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Open Access Publications from the University of California

Volume 20, Issue 3, 2019

WestJEM Full-Text Issue

Behavioral Health

Variations in Opioid Prescribing Behavior by Physician Training

Introduction: Opioid abuse has reached epidemic proportions in the United States. Patients often present to the emergency department (ED) with painful conditions seeking analgesic relief. While there is known variability in the prescribing behaviors of emergency physicians, it is unknown if there are differences in these behaviors based on training level or by resident specialty.

Methods: This is a retrospective chart review of ED visits from a single, tertiary-care academic hospital over a single academic year (2014-2015), examining the amount of opioid pain medication prescribed. We compared morphine milligram equivalents (MME) between provider specialty and level of training (emergency medicine [EM] attending physicians, EM residents in training, and non-EM residents in training).

Results: We reviewed 55,999 total ED visits, of which 4,431 (7.9%) resulted in discharge with a prescription opioid medication. Residents in a non-EM training program prescribed higher amounts of opioid medication (108 MME, interquartile ratio [IQR] 75-150) than EM attendings (90 MME, lQR 75-120), who prescribed more than residents in an EM training program (75 MME, IQR 60-113) (p<0.01).

Conclusion: In an ED setting, variability exists in prescribing patterns with non-EM residents prescribing larger amounts of opioids in the acute setting. EM attendings should closely monitor for both over- and under-prescribing of analgesic medications.


Health Outcomes

Association of Vital Signs and Process Outcomes in Emergency Department Patients

Introduction: We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients.

Methods: We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality.

Results: Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours.

Conclusion: In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting.

Infectious Disease

Epidemiology of Community-Onset Staphylococcus aureus Bacteremia

Introduction: Staphylococcus aureus bacteremia (SAB) is the second-most common cause of community-onset (CO) bacteremia. The incidence of methicillin-resistant S. aureus (MRSA) has recently decreased across much of the United States, and we seek to describe risk factors for COMRSA bacteremia, which will aid emergency providers in their choice of empiric antibiotics.

Methods: This is a retrospective cohort study of all patients with SAB at a 500-bed safety net hospital. The proportion of S. aureus isolates that were MRSA ranged from 32-35% during the study period. Variables of interest included age, comorbid medical conditions, microbiology results, antibioticadministration, duration of bacteremia, duration of hospital admission, suspected source of SAB, and Elixhauser comorbidity score. The primary outcome was to determine risk factors for CO-MRSA bacteremia as compared to methicillin-susceptible S. aureus (MSSA) bacteremia in patients admittedto the hospital through the emergency department.

Results: We identified 135 consecutive patients with CO-SAB. In comparison to those with MSSA bacteremia, patients with MRSA bacteremia were younger (odds ratio [OR] 0.5, 95% confidence interval [CI], 0.4-0.7) with higher Elixhauser comorbidity scores (OR 1.4, 95% CI, 1.1-1.7). Additionally, these patients were more likely to have a history of MRSA infection or colonization (OR 8.9, 95% CI,2.7-29.7) and intravenous drug use (OR 2.4, 95% CI, 1.0-5.7).

Conclusion: SAB continues to be prevalent in our urban community with CO-MRSA accounting for almost one-third of SAB cases. Previous MRSA colonization was the strongest risk factor for current MRSA infection in this cohort of patients with CO-SAB.


Mortality and Thrombosis in Injured Adults Receiving Tranexamic Acid in the Post-CRASH-2 Era

Introduction: The CRASH-2 trial demonstrated that tranexamic acid (TXA) reduced mortality with no increase in adverse events in severely injured adults. TXA has since been widely used in injured adults worldwide. Our objective was to estimate mortality and adverse events in adults with trauma receiving TXA in studies published after the CRASH-2 trial.

Methods: We systematically searched PubMed, Embase, MicroMedex, and for studies that included injured adults who received TXA and reported mortality and/or adverse events. Two reviewers independently assessed study eligibility, abstracted data, and assessed the risk of bias. We conducted meta-analyses using random effects models to estimate the incidence of mortality at 28 or 30 days and in-hospital thrombotic events.

Results: We included 19 studies and 13 studies in the systematic review and meta-analyses, respectively. The pooled incidence of mortality at 28 or 30 days (five studies, 1538 patients) was 10.1% (95% confidence interval [CI], 7.8-12.4%) (vs 14.5% [95% CI, 13.9-15.2%] in the CRASH-2 trial), and the pooled incidence of in-hospital thrombotic events (nine studies, 1656 patients) was 5.9% (95% CI, 3.3-8.5%) (vs 2.0% [95% CI, 1.8-2.3%] in the CRASH-2 trial).

Conclusion: Compared to the CRASH-2 trial, adult trauma patients receiving TXA identified in our systematic review had a lower incidence of mortality at 28 or 30 days, but a higher incidence of in-hospital thrombotic events. Our findings neither support nor refute the findings of the CRASH-2 trial but suggest that incidence rates in adults with trauma in settings outside of the CRASH-2 trial may be different than those observed in the CRASH-2 trial.


  • 1 supplemental file

Patient Communication

What Are We Measuring? Evaluating Physician-Specific Satisfaction Scores Between Emergency Departments

Introduction: Most emergency departments (ED) use patient experience surveys (i.e., Press Ganey) that include specific physician assessment fields. Our ED group currently staffs two EDs – one at a large, tertiary-care hospital, and the other at a small, affiliated, community site. Both are staffed by the same physicians. The goals of this study were to determine whether Press Ganey ED satisfaction scores for emergency physicians working at two different sites were consistent between sites, and to identify factors contributing to any variation.

Methods: We conducted a retrospective study of patients seen at either ED between September 2015 and March 2016 who returned a Press Ganey satisfaction survey. We compiled a database linking the patient visit with his or her responses on a 1-5 scale to questions that included “overall rating of emergency room care” and five physician-specific questions. Operational metrics including time to room, time to physician, overall length of stay, labs received, prescriptions received, demographic data, and the attending physician were also linked. We averaged scores for physicians staffing both EDs and compared them between sites using t-tests. Multiple logistic regression was used to determine the impact of visit-specific metrics on survey scores.

Results: A total of 1,012 ED patients met the inclusion criteria (site 1=457; site 2=555). The overall rating-of-care metric was significantly lower at the tertiary-care hospital ED compared to our lower volume ED (4.30 vs 4.65). The same trend was observed when the five doctor-specific metrics were summed (22.06 vs 23.32). Factors that correlated with higher scores included arrival-to-first-attending time (p=0.013) and arrival-to-ED-departure time (p=0.038), both of which were longer at the tertiary-care hospital ED.

Conclusion: Press Ganey satisfaction scores for the same group of emergency physicians varied significantly between sites. This suggests that these scores are more dependent on site-specific factors, such as wait times, than a true representation of the quality of care provided by the physician.

Population Health Research Design

Access to Top-Cited Emergency Care Articles (Published Between 2012 and 2016) Without Subscription

Introduction: Unrestricted access to journal publications speeds research progress, productivity, and knowledge translation, which in turn develops and promotes the efficient dissemination of content. We describe access to the 500 most-cited emergency medicine (EM) articles (published between 2012 and 2016) in terms of publisher-based access (open access or subscription), alternate access routes (self-archived or author provided), and relative cost of access.

Methods: We used the Scopus database to identify the 500 most-cited EM articles published between 2012 and 2016. Access status was collected from the journal publisher. For studies not available via open access, we searched on Google, Google Scholar, Researchgate,, and the Unpaywall and Open Access Button browser plugins to locate self archived copies. We contacted corresponding authors of the remaining inaccessible studies for a copy of each of their articles. We collected article processing and access costs from the journal publishers, and then calculated relative cost differences using the World Bank purchasing power parity index for the United States (U.S.), Germany, Turkey, China, Brazil, South Africa, and Australia. This allows costs to be understood relative to the economic context of the countries from which they originated.

Results: We identified 500 articles for inclusion in the study. Of these, 167 (33%) were published in an open access format. Of the remaining 333 (67%), 204 (61%) were available elsewhere on the internet, 18 (4%) were provided by the authors, and 111 (22%) were accessible by subscription only. The mean article processing and access charges were $2,518.62 and $44.78, respectively. These costs were 2.24, 1.75, 2.28 and 1.56 times more expensive for South African, Chinese, Turkish, and Brazilian authors, respectively, than for U.S. authors (p<0.001 all).

Conclusion: Despite the advantage of open access publication for knowledge translation, social responsibility, and increased citation, one in five of the 500 EM articles were accessible only via subscription. Access for scientists from upper-middle income countries was significantly hampered by cost. It is important to acknowledge the value this has for authors from low- and middle-income countries. Authors should also consider the citation advantage afforded by open access publishing when deciding where to publish.


Critical Care

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine

Endotracheal intubation (ETI) is a high-risk procedure commonly performed in emergency medicine, critical care, and the prehospital setting. Traditional rapid sequence intubation (RSI), the simultaneous administration of an induction agent and muscle relaxant, is more likely to harm patients who do not allow appropriate preparation and preoxygenation, have concerning airway anatomy, or severe hypoxia, acidemia, or hypotension. Ketamine, a dissociative anesthetic, can be used to facilitate two alternatives to RSI to augment airway safety in these scenarios: delayed sequence intubation – the use of ketamine to allow airway preparation and preoxygenation in the agitated patient; and ketamine-only breathing intubation, in which ketamine is used without a paralytic to facilitate ETI as the patient continues to breathe spontaneously. Ketamine may also provide hemodynamic benefits during standard RSI and is a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine’s unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety.

Emergency Department Access

A Geospatial Analysis of Freestanding and Hospital Emergency Department Accessibility via Public Transit

Introduction: Emergency departments (ED) are an important source of care for underserved populations and represent a significant part of the social safety net. In order to explore the effect of freestanding emergency departments (FSED) on access to care for urban underserved populations, we performed a geospatial analysis comparing the proximity of FSEDs and hospital EDs to public transit lines in three United States (U.S.) metropolitan areas: Houston, Denver, and Cleveland.

Methods: We used publicly available U.S. Census data, public transportation maps obtained from regional transit authorities, and geocoded FSED and hospital ED locations. Euclidean distance from each FSED and hospital ED to the nearest public transit line was calculated in ArcGIS. We calculated the odds ratio (OR) of an FSED, relative to a hospital ED, being located within 0.5 miles (mi) of a public transit line using logistic regression, adjusting for population density and median household income and with error clustered at the metropolitan statistical area (MSA) level.

Results: The median distance from FSEDs to public transit lines was significantly greater than from hospital EDs across all three markets. In Houston, Denver, and Cleveland, the median distance between FSEDs and public transit lines was greater than from hospital EDs by 1.0 mi, 0.2 mi, and 1.6 mi, respectively. The OR of a public transit line being located within 0.5 mi of an FSED, as compared with a hospital ED, across all three MSAs was 0.21 (95% confidence interval [CI], 0.13–0.34) unadjusted and 0.20 (95% CI, 0.11–0.40) adjusted for population density and median household income.

Conclusion: In comparison with hospital EDs, FSEDs are located farther from public transit lines and are less likely to be within walking distance of public transportation. These findings suggest that FSEDs are unlikely to directly increase access to care for patients without private means of transportation. Further research is necessary to explore both the direct and indirect impact of FSEDs on access to care, potentially through effects on hospital ED crowding and overall healthcare expenditures, as well as the ultimate role and responsibility of FSEDs in improving access to care for underserved populations.

Emergency Department Administration

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

Introduction: Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions.

Methods: A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins.

Results: Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality.

Conclusion: While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.

  • 1 supplemental file

Provider Workforce

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Each year more than 400 physicians take their lives, likely related to increasing depression and burnout. Burnout—a psychological syndrome featuring emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment—is a disturbingly and increasingly prevalent phenomenon in healthcare, and emergency medicine (EM) in particular. As self-care based solutions have proven unsuccessful, more system-based causes, beyond the control of the individual physicians, have been identified. Such system-based causes include limitations of the electronic health record, long work hours and substantial educational debt, all in a culture of “no mistakes allowed.” Blame and isolation in the face of medical errors and poor outcomes may lead to physician emotional injury, the so-called “second victim” syndrome, which is both a contributor to and consequence of burnout. In addition, emergency physicians (EP) are also particularly affected by the intensity of clinical practice, the higher risk of litigation, and the chronic fatigue of circadian rhythm disruption. Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs. Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone. This paper reviews the scope of burnout, contributors, and consequences both for medicine in general and for EM in particular.

  • 1 supplemental file


Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation

Introduction: Copperhead envenomation causes local tissue destruction, leading people to seek treatment for the pain and swelling. First-line treatment for the pain is opioid medications. There is rising concern that an initial opioid prescription from the emergency department (ED) can lead to long-term addiction. This analysis sought to determine whether use of Fab antivenom (FabAV) for copperhead envenomation affected opioid use.

Methods: We performed a secondary analysis using data from a randomized clinical trial designed to determine the effect of FabAV on limb injury recovery following mild to moderate copperhead envenomation. Opioid use was a defined secondary outcome in the parent trial. Patients were contacted after discharge, and data were obtained regarding medications used for pain and the patients’ functional status. This analysis describes the proportion of patients in each treatment group reporting opioid use at each time point. It also assesses the interaction between functional status and use of opioids.

Results: We enrolled 74 patients in the parent trial (45 received FabAV, 29 placebo), of whom 72 were included in this secondary analysis. Thirty-five reported use of any opioids after hospital discharge. A smaller proportion of patients treated with FabAV reported opioid use: 40.9% vs 60.7% of those in the placebo group. The proportion of patients using opioids remained smaller in the FabAV group at each follow-up time point. Controlling for confounders and interactions between variables, the model estimated that the odds ratio of using opioids after hospital discharge among those who received placebo was 5.67 times that of those who received FabAV. Patients who reported higher baseline pain, those with moderate as opposed to mild envenomation, and females were more likely to report opioid use at follow-up. Patients with ongoing limitations to functional status had an increased probability of opioid use, with a stronger association over time. Opioid use corresponded with the trial’s predefined criteria for full recovery, with only two patients reporting opioid use in the 24 hours prior to achieving full limb recovery and no patients in either group reporting opioid use after full limb recovery.

Conclusion: In this study population, the proportion of patients using opioids for pain related to envenomation was smaller in the FabAV treatment group at all follow-up time points.

Availability of Bedside and Laboratory Testing for Carbon Monoxide Poisoning in the Upper Midwestern United States

Introduction: The objective of this study was to assess the ability to test patients for carbon monoxide (CO) exposure in all hospitals in three United States (U.S.) Midwestern states.

Methods: We surveyed hospitals in three states. Telephone queries assessed processes for measuring carboxyhemoglobin, including capacity for real-time vs send-out testing. Facilities wereseparated based on their location’s population size for further analysis. Descriptive statistics are reported.

Results: Of the 250 hospitals queried, we ultimately excluded 25. Nearly all (220, 97.8%) reported a process in place to test for CO exposure. Over 40% (n=92) lacked real-time testing. Testing ability was positively associated with increasing population size quartile (range 32.6% - 100%). Hospitals in the lowest-quartile population centers were more likely to report that they were unable to test in realtime than those in the largest-quartile population centers (67.4% vs 0%).

Conclusion: In a large geographic region encompassing three states, hospital-based and real-time capacity to test for CO exposure is not universal. Hospitals in smaller population areas are morelikely to lack real-time testing or any testing at all. This may have significant public health, triage, andreferral implications for patients.


Feasibility of Telesimulation and Google Glass for Mass Casualty Triage Education and Training

Introduction: Our goal was to evaluate the feasibility and effectiveness of using telesimulation to deliver an emergency medical services (EMS) course on mass casualty incident (MCI) training to healthcare providers overseas.

Methods: We conducted a feasibility study to establish the process for successful delivery of educational content to learners overseas via telesimulation over a five-month period. Participants were registrants in an EMS course on MCI triage broadcast from University of California, Irvine Medical Simulation Center. The intervention was a Simple Triage and Rapid Treatment (START) course. The primary outcome was successful implementation of the course via telesimulation. The secondary outcome was an assessment of participant thoughts, feelings, and attitudes via a qualitative survey. We also sought to obtain quantitative data that would allow for the assessment of triage accuracy. Descriptive statistics were used to express the percentage of participants with favorable responses to survey questions.

Results: All 32 participants enrolled in the course provided a favorable response to all questions on the survey regarding their thoughts, feelings, and attitudes toward learning via telesimulation with wearable/mobile technology. Key barriers and challenges identified included dependability of Internet connection, choosing appropriate software platforms to deliver content, and intercontinental time difference considerations. The protocol detailed in this study demonstrated the successful implementation and feasibility of providing education and training to learners at an off-site location.

Conclusion: In this feasibility study, we were able to demonstrate the successful implementation of an intercontinental MCI triage course using telesimulation and wearable/mobile technology. Healthcare providers expressed a positive favorability toward learning MCI triage via telesimulation. We were also able to establish a process to obtain quantitative data that would allow for the calculation of triage accuracy for further experimental study designs.

Targeted Simulation-based Leadership Training for Trauma Team Leaders

Introduction: Effective team leadership is linked to better teamwork, which in turn is believed to improve patientcare. Simulation-based training provides a mechanism to develop effective leadership behaviors. Traditionally, healthcare curricula have included leadership as a small component of broader teamwork training, with very few examples of leadership-focused curricula. The objective of this work is to describe a novel simulation-basedteam leadership curriculum that easily adapts to individual learners.

Methods: We created a simulation-based team leadership training for trauma team leaders in graduatemedical education. Participants included second- and third-year emergency medicine and surgery residents. Training consisted of a single, four-hour session and included facilitated discussion of trauma leadership skills,a brief didactic session integrating leadership behaviors into Advanced Trauma Life Support®, and a seriesof simulations and debriefing sessions. The simulations contained adaptable components that facilitated individualized learning while delivering set curricular content. A survey evaluation was administered 7-24 months following the training to assess self-reported implementation of trained material.

Results: A total of 36 residents participated in the training and 23 (64%) responded to the survey. The majority of respondents (n = 22, 96%) felt the training was a valuable component of their residency education and allrespondents reported ongoing use of at least one behavior learned during the training. The most commonly cited skills for ongoing use included the pre-arrival brief (n = 21, 91%) and prioritization (n = 21, 91%).

Conclusion: We delivered a leadership-focused, simulation-based training that 1) adapted to learners’individual needs, and 2) was perceived to impact practice up to 24 months post-training. More work is needed tounderstand the impact of this training on learner knowledge and behavior, as well as patient outcomes.


  • 3 supplemental files

The Flipped Classroom: A Critical Appraisal

Introduction: The objective of this study was to review and critically appraise the medical education literature pertaining to a flipped-classroom (FC) education model, and to highlight influential papers that inform our current understanding of the role of the FC in medical education.

Methods: A search of the English-language literature querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 296 papers related to the FC using either quantitative, qualitative, or review methods. Two reviewers independently screened each category of publications using previously established exclusion criteria. Eight reviewers then independently scored the remaining 54 publications using either a qualitative, quantitative, or review-paper scoring system. Each scoring system consisted of nine criteria and used parallel metrics that have been previously used in critical appraisals of education research.

Results: A total of 54 papers (33 quantitative, four qualitative, and 17 review) on FC met a priori criteria for inclusion and were critically appraised and reviewed. The top 10 highest scoring articles (five quantitative studies, two qualitative studies, and three review papers) are summarized in this article.

Conclusion: This installment of the Council of Emergency Medicine Residency Directors (CORD) Academy Critical Appraisal series highlights 10 papers that describe the current state of literature on the flipped classroom, including an analysis of the benefits and drawbacks of an FC approach, practical implications for emergency medicine educators, and next steps for future research.

  • 3 supplemental files


This Article Corrects: “Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry”

Introduction: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications.

Methods: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED.

Results: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use.

Conclusion: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.