­dependent propensity vanced airway management in Japan, early advanced airway man-
scores to determine whether early advanced airway management in agement was found to be associated with favorable neurological
the overall resuscitation time is associated with the outcomes for outcomes.7,8 A secondary analysis of the Resuscitation Outcomes
OHCA patients. In analyses where early advanced airway manage- Consortium Prehospital Resuscitation using an Impedance Valve
ment was defined as ≤5 and 10 min, it showed a significantly associa- and Early versus Delayed (ROC PRIMED) study conducted in the
tion with favorable neurological outcome and survival at 1 month. United States and Canada showed that early advanced airway
When early advanced airway management was defined as ≤20 min, management was associated with an increased probability of

TA B L E 4 Outcomes between early and late advanced airway management in risk-­set matching using time-­dependent propensity score in
subgroup analysis.

18–60 years of age >60 years of age

Early advanced airway management defined as ≤10 min n = 7441 n = 35,425

Favorable neurological outcome at 1 month after cardiac arrest 0.995 (0.986–1.004) 0.998 (0.995–1.000)
Survival at 1 month after cardiac arrest 0.989 (0.978–1.001) 0.991 (0.986–0.995)
Early advanced airway management defined as ≤5 min n = 2891 n = 14,541
Favorable neurological outcome at 1 month after cardiac arrest 0.998 (0.983–1.013) 0.995 (0.991–0.999)
Survival at 1 month after cardiac arrest 0.997 (0.978–1.018) 0.990 (0.983–0.998)
Early advanced airway management defined as ≤20 min n = 11,655 n = 50,831
Favorable neurological outcome at 1 month after cardiac arrest 1.000 (0.992–1.007) 0.999 (0.998–1.001)
Survival at 1 month after cardiac arrest 0.998 (0.988–1.008) 0.994 (0.990–0.997)
Witness No witness
Early advanced airway management defined as ≤10 min n = 19,102 n = 23,764
Favorable neurological outcome at 1 month after cardiac arrest 0.994 (0.989–0.999) 0.999 (0.997–1.001)
Survival at 1 month after cardiac arrest 0.980 (0.971–0.999) 0.998 (0.994–1.001)
Early advanced airway management defined as ≤5 min n = 7816 n = 9616
Favorable neurological outcome at 1 month after cardiac arrest 0.993 (0.985–1.002) 0.997 (0.994–1.000)
Survival at 1 month after cardiac arrest 0.981 (0.968–0.995) 0.998 (0.993–1.004)
Early advanced airway management defined as ≤20 min n = 28,472 n = 34,014
Favorable neurological outcome at 1 month after cardiac arrest 0.997 (0.994–1.001) 1.001 (0.999–1.002)
Survival at 1 month after cardiac arrest 0.985 (0.979–0.992) 1.001 (0.998–1.004)
Shockable rhythm Non-­shockable rhythm
Early advanced airway management defined as ≤10 min n = 3178 n = 39,688
Favorable neurological outcome at 1 month after cardiac arrest 0.984 (0.957–1.012) 0.998 (0.996–1.000)
Survival at 1 month after cardiac arrest 0.969 (0.931–1.008) 0.992 (0.988–0.995)
Early advanced airway management defined as ≤5 min n = 1285 n = 16,147
Favorable neurological outcome at 1 month after cardiac arrest 0.956 (0.914–0.999) 0.998 (0.995–1.001)
Survival at 1 month after cardiac arrest 0.978 (0.913–1.048) 0.992 (0.986–0.998)
Early advanced airway management defined as ≤20 min n = 4495 n = 57,991
Favorable neurological outcome at 1 month after cardiac arrest 0.990 (0.966–1.014) 1.000 (0.999–1.001)
Survival at 1 month after cardiac arrest 0.983 (0.950–1.016) 0.995 (0.992–0.998)

Note: Data are reported as RR (95% CI).

Abbreviation: RR, risk ratio.
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764 EARLY VS. LATE ADVANCED AIRWAY MANAGEMENT FOR OHCA

TA B L E 5 Outcomes between early and late advanced airway ROSC in adult OHCA patients who were witnessed and received
management in risk set matching using time-­dependent propensity prehospital advanced airway management.9 Although these stud-
score in a subgroup analysis of different devices for advanced ies reported that early advanced airway management was asso-
airway management.
ciated with better outcomes, they did not address resuscitation
Laryngeal mask time bias, which may have influenced these results. Patients with
Early advanced airway management n = 4487 a later advanced airway management tended to have longer re-
defined as ≤10 min suscitation times than those with an earlier advanced airway man-
Favorable neurological outcome at 0.997 (0.989–1.005) agement. Since longer periods of arrest are associated with worse
1 month after cardiac arrest outcomes, resuscitation time bias may lead to poorer outcomes in
Survival at 1 month after cardiac arrest 0.984 (0.972–0.997) patients with late advanced airway management.10,11 Therefore,
Early advanced airway management n = 2561 resuscitation time bias is an important consideration when exam-
defined as ≤5 min ining the effectiveness of treatments such as advanced airway
Favorable neurological outcome at 0.990 (0.981–1.000) management during resuscitation.
1 month after cardiac arrest A Japanese observational study of prehospital advanced air-
Survival at 1 month after cardiac arrest 0.988 (0.972–1.004) way management in 310,620 patients with OHCA that addressed
Early advanced airway management n = 4872 resuscitation time bias using risk set matching with time-­dependent
defined as ≤20 min propensity scores reported that advanced airway management was
Favorable neurological outcome at 0.999 (0.991–1.006) associated with better survival in patients with a nonshockable
1 month after cardiac arrest
rhythm.14 However, that study only assessed whether prehospital
Survival at 1 month after cardiac arrest 0.991 (0.980–1.002)
advanced airway management was performed and did not examine
Esophageal obturator the timing of advanced airway management. A secondary analysis of
Early advanced airway management n = 29,711 2146 patients enrolled in the Pragmatic Airway Resuscitation Trial
defined as ≤10 min
(PART), a clinical trial comparing the effects of epiglottis tubes and
Favorable neurological outcome at 0.996 (0.993–0.998) endotracheal intubation on the outcomes after OHCA in adults, used
1 month after cardiac arrest
risk set matching with a time-­dependent propensity score to com-
Survival at 1 month after cardiac arrest 0.992 (0.993–0.999)
pare patients who received advanced airway management within 5,
Early advanced airway management n = 12,276 5–10, 10–15, and 15–20 min of advanced life support arrival to those
defined as ≤5 min
who did not.16 The results showed that the timing of an advanced
Favorable neurological outcome at 0.996 (0.991–1.001)
airway placement attempt was not associated with survival to hospi-
1 month after cardiac arrest
tal discharge, which is consistent with the results of this study.
Survival at 1 month after cardiac arrest 0.994 (0.986–1.003)
This study used a large registry that included both prehospital
Early advanced airway management n = 38,723
and in-­hospital data to compare early and late advanced airway
defined as ≤20 min
management in terms of overall resuscitation time. Additionally, we
Favorable neurological outcome at 0.997 (0.995–0.999)
1 month after cardiac arrest addressed the resuscitation time bias and adjusted for confounding
and time-­dependent confounding factors by risk set matching using
Survival at 1 month after cardiac arrest 0.993 (0.990–0.997)
time-­dependent propensity score matching. The Fine–Gray model
Endotracheal tube
was used to estimate time-­dependent propensity scores, and ROSC
Early advanced airway management n = 8668
before advanced airway management was considered a competing
defined as ≤10 min
risk. Therefore, we rigorously evaluated the effects of advanced
Favorable neurological outcome at 1.001 (0.996–1.008)
1 month after cardiac arrest airway management during CPR. The results showed that early

Survival at 1 month after cardiac arrest 0.987 (0.977–0.998)

advanced airway management was significantly associated with
survival and favorable neurological outcomes. However, the large
Early advanced airway management n = 2595
defined as ≤5 min sample size was considered the reason for the significant difference,

Favorable neurological outcome at 0.998 (0.985–1.011) and the effect sizes suggest that early advanced airway management
1 month after cardiac arrest is not clinically associated with improved outcomes. The sensitiv-
Survival at 1 month after cardiac arrest 0.981 (0.960–1.002) ity analysis using different cutoff times and the sensitivity analysis
Early advanced airway management n = 18,891 focusing solely on cases that received prehospital advanced airway
defined as ≤20 min management yielded robust results. The subgroup analysis based on
Favorable neurological outcome at 1.007 (1.002–1.012) patient characteristics showed no notable significant effect modi-
1 month after cardiac arrest fiers. Additionally, the subgroup analysis considering the devices
Survival at 1 month after cardiac arrest 1.000 (0.993–1.007) used for advanced airway management showed no clear differences

Note: Data are reported as RR (95% CI). among the devices. Prior studies have reported no clear difference
Abbreviation: RR, risk ratio. in efficacy among these techniques in the prehospital setting.32,33
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AMAGASA et al. 765

Building on these preliminary findings, our analysis provides an the timing of advanced airway management based on individual
insight into the potential lack of distinct device-­specific variations patient needs. Future randomized control trials are needed to bet-
in timing. These results suggest that prioritizing advanced airway ter clarify the effect of early advanced airway placement in out-­of-­
placement may not be necessary for all patients with OHCA and that hospital cardiac arrest.
its timing should be based on the individual needs of the patient.
AU T H O R C O N T R I B U T I O N S
Study concept and design: Shunsuke Amagasa, Masahiro
LI M ITATI O N S Kashiura, Hideto Yasuda , and Yuki Kishihara. Acquisition of the
data: Shunsuke Amagasa. Analysis and interpretation of the data:
Our study has several limitations. First, although the findings ad- Shunsuke Amagasa and Shintaro Iwamoto. Drafting of the manu-
justed for many confounding factors, the possibility of unknown or script: Shunsuke Amagasa. Critical revision of the manuscript
unmeasured confounders could not be ruled out because this was for important intellectual content: Shintaro Iwamoto, Masahiro
an observational study. Potential confounders not addressed in this Kashiura, Hideto Yasuda, Yuki Kishihara, Satoko Uematsu,
study included difficulty in ventilation during CPR, underlying dis- and Takashi Moriya. Statistical expertise: Shintaro Iwamoto.
ease, first-­pass success, and the number of failed intubations. In ad- Acquisition of funding: None.
dition, confounding by indication, which is important consideration
in such studies, could not be completely excluded. Each patient's C O N F L I C T O F I N T E R E S T S TAT E M E N T
detailed characteristics and medical history may influence the tim- The authors declare no conflicts of interest.
ing of advanced airway management, which may have also affected
the outcomes. To further clarify the causal relationship between ORCID
early and late airway management and outcomes, randomized Shunsuke Amagasa https://orcid.org/0000-0002-8371-1507
controlled trials are needed to address these confounding issues. Masahiro Kashiura https://orcid.org/0000-0002-1989-656X
Second, EMS systems vary from country to country and region to
region, which limited the generalizability of our study results. For
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Nationwide public-­access defibrillation in Japan. New Engl J Med. glottic airway device vs tracheal intubation during out-­of-­hospital
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International Liaison Committee on Resuscitation (American
How to cite this article: Amagasa S, Iwamoto S, Kashiura M,
Heart Association, European Resuscitation Council, Australian
Resuscitation Council, New Zealand Resuscitation Council, et al. Early versus late advanced airway management for
Heart and Stroke Foundation of Canada, InterAmerican adult patients with out-­of-­hospital cardiac arrest: A time-­
Heart Foundation, Resuscitation Council of Southern Africa). dependent propensity score–matched analysis. Acad Emerg
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Received: 8 December 2023 | Revised: 22 February 2024 | Accepted: 22 February 2024

DOI: 10.1111/acem.14898

ORIGINAL ARTICLE

Perspectives from persons living with dementia and their

caregivers on emergency department visits, care transitions,
and outpatient follow-­up: A qualitative study

Megan C. McHugh PhD1,2 | Kayla M. Muschong BA1 | Sara M. Bradley MD3 |

Alexander X. Lo MD, PhD1,2

1
Department of Emergency Medicine,
Northwestern University Feinberg School Abstract
of Medicine, Chicago, Illinois, USA
Background: Persons living with dementia (PLWD) experience frequent and costly
2
Center for Health Services and Outcomes
Research, Institute for Public Health
emergency department (ED) visits, with poor outcomes attributed to suboptimal care
and Medicine, Northwestern University and postdischarge care transitions. Yet, patient-­centered data on ED care experiences
Feinberg School of Medicine, Chicago,
Illinois, USA
and postdischarge needs are lacking. The objective of this study was to examine the
3
Department of Medicine, Northwestern facilitators and barriers to successful ED care and care transitions after discharge, ac-
University Feinberg School of Medicine, cording to PLWD and their caregivers.
Chicago, Illinois, USA
Methods: We conducted a qualitative study involving ED patients ages 65 and older
Correspondence with confirmed or suspected dementia and their caregivers. The semistructured
Megan C. McHugh, Department of
Emergency Medicine, Northwestern interview protocol followed the National Quality Forum's ED Transitions of Care
University Feinberg School of Medicine, Framework and addressed ED care, care transitions, and outpatient follow-­up care.
Chicago, IL 60611, USA.
Email: [email protected] Interviews were conducted during an ED visit at an urban, academic ED. Traditional
thematic analysis was used to identify themes.
Funding information
Emergency Medicine Foundation; Results: We interviewed 11 patients and 19 caregivers. Caregivers were more forth-
National Institutes of Health-­National coming than patients about facilitators and challenges experienced. Characteristics
Institute on Aging, Grant/Award Number:
R33AG069822; Davee Foundation; West of the patients’ condition (e.g., resistance to care, forgetfulness), the availability of
Health Institute family resources (e.g., caregiver availability, primary care access), and system-­level
factors (e.g., availability of timely appointments, hospital policies tailored to persons
with dementia) served as facilitators and barriers to successful care. Some resources
that would ameliorate care transition barriers could be easily provided in the ED, for
example, offering clear discharge instructions and care coordination services and im-
proving patient communication regarding disposition timeline. Other interventions
would require investment from other parts of the health care system (e.g., respite for
caregivers, broader insurance coverage).

This study was supported by a grant from The Geriatric Emergency Care Applied Research Network 2.0–Advancing Dementia Care (GEAR 2.0 ADC) with funding from the National
Institutes of Health-­National Institute on Aging (R33AG069822), West Health Institute, and Emergency Medicine Foundation. Dr. Lo's work on this study was also supported by the
Davee Foundation.

Supervising Editor: Kabir Yadav

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.

Acad Emerg Med. 2024;31:767–776.  wileyonlinelibrary.com/journal/acem | 767

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768 PERSPECTIVES ON CARE FOR PATIENTS WITH DEMENTIA

Conclusions: ED care and care transitions for PLWD are suboptimal, and patient-­level
factors may exacerbate existing system-­level deficiencies. Insight from patients and
their caregivers may inform the development of ED interventions to design special-
ized care for this patient population. This qualitative study also demonstrated the
feasibility of conducting ED-­based studies on PLWD during their ED visit.

I NTRO D U C TI O N limited to dementia) within 1 week of ED discharge reported sev-

eral barriers including poor communication and lack of caregiver
Between 2020 and 2030, the number of persons living with demen- engagement, caregivers’ feeling overwhelmed, and caregivers’ chal-
tia (PLWD) in the United States is projected to increase by almost lenges navigating the health care system after the ED visit. 26 The
1,2
45% from 5.8 million to 8.4 million. One in two PLWD will have importance of ED care transitions is not unique to PLWD. Older ED
at least one emergency department (ED) visit per year, and their ED patients without cognitive impairment rated ED care transition as
care is often resource-­intensive and costly and results in poor out- the most important outcome measure after an ED visit, and rated
comes after ED discharge.3–12 Compared to persons without demen- symptoms and quality of life as a higher outcome measure than did
tia, PLWD have a higher rate of ED visits and ED return visits.3,11,13 expert clinicians. 27 What remains unclear is the specific concerns of
PLWD also have a 40% higher rate of hospitalizations and a nearly PLWD and their caregivers during the transition from the ED back to
80% higher rate of unnecessary hospitalizations.14 One understud- the outpatient care environment.
ied driver of ED return visits, unnecessary hospitalizations, and poor The aim of this qualitative study was to examine factors that fa-
outcomes is deficiencies with effective care transitions from the ED cilitate or hinder (i) successful ED care and (ii) care transitions from
to home, assisted living, or other receiving facility and subsequent the ED to the outpatient care environment, including primary care
fragmented care.12,15–17 Importantly, as many as to 60% of PLWD and community resources, according to PLWD and their caregivers.
do not have a formal diagnosis of dementia,18–20 which exacerbates This aim was identified as a research priority by the NIA-­supported
the challenges of care transitions, as undiagnosed PLWD lack spe- GEAR 2.0-­ADC working group and follows the group's direction to
cialized outpatient care and resources critical to the management of (1) include perspectives of patients and caregivers and (2) recognize
dementia.4,7,15,18,21 that many PLWD have not been diagnosed. This study is the first,
A recent series of four scoping reviews on multiple elements of to our knowledge, to obtain the perspectives of ED patients with
successful ED care and care transitions from ED to home were re- confirmed and possible dementia and their caregivers during their
cently published by the National Institute on Aging (NIA)-­f unded ED visit and may be instructional in the design of interventions for
Geriatric Emergency Care Applied Research 2.0–Alzheimer's this population in the future.
Dementia Care (GEAR 2.0-­A DC) Network interdisciplinary work-
ing group and consensus conferences. 22–25 Among these, the
review by Dresden et al. 22 on optimal ED practices for care of M E TH O D S
PLWD found insufficient evidence to produce recommendations
on best practices; however, ample evidence indicated that PLWDs Recruitment and sampling
and their caregivers were frustrated by the lack of input or opin-
ion toward the development of optimal emergency care. Gettel This was a qualitative study utilizing a phenomenological research
et al. 23 found a small number of reports describing successful design that sought to describe patient and caregiver experiences. 28
ED care transitions for PLWD, but these were heterogeneous in Patients seeking care at an ED in an urban, academic hospital were
composition and thus precluded the generation of any consensus eligible to participate in the study if they were 65 or older, not
recommendations. The working group also reported discordance COVID-­19–positive, and English-­speaking and had a diagnosis of de-
between traditional health care outcome metrics and aspects mentia (“confirmed dementia”) or reported memory problems over
of care that actually matter to PLWD and their caregivers, with the past year (“possible dementia”). This study's screening approach
PLWD and caregivers emphasizing the need to identify personal- to identify “possible dementia” follows the same approach used by
23
ized barriers to care that incorporated local resources. Two ad- the NIA-­funded IMPACT study, 29,30 using the lead question from the
ditional reviews highlighted the limited evidence to guide optimal Cognitive Function Instrument,31 which can detect cognitive de-
communication between the ED care team and both PLWD and cline in asymptomatic dementia patients.32 Specifically, patients or
24
caregivers and the similar lack of data to guide dementia screen- their caregiver (on behalf of the patients) were asked, “Have you (or
25
ing strategies in the ED setting. the patient) experienced memory or thinking problems during the
The scoping reviews underscored the lack of patient-­centered past year?” If the patient or their caregiver answered affirmatively,
data on PLWD at the time of their ED encounter. A telephone-­based the patient was potentially eligible for the study. The accompany-
survey of caregivers of ED patients with cognitive impairment (not ing caregivers were also eligible to participate, 26 and we included
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McHUGH et al. 769

English-­speaking caregivers even if their patient was excluded for Medicine Institutional Review Board, and written consent was ob-
non–English-­speaking. Patients and their caregivers were identified tained from all participants. Our planning and reporting aligned with
in one of three ways. First, upon intake, some older adult patients the Standards for Reporting Qualitative Research (SRQR).36
were asked by a triage nurse if they have ever been diagnosed with
dementia or if they experienced any memory or thinking problems in
the past year. Second, if the dementia screening was not conducted Data analysis
during triage (typically due to capacity constraints), then one of
three experienced ED research assistants (RAs) approached patients Traditional thematic analysis was used to identify themes across all
ages 65 and older and their caregivers to ask the screening ques- transcripts.37 Transcripts were read by two team members for overall
tions. There was an on-­duty RA in the ED from 9 a.m. to 5 p.m. every clarity—an emergency physician with expertise in dementia (AL) and
weekday and occasional evenings (2–9 p.m.) and weekends. Third, a doctorally trained, senior health services research faculty member
the care team alerted the on-­duty RA that a patient had documented with extensive experience using and teaching qualitative research
or suspected dementia or memory loss. methods (MM). They met to discuss initial observations and redun-
Next, an RA explained the purpose of the study to the identi- dancy of the data, concluding that data saturation was reached.38
fied patients, and if accompanied, their caregivers. If the patient in- Next, the team developed a set of deductive codes, based on the
dicated a willingness to participate, the RA assessed the potential interview questions and inductive codes, based on the initial discus-
respondent's capacity to consent using the UCSD Brief Assessment sion.39 MM and AL independently coded four transcripts, and after
of Capacity to Consent (UBACC).33 Caregivers were not screened discussions of discrepancies, the remaining transcripts were coded
for capacity to consent. In instances where the patient and caregiver by one investigator (MM or AL). The two team members indepen-
both agreed to be interviewed, they were given the choice of being dently wrote analytic memos, which aided in data reduction by tying
interviewed together or separately. All individuals who were inter- together different pieces of data into conceptual clusters and pro-
viewed received a $30 gift card. Before beginning the interview, the ducing candidate themes.40,41 The two team members shared their
RA confirmed with the patient's care team that the interview would individual memos, and through a discussion that included the RA
not interfere with or delay the patient's care. If the care team recom- that conducted the most interviews (KM), agreed upon primary and
mended against the interview (e.g., patient was too ill, concern about secondary themes. The themes were then checked to ensure they
aggressive behavior by the patient, the interview could potentially captured the most important features of the coded data and were
interrupt patient care), the patient was deemed ineligible. coherent and substantial with clear boundaries, resulting in a final
set of primary and secondary themes. Lastly, the team selected ver-
batim quotations to illustrate the themes.42 Throughout the process,
Data collection coding definitions, analysis decisions, and ideas about emerging
themes were kept in a log so that the process could be replicated.
Three versions of the semistructured interview protocol were de- Results are presented for each topic area (ED care, care transitions,
veloped: one for patients, one for caregivers, and one for both re- and outpatient follow-­up care).
spondents if they opted for a joint interview. Questions followed
the National Quality Forum's ED Transitions of Care Framework34
and included questions about accessing care in the outpatient set- R E S U LT S
ting, concerns about post-­ED care needs, challenges associated
with care transitions, and recommendations for improving care in Participant characteristics
the ED. All interviews were conducted in the ED and led by one of
the three RAs. Their experience collecting data in the ED ranged Of the 128 patients ages 65 and older who had diagnosed or sus-
from 1.5 to 3.75 years. None of the RAs had met the participants pected dementia and were initially screened for this study, 11 (8.6%)
prior to the study. The interview questions were piloted in January were interviewed (see Figure S1 for enrollment diagram). Eighty-­
2023 with two patients and one caregiver, and minor modifications three (64.8%) of the 128 were determined to be ineligible for partici-
to the wording of questions were made. The final interview guide pation, most frequently due to an inability to provide consent based
for patient respondents is available in Data S1. Data from the pilot on the RA's judgment, non-­English fluency, or a UBACC score indi-
interviews were not included in the final analysis. All remaining in- cating an inability to provide consent. Further, 34 (26.6%) patients
terviews were conducted between February 2023 and May 2023. declined participation, most commonly because of lack of interest
Interviews lasted, on average, 19 min for patients, 21 min for caregiv- or feeling too sick or tired. Fifty-­six patients (43.7%) had an accom-
ers, and 22 min for dyads. Interviews were digitally recorded and panying caregiver, and 19 caregivers were enrolled and interviewed.
professionally transcribed verbatim, and stored in Atlas.ti, a quali- Of the 37 caregivers who declined participation, most declined be-
tative software program, for analysis.35 The transcripts were in a cause they were “not interested.” Among the enrolled patients and
password-­protected file accessible only to the study team. The study caregivers, there were three dyads, meaning both the patient and
was approved by the Northwestern University Feinberg School of their accompanying caregiver enrolled. The dyadic interviews were
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770 PERSPECTIVES ON CARE FOR PATIENTS WITH DEMENTIA

conducted jointly with both respondents present. Altogether, our the ED (Table 1). Because of this discomfort, caregivers expressed
interviews covered 27 unique ED visits. a desire for the patient to be discharged as quickly as possible.
Two of the patients had diagnosed dementia; nine had possible Further, some caregivers emphasized the importance of always hav-
dementia. Among the 11 patients, seven were female (63.6%), seven ing someone with the patient in the ED, which makes it difficult for
were Black (77.8%), four were White (44.4%), and none identified the caregiver to take care of logistical issues, like parking. Overall,
as Hispanic (see Table S1 for demographic table). Most caregivers respondents expressed few concerns about communication with
(15/19, 79.0%) were female. Thirteen caregivers were the children their providers in the ED. Specifically, both patients and caregivers
of the patient and three were spouses of the patient. The remaining noted that providers were taking their opinions into consideration
caregivers were other relatives, and one was a paid employee. Eleven during the visit and that providers were explaining the care plan and
caregivers were White (57.9%), seven were Black (36.8%), and one the sequence of events during the ED visit sufficiently for them to
was of mixed race (5.3%). One caregiver was Hispanic (5.3%). understand what was happening.
Among the 27 unique ED visits, nine of the 27 ED patients pre-
sented to the ED for an acute fall (33.3%), of whom three had a his-
tory of a recurrent falls (11.1%). Additionally, nine patients (33.3%) Patient and caregiver perspectives on transitioning
had specific complaints not related to falls, including one (3.7%) who from the ED
had syncope and one (3.7%) who was lightheaded and caught from
falling, and two patients felt unwell (7.4%) or were worried some- During their ED visit, patients and caregivers were asked whether
thing was wrong, even though they could not identify any particular they had any concerns about the forthcoming care transition from
sign or symptom. Five patients (18.5%) were brought to the ED by the ED. Few patients expressed any concerns, but caregivers had
family for behavioral concerns related to their dementia, for exam- several. Most commonly, caregivers expressed worry that the prob-
ple, confusion, wandering, or a change in behavior. Only two (7.4%) lem that motivated the ED visit would reoccur, for example, the
were sent to the ED by their primary care physician. None of the patient falling again or getting lost again or the patient consuming
patients returned to the ED for the issue for which they had been enough fluids, so a kidney problem was not exacerbated (Table 2).
seen in an ED previously. Caregivers expressed stress and not wanting to “relive” the expe-
rience of having to come to the ED. Additionally, a few caregivers
were also concerned about patients getting the “right” care, to avoid
Patient and caregiver perspectives on ED care unnecessary discomfort, hassles, and expenses. These caregivers
gave examples of a prior misdiagnosis or improper care, and they
The enrolled patients and caregivers expected long waits and were worried it might happen again. A few respondents expressed
crowded waiting rooms in advance of their visit. Nevertheless, car- concern about whether the patient would be able to access the care
egivers in particular were vocal about the discomfort experienced they needed after the ED visit. Several others were concerned about
by PLWD during an ED visit due to the long waits and business of how they would manage the patients’ mobility limitations back at

TA B L E 1 Challenges of seeking care in

Concern Representative quote
the emergency department, according to
Long wait times make some “When we come to the ER, the biggest difficulty is caregivers.
patients physically the fact that the wait time is so long … Because
uncomfortable she's bedridden, sitting up for an extended period
of time is very hard. It's like a physical exercise for
her whereas it wouldn't—it's not a big deal for us,
but she doesn't have any core. One of the biggest
deterrents to coming to the ER from both of our
perspectives is how long it's gonna take for her to
just be able to lay down and be seen.”
Crowded EDs can feel frightening “I think just in general I think people have to
remember that it's frightening down here for the
patient and the advocate, scary.”
Caregivers do not feel comfortable “In regard to dealing with the ER … part of the
leaving patients alone challenge is me having to go park [my car] …
because of the cognitive stuff … dementia, just
orientation issues. I don't like to just leave her and
go do X, Y, Z. I have found even in this ER is that,
sometimes, people aren't so willing to [help] I'll say,
‘I just wanna park the car. Can you just watch my
mom,’ or whatever. I guess maybe because it's too
busy or whatever.”
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McHUGH et al. 771

TA B L E 2 Concerns of patients and caregivers during transitions from the ED.

Concern Representative quote

The problem will reoccur, “I have concerns about some of the memory loss problems—why she fell, if that's going to happen again, and
necessitating a return whether or not it's going to get controlled properly.”
to the ED
The patient will not receive “It's inconclusive at this point, but we think it's probably related to a UTI. I've had situations where they didn't send
the “right” care the cultures off. Then we didn't know if the susceptibility was correct. I've had it happen when they've sent
us home, and I've had it happen when she stayed in the hospital. That led to a very bad experience, actually,
in March because they gave her—because they didn't know what they were treating, they gave her this broad
spectrum, or they kept her on this very broad spectrum antibiotic, which she had a really bad reaction to.”
The patient (and caregiver) “How long will we be down here, ‘cause I know she's not comfortable and she would like to be, number one, going
will have to wait a long home.”
time for discharge
The patient will have “Biggest concerns are to continue getting the support that I need—that she needs—in the community. Biggest
trouble accessing worry is that it may not be sufficient, and she may need to go into a memory care unit.”
follow-­up care
The caregiver will have “Just a little bit concerned about mobility, and our having the appropriate tools to be able to get him moved around
trouble managing ‘cause he's very weak right now. He can't stand at all on his own. He can't raise his upper body on his own, so
the patient's mobility he needs a lot of assistance. At this point, we're hopin' that it would be get better, but that's a concern. You
limitations know? Once we get home, how can we manage this ‘cause it's always gonna takes two people, it appears, to
get him mobile and moving around and cleaned and to the breakfast table.”

home. For example, they noted that the patient had become weak caregivers who reported fewer access problems. However, as noted
and might not be able to manage stairs. Several patients and caregiv- by a small number of respondents, additional supports would be
ers wanted to understand the timeline, specifically when they would welcomed, but these supports come at great expense. Importantly,
be able to return home from the ED visit. When asked about sup- family caregivers were also seen as a tremendously valuable re-
ports or resources that might be helpful to them as they transition source for accessing care. Most commonly caregivers in our study
out of the ED, respondents identified several that they would find were family members and they described tremendous personal sac-
valuable (Table 3). rifices to help the patients obtain the care they need.
Finally, caregivers described several deficiencies within the pri-
mary care system that should be addressed to make care more ac-
Patient and caregiver perspectives on accessibility of cessible for PLWD. Because of patients’ mobility limitations, several
outpatient follow-­up care caregivers noted the benefits of home-­based health care and the
very limited availability of home-­based care. One respondent also
When asked about any difficulties experienced when trying to ac- suggested an expansion of the scope of services that might be avail-
cess ongoing care for chronic illness, once again there was a strik- able at home to avoid having to transport the patient. Respondents
ing difference in responses between patients and caregivers. also identified challenges making appointments, including finding
Overwhelmingly, patients reported no problems accessing primary a physician, obtaining a timely appointment, and sharing medical
care; for example, one patient noted, “Oh, I've always gotten the records across providers. A few respondents also noted that some
care I needed, that was recommended for me.” Conversely, caregiv- physicians do not treat PLWD in a respectful manner, and one men-
ers noted several challenges associated with accessing ongoing care tioned office policies that limit caregiver access during appointments.
for patients. Some of these challenges stemmed from the patient's
dementia or comorbid conditions, for example, their confusion or
forgetfulness (Table 4). Some patients resisted care, not understand- Summary of major themes
ing the need for it, making it difficult for the caregivers to move
forward with arranging appointments. Other caregivers expressed The primary themes across the three topic areas are summarized in
difficulties physically getting patients to providers due to mobility Table 5. Across all three topic areas—ED care, ED care transitions,
challenges. and outpatient follow-­up care—caregivers were more forthcoming
Caregivers also described how resources (or lack thereof) im- than patients about concerns and challenges. Overall, dementia
pacted patients’ ability to access ongoing care in the outpatient set- and memory loss exacerbated existing deficiencies across the three
ting. Concierge primary care physicians, high-­quality nursing home topic areas. Patients and caregivers offered suggestions for address-
care with transportation services, social work services, and paid ing some of these deficiencies, some of which would require signifi-
caregivers were all identified as important resources among those cant new investments for supporting care for PLWD.
Other documents randomly have
different content
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PIONEERS 253 January, 1873, it became one of the

townships in the municipality of the united townships of Albemarle,
Eastnor, Lindsay and St. Edmunds. On the 1st January, 1878, the
three northern townships were separated from Albemarle. On the
1st of January, 1883, Lindsay and St. Edmunds were erected into a
separate municipality, which union continued to exist until the 1st
January, 1903, when each of these two townships became separate
municipalities. In a footnote1 are given the names of the various
parties who have filled the position of reeve for the united townships
of Lindsay and St. Edmunds, and since the separation as reeve of
Lindsay. The deben ture debt of the three united townships at the
date of the dissolution of the union amounted to $7,600. The two
united townships of Lindsay and St. Edmunds, in settlement of the
proportion of this indebtedness due by them, agreed to pay to
Eastnor an annual pay ment of $257.22 until the debentures
matured, some seventeen years later. The first Council of the united
townships of Lindsay and St. Edmunds consisted of Donald
McDonald, Alex. Patch, John Shute, councillors, and Peter McVicar,
reeve. The joint office of clerk and treasurer was held by James
Weatherhead, and Alex. Currie was the first collector. The following
are the names of some of the pioneers of Lindsay, in addition to
those who are already mentioned: Kenneth Smith, Roderick
McLennan, John Kelly, John Ceasor, Donald McLean, Andrew Clarke,
James Finch, James Nixon, John McArthur, Sam Bestward, John
Holmes, John Steip, John Witherspoon (postmaster at Miller Lake for
many years), John Smith, James, William and Alex. Weatherhead,
Alex. Currie (township treasurer for several years), Thomas Tyndall,
William Matheson, James Watson, John Jackman, William McNair,
John McDonald, John and James Shute and Norman Smith. From the
very first lumbering has been the main industry in Lindsay. Probably
the first mill was that of Hiram Lymburner, at Gillies Lake, erected in
1880, and which he and his sons operated until 1905. Power was
derived by widening and deepening the little creek flowing from the
lake; this enlargement was increased from time to time as the
demand for power made it necessary. The Messrs. 'The following are
the names of the reeves of the township of Lindsay and St. Edmunds
: Peter McVicar, 1883; J. Weatherhead, 1884, '86; James Shute,
1885; Alex. McDonald. 1887, '88, '89, 1890, '91, '92, '93, '94, '95,
'96, '97, '98, '99, 1900; John Shute, 1901, '02. As reeve of Lindsay,
Peter AMerson, 1903, '04, '05, '06.
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254 MINING FOR SILVER Lymburner showed a good deal of

enterprise in launching a small tug on Gillies Lake named the Gertie,
used to tow rafts of logs to the mill, this little boat being the second
steamer ever used on the inland waters of the county. Lindsay is the
only township in the county of Bruce in which mining for precious
metals has been carried on. In the early nineties a Mr. E. Clendening
sank a shaft over 300 feet deep on lots 9 and 10, concession 4,
E.B.E. The work was continued for two summers and one winter. Ore
is said to have been found which showed some silver, but not in
sufficient quantities to pay for working it. Mr. Clendening later on did
some prospecting on lot 5, concession 2, W.B.R., but with similar
results. Those who were engaged in this prospecting supplied but
little information to outsiders, so what is here given is but from
hearsay. The amount of land in Lindsay that might be classed as
good farming land is not very large. A visitor to the township finds
the principal settlement therein between the fourth concession west
of the Bury Road and the fifth concession east of it, with a limit of
about four miles in width north from the Eastnor boundary. The
following incident, the facts of which are given in the Wiarion
Canadian, although not strictly speaking an historical item, yet
deserves to be recorded as an instance of motherly love and devo
tion as manifested by one of the good wives of Lindsay . " Though
rattlesnakes are reported to be fairly plentiful in Lindsay and St.
Edmunds, fortunately accidents of a serious nature such as follow
the bite of these reptiles have not been numerous, and settlers have
become rather careless . On a warm day in August, 1902, a six -
yearold son of Mr. Robt. Bartley, residing north of Dyer's Bay, playing
about his home bare-footed and bare-legged to his knees, was so
unfortunate as to step on a three-foot snake, which was lying
basking in the sun. The rude awakening aroused the temper of the
reptile, and in a twinkling its fangs were buried in the child's leg. An
angry snake strikes very quickly, and before the child got beyond
reach the beast struck him in five different places. His screams
brought his mother to the scene, and realizing the trouble and
danger, instead of fainting or going into hysterics, she bravely
sucked the wounds, tied a ligature tightly round the limb to stop the
circulation of the blood, then hitched a horse and started on a
fifteen-mile drive to Lion's Head with the boy. Before reaching
medical aid at that village the child was nearly crazy from the pain
caused by the ligature
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NAMES 255 stopping the circulation in the limb, and his

cries could be heard for a long distance. But the heroic woman held
on and fortunately found Dr. Sloan at home. The wounds were
cauterized and dressed, and fortunately little or no ill effects resulted
from this exciting experience." The origin of the following names in
Lindsay are here given by the author on what he considers good
authority : Lake Miller bears the name of B. B. Miller, first Indian
Land Agent at Wiarton; Gillies Lake is called after John Gillies, M.P.
for North Bruce in the seventies; Cabot Head is said to have been
named by Governor Simcoe in honor of Cabot, the discoverer of
Canada. The light house at this point was established in 1896.
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CHAPTER XVII. TOWNSHIP OF 8T. EDMUNDS! THE

chapters in this volume which give the history of a town ship are in
each instance prefaced by extracts from the report of the county
valuators, with the solitary exception of St. Edmunds. For such
information referring specially to St. Edmunds as is to be found in
these extracts the reader is referred back to the preceding chapter,
because the valuators in every report have joined Lindsay and St.
Edmunds together, and it is impossible to separate the general
remarks of the valuators and apply specially to Lindsay or St.
Edmunds. Although further north than Lindsay, St. Edmunds seems
to have been but little behind it in receiving its pioneer settlers, it
being in the summer of 1871 that Captain John Charles Earl2 settled
at what is known as " The Big Tub." In November of the same year
Captain Earl had a companion come to share the loneliness of his
pioneer life in the person of Abraham Davis, who settled at Dunk's
Bay. These pioneers were joined at various intervals, in somewhat of
the following order, by Captain Alexander Marks, Michael Belrose,
Jacob Belrose, George and Neil Currie, Eobert, John C. and James H.
Hopkins, Thomas and George Bartman, Benjamin and Alexander
Butchart, Donald McDonald (first postmaster at Tobermory) and
Benjamin and William Young. Mr. Solomon Spears (to whom the 'Thij
township is named after Bury St. Edmunds. There has been from the
first a disagreement as to the spelling of the name; the_ Toronto
Government officials giving "s" as the final letter, and the Indian
Land Office, Ottawa, spelling it without. The township, on its
becoming incor porated, adopted the former method of spelling and
calls itself " St. Edmunds. ' ' 2The perfect safety with which vessels
could lie in the basin at Tober mory has made it a much frequented
harbor of refuge. For the con venience of navigators, Captain Earl
made a practice of hanging a lantern at the top of a high pole as a
range light and so ensure safe navigation to vessels when making
the harbor. He was remunerated for this service by various captains,
they presenting him with useful house supplies, such as a bag of
potatoes, flour, or some coal-oil, etc. In the course of a few years
the Government acknowledged this service and paid him a salary of
about $30 a year. 256
10
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LUMBERING 259 author is indebted for many of the facts

connected with the history of St. Edmunds) settled in the township
in March, 1883. The lumbering resources of St. Edmunds have been
exploited to an extent not equalled in any other township of the
county. In IST'^ Cockwell & (.{rant erected a large saw-mill and
shingle-mill on the Crane River, at what is now called " MeYicar's."
This firm cut a road from Pine Tree Harbor through the woods for a
distance of ten miles to a point at which they built their saw-mill;
they also laid out a large sum in cleaning the river so that the
produce of their mill might be iloated down to the harbor. This mill
and its limits were purchased in ISSii by IVter McYicar.1 who built
another mill in the following year as well as a wharf at Johnston's
Harbor. In 1881 a mill was built at Tobermory by Messrs. Maitland ^
Kixon. This mill was burnt down in March, 1883, but rebuilt in the
same year by the same firm, who after running it six years moved it
to Owen Sound. About IS!)-' the Southampton Lumber Companv
built a saw-mill at Tine Tree Harbor. In 1.~> a mill was built at Tober
mory by Richard Badstone (since purchased and run by Hector
Currie). In I'.MM) another mill was erected by E. M. Meirs. and
another in the following year by Messrs. Simpson \- Culhert, which
gave Tobermory three saw-mills in constant operation, adding
materially to the trade of the village. The post-otlice at Tobermory
was established in 1SS1. the mail being carried on foot from Stokes
Bay. .Mr. Benjamin Butcliart wa> the lirst mail-carrier. St. Edmunds'
first school was opened in 18S:5. Its first Hoard of Trustees were
Michael Belrose, Donald Mi-Donald and Jacob Belrose. The first
teacher \\as a Miss Ella Conklin. A- a -eparate municipality St.
Edmunds ha- evicted since the 1st of January, 1903. Its previous
municipal relations an- related in the preceding chapter, referring to
the township of Lindsay. The iirst reeve of the municipality was
Solomon Spears, who also filled the oHice in l!HHi, his successor for
I'.HM and 1(.M>.~> being William Simpson. The clerk of the
municipality was -lame- Campbell and the treasurer John C. Hopkins.
The lirst public religious service in the township is said to have been
conducted by a Presbyterian student, possibly a Mr. Peter McLean,
who was the first to preach in Lindsay. The lirst regular M'eter
McYirar continued tin- running of this mill for twentv rears, when, in
I'.HH, In- retired to spend his dec! ininy years at flu- town of JVrtli.
Mr. M. -Vicar was the lirst reeve of Carrick. in j sril! and IS.', 7. and
also the lirst reeve of tin- united townships of Lindsay and St.
Kdmnnds in 188
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200 NAMES stationed minister belonged to the Methodist

Church, the Rev. Robert Walker. Succeeding him was the Rev. Mr.
Sparling. Under his ministration a church was built at Tobermory
Harbor. The next minister was the Rev. W. D. Dainard, who was
instrumental in the building of a church at " The Settlement/' a point
on the Bury Road some two and a half or three miles south of the
harbor. There is also a Baptist church at the town plot of Bury, but
the author is not able to give the year of its erection. St. Edmunds
being at the extreme north of the peninsula nearly all the vessels
passing into the Georgian Bay sail along its coast. This has
necessitated the erection of several lighthouses. The first one to be
erected was that at Cove Island.1 This is a white, circular stone
building, built in 1859. which in addition to a powerful light is also
equipped with a fog horn to indicate the locality when fog covers the
water. The lighthouse at Tobermory was erected in 1885, and the
one at Flower Pot Island in 1897. In regard to the local names in St.
Edmunds the following com prises all the information the author has
been able to obtain: Lake Kent on the maps, but locally called Lake
Cameron, is named after John Cameron, of Southampton, a man
well known to the Indians and fishermen throughout the Peninsula in
the days before settle ments were formed. Lake Cyprus received its
name from the island in the Mediterranean Sea, the name being
given at the time that island was ceded to Great Britain. Tobermory
was named by the Highland fishermen after a town in Mull. (In
Bayfield's chart it is named " Collins Harbor.") The three lakes on
concessions 5, 6, 7 and 8, east of the Bury Road, were intended to
bear the names of the patron saints of England, Scotland and
Ireland. This was carried out to the extent of St. George and St.
Andrew, but a young man named Emmett Smith, working in the
office of B. B. Miller, the Indian Land Agent, persuaded Mr. Miller to
let one of the lakes be called after him, so as Lake Emmett it will
probably be always known. Bury town plot is named after Viscount
Bury, SuperintendentGeneral of Indian Affairs in 1855. The entrance
of the telegraph and telephone wires into Tobermory has brought
what was the jumping-off place of the county into touch with the
rest of the world, and if the proposed railway ever reaches there we
shall look for great things in the township of St. Edmunds. 1After
being in charge of Cove Island lighthouse for twenty-five years,
George Currie retired in the summer of 1903. He was succeeded by
Kenneth McLeod, of Tobermory.
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Photographed i>.\ II. <;. TU<-UIT KI.OUKK PUT UI.\MI,

TOWNSHIP di ST. KHMINDS. I-. -i;
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THE FLOWER POT 261 There are extensive caves to be

seen in (St. Edmunds. The lime stone rock, so common throughout
the peninsula, seemingly has here suffered from the erosion of water
more than elsewhere. Possibly the largest of these caves is to be
seen on Flower Pot Island, the extent of which is not known, as it
has not been fully explored. The island takes its name, that of "
Flower Pot," from a peculiar shaped rock standing about fifty feet in
height. The illustration here given shows what a natural curiosity it is
and how appropriate is the name.
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CHAPTER XVIII. TOWNSHIP OF ARRAN.1 EXTRACT FROM

THE EEPORT OF C'OUXTY VALUATORS, 1901. ' ' Stone is the chief
drawback to this township, and while there has been a large quantity
gathered into heaps and fences, yet there is a great work to be done
in this respect still. There are some places it would cost more to
clear the land of stones than it would be worth after the work was
done. Arran is well watered generally, the swamp lands in the north
half of the township are very difficult to drain, and in many places
they are not so valuable as they were twelve years ago, as since that
time the timber has been removed, and the land generally has not
been improved. The Saiible is a poor source of drainage, having no
banks and a slow current. There is considerable wet land from Arran
Lake north-eastward to the corner of the township, which it is
doubtful if it will ever be of much value. The soil of Arran is fair, with
the exception of about two thousand acres in the north-west corner,
which is almost unproductive, it being so light. It comes in touch
here with the north part of Saugeen Township, and is largely similar
in quality. Buildings and orchards compare favorably with any
municipality in the county. The roads also are good. The rate per
acre is $31.11, of which amount the village property makes 90 cents
per acre." THE lands in the township of Arran were those classed as
" school lands," and were opened for sale July 30th, 1852.2 This sale
included all lots which were in the original survey of the town ship.
The lands included in " The Half Mile Strip," as noted in Chapter V.,
were offered for sale by the Indian Land Department,3 'The
township of Arran is named after the Island of Arran, at the mouth
of the Clyde, Scotland. 2See Appendix J. The first whose name was
entered as a purchaser was Mathew Latimer, for lots 3 and 4,
concession 8th, date being Sep tember 29th, 1852. Mr. John M.
McXabb, in a published letter, stated: " That in the year 1852 the
late Alex. McNabb, Crown Land Agent for the county of Bruce, was
in receipt of a communication from Mr. Ezra Jewett, a famous raiser
of Merino sheep, in which letter Mr. Jewett stated that he and his
friends residing in the Eastern States were anxious to acquire the
whole township of Arran for the purpose of raising sheep on a large
scale, provided they obtained it on reasonable terms. The Gov
ernment of the day refused to enter into any terms on account of
the parties being Americans, and the scheme fell through." 3See
Appendix I. The shape of these lots is unique within the county, they
being in depth but half a mile, only four lots could be included from
side-road to side-road if the lots were to approximate one hundred
acres each. 262
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PIONEERS 265 July 23rd, 1852. The survey of the

township, both of Indian and school lands, was made in the year
1851; Charles Eankin had the contract from the Government of
making these surveys, but the work was done by George Gould,
afterwards County Clerk. Arran's pioneer settler was Henry Boyle; his
coming into Arran antedating by a year that of the surveyors. He
took up the most northerly lot (Xo. 21) on concession A, where,
when the necessity arose later on, from the large number of persons
seeking lands, he opened a tavern. The author has met with much
difficulty in fixing the order of priority of settlement of the pioneers
of Arran. This has arisen because of a common practice which
prevailed among them of return ing to the settlements to earn some
money, just as soon as they had done enough work on their bush lot
to establish their squatter's claim thereto, which consisted in making
a small "slashing" and building a hit of a shanty. During their
absence other settlers came in, these remaining permanently and
not finding on their entrance into the bush any one in the
neighborhood, felt justified in claiming the title of being the first
settlers. This explanation is given in case the assertion be made that
this narrative lacks in accuracy. If such should be the case, the
author can only say thai every effort possible has been put forth to
obtain information at first hands; then, when these sources of his
information seemed to be contradictory, to try and blend the several
narratives to the best of his ability into the account as here
presented to the reader. The author has m-cived from Da\i 1
Chalmers, the first to settle in the eastern part of Arran, a letter
giving an account of his experi ences on entering the township in
1851. This letter, with some few omissions, is given in a footnote,1
believing that the narrative will be appreciated. . . " In the in. .nth of
May, 18.11, throe travellers left Owen Sound on a land hunt,
intending to locate and settle as farmers in the township of Arran.
The party consisted of Mr. David Butchart, a man of about forty
years ..f a^e; M,-. .T;irnes R0ch, an importation from Dundee,
Scotia n. I, and myself, a lad of about twentv years of age. All throe
of us were practically ^reeii at bush work; on starting we took the
road carry ing heavy loads of provisions and an axe each, and such
a road ! But we were Strong and of ^>od courage and so
floundered through ,m,,| an(j water for twelve miles: there were
onlv three shanties with small clearin-'S all the way. Whin at last we
arrive,! at the house of Mr. .lames Barber Hi concession of Derby, on
the l.onndarv between (Jrev and Bruce we were very tired and -ladly
accepted the hospitality of Mr. Barber for the night. Enquiries were
made as to our object in visit injr him, and on wing informed that we
wanted land, he told aa that we were somewhat premature m our
ritit, that the t..«-nshij, ,,f Arran was not yet surveyed
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266 DAVID CHALMERS When the surveying party returned

to Owen Sound after com pleting the survey of the township of
Arrau, which was in the fall of 1851, two of the staff, who had been
impressed with the undeveloped possibilities of the township,
decided to take up land therein in the vicinity of where water power
might be developed. These two were George Gould and Richard
Berford. Each sought out a companion to go with him, one who
might prove helpful as a future neignbor. Mr. Gould found such a one
in J. AY. Linton, and Mr. Berford in John Hamilton. No time was lost,
for fear that someone else might pre-empt the lands they thought of
taking up before their arrival, so and that there would be no use
coming to hunt for farms until mid summer. However, we were
anxious to see the land we came to seek, so in the morning we
started on the old blase of the county line. About one and a half
miles north on that line we started to fell timber to clear a potato
patch. We piled the brush, built a small shanty of small logs, bought
five bushels of potatoes from Mr. Barber, and planted them among
the logs. The crop turned out well. I dug the crop up in the fall as
Mr. Butchart and Mr. Koch did not turn up to assist. These potatoes
which I raised can safely be called the first crop raised in Arran. " In
the summer the survey of the township was proceeded with, and
early in the fall I started to select a farm for myself. I went alone. On
lot 25, concession 6, I found the surveyor's party, with whom I
stayed all night. This party was, I remember, in charge of Mr. George
Gould and Mr. Eichard Berford. One of the party was my old fellow
traveller, James Eoch. He asked me, as a- friend, if I would do a little
chopping for him between lots 29 and 30, concession 8, as he could
not leave his work on the survey. Of course, like a greeny, I
consented and felled some timber to indicate that the lots were
located, and thus gave up the chance of possessing two of the most
valuable lots in Arran. Tara is now on lots 30 and 31. Koch never
came near the property afterwards. I left the camp in the morning
and went north up side-line 25 and 26, then went east until I came
to the Sauble again, on lot 27, concession 9, and made up my mind
to locate on it, which I did, and it was my home from that time until
1874, when I removed to Manitoba with my family. In the fall of the
year I got a friend to assist me to put up a shanty. We cut such
poles as we could carry on our shoulders, put up the building and
covered it with cedar clapboards. I think I spent the happiest days of
my life chopping down the big trees and allowing more sunlight in
my little clearing. I baked my saleratus-cakes, fried my pork, made
my black-currant-leaf-tea, or bread-coffee and made my supper, as
happy as a king. I would put on a big fire of beech or maple logs,
stretch out on the floor and read till bed-time, and retire to my one-
post bedstead, which had a heavy layer of hemlock brush for a
mattress, and awake in the morning with sometimes two inches of "
the beautiful " on my bedcover, the snow having drifted through the
cracks of my clapboard roof. I was contented, hopeful for the future,
and happy. For three years I kept bachelor's hall and never felt
lonely. After getting fairly domiciled in my shanty on the banks of the
Sauble, the question of grub for the winter's work presented itself, a
most serious matter, as it necessitated my carrying it on my back
from Mr. Kobert Linn's in Derby, a distance of eleven miles, four
miles of which were merely a surveyor's blaze. As I had bought a pig
from Mr. Linn, I determined that my pork should carry itself. I got my
piggy along very well for seven miles, then it began to get tuckered
out. These seven miles of road had been chopped through the bush,
but the remaining four miles were only blazed. How to get my
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