Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Overdose deaths from high-potency synthetic opioids, including fentanyl and its analogs, continue to rise along with emergency department (ED) visits for complications of opioid use disorder (OUD). Fentanyl accumulates in adipose tissue; although rare, this increases the risk of precipitated withdrawal in patients upon buprenorphine initiation. Many EDs have implemented medication for opioid use disorder (MOUD) programs using buprenorphine. However, few offer methadone, a proven therapy without the risk of precipitated withdrawal associated with buprenorphine initiation. We describe the addition of an ED-initiated methadone treatment pathway and compared its 72-hour follow-up outpatient treatment engagement rates to our existing ED-initiated buprenorphine MOUD program.

Methods: We expanded our ED MOUD program with a methadone treatment pathway. From February 20–September 19, 2023, we screened 20,504 ED arrivals; 5.1% had signs of OUD. We enrolled 61 patients: 28 in the methadone; and 33 in the buprenorphine pathways. For patients who screened positive for opioid use, shared decision-making was employed to determine whether buprenorphine or methadone therapy was more appropriate. Patients in the methadone pathway received their first dose of up to 30 milligrams (mg) of methadone in the ED. Two additional methadone doses of up to 40 mg were dispensed at the time of the ED visit and held in the department, allowing patients to return each day for observed dosing until intake at an opioid treatment program (OTP). We compared 72-hour rates of outpatient follow-up treatment engagement at the OTP (for those on methadone) or at the addiction treatment center (ATC) (for those on buprenorphine) for the two treatment pathways.

Results: Of the 28 patients enrolled in the methadone pathway, 12 (43%) successfully engaged in follow-up treatment at the OTP. Of the 33 patients enrolled in the buprenorphine pathway, 15 (45%) successfully engaged in follow-up treatment at the ATC (relative risk 1.06; 95% confidence interval 0.60–1.87).

Conclusion: Methadone initiation in the ED to treat patients with OUD resulted in similar 72-hour follow-up outpatient treatment engagement rates compared to ED-buprenorphine initiation, providing another viable option for MOUD.

Background: Growing data indicates that thiamine deficiency occurs during acute illness in the absence of alcohol use disorder. Our primary objective was to measure clinical factors associated with thiamine deficiency in patients with sepsis, diabetic ketoacidosis, and oncologic emergencies.

Methods: This was an analysis of pooled data from cross-sectional studies that enrolled adult emergency department (ED) patients at a single academic center with suspected sepsis, diabetic ketoacidosis, and oncologic emergencies. We excluded patients who had known alcohol use disorder or who had received ED thiamine treatment prior to enrollment. Investigators collected whole blood thiamine levels in addition to demographics, clinical characteristics, and available biomarkers. We defined thiamine deficiency as a whole blood thiamine level below the normal reference range and modeled the adjusted association between this outcome and age.

Results: There were 269 patients, of whom the average age was 57 years; 46% were female, and 80% were Black. Fifty-five (20.5%) patients had thiamine deficiency. In univariate analysis, age >60 years (odds ratio [OR] 2.5, 95% confidence interval [CI], 1.3–4.5), female gender (OR 1.9, 95% CI 1.0–3.4), leukopenia (OR 4.9, 95% CI 2.3–10.3), moderate anemia (OR 2.8, 95% CI 1.5–5.3), and hypoalbuminemia (OR 2.2, 95% CI 1.2–4.1) were associated with thiamine deficiency. In adjusted analysis, thiamine deficiency was significantly higher in females (OR 2.1, 95% CI 1.1–4.1), patients >60 years (OR 2.0, 95% CI 1.0–3.8), and patients with leukopenia (OR 5.1, 95% CI 2.3–11.3).

Conclusion: In this analysis, thiamine deficiency was common and was associated with advanced age, female gender, and leukopenia. 

Background: Patients who present to the emergency department (ED) with severe hypertension defined as a systolic blood pressure (SBP) ≥180 millimeters of mercury (mm Hg) or diastolic (DBP) ≥120 (mm Hg) without evidence of acute end-organ damage are often deemed high risk and treated acutely in the ED. However, there is a dearth of evidence from large studies with long-term follow-up for the assessment of major adverse cardiovascular events (MACE). We conducted the largest study to date of patients presenting with severe hypertension to identify predictors of MACE and examine whether blood pressure at discharge is associated with heightened risk.

Methods: We enrolled ED patients with a SBP of 180–220 mm Hg but without signs of end-organ damage and followed them for one year. The primary outcome was MACE within one year of discharge. Secondarily, we performed a propensity-matched analysis to test whether SBP ≤160 mm Hg at discharge was associated with reduced MACE at 30 days.

Results: A total of 12,044 patients were enrolled. The prevalence of MACE within one year was 1,865 (15.5%). Older age, male gender, history of cardiovascular disease, cerebrovascular disease, diabetes, smoking, presentation with chest pain, altered mental status, dyspnea, treatment with intravenous and oral hydralazine, and oral metoprolol were independent predictors for one-year MACE. Additionally, discharge with an SBP ≤160 mm Hg was not associated with 30-day MACE-free survival after propensity matching (hazard ratio 0.99, 95% confidence interval 0.78–1.25, P = 0.92).

Conclusion: One-year MACE was relatively common in our cohort of ED patients with severe hypertension without acute end-organ damage. However, discharge blood pressure was not associated with 30-day or one-year MACE, suggesting that BP reduction in and of itself is not beneficial in such patients.

Introduction: Determining which patients who meet systemic inflammatory response syndrome (SIRS) criteria have bacterial sepsis is a difficult challenge for emergency physicians. We sought to determine whether the neutrophil-to-lymphocyte ratio (NLR) could be used to exclude bacterial sepsis in adult patients who meet ≥2 SIRS criteria and are being evaluated for sepsis.

Methods: Consenting adult patients meeting ≥2 SIRS criteria and undergoing evaluation for sepsis were enrolled. We recorded patient age, gender, vital signs, and laboratory results. We then later reviewed health records for culture results, end organ dysfunction, survival to discharge, and final diagnoses.
Patients were classified as having sepsis if they met ≥2 SIRS criteria and were ultimately diagnosed with a bacterial source. We analyzed data using descriptive statistics and sensitivity and specificity analyses. A receiver operating characteristic curve (ROC) was created to determine test characteristics.

Results: A total of 231 patients had complete datasets. Patients’ median age was 69 (interquartile range [IQR] 54–81), and 49.6% were male. There were 154 patients (66.7%) ultimately diagnosed with sepsis with an identified bacterial source, while 77 patients with ≥2 SIRS criteria had non-infectious reasons for their presentations (33.3%). Septic patients had a median NLR 12.36 (IQR [interquartile range] 7.29–21.69), compared to those without sepsis (median NLR 5.62, IQR 3.89–9.11, P < 0.001). The NLR value of 3 applied as a cutoff for sepsis had a sensitivity of 96.8 (95% confidence interval [CI] 92.2–98.8), and a specificity of 18.2 (95% CI 10.6–29.0). The ROC for NLR had an area under the curve of 0.74.

Conclusion: The neutrophil-to-lymphocyte ratio is a sensitive tool to help determine which patients with abnormal SIRS screens have bacterial sepsis.

Background: The prognostic value of body temperature in sepsis-induced coagulopathy (SIC) remains unclear. In this study we aimed to investigate the association between temperature and mortality among SIC patients.

Methods: We analyzed data for 9,860 SIC patients from an intensive care database. Patients were categorized by maximum temperature in the first 24 hours into the following: ≤36.0°C; 36.0–37.0°C; 37.0–38.0°C; 38.0–39.0°C; and ≥39.0°C. The primary outcome was 28-day mortality. We used multivariate regression to analyze the temperature-mortality association.

Results: The 37.0–38.0°C, 38.0–39.0°C and ≥39.0°C groups correlated with lower 28-day mortality (adjusted HR 0.70, 0.76 and 0.72, respectively), while the <36.0°C group correlated with higher mortality compared to the 36.0–37.0°C group (adjusted HR 2.60). A nonlinear relationship was observed between temperature and mortality. Subgroup analysis found no effect modification except in cerebrovascular disease.

Conclusion: A body temperature in the range of 37.0–38.0°C was associated with a significantly lower mortality compared to the normal temperature (36.0–37.0°C) group. Additionally, a gradual but statistically insignificant increase in mortality risk was observed when body temperature exceeded 38.0°C. Further research should validate these findings and elucidate involved mechanisms, especially in cerebrovascular disease subgroups.

Introduction: The use of push-dose vasopressors to treat anesthesia-induced hypotension is a common evidence-based practice among anesthesiologists. In more recent years, the use of push-dose vasopressors has transitioned to the emergency department (ED) and critical care setting. There is debate on the best choice of a push-dose vasopressor, with push-dose epinephrine or phenylephrine being more commonly used. This scoping review evaluated publications regarding the clinical use of push-dose norepinephrine.

Methods: We queried research studies in both PubMed and Google Scholar on the use of push-dose norepinephrine in human subjects, with numerous randomized controlled trials that compare norepinephrine to other vasopressors including phenylephrine, ephedrine, and epinephrine.

Results: A large majority of the studies were performed in the setting of spinal anesthesia prior to cesarean section, while several involved the administration of general anesthesia, with limited-to-no literature in the emergency and critical care setting. Of the 27 studies that we included in the review, 17 were randomized controlled trials. These studies demonstrated that norepinephrine was safe and effective.

Conclusion: Prior research has demonstrated the superiority of norepinephrine as a pressor of choice for various shock states. In this review, the safety and efficacy of push-dose norepinephrine is demonstrated, and favorable hemodynamic markers are shown in comparison to other agents. In addition, there are some safety and efficiency benefits to using push-dose norepinephrine from an administration standpoint, as well as clinically in decreased need for repeat doses. Further high-quality studies in the emergency and critical care realm would be beneficial to confirm these findings.

Introduction: Program signaling (PS), which enables residency applicants to signal their preference for a specific program, was introduced in emergency medicine (EM) in the 2022–2023 residency application cycle. In this study we evaluated EM program directors’ (PD) utilization of PS in application review and ranking. This study also explores the relationship between program characteristics and number of signals received as well as the relative importance and utilization of signals related to the number of signals received.

Methods: This is an institutional review board-approved, cross-sectional study of PDs at Accreditation Council for Graduate Medical Education-accredited EM residency programs. We used descriptive statistics to describe the characteristics of residency programs and practices around PS. Measures of central tendency and dispersion summarized continuous variables. We used chi-square analysis or the Fisher exact test for comparisons between groups for categorical variables. Comparisons for continuous variables were made using the t-test for independent samples or analysis of variance.

Results: The response rate was 41% (n = 113/277 EM programs). Most programs participated in PS
(n = 261/277 EM programs, 94.2%). Mean number of signals received was 60 (range 2–203). Signals received varied based on program characteristics including geographic location and program type, duration, environment, and longevity. Most used PS in holistic review (52.2%), but other uses varied by proportion of applications that were signaled. The importance of PS in application review (mean 2.9; 1–5scale,1= not important, 5 = extremely important) and rank list preparation (2.1) was relatively low compared to other application elements such as standardized letters of evaluation (4.97 for review, 4.90 for ranking).

Conclusion: The study provides insights into PS utilization in EM’s inaugural year. We have identified patterns of signal use based on program characteristics and number of signals received that can inform signal allocation and utilization on an individual applicant and program level. A more nuanced understanding of signal use can provide valuable insight as the specialty of EM grapples with fluctuations in its applicant numbers and shifting demographics of its applicant pool.

Introduction: Eye emergencies make up nearly 3% of US emergency department (ED) visits. While emergency physicians (EP) should diagnose and treat these ophthalmologic emergencies, many trainees report limited ocular exposure and insufficient training throughout their residency to confidently conduct a thorough slit-lamp exam.

Methods: We created an interdisciplinary, simulation-based mastery learning (SBML) curriculum to teach emergency attending physicians how to operate the slit lamp with multimodal learning methodology at a tertiary academic center. The EPs first demonstrate their initial slit-lamp competency with a 20-item checklist, and they then review the necessary curricular content to pass their independent readiness test before completing their in-person teaching and demonstration session with an ophthalmology attending to demonstrate procedural mastery (minimal passing score >90%).

Results: Fifteen EPs were enrolled; all completed the final exam of the curriculum. The pre- and post-curriculum checklist scores increased by an average of seven points (P = .002); 86.7% of EPs felt confident in completing a slit-lamp exam after the curriculum, compared to 20% at the beginning. Five of 15 reported teaching learners within the two-month post-curricular period, ranging from 5–30 students. The hands-on teaching was the most positively reviewed element of the curriculum.

Conclusion: The SBML program successfully trained EPs on performing a comprehensive slit-lamp exam with promising results of downstream education to junior learners. We encourage other institutions to leverage SBML as a teaching modality for procedural-based training and advocate cross-discipline education initiatives.

Background: The emergency medicine (EM) milestones are objective behaviors that are categorized into thematic domains called “subcompetencies” (eg, emergency stabilization). The scale for rating milestones is predicated on the assumption that a rating (level) of 1.0 corresponds to an incoming EM-1 resident and a rating of 4.0 is the “target rating” (albeit not an expectation) for a graduating resident. Our aim in this study was to determine the frequency with which graduating residents received the target milestone ratings.

Methods: This retrospective, cross-sectional study was a secondary analysis of a dataset used in a prior study but was not reported previously. We analyzed milestone subcompetency ratings from April 25–June 24, 2022 for categorical EM residents in their final year of training. Ratings were dichotomized as meeting the expected level at the time of program completion (ratings of ≥3.5) and not meeting the expected level at the time of program completion (ratings of ≤3.0). We calculated the number of residents who did not achieve target ratings for each of the subcompetencies.

Results: In Spring 2022, of the 2,637 residents in the spring of their last year of training, 1,613 (61.2%)
achieved a rating of ≥3.5 on every subcompetency and 1,024 (38.8%) failed to achieve that rating on at least one subcompetency. There were 250 residents (9.5%) who failed to achieve half of their expected
subcompetency ratings and 105 (4.0%) who failed to achieve the expected rating (ie, rating was ≤3.0) on every subcompetency.

Conclusion: When using an EM milestone rating threshold of 3.5, only 61.2% of physicians achieved the target ratings for program graduation; 4.0% of physicians failed to achieve target ratings for any milestone subcompetency; and 9.5% of physicians failed to achieve the target ratings for graduating residents in half of the subcompetencies.

Introduction: Social medicine seeks to incorporate patients’ social contexts into their medical care. Emergency physicians are uniquely positioned to address social determinants of health (SDoH) on the frontlines of the healthcare system. Miami-Dade County (MDC) is a diverse and socially vulnerable area. In 2020, the University of Miami-Jackson Health System (UM-JHS) emergency medicine (EM) residency program launched a multimodal, resident-led Social EM program to identify and address SDoH in the emergency department (ED).

Methods: We use a four-pillar approach to SDoH in the ED: Curriculum Integration; Community Outreach; Access to Care; and Social Justice. Residents graduate with a knowledge of Social EM principles through an 18-month curriculum, an elective, and a longitudinal track. We developed sustainable initiatives through interdepartmental and community-based partnerships, including a Narcan distribution initiative, an ED-based program linking uninsured patients to follow-up care, a human trafficking education initiative, and a quality improvement initiative for incarcerated patients.

Results: Given that the 18-month curriculum was launched in 2022, a full rotation of the curriculum had not been completed as of this writing, and data collection and analysis is an ongoing process. The initial pretest and post-test survey data show improvement in knowledge and confidence in managing Social EM topics. The Narcan initiative has screened 1,188 patients, of whom 144 have received Narcan. The ED-based patient navigation program has enrolled 31 patients to date, 18 of whom obtained outpatient care. Analysis of the impact/effectiveness of the program’s other initiatives is ongoing.

Conclusion: To our knowledge, this is one of the most robust social EM programs to date, as many other programs primarily focus on service opportunities. Rooted in the revised principles of Bloom’s taxonomy of cognitive learning, this program moves beyond understanding Social EM tenets to generating solutions to address SDoH in and outside the ED.

Objective: Because admitted emergency department (ED) patients waiting for an inpatient bed contribute to dangerous ED crowding, we conducted a patient flow investigation to discover and solve outflow delays. After solution implementation, we measured whether the time admitted ED patients waited to leave the ED was reduced.

Methods: In June 2022, a team using Lean Healthcare methodologies identified flow delays and underlying barriers in a Midwest, mid-sized hospital. We calculated barriers’ magnitudes of burden by the frequency of involvement in delays. During October–December 2022, solutions targeting barriers were implemented. In October 2023, we tested whether waiting time, defined as daily median time in minutes from admission disposition to departure (ADtoD), declined by conducting independent sample, single-tailed t-test comparing pre- to post-intervention time periods, January 1–September 30, 2022 (273 days) to January 1–September 30, 2023 (273 days). Additionally, we regressed ADtoD onto pre-/post period while controlling for ED volume (total daily admissions and ED daily encounters) and hospital occupancy. A run chart analysis of monthly median ADtoD assessed improvement sustainability.

Results: Process mapping revealed that three departments (ED, environmental services [EVS], and transport services) co-produced the outflow of admitted ED patients wherein 18 delays were identified. The EVS-clinical care collaboration failures explained 61% (11/18) of delays. Technology contributed to 78% (14/18) of delays primarily because staff’s technology did not display needed information, a condition we coined “digital blindness.” Comparing pre- and post-intervention days (3,144 patients admitted pre-intervention and 3,256 patients post), the median minutes a patient waited (ADtoD) significantly decreased (96.4 to 87.1 minutes, P = 0.04), even while daily ED encounter volume significantly increased (110.7 to 117.3 encounters per day, P < 0.001). After controlling in regression for other factors associated with waiting, the intervention reduced ADtoD by 12.7 minutes per patient (standard error 5.10, P = 0.01; 95% confidence interval −22.7, −2.7). We estimate that the intervention translated to ED staff avoiding 689 hours of admitted patient boarding over nine months (ADtoD coefficient [−12.7 minutes] multiplied by post-intervention ED admissions [3,256] and divided by 60). Run chart analysis substantiated the intervention’s sustainability over nine months.

Conclusion: After systemwide patient flow investigation, solutions resolving digital blindness and environmental services-clinical care collaboration failures significantly reduced ED admitted patient boarding. 

Introduction: The United States lacks a national interfacility patient transfer coordination system. During the coronavirus 2019 (COVID-19) pandemic, many hospitals were overwhelmed and faced difficulties transferring sick patients, leading some states and cities to form transfer centers intended to assist sending facilities. In this study we aimed to explore clinician experiences with newly implemented transfer coordination centers.

Methods: This mixed-methods study used a brief national survey along with in-depth interviews. The American College of Emergency Physicians Emergency Medicine Practice Research Network (EMPRN) administered the national survey in March 2021. From September–December 2021, semi-structured qualitative interviews were conducted with administrators and rural emergency clinicians in Arizona and New Mexico, two states that started transfer centers during COVID-19.

Results: Among 141 respondents (of 765, 18.4% response rate) to the national EMPRN survey, only 30% reported implementation or expansion of a transfer coordination center during COVID-19. Those with new transfer centers reported no change in difficulty of patient transfers during COVID-19 while those without had increased difficulty. The 17 qualitative interviews expanded upon this, revealing four major themes: 1) limited resources for facilitating transfers even before COVID-19; 2) increased number of and distance to transfer partners during the COVID-19 pandemic; 3) generally positive impacts of transfer centers on workflow, and 4) the potential for continued use of centers to facilitate transfers.

Conclusion: Transfer centers may have offset pandemic-related transfer challenges brought on by the COVID-19 pandemic. Clinicians who frequently need to transfer patients may particularly benefit from ongoing access to such transfer coordination services.

Introduction: Effective medical education must balance clinical service demands for institutions and learning needs of trainees. The question of whether these are competing demands or can serve complementary roles has profound impacts on graduate medical education, ranging from funding decisions to the willingness of community-based hospitals and physicians to include learners at their clinical sites. Our objective in this article was to systematically review the evidence on the impact of medical trainees on productivity and efficiency in the emergency department (ED).

Methods: We queried PubMed, Embase, Scopus, and Web of Science from earliest available dates to March 2023. We identified all studies evaluating the impact of medical students and/or residents in the ED on commonly used productivity and efficiency metrics. Only studies in EDs in the United States were included. No additional filters were used. We assessed the risk of bias of included studies using the Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) tool. Certainty of evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study findings were combined in a narrative synthesis and reported according to PRISMA guidelines.

Results: The literature search yielded 3,390 unique articles for abstract screening. Eighty-one abstracts were identified as relevant to our PICO question (population, intervention, control, and outcomes), 76 of which had retrievable full-text articles and the themes of which were discussed in a narrative synthesis. We selected 13 of the full-text articles for final inclusion in a systematic review. Studies were roughly split between observational (6) and quasi-experimental (7) designs. The majority of studies (11) were single-site studies. Only two studies could be graded as low risk of bias per the ROBINS-I tool.

Conclusion: Low-GRADE evidence suggests that students and residents decrease ED efficiency by a statistically small effect size of debatable clinical importance. Residents provide a moderate boost to ED productivity. Students do not produce a statistically or clinically significant impact on ED productivity. Residents increase emergency department relative value units revenue by $26.30 an hour, while students have no impact. Both types of learners decrease efficiency.

Background: Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers.

Methods: This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality.

Results: The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019–September 10, 2020) and the post-implementation period (September 11, 2020–December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45–2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as “good.”

Conclusion: In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as “good.”

Introduction: When used appropriately, focused limited-scope ultrasound exams could potentially provide paramedics with accurate and actionable diagnostic information to guide prehospital decision-making. In this study we aimed to investigate the impact of a 13-hour prehospital ultrasound training course on the simulated clinical decision-making of paramedics as well as their ultrasound skills, knowledge, and self-confidence.

Methods: We evaluated the ultrasound competence of 31 participants using post-course written and practical assessments. Written clinical decision scenarios were administered pre- and post-training. Post-training scenarios included an uninterpreted ultrasound clip to aid decision-making. Scenarios included extended focused assessment with sonography in trauma, pulmonary exam, and focused echocardiography combined with carotid pulse check exams. Correct answers to scenarios were defined as those selected by a veteran emergency physician. Participants also indicated their confidence in each of their decisions using a Likert scale.

Results: Training yielded a statistically significant increase in both mean scenario score (35.5%absolute increase) and mean participant self-confidence (15.8% relative increase), across all exam/decision types assessed (P ≤ 0.001). The focused pulmonary exam yielded the largest increase in both mean score improvement (59.7% absolute increase) and paramedic confidence in their decisions (28.6% increase).

Conclusion: Trained paramedics can perform focused ultrasound exams and accurately interpret and apply actionable exam findings in the context of written scenarios. Analysis through our model characterized the theoretical clinical yield of each prehospital ultrasound exam and demonstrated how each exam may provide improved decision accuracy in several specific simulated clinical contexts. These results provide support for growing evidence that focused limited-scope ultrasound may be an effective prehospital diagnostic tool in the hands of trained paramedics.

Introduction: Historically, prehospital care of trauma patients has included nearly universal use of a cervical collar (C-collar) and long spine board (LSB). Due to recent evidence demonstrating harm in using LSBs, implementation of new spinal motion restriction (SMR) protocols in the prehospital setting should reduce LSB use, even among patients with spinal cord injury. Our goal in this study was to evaluate the rates of and reasons for LSB use in high-risk patients—those with hospital-diagnosed spinal cord injury (SCI)—after statewide implementation of SMR protocols.

Methods: Applying data from a state emergency medical services (EMS) registry to a state hospital discharge database, we identified cases in which a participating EMS agency provided care for a patient later diagnosed in the hospital with a SCI. Cases were then retrospectively reviewed to determine the prevalence of both LSB and C-collar use before and after agency adoption of a SMR protocol. We reviewed cases with LSB use after SMR protocol implementation to determine the motivations driving continued LSB use. We used simple descriptive statistics, odds ratios (OR) with 95% confidence intervals (CI) to describe the results.

Results: We identified 52 EMS agencies in the state of Arizona with 417,979 encounters. There were 225 patients with SCI, of whom 74 were excluded. The LSBs were used in 52 pre-SMR (81%) and 49 post-SMR (56%) cases. The odds of LSB use after SMR protocol implementation was 70% lower than it had been before implementation (OR 0.297, 95% CI 0.139–0.643; P = 0.002). Use of a C-collar after SMR implementation was not significantly changed (OR 0.51, 95% CI 0.23–1.143; P = 0.10). In the 49 cases of LSB use after agency SMR implementation, the most common reasons for LSB placement were ease of lifting (63%), placement by non-transporting agency (18%), and extrication (16.3%). High suspicion of SCI was determined as the primary or secondary reason for not removing LSB after assessment in 63% of those with LSB placement, followed by multiple transfers required (20%), and critical illness (10%).

Conclusion: Implementation of selective spinal motion restriction protocols was associated with a statistically significant decrease in the utilization of long spine boards among prehospital patients with acute traumatic spinal cord injury.

Objective: The medical literature has demonstrated disparities and variability in physician salaries and, specifically, emergency physician (EP) salaries. We sought to investigate individual physician characteristics, including sex and educational background, together with individual preferences of graduating EPs, and their association with the salary of their first job.

Methods: The American College of Emergency Physicians and the George Washington University Mullan Institute surveyed 2019 graduating EPs. The survey included respondents’ demographic and educational background, post-training job characteristics and location, hospital characteristics, importance of different personal priorities, and starting salaries. We performed a multivariable regression analysis to determine how salaries were associated with job types and individuals’ characteristics.

Results: We sent surveys to 2,192 graduating residents in 2019. Of these, 487 (22.2%) responded, and 270 (55.4%) accepted first-time clinical jobs and included salary data (12.3% of all surveys sent). Male sex, osteopathic training, and full-time work were significantly associated with higher salary. Men and women prioritized different factors in their job search. Women were more likely to consider such factors as parental leave policy, proximity to family, desired practice setting, type of hospital, and desired location as important. Salary/compensation was considered very important by 51.8% of men and 29.6%
of women. Men’s median salary was $30,000 more than women’s (p= 0.01, 95% CI +$6,929 ± $53,071), a significant pay differential.

Conclusion: Salaries of graduating emergency medicine residents are associated with the resident’s sex and degree type: doctor of osteopathic medicine or doctor of allopathic medicine. Multiple factors may contribute to men having higher salaries than women, and some of this difference reflects different priorities in their job search. Women were more likely to consider job conditions and setting to be more important, while men considered salary and compensation more important.

Introduction: Patients with long bone fractures often present to the emergency department (ED) with severe pain and are typically treated with opioid and non-opioid analgesics. Historical data reveals racial disparities in analgesic administration, with White patients more likely to receive analgesics. With the diversifying US population, health equity is increasingly crucial. In this study we aimed to evaluate the early administration of opioid and non-opioid analgesia among Black and White patients with long bone and femur fractures in EDs over different time frames using a substantial database.

Methods: We retrospectively extracted Information from 57 US healthcare organizations within the TriNetX database, encompassing 95 million patients. The ED records from 2003–2023 were subjected to propensity score matching for age and gender. We focused on four cohorts: two comprising Black and White patients diagnosed with long bone fractures, and another two with Black and White patients diagnosed solely with femur fractures. We examined analgesic administration rates over 20 years (2003–2023) at five-year intervals (2003–2008; 2008–2013; 2013–2018; 2018–2023), and further analyzed the rates for the most recent two-year period (2021–2023).

Results: Disparities in analgesic administration significantly diminished over the study period. For patients with long bone fractures (1,095,052), the opioid administration gap narrowed from 6.3% to 1.1%, while non-opioid administration disparities reduced from 4.4% to 0.3%. Similar trends were noted for femur fractures (265,181). By 2021–2023, no significant differences in analgesic administration were observed between racial groups.

Conclusion: Over the past 20 years, the gap in early administration of opioid and non-opioid analgesics for Black and White patients presenting with long bone fractures or femur fractures has been disappearing.

Introduction: Emergency department (ED) patients requiring immediate treatment often bypass a triage process that includes HIV screening. In this study we aimed to investigate the potential missed opportunity to screen these patients for HIV.

Methods: We conducted this cross-sectional study in a municipal ED over a six-week period between June–August 2019. The patient population in this study arrived in the ED as a pre-notification from prehospital services or designated by the ambulance or walk-in triage nurse as requiring immediate medical attention. Medical student researchers collected demographic data and categorized patients into three clinical groups (trauma, medical, psychiatric). They documented the patient’s eligibility for HIV screening as determined by a physician and confirmed that the patient met criteria of clear mental status, controlled pain, stable vital signs, and ability to contribute to a medical history and physical examination. The student researchers did this at initial presentation and then again during the patient’s ED stay of up to eight hours. The study outcomes measured the percentage of total patients within each clinical group (trauma, medical, psychiatric) able to engage in the HIV screening process upon arrival and during an eight-hour ED stay.

Results: On average, 700 patients per month are announced on arrival via overhead page, indicating that they require immediate medical attention. During the six-week study, 205 patients (approximately 20% of total) were enrolled: 114 trauma; 56 medical; and 35 psychiatric presentations. The average patient age was 53; 60% of patients were male. Niney-eight (48%) patients were eligible for HIV screening within an eight-hour ED stay; 63 (31%) were able to be screened upon initial presentation and 35 (17%) in the first eight hours of their ED visit. Within medical and trauma subgroups, there was no significant difference in the proportion (36%) of patients that could be screened upon presentation. Among the psychiatric presentations, only five (14%) were able to be screened during their hospital stay.

Conclusion: Triage protocols for high-acuity medico-surgical patients resulted in a missed opportunity to screen 48% of patients for HIV. Acute psychiatric patients represented a particular missed opportunity. We advocate for universal HIV screening, facilitated through electronic best practice advisories and a modified triage tailored to higher acuity patients. Implementing these changes would ensure that HIV screening is not overlooked in high-acuity ED patients, leading to early detection and timely interventions.

Introduction: In the United States, more chronic and preventive healthcare is being delivered in the emergency department (ED) setting. Understanding the availability of preventive health services in the ED setting is crucial. Our goal was to understand the availability of a subset of preventive health services in US EDs and explore how that has changed over time.

Methods: In 2022–2023, using the National Emergency Department Inventory (NEDI)-USA, we surveyed a random 20% (1,064) sampling of all 5,613 US EDs. We asked directors of these EDs about the availability of and preference for 12 preventive health services, social worker availability, self-reported percentage of uninsured ED patients, and measures of ED crowding. We also asked about perceptions of barriers to implementing preventive health services in the ED. We used unadjusted and multivariable logistic regression models to compare service frequency in 2022–2023 to prior findings from 2008–2009 that represented a 5.7% random sampling of all EDs.

Results: Among 302 responders to the 2022–2023 survey (5.4% random sampling, 28.4% response rate), 94% reported offering at least one preventive health service, with a median of five services. The most common service offered was intimate partner violence screening (83%), while the least common was routine HIV screening (19%). Seven services (eg, intimate partner violence, alcohol risk, and smoking cessation screening) had a higher odds of being offered in 2022–2023 than in 2008–2009; findings were unchanged in sensitivity analyses. A small proportion of directors opposed offering preventive health services. However, many expressed concerns that preventive health services in the ED would lead to longer lengths of stay (56%), increased costs to their ED (58%), a diversion of staff time from providing acute care (50%), or that their patients would not have access to adequate follow-up (49%).

Conclusion: Nearly all EDs offer at least one preventive health service. Many offer multiple services; rates were higher than those identified in 2008–2009, in both unadjusted and multivariable models. Although limited by the response rate, this work provides the most recent and comprehensive snapshot of the type and frequency of a subset of preventive health services currently offered in US EDs.

Purpose: During the third-year emergency medicine (EM) clerkship, medical students are immersed in traumatic incidents with their patients and clinical teams. Trauma-informed medical education (TIME) applies trauma-informed care (TIC) principles to help students manage trauma. We aimed to qualitatively describe the extent to which students perceived the six TIME domains as they navigated critical incidents during their EM clerkship.

Methods: We employed a constructivist, modified grounded theory approach to explore medical students’ experiences. We used the critical incident technique to elicit narratives to better understand the six TIME domains as they naturally appear in the clerkship. Participants were asked to describe a traumatic incident they experienced during the clerkship, followed by the clerkship’s role in helping them manage the incident. Using the framework method, transcripts were analyzed 1) deductively by matching transcript excerpts to relevant TIME domains and 2) inductively by generating de novo themes to capture factors that affected students’ handling of trauma during critical incidents.

Results: Twelve participants were enrolled and interviewed in July 2022. “Safety” was the most frequently described TIME domain, whereas “Gender, Cultural, and Historical issues” and “Peer Support” were discussed least. Inductive analysis revealed themes that hindered or supported their ability to manage traumatic experiences, which were grouped into three categories: 1) student interactions with the learning environment: complex social determinants of health, inequalities in care, and overt discrimination; 2) student interactions with patients: ethically ambiguous care, witnessing acute patient presentations, and reactivation of past trauma; and 3) student interactions with supervisors: power dynamics, invalidation of contributions, role-modeling, and student empowerment.

Conclusion: The six TIME domains are represented in students’ perceptions of immediate, stressful critical incidents during their EM clerkship, with “Safety” being the most commonly described; however, the degree to which these domains are supported in students’ experiences of the EM clerkship differ, and instances of inadequately experienced domains may contribute to student distress. Understanding the EM clerkship through the specific lens of students’ experiences of trauma may be an effective strategy to guide curricular changes that promote a supportive learning environment for students in the emergency department.

Background and Objectives: Drowning, the leading cause of unintentional injury death among California children less than five years of age, averaged 49 annual fatalities for the years 2010–2021. The California Pool Safety Act aims to reduce fatalities by requiring safety measures around residential pools. This study was designed to analyze annual fatality rates and drowning incidents in California among children 1–4 years of age from 2017–2021.

Methods: We identified fatalities, injury hospitalizations, and emergency department (ED) visits from California state vital statistics death data and state hospital and ED discharge data using the EpiCenter California Injury Data Online website.

Results: Over the five-year study period, 4,166 drowning incidents were identified: 234 were fatalities, 846 were hospitalizations, and 3,086 were ED visits. The observed difference in fatality rates from 2017 to 2021 failed to achieve statistical significance (P = 0.88). Location-based analysis of the 234 fatal drowning incidents revealed that pools were the most common injury site, accounting for 65% of the cases.

Conclusion: Drowning remains the leading cause of unintentional, injury-related death among California children 1–4 years of age, as the annual rate of fatality over the five-year study period did not decline. While the EpiCenter California Injury Data Online website is excellent for analyzing annual rates of drowning incidents among California residents over time, it is limited in providing insight into modifiable risk factors and event circumstances that can further inform prevention. The development of robust integrated fatal and non-fatal local, state, and national systematic data collection systems could aid in moving the needle in decreasing pool fatalities among young children.

Providing appropriate patient education during a medical encounter remains an important area for improvement across healthcare settings. Personalized resources can offer an impactful way to improve patient understanding and satisfaction during or after a healthcare visit. ChatGPT is a novel chatbot—computer program designed to simulate conversation with humans— that has the potential to assist with care-related questions, clarify discharge instructions, help triage medical problem urgency, and could potentially be used to improve patient-clinician communication. However, due to its training methodology, ChatGPT has inherent limitations, including technical restrictions, risk of misinformation, lack of input standardization, and privacy concerns. Medicolegal liability also remains an open question for physicians interacting with this technology. Nonetheless, careful utilization of ChatGPT in clinical medicine has the potential to supplement patient education in important ways.

Door-in-door-out (DIDO) time has been considered an important factor for prognostication in large vessel occlusion stroke (LVOS) patients. Recently, Sigal et al. have concluded in their paper, “A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke,” that DIDO was not an independent risk factor for worse outcomes following LVOS. In this letter to the editor, we argue that DIDO time should still be considered an important prognosticator for outcomes in LVOS, despite not being found to be significant in their multivariable analysis. Despite our concerns, we wholeheartedly agree with the authors that clinicians should still need to expedite patients who have LVOS to undergo thrombectomy, regardless of where they are during the critical period of time.