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Open Access Publications from the University of California

Volume 21, Issue 2, 2020

WestJEM Full-Text Issue Volume 21, Issue 2


Management of Stroke with Pharmacological Fibrinolysis in an Emergency Department at a Level 2 Hospital in Central Ecuador

Introduction: A timely and organized response in the emergency department is crucial for the treatment of stroke with pharmacological fibrinolysis. Currently, few stroke patients have access to fibrinolytic treatment in Ecuador, as most hospitals lack a well-coordinated stroke response. This remains true at even the highest acuity (level 3) hospitals. In this study we report the initial results of the first code stroke and fibrinolysis pathway established in a level 2 public hospital in a small city (pop 300,000) in Ecuador.

Objective: To develop an organized and coordinated pathway within the hospital for the correct diagnosis and treatment of patients with clinical presentation of stroke, starting with early identification of signs/symptoms and the activation of a specific pathway, which in turn improves the prognosis and the quality of life of acute ischemic stroke patients.

Methods: This was a prospective, longitudinal, descriptive study of patients presenting with stroke symptoms, for whom a code stroke and red triage priority was applied in the emergency department of Hospital General Docente Ambato in the first three months of 2019. To be eligible for thrombolysis, patients had to arrive within 4.5 hours of symptom onset and not have any contraindications to thrombolysis.

Results: 30 patients arrived at the emergency department with stroke symptoms, and in each case a code stroke was activated upon arrival to the emergency department. The mean age of patients was 66.63 years, and 15 patients were male (50%). 19 patients (63%) arrived within 4.5 hours of symptom onset, of which 8 patients (42%) had no contraindication and received thrombolysis. The mean door-to-needle time was 66 minutes.

Conclusions: This study demonstrates that it is feasible to establish a code stroke and fibrinolysis treatment pathway in level 2 hospitals in Ecuador. Many other hospitals in the country could establish similar treatment protocols and improve their management of ischemic stroke patients.

Applicability of Winthrop Score for the Diagnosis of Influenza A in the Emergency Department of Hospital Pablo Arturo Suárez, January to March of 2018

Introduction: In 2010, the Department of Infectious Diseases at Winthrop University Hospital designed a score system for the diagnosis of Legionella pneumonia. In this study, we applied the score to patients with acute respiratory symptoms suspected of having type A influenza. The identification of patients at medium to high risk of Influenza A allows for early initiation of treatment.

Objective: To study the applicability of the Winthrop score for the diagnosis of Influenza A.

Methodology: A prospective cohort study was performed in 2018 at Hospital Pablo Arturo Suárez, in Quito, Ecuador. Patients 0 to 100 years old presenting to the emergency department with influenza-like illness in January-March of 2018 were included in the study. Winthrop score results were then compared with the result of the reverse transcription polymerase chain reaction (RT-PCR) for influenza A, the gold standard for diagnosis. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were used to establish the diagnostic performance of this point system for influenza A within the sample at large and in subgroup analyses by age (<5 years, 5-65 years, and >65 years) and comorbidities.

Results: 149 patients were enrolled in the study period. The study population included 81 males (54.4%) and the majority of patients were less than 5 years of age (N=85, 57.0%). Furthermore, almost one-third of the patients were less than one year old (N=38, 25.5%). According to the Winthrop point system, 68.5% of the cases had a low probability of having influenza (n = 102), 8.7% of cases had a medium probability (n = 13) and 22.8 % of cases had a high probability (n = 34). The RT-PCR test for influenza was positive for 26.2% of patients (n = 39). The Winthrop point system had a sensitivity of 97.4%, specificity of 91.8%, positive predictive value of 80.8%, negative predictive value of 99.0%, positive likelihood ratio of 11.9, and negative likelihood ratio of 35.8 in the total study population. For children under 5 years, a sensitivity of 100%, specificity of 96.3%, positive predictive value of 77.7%, negative predictive value of 100%, positive likelihood ratio of 27, and negative likelihood ratio of 0. In patients older than 6 years, a sensitivity of 96.9%, specificity of 89%, positive predictive value of 84.21%, negative predictive value of 98%, positive likelihood ratio of 8.8, and negative likelihood ratio of 29.4. Testing in patients over 65 years had a sensitivity of 100%, specificity of 90%, positive predictive value of 87.5%, negative predictive value of 100%, positive likelihood ratio of 10 and negative likelihood ratio of 0. Finally, patients with comorbidities had a sensitivity of 90%, specificity of 88.24%, positive predictive value of 81.82%, negative predictive value of 93.75%, positive likelihood ratio of 7.65, and negative likelihood ratio of 8.82.

Conclusions: The Winthrop score performed well in predicting Influenza A in patients with acute respiratory symptoms. This score may be useful in settings were Influenza A PCR testing is unavailable.

Endemic Infections

2019-nCoV: The Identify-Isolate-Inform (3I) Tool Applied to a Novel Emerging Coronavirus

2019 Novel Coronavirus (2019-nCoV) is an emerging infectious disease closely related to MERS-CoV and SARS-CoV that was first reported in Wuhan City, Hubei Province, China in December 2019. As of January 2020, cases of 2019-nCoV are continuing to be reported in other Eastern Asian countries as well as in the United States, Europe, Australia, and numerous other countries. An unusually high volume of domestic and international travel corresponding to the beginning of the 2020 Chinese New Year complicated initial identification and containment of infected persons. Due to the rapidly rising number of cases and reported deaths, all countries should be considered at risk of imported 2019-nCoV. Therefore, it is essential for prehospital, clinic, and emergency department personnel to be able to rapidly assess 2019-nCoV risk and take immediate actions if indicated. The Identify-Isolate-Inform (3I) tool, originally conceived for the initial detection and management of Ebola virus and later adjusted for other infectious agents, can be adapted for any emerging infectious disease. This paper reports a modification of the 3I tool for use in the initial detection and management of patients under investigation for 2019-nCoV. After initial assessment for symptoms and epidemiological risk factors, including travel to affected areas and exposure to confirmed 2019-nCoV patients within 14 days, patients are classified in a risk-stratified system. Upon confirmation of a suspected 2019-nCoV case, affected persons must immediately be placed in airborne infection isolation and the appropriate public health agencies notified. This modified 3I tool will assist emergency and primary care clinicians, as well as out-of-hospital providers, in effectively managing persons with suspected or confirmed 2019-nCoV.

Scabies: Application of the Novel Identify-Isolate-Inform Tool for Detection and Management

Scabies is a highly contagious, globally prevalent, parasitic skin infestation caused by Sarcoptes scabiei var. hominis, also known as the itch mite. There have been outbreaks not only in the developing world, but also in the developed world among refugees and asylum seekers. Once infested with scabies mites, symptomatic patients, as well as asymptomatic carriers, quickly spread the disease through direct skin-to-skin contact. Typically, symptoms of scabies are characterized by an erythematous, papular, pruritic rash associated with burrows. Treatment of scabies involves using topical or systemic scabicides and treating secondary bacterial infections, if present. Given the prevalence and contagiousness of scabies, measures to prevent its spread are essential. Through application of the novel Identify-Isolate-Inform (3I) Tool, emergency medical providers can readily identify risk factors for exposure and important symptoms of the disease, thus limiting its spread through prompt scabicide therapy; isolate the patient until after treatment; and inform local public health authorities and hospital infection prevention, when appropriate. Ultimately, these three actions can aid public health in controlling the transmission of scabies cases, thus ensuring the protection of the general public from this highly contagious skin infestation.

Commentary (Limit 2000 words)

Using Tenecteplase for Acute Ischemic Stroke: What Is the Hold Up?

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

Women's Health

Human Papillomavirus Awareness, Vaccine Status, and Risk Factors in Female Emergency Patients

Introduction: A vaccine targeting high-risk human papillomavirus (HPV) strains can effectively prevent HPV-associated cervical cancer risk. However, many girls and women do not receive the vaccine, more often those impacted by health disparities associated with race and/or socioeconomic status. This same disparate population has also been shown to be at higher risk for cervical cancer. Many of these women also rely on the emergency department (ED) as a safety net for their healthcare. This study sought to gather information pertaining to HPV and cervical cancer risk factors, awareness of HPV and the vaccine, as well as HPV vaccine uptake in female patients presenting to an ED.

Methods: We obtained 81 surveys completed by female ED patients. Demographics included age, race, income, insurance status, primary care provider status, and known cervical-cancer risk factors. Subsequent survey questions explored respondents’ knowledge, familiarity, and attitudes regarding HPV, cervical cancer, and the HPV vaccine, including vaccination uptake rates. We analyzed data using descriptive statistics and Fisher’s exact test.

Results: Approximately one in seven respondents (14.8%) had never previously heard of HPV and 32.1% were unaware of the existence of a HPV vaccine. Minority patients, including those who were Black and Hispanic patients, low income patients, and uninsured and publicly insured patients were less likely to be aware of HPV and the vaccine and likewise were less likely to be offered and receive the vaccine. More than 60% of all respondents (61.3%) had never previously been offered the vaccine, and only 24.7% of all respondents had completed the vaccine series.

Conclusion: Female ED patients may represent an at-risk cohort with relatively low HPV awareness and low HPV vaccine uptake. The ED could represent a novel opportunity to access and engage high-risk HPV populations.

  • 3 supplemental ZIPs

Healthcare Utilization

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey

Introduction: Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided.

Methods: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression.

Results: NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08). Conclusion: From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.

  • 1 supplemental ZIP


Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation

Introduction: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock.

Methods: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma.

Results: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma  (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0).

Conclusion: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock.

Critical Care

Screening for QT Prolongation in the Emergency Department: Is There a Better “Rule of Thumb?”

Introduction: Identification of QT prolongation in the emergency department (ED) is critical for appropriate monitoring, disposition, and treatment of patients at risk for torsades de pointes (TdP). Unfortunately, identifying prolonged QT is not straightforward. Computer algorithms are unreliable in identifying prolonged QT. Manual QT-interval assessment methods, including QT correction formulas and the QT nomogram, are time-consuming and are not ideal screening tools in the ED. Many emergency clinicians rely on the “rule of thumb” or “Half the RR” rule (Half-RR) as an initial screening method, but prior studies have shown that the Half-RR rule performs poorly as compared to other QT assessment methods. We sought to characterize the problems associated with the Half-RR rule and find a modified screening tool to more safely assess the QT interval of ED patients for prolonged QT.

Methods: We created graphs comparing the prediction of the Half-RR rule to other common QT assessment methods for a spectrum of QT and heart rate pairs. We then proposed various modifications to the Half-RR rule and assessed these modifications to find an improved “rule of thumb.”

Results: When compared to other methods of QT correction, the Half-RR rule appears to be more conservative at normal and elevated heart rates, making it a safe initial screening tool. However, in bradycardia, the Half-RR rule is not sufficiently sensitive in identifying prolonged QT. Adding a fixed QT cutoff of 485 milliseconds (ms) increases the sensitivity of the rule in bradycardia, creating a safer initial screening tool.

Conclusion: For a rapid and more sensitive screening evaluation of the QT interval on electrocardiograms in the ED, we propose combining use of the Half-RR rule at normal and elevated heart rates with a fixed uncorrected QT cutoff of 485 ms in bradycardia.

Legal Medicine

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies

Introduction: The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition – labor – specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care.

Methods: We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements.

Results: Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB  (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle.

Conclusion: Despite inclusion of the term “labor” in the law’s title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

  • 3 supplemental ZIPs

Provider Workforce

Public Performance Metrics: Driving Physician Motivation and Performance

Introduction: As providers transition from “fee-for-service” to “pay-for-performance” models, focus has shifted to improving performance. This trend extends to the emergency department (ED) where visits continue to increase across the United States. Our objective was to determine whether displaying public performance metrics of physician triage data could drive intangible motivators and improve triage performance in the ED.

Methods: This is a single institution, time-series performance study on a physician-in-triage system. Individual physician baseline metrics—number of patients triaged and dispositioned per shift—were obtained and prominently displayed with identifiable labels during each quarterly physician group meeting. Physicians were informed that metrics would be collected and displayed quarterly and that there would be no bonuses, punishments, or required training; physicians were essentially free to do as they wished. It was made explicit that the goal was to increase the number triaged, and while the number dispositioned would also be displayed, it would not be a focus, thereby acting as this study’s control. At the end of one year, we analyzed metrics.

Results: The group’s average number of patients triaged per shift were as follows: Q1-29.2; Q2-31.9; Q3-34.4; Q4-36.5 (Q1 vs Q4, p < 0.00001). The average numbers of patients dispositioned per shift were Q1-16.4; Q2-17.8; Q3-16.9; Q4-15.3 (Q1 vs Q4, p = 0.14). The top 25% of Q1 performers increased their average numbers triaged from Q1-36.5 to Q4-40.3 (ie, a statistically insignificant increase of 3.8 patients per shift [p = 0.07]). The bottom 25% of Q1 performers, on the other hand, increased their averages from Q1-22.4 to Q4-34.5 (ie, a statistically significant increase of 12.2 patients per shift [p = 0.0013]).

Conclusion: Public performance metrics can drive intangible motivators (eg, purpose, mastery, and peer pressure), which can be an effective, low-cost strategy to improve individual performance, achieve institutional goals, and thrive in the pay-for-performance era.

#MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment

Introduction: Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians’ experiences with workplace gender discrimination and sexual harassment.

Methods: We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians’ experiences using correlation analyses.

Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6–6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%-65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%-25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%-43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.

Conclusion: Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.


  • 1 supplemental ZIP

Behavioral Health

Emergency Department Clinicians’ Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study

Introduction: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians’ attitudes toward the initiation of buprenorphine treatment in the ED.

Methods: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital.

Results: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up.

Conclusion: ED clinicians’ perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine.

Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience

Introduction: Two protocols were developed to guide the use of subdissociative dose ketamine (SDDK) for analgesia and dissociative sedation ketamine for severe agitation/excited delirium in the emergency department (ED). We sought to evaluate the safety of these protocols implemented in 18 EDs within a large health system.

Methods: We conducted a retrospective chart review to evaluate all adult patients who received intravenous (IV) SDDK for analgesia and intramuscular (IM) dissociative sedation ketamine for severe agitation/excited delirium in 12 hospital-based and six freestanding EDs over a one-year period from the protocol implementation. We developed a standardized data collection form and used it to record patient information regarding ketamine use, concomitant medication use, and any comorbidities that could have impacted the incidence of adverse events.

Results: Approximately 570,000 ED visits occurred during the study period. SDDK was used in 210 ED encounters, while dissociative sedation ketamine for severe agitation/excited delirium was used in 37 ED encounters. SDDK was used in 83% (15/18) of sites while dissociative sedation ketamine was used in 50% (9/18) of sites. Endotracheal intubation, non-rebreather mask, and nasal cannula ≥ four liters per minute were identified in one, five, and three patients, respectively. Neuropsychiatric adverse events were identified in 4% (9/210) of patients who received SDDK.

Conclusion: Patients experienced limited neuropsychiatric adverse events from SDDK. Additionally, dissociative sedation ketamine for severe agitation/excited delirium led to less endotracheal intubation than reported in the prehospital literature. The favorable safety profile of ketamine use in the ED may prompt further increases in usage.

Violence Assessment and Prevention

Co-Occurrence of Multiple Risk Factors and Intimate Partner Violence in an Urban Emergency Department

Introduction: Urban emergency departments (ED) provide care to populations with multiple health-related and overlapping risk factors, many of which are associated with intimate partner violence (IPV). We examine the 12-month rate of physical IPV and its association with multiple joint risk factors in an urban ED.

Methods: Research assistants surveyed patients regarding IPV exposure, associated risk factors, and other sociodemographic features. The joint occurrence of seven risk factors was measured by a variable scored 0–7 with the following risk factors: depression; adverse childhood experiences; drug use; impulsivity; post-traumatic stress disorder; at-risk drinking; and partner’s score on the Alcohol Use Disorders Identification Test. The survey (N = 1037) achieved an 87.5% participation rate.

Results: About 23% of the sample reported an IPV event in the prior 12 months. Logistic regression showed that IPV risk increased in a stepwise fashion with the number of present risk factors, as follows: one risk factor (adjusted odds ratio [AOR] [3.09]; 95% confidence interval [CI], 1.47-6.50; p<.01); two risk factors (AOR [6.26]; 95% CI, 3.04-12.87; p<.01); three risk factors (AOR = 9.44; 95% CI, 4.44-20.08; p<.001); four to seven risk factors (AOR [18.62]; 95% CI, 9.00-38.52; p<001). Ordered logistic regression showed that IPV severity increased in a similar way, as follows: one risk factor (AOR [3.17]; 95% CI, 1.39-7.20; p<.01); two risk factors (AOR [6.73]; 95% CI, 3.04-14.90; p<.001); three risk factors (AOR [10.36]; 95%CI, 4.52-23.76; p<.001); four to seven risk factors (AOR [20.61]; 95% CI, 9.11-46.64; p<001).

Conclusion: Among patients in an urban ED, IPV likelihood and IPV severity increase with the number of reported risk factors. The best approach to identify IPV and avoid false negatives is, therefore, multi-risk assessment.

Location of Violent Crime Relative to Trauma Resources in Detroit: Implications for Community Interventions

Introduction: Detroit, Michigan, is among the leading United States cities for per-capita homicide and violent crime. Hospital- and community-based intervention programs could decrease the rate of violent-crime related injury but require a detailed understanding of the locations of violence in the community to be most effective.

Methods: We performed a retrospective geospatial analysis of all violent crimes reported within the city of Detroit from 2009-2015 comparing locations of crimes to locations of major hospitals. We calculated distances between violent crimes and trauma centers, and applied summary spatial statistics.

Results: Approximately 1.1 million crimes occurred in Detroit during the study period, including approximately 200,000 violent crimes. The distance between the majority of violent crimes and hospitals was less than five kilometers (3.1 miles). Among violent crimes, the closest hospital was an outlying Level II trauma center 60% of the time.

Conclusion: Violent crimes in Detroit occur throughout the city, often closest to a Level II trauma center. Understanding geospatial components of violence relative to trauma center resources is important for effective implementation of hospital- and community-based interventions and targeted allocation of resources.


Population Health Research Design

Quality and Publication of Emergency Medicine Trials Registered in

Introduction: Promoting emergency medicine (EM) clinical trials research remains a priority. To characterize the status of clinical EM research, this study assessed trial quality, funding source, and publication of EM clinical trials and compared EM and non-EM trials on these key metrics. We also examined the volume of EM trials and their subspecialty areas.

Methods: We abstracted data from (February 2000 - September 2013) and used individual study National Clinical Trial numbers to identify published trials (January 2007 - September 2016). We used descriptive statistics and chi-square tests to examine study characteristics by EM and non-EM status, and Kaplan-Meier curves and log-rank tests to compare time to publication of completed EM and non-EM studies.

Results: We found 638 interventional EM trials and 59,512 non-EM interventional trials conducted in the United States between February 2000 and September 2013, registered on EM studies were significantly less likely than non-EM studies to be National Institutes of Health-funded or to evaluate a drug or biologic. However, EM studies had significantly larger sample sizes, and were significantly more likely to use randomization and blinding. Overall, 34.3% of EM and 26.0% of non-EM studies were published in peer-reviewed journals. By subspecialty, more EM trials concerned medical/surgical and psychiatric/neurological conditions than trauma.

Conclusion: Although EM studies were less likely to have received federal or industry funding, and the EM portfolio consisted of only 638 trials over the 14-year study period, the quality of EM trials surpassed that of non-EM trials, based on indices such as randomization and blinding. This novel finding bodes well for the future of clinical EM research, as does the higher proportion of published EM than non-EM trials. Our study also revealed that trauma studies were under-represented among EM studies. Periodic assessment of EM trials with the metrics used here could provide an informative and valuable longitudinal view of progress in clinical EM research.

Federal Funding in Emergency Medicine: Demographics and Perspectives of Awardees

Introduction: Emergency physicians face multiple challenges to obtaining federal funding. The objective of this investigation was to describe the demographics of federally-funded emergency physicians and identify key challenges in obtaining funding.

Methods: We conducted a retrospective database search of the National Institutes of Health (NIH) Research Portfolio Online Reporting Tool (NIH RePORTER) to collect data regarding the distribution and characteristics of federally-funded grants awarded to emergency medicine (EM) principal investigators between 2010-2017.  An electronic survey was then administered to the identified investigators to obtain additional demographic data, and information regarding their career paths, research environment, and perceived barriers to obtaining federal funding.

Results: We identified 219, corresponding to 51 unique, mentored career development awardees and 105 independent investigators. Sixty-two percent of investigators responded to the electronic survey. Awardees were predominantly White males, although a larger portion of the mentored awardee group was female. Greater than half of respondents reported their mentor to be outside of the field of EM. The most common awarding institution was the National Heart Lung and Blood Institute. Respondents identified barriers in finding adequate mentorship, time to gather preliminary data, and the quality of administrative support.

Conclusion: The last five years have showed a trend toward increasing grants awarded to EM investigators; however, we identified several barriers to funding. Initiatives geared toward support and mentorship of junior faculty, particularly to females, minorities, and those in less heavily funded areas of the country are warranted.

  • 2 supplemental PDFs

Emergency Department Operations

“Breaking” the Emergency Department: Does the Culture of Emergency Medicine Present a Barrier to Self-Care?

Introduction: Our goal was to critically examine emergency physician’s (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following: 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative.

Methods: We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a “cut-and-sort” process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation.

Results: We identified six themes that represented the pooled outcomes of both resident and faculty focus groups: 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care.

Conclusion: The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care.

A Playroom Internal Waiting Area Improves Productivity in the Pediatric Emergency Department

Introduction: Pediatric emergency department (PED) volume is often constrained by the number of available treatment rooms. In many PEDs patients occupy treatment rooms while awaiting test results or imaging, thereby delaying care for patients who arrive after them.

Methods: We opened a PED where selected patients were moved to a playroom when they did not actively require a treatment room. The treatment room was then available for the next patient. We measured the effect of using the playroom on time from arrival to rooming and length of stay (LOS) using proportional hazards regression and the odds of being roomed within 30 minutes of arrival using logistic regression. We adjusted for the number  of the previous eight patients who were “playroom eligible”; age; triage category; provider; the number of patients who arrived within the preceding hour; prior census; and testing ordered in the preceding eight patients.

Results: We analyzed 43,634 patient encounters, of which 10,134 (23%) were playroom eligible. The adjusted hazards ratio for the next patient being roomed was 1.14 (95% confidence interval [CI], 1.10-1.18) per prior playroom eligible patient. The adjusted odds ratio of the next patient being roomed within 30 minutes was 1.46 (95% CI, 1.33-1.56) per prior playroom eligible patient. The playroom typically decreased median rooming time by four to 42 minutes and LOS by two to 40 minutes depending on patient volumes and acuity. The benefit of the playroom was maximal at busier times.

Conclusion: Implementing a playroom in the PED for selected patients generally decreased time to rooming of the next patient and LOS.

Health Outcomes

Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians

Introduction: We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs’ perceptions about ongoing critical care delivery in the ED while awaiting ICU admission.

Methods: Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients “boarding” in the ED for >4-6 hours.

Results: We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs’ ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients.

Conclusion: Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints.

  • 2 supplemental ZIPs

Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage

Introduction: Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary.

Methods: We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure.

Results: A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93).

Conclusion: This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.


  • 1 supplemental ZIP

Prediction Model for 30-day Outcomes Among Emergency Department Patients with Lower Gastrointestinal Bleeding

Introduction: There are currently no robust tools available for risk stratification of emergency department (ED) patients with lower gastrointestinal bleed (LGIB). Our aim was to identify risk factors and develop a preliminary model to predict 30-day serious adverse events among ED LGIB patients.

Methods: We conducted a health records review including adult ED patients with acute LGIB. We used a composite outcome of 30-day all-cause death, recurrent LGIB, need for intervention to control the bleeding, and severe adverse events resulting in intensive care unit admission. One researcher collected data for variables and a second researcher independently collected 10% of the variables for inter-observer reliability. We used backward multivariable logistic regression analysis and SELECTION=SCORE option to create a preliminary risk-stratification tool. We assessed the diagnostic accuracy of the final model.

Results: Of 372 patients, 48 experienced an adverse outcome. We found that age ≥75 years, hemoglobin ≤100 g/L, international normalized ratio ≥2.0, ongoing bleed in the ED, and a medical history of colorectal polyps were statistically significant predictors in the multivariable regression analysis. The area under the curve (AUC) for the model was 0.83 (95% confidence interval, 0.77-0.89). We developed a scoring system based on the logistic regression model and found a sensitivity 0.96 (0.90-1.00) and specificity 0.53 (0.48-0.59) for a cut-off score of 1.

Conclusion: This model showed good ability to differentiate patients with and without serious outcomes as evidenced by the high AUC and sensitivity. The results of this study could be used in the prospective derivation of a clinical decision tool.

Technology in Emergency Care

Tricuspid Annular Plane of Systolic Excursion for the Evaluation of Patients with Severe Sepsis and Septic Shock

Introduction: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis.

Methods: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values.

Results: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm-20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS.

Conclusion: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

Comparison of Ultrasound-Guided Vs Traditional Arterial Cannulation by Emergency Medicine Residents

Introduction: We sought to determine whether ultrasound-guided arterial cannulation (USGAC) is more successful than traditional radial artery cannulation (AC) as performed by emergency medicine (EM) residents with standard ultrasound training.

Methods: We identified 60 patients age 18 years or older at a tertiary care, urban academic emergency department who required radial AC for either continuous blood pressure monitoring or frequent blood draws. Patients were randomized to receive radial AC via either USGAC or traditional AC. If there were three unsuccessful attempts, patients were crossed over to the alternative technique. All EM residents underwent standardized, general ultrasound training.

Results: The USGAC group required fewer attempts as compared to the traditional AC group (mean 1.3 and 2.0, respectively; p<0.001); 29 out of 30 (96%) successful radial arterial lines were placed using USGAC, whereas 14 out of 30 (47%) successful lines were placed using traditional AC (p<0.001). There was no significant difference in length of procedure or complication rate between the two groups. There was no difference in provider experience with respect to USGAC vs traditional AC.

Conclusion: EM residents were more successful and had fewer cannulation attempts with USGAC when compared to traditional AC after standard, intern-level ultrasound training.


Does Orally-Administered Radiocontrast Impair Ultrasound Image Quality in Pediatric Patients?

Introduction: It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality.

Methods: We designed a prospective observational study of children <18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdominal aorta and right lower quadrant (RLQ) structures (psoas muscle and iliac vessels) pre- and post- ORC administration. Images were compared independently by two blinded emergency US-certified physician-assessors for quality, specifically to determine whether ORC obscured the anatomical structures in question.

Results: A total of 17 subjects were enrolled, and each subject had two POCUS studies of the abdomen, one pre- and one post-ORC administration looking to visualize the anatomy of the RLQ and abdominal aorta in both studies. Statistical analysis showed no significant differences in mean values of POCUS image quality scoring by two blinded US-trained physician-assessors for either RLQ structures or abdominal aorta when performed pre- and post-administration of ORC.

Conclusion: Early ORC administration in children with abdominal pain does not adversely affect image quality of a subsequently performed abdominal US. Patients who may require abdominal CT to determine the etiology of abdominal pain can receive early administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.

Disaster Medicine/ Emergency Medical Services

How to Stop the Bleed: First Care Provider Model for Developing Public Trauma Response Beyond Basic Hemorrhage Control

Introduction: Since 2013, the First Care Provider (FCP) model has successfully educated the non-medical population on how to recognize life-threatening injuries and perform interventions recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) and the Hartford Consensus in the disaster setting. Recent programs, such as the federal “Stop The Bleed” campaign, have placed the emphasis of public training on hemorrhage control. However, recent attacks demonstrate that access to wounded, recognition of injury, and rapid evacuation are equally as important as hemorrhage control in minimizing mortality. To date, no training programs have produced a validated study with regard to training a community population in these necessary principles of disaster response.

Methods: In our study, we created a reproducible community training model for implementation into prehospital systems. Two matched demographic groups were chosen and divided into “trained” and “untrained” groups. The trained group was taught the FCP curriculum, which the Department of Homeland Security recognizes as a Stop the Bleed program, while the untrained group received no instruction. Both groups then participated in a simulated mass casualty event, which required evaluation of multiple victims with varying degree of injury, particularly a patient with an arterial bleed and a patient with an airway obstruction.

Results: The objective measures in comparing the two groups were the time elapse until their first action was taken (T1A) and time to their solution of the simulation (TtS). We compared their times using one-sided t-test to demonstrate their responses were not due to chance alone. At the arterial bleed simulation, the T1A for the trained and untrained groups, respectively, were 34.75 seconds and 111 seconds (p-value = .1064), while the TtS were 3 minutes and 33 seconds in the trained group and eight minutes in the untrained groups (physiologic cutoff) (p-value = .0014). At the airway obstruction simulation, the T1A for the trained and untrained groups, respectively, were 20.5 seconds and 43 seconds (p-value = .1064), while the TtS were 32.6 seconds in the trained group and 7 minutes and 3 seconds in the untrained group (p-value = .0087). Simulation values for recently graduated nursing students and a local fire department engine company (emergency medical services [EMS]) were also given for reference. The trained group’s results mirrored times of EMS.

Conclusion: This study demonstrates an effective training model to civilian trauma response, while adhering to established recommendations. We offer our model as a potential solution for accomplishing the Stop The Bleed mission while advancing the potential of public disaster response.


  • 2 supplemental PDFs

Tree of Life Synagogue Shooting in Pittsburgh: Preparedness, Prehospital Care, and Lessons Learned

On Saturday, October 27, 2018, a man with anti-Semitic motivations entered Tree of Life synagogue in the Squirrel Hill section of Pittsburgh, Pennsylvania; he had an AR-15 semi-automatic rifle and three handguns, opening fire upon worshippers. Eventually 11 civilians died at the scene and eight people sustained non-fatal injuries, including five police officers. Each person injured but alive at the scene received care at one of three local level-one trauma centers.  The injured had wounds often seen in war-settings, with the signature of high velocity weaponry.  We describe the scene response, specific elements of our hospital plans, the overall out-of-hospital preparedness in Pittsburgh, and the lessons learned.

UNIFIED: Understanding New Information from Emergency Departments Involved in the San Bernardino Terrorist Attack

Introduction: Emergency departments (ED) are on the front line for treating victims of multi-casualty incidents. The primary objective of this study was to gather and detail the common experiences from those hospital-based health professionals directly involved in the response to the San Bernardino terrorism attack on December 2, 2015. Secondary objectives included gathering information on experiences participants found were best practices.

Methods: We undertook a qualitative study using Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines by performing semi-structured interviews with physicians, nurses, and incident management staff from multiple institutions responding to the San Bernardino terrorist attack. We coded transcripts using qualitative analysis techniques and we delineated and agreed upon a refined list with code definitions using a negotiated group process. Final themes were developed and analyzed.

Results: A total of 26 interviews were completed; 1172 excerpts were coded and categorized into 66 initial themes. Six final categories of communication, training, unexpected help, process bypassed, personal impact/emotions, and practical advice resulted.

Conclusion: Our study provides context regarding the response of healthcare personnel from multiple institutions to a singular terrorist attack in the United States. It elucidates several themes to help other institutions prepare for similar events. Understanding these common experiences provides opportunity to prepare for future incidents and develop questions to study in future events.

Emergency Department Administration

Predictors of Patient Satisfaction and the Perceived Quality of Healthcare in an Emergency Department in Portugal

Introduction: The predictors of patient satisfaction in emergency medicine (EM) have been widely studied and discussed in the scientific literature; the results vary depending on the specific EM attributes, cultural aspects, researchers’ preferences, and approaches. However, it is not clear whether the same predictors of patient satisfaction can contribute to a better-perceived quality of healthcare or whether patients’ perceptions form a different attitude toward satisfaction and perceived quality of healthcare. The goal of this study was to identify the key predictors of patient satisfaction and perceived quality of healthcare in the framework of an emergency department (ED).

Methods: We conducted a retrospective study of patients seen at an ED between January -December 2016. Data collection took place in the public hospital in Lisbon, Portugal, between May - November 2017. The total sample size included 382 patients. The sample distribution had a 5% margin of error and a 95% confidence interval. Data for this research, using a questionnaire, was collected by mail or e-mail according to the respondent’s preference.

Results: A detailed analysis showed that three out of the 18 predictors had a statistically significant relationship with satisfaction: overall satisfaction with doctors, with a positive correlation (r = 0.14, p ≤ 0.01); qualitative perceived waiting time for triage, with a positive correlation (r = 0.08, p ≤ 0.05); and meeting expectations, with a positive correlation (r = 0.53, p ≤ 0.01). Furthermore, a detailed analysis showed that only two out of the 18 predictors had a statistically significant relationship with the perceived quality of healthcare (PQHC): overall satisfaction with doctors, with a positive correlation (r = 0.43, p ≤ 0.01) and meeting expectations, with a positive correlation (r = 0.26, p ≤ 0.01).

Conclusion: The main predictors of satisfaction and perceived quality of healthcare were overall satisfaction with doctors and meeting expectations. We should note that “meeting expectations” plays the most important role in terms of satisfaction; however, in terms of PQHC the predictor “overall satisfaction with doctors” plays the most important role due to its stronger correlation. In addition, the qualitative perceived waiting time for triage could be considered as another predictor, influencing satisfaction only, thus emphasizing similarities and differences between satisfaction and the PQHC in an ED context.


Role of Point-of-Care Testing in Reducing Time to Treatment Decision-Making in Urgency Patients: A Randomized Controlled Trial

Introduction: Shortening emergency department (ED) visit time can reduce ED crowding, morbidity and mortality, and improve patient satisfaction. Point-of-care testing (POCT) has the potential to decrease laboratory turnaround time, possibly leading to shorter time to decision-making and ED length of stay (LOS). We aimed to determine whether the implementation of POCT could reduce time to decision-making and ED LOS.

Methods: We conducted a randomized control trial at the Urgency Room of Siriraj Hospital in Bangkok, Thailand. Patients triaged as level 3 or 4 were randomized to either the POCT or central laboratory testing (CLT) group. Primary outcomes were time to decision-making and ED LOS, which we compared using Mann-Whitney-Wilcoxon test.

Results: We enrolled a total of 248 patients: 124 in the POCT and 124 in the CLT group. The median time from arrival to decision was significantly shorter in the POCT group (106.5 minutes (interquartile [IQR] 78.3-140) vs 204.5 minutes (IQR 165-244), p <0.001). The median ED LOS of the POCT group was also shorter (240 minutes (IQR 161.3-410) vs 395.5 minutes (IQR 278.5-641.3), p <0.001).

Conclusion: Using a point-of-care testing system could decrease time to decision-making and ED LOS, which could in turn reduce ED crowding.

  • 1 supplemental ZIP

New Clarification About Observation Billing May Improve Care for Behavioral Health Patients

Emergency Physicians provide ongoing care to psychiatric patients beyond the confines of a standard emergency room visit.  Often, when we identify patients who need specialty psychiatric care, patients board in the emergency department awaiting acceptance and transfer to an outside facility.  Even in cases where it has taken multiple days to complete the transfer, it has been unclear how to properly obtain reimbursement for this care.  We discuss a new coding clarification that may provide a pathway to improve part of this situation.


Evidence-Based Interventions that Promote Resident Wellness from the Council of Emergency Residency Directors

Initiatives for addressing resident wellness are a recent requirement of the Accreditation Council for Graduate Medical Education in response to high rates of resident burnout nationally. We review the literature on wellness and burnout in residency education with a focus on assessment, individual-level interventions, and systemic or organizational interventions.

  • 1 supplemental ZIP

The Impact of Due Process and Disruptions on Emergency Medicine Education in the United States

Introduction: Academic Emergency Medicine (EM) departments are not immune to natural disasters, economic or political forces that disrupt a training program’s operations and educational mission. Due process concerns are closely intertwined with the challenges that program disruption brings. Due process is a protection whereby an individual will not lose rights without access to a fair procedural process. Effects of natural disasters similarly create disruptions in the physical structure of training programs that at times have led to the displacement of faculty and trainees. Variation exists in the implementation of transitions amongst training sites across the country, and its impact on residency programs, faculty, residents and medical students.

Methods: We reviewed the available literature regarding due process in emergency medicine. We also reviewed recent examples of training programs that underwent disruptions. We used this data to create a set of best practices regarding the handling of disruptions and due process in academic EM.

Results: Despite recommendations from organized medicine, there is currently no standard to protect due process rights for faculty in emergency medicine training programs. Especially at times of disruption, the due process rights of the faculty become relevant, as the multiple parties involved in a transition work together to protect the best interests of the faculty, program, residents and students. Amongst training sites across the country, there exist variations in the scope and impact of due process on residency programs, faculty, residents and medical students.

Conclusion: We report on the current climate of due process for training programs, individual faculty, residents and medical students that may be affected by disruptions in management. We outline recommendations that hospitals, training programs, institutions and academic societies can implement to enhance due process and ensure the educational mission of a residency program is given due consideration during times of transition.

  • 2 supplemental ZIPs

Innovative Approaches to Emergency Medical Services Fellowship Challenges

Introduction: Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum.

Methods: Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following: a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows’ rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician.

Results: Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system.

Conclusion: Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges.

Does the Removal of Textbook Reading from Emergency Medicine Resident Education Negatively Affect In-Service Scores?

Introduction: In-service exam scores are used by residency programs as a marker for progress and success on board exams. Conference curriculum helps residents prepare for these exams. At our institution, due to resident feedback a change in curriculum was initiated. Our objective was to determine whether assigned Evidence-Based Medicine (EBM) articles and Rosh Review questions were non-inferior to Tintinalli textbook readings. We further hypothesized that the non-textbook assigned curriculum would lead to higher resident satisfaction, greater utilization, and a preference over the old curriculum.

Methods: We collected scores from both the allopathic In-training Examination (ITE) and osteopathic Emergency Medicine Residency In-service Exam (RISE) scores taken by our program’s residents from both the 2015-2016 and 2016-2017 residency years. We compared scores pre-curriculum change (pre-CC) to scores post-curriculum change (post-CC). A five-question survey was sent to the residents regarding their satisfaction, preference, and utilization of the two curricula.

Results: Resident scores post-CC were shown to be non-inferior to their scores pre-CC for both exams. There was also no significant difference when we compared scores from each class post-CC to their respective class year pre-CC for both exams. Our survey showed significantly more satisfaction, utilization, and preference for this new curriculum among residents.

Conclusion: We found question-based learning and Evidence-Based Medicine articles non-inferior to textbook readings. This study provides evidence to support a move away from textbook readings without sacrificing scores on examinations.

Emergency Medical Services

Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score

Introduction: There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol.

Methods: We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of “stroke/TIA,” “CVA,” or “neurological problem” were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score’s metrics were evaluated as a surrogate marker for a successful EMS triage protocol.

Results: We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%.

Conclusion: In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.

  • 1 supplemental ZIP

Mistriaged Advanced Life Support Patients in a Two-Tiered, Suburban Emergency Medical Services System

Introduction: Emergency medical services (EMS) systems exist to provide prehospital care in diverse environments throughout the world. Advanced Life Support (ALS) services can provide advanced care including 12-lead electrocardiogram (ECG), endotracheal intubation and parenteral medication administration. Basic Life Support (BLS) can provide basic care such as splinting, wound care and cardiopulmonary resuscitation. ALS can release patients to BLS for transport to the hospital, and this is an area of high risk. Our study examines patients who were triaged and admitted to a critical care location, including an intensive care unit (ICU), cardiac catheterization laboratory, or operating room (OR).

Methods: The analysis included data from 2007–2015 of all patients who were triaged. We evaluated demographics, admission diagnoses, and dispositions using descriptive statistics. Diagnoses were grouped into categories based on the system.

Results: We found that 372/17,639 (2%) of patients were mistriaged to BLS and admitted to a critical care location. The average age was 64. The most common diagnosis categories were neurological (24%), gastrointestinal (GI)/abdominal pain (15%), respiratory (12%), and cardiac (12%).

Conclusion: It is uncommon for patients triaged from ALS to BLS to be admitted to an ICU, catheterization lab or OR, with a rate of 2%. Neurological, GI, sepsis, and trauma diagnoses were the most frequent categories of patient complaints that were mistriaged. This study should lead to further studies to examine this patient population.

Prehospital Trauma Scene and Transport Times for Pediatric and Adult Patients

Introduction: Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients.

Methods: We performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013-2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid’s Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling.

Results: A total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9-14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0-17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001).

Conclusion: This study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.

  • 1 supplemental ZIP

Qualitative Research of Violent Incidents Toward Young Paramedics in the Czech Republic

Introduction: Prehospital and emergency medical services (EMS) providers are usually the first to respond to an individual’s urgent health needs, sometimes in emotionally charged circumstances. Because violence toward EMS providers in the Czech Republic is often overlooked and under-reported, we do not have a complete understanding of the extent of such violence, nor do we have recommendations from EMS professional organizations on how to resolve this problem in prehospital emergency medicine.

Methods: We conducted this study to explore the process of violence against EMS providers, using the Strauss/Corbin systematic approach of grounded theory to create a paradigm model. The participants in this research included personnel who had at least two years experience in the EMS systems of the city of Prague and the Central Bohemian Region, and who had been victims of violence. Our sample included 10 registered paramedics and 10 emergency medical technicians ages 23–33 (mean ± standard deviation: 27.7). The impact of communication during EMS delivery, in the context of violence from patients or their relatives, emerged as the core category and the main focus of our study. The five main groups of the paradigm model of violence against EMS personnel included causal, contextual and intervening conditions, strategies, and consequences.

Results: Of the 20 study participants, 18 reported experiencing an attack during the night shift. Ten participants experienced violence on the street, and 10 inside an ambulance. The perpetrators in all 18 cases were men. The behavior of EMS personnel plays a crucial role in how violent confrontations play out: nonprofessional behavior with drunken or addict patients increases the possibility of violence in 70% of cases.

Conclusion: We found that paramedics and EMTs were exposed to verbal abuse and physical violence. However, in 10 of the violent encounters reported by our 20 participants, the attack was perpetrated by otherwise-ordinary people (ie, individuals with strong family support and good jobs) who found themselves in a very stressful situation. Thanks to grounded theory we learned that for all 20 participants there was a potential opportunity to prevent the conflict.