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Open Access Publications from the University of California

Volume 21, Issue 4, 2020

Patient Safety

The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department

Introduction: Droperidol carries a boxed warning from the United States Food and Drug Administration for QT prolongation and torsades des pointes (TdP). After a six-year hiatus, droperidol again became widely available in the US in early 2019. With its return, clinicians must again make decisions regarding the boxed warning. Thus, the objective of this study was to report the incidence of QT prolongation or TdP in patients receiving droperidol in the ED.

Methods: Patients receiving droperidol at an urban Level I trauma center from 1997–2001 were identified via electronic health record query. All patients were reviewed for cardiac arrest. We reviewed electrocardiogram (ECG) data for both critically-ill and noncritical patients and recorded Bazett’s corrected QT intervals (QTc). ECGs from critically-ill patients undergoing resuscitation were further risk-stratified using the QT nomogram.

Results: Of noncritical patients, 15,374 received 18,020 doses of droperidol; 2,431 had an ECG. In patients with ECGs before and after droperidol, the mean QTc was 424.3 milliseconds (ms) (95% confidence interval [CI], 419.7-428.9) before and 427.6 ms (95% CI, 424.3-430.9), after droperidol(n = 170). Regarding critically-ill patients, 1,172 received droperidol and 396 had an ECG. In the critically-ill group with ECGs before and after droperidol mean QTc was 435.7 ms (95% CI, 426.7–444.7) before and 435.8 ms (95% CI, 427.5–444.1) after droperidol (n = 114). Of 337 ECGs suitable for plotting on the QT nomogram, 13 (3.8%) were above the “at-risk” line; 3/136 (2.2%; 95% CI, 0.05-6.3%) in the before group, and 10/202 (4.9%; 95% CI, 2.4%-8.9%) in the after group. A single case of TdP occurred in a patient with multiple risk factors that did not reoccur after a droperidol rechallenge. Thus, the incidence of TdP was 1/16,546 (0.006%; 95% CI, 0.00015 - 0.03367%).

Conclusion: We found the incidence of QTc prolongation and TdP in ED patients receiving droperidol to be extremely rare. Our data suggest the FDA “black box warning” is overstated, and that close ECG monitoring is useful only in high-risk patients.

Impact of Emergency Department Crowding on Delays in Acute Stroke Care

Introduction: Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care.

Methods: We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016–August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients’ presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale.

Results: Of the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17-52); DTN time was 43 minutes (IQR 31-59); and median DTP was 58.5 minutes (IQR 56.5-100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing.

Conclusion: In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.

  • 1 supplemental file

Patient Safety Event Reporting and Opportunities for Emergency Medicine Resident Education

Introduction: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education.

Methods: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories.

Results: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and <1% requiring simulation.

Conclusion: Twenty years after the publication of To Err is Human, gains have been made integrating quality assurance and patient safety within medical education and hospital systems, but there remains extensive work to be done. Through a review and analysis of our patient safety event reporting system, we were able to gain a better understanding of the events that are submitted, including the types of events and their severity, and how these relate to the types of educational interventions provided (eg, feedback, simulation). We also determined that these events can help inform resident education and learning using various types of education. Additionally, incorporating residents in the review process, such as through root cause analyses, can provide residents with high-quality, engaging learning opportunities and useful, lifelong skills, which is invaluable to our learners and future physicians.

Endemic Infections

Remdesivir for the Treatment of COVID-19: A Systematic Review of the Literature

In March 2020, the World Health Organization declared the spread of SARS-CoV-2 a global pandemic. To date, coronavirus disease-2019 (COVID-19) has spread to over 200 countries, leading to over 1.6 million cases and over 99,000 deaths. Given that there is neither a vaccine nor proven treatment for COVID-19, there is currently an urgent need for effective pharmacotherapy. To address the need for an effective treatment of SARS-CoV-2 during the worldwide pandemic, this systematic review of intravenous (IV) remdesivir was performed. Remdesivir, an anti-viral prodrug originally developed to treat Ebola virus disease, has shown broad spectrum activity against the Coronavirus family. A recent case report reported improvement of clinical symptoms with remdesivir in a patient with COVID-19. After conducting a systematic search of 18 clinical trial registries and three large scientific databases, we identified 86 potentially eligible items. Following removal of duplicates (n = 21), eligible studies were reviewed independently by two authors. After the first round of screening, inter-rater agreement was 98.5% (κ = 0.925). After the second round of full-text screening, inter-rater agreement was 100%. A total of seven ongoing and recruiting clinical trials of remdesivir (100-200 milligrams, intravenous [IV]) were included. We identified the following primary outcomes: patients discharged (n = 2); time to clinical status improvement (n = 2); improved O2 saturation (n = 2); body temperature normalization (n = 2); and clinical status (n = 1). Secondary outcomes in all identified studies included documentation of adverse events. Phase 3 trials are expected to be completed between April 2020–2023. Therefore, despite supportive data from in vitro and in vivo studies, the clinical effectiveness of IV remdesivir for treatment of COVID-19 and potential side effects remain incompletely defined in the human population.

First Do No Harm With COVID-19: Corona Collateral Damage Syndrome

Language matters and communication has consequences, sometimes unforseen.  During the Covid-19 public health emergency, public health and elected leaders messaged "Stay at Home" to encourage social distancing to reduce viral transmission. The message in combination with a widespread public fear of acquiring Covid-19 at hospital emergency rooms, resulted in a steep decline in ER visits, even for time sensitive conditions. The Corona Collateral Damage Syndrome is described. A public health messaging course correction is suggested to encourage people with emergencies to come to the emergency room for care.

Electronic Health Record-Based Surveillance for Community Transmitted COVID-19 in the Emergency Department

Introduction: SARS-CoV-2, a novel coronavirus, manifests as a respiratory syndrome (COVID-19) and is the cause of an ongoing pandemic. The response to COVID-19 in the United States has been hampered by an overall lack of diagnostic testing capacity. To address uncertainty about ongoing levels of SARS-CoV-2 community transmission early in the pandemic, we aimed to develop a surveillance tool using readily available emergency department (ED) operations data extracted from the electronic health record (EHR). This involved optimizing the identification of acute respiratory infection (ARI)-related encounters and then comparing metrics for these encounters before and after the confirmation of SARS-CoV-2 community transmission.

Methods: We performed an observational study using operational EHR data from two Midwest EDs with a combined annual census of over 80,000. Data were collected three weeks before and after the first confirmed case of local SARS-CoV-2 community transmission. To optimize capture of ARI cases, we compared various metrics including chief complaint, discharge diagnoses, and ARI-related orders. Operational metrics for ARI cases, including volume, pathogen identification, and illness severity, were compared between the pre- and post-community transmission timeframes using chi-square tests of independence.

Results: Compared to our combined definition of ARI, chief complaint, discharge diagnoses, and isolation orders individually identified less than half of the cases. Respiratory pathogen testing was the top performing individual ARI definition but still only identified 72.2% of cases. From the pre to post periods, we observed significant increases in ED volumes due to ARI and ARI cases without identified pathogen.

Conclusion: Certain methods for identifying ARI cases in the ED may be inadequate and multiple criteria should be used to optimize capture. In the absence of widely available SARS-CoV-2 testing, operational metrics for ARI-related encounters, especially the proportion of cases involving negative pathogen testing, are useful indicators for active surveillance of potential COVID-19 related ED visits.

In Young Adults with COVID-19, Obesity Is Associated with Adverse Outcomes

Introduction: For patients with COVID-19, several characteristics have been identified that may be associated with adverse outcomes. However, there is a paucity of data regarding the effect of obesity on young adult patients with COVID-19. We sought to identify whether adverse outcomes are associated with obesity, particularly in COVID-19 patients 45 years and younger.

Methods: This was a two-center, retrospective cohort study that included 210 patients. Eligible patients were between the ages of 18-45 years old, had tested positive for SARS-CoV-2 on real-time reverse transcription polymerase chain reaction via nasopharyngeal swab, and were not pregnant. Primary outcomes were defined as follows: 1) in-hospital mortality during the study period; 2) need for mechanical ventilation; and 3) admission to the hospital. We analyzed baseline characteristics of the cohort using descriptive statistics. Odds ratios (OR) were calculated to assess associations between outcomes and obesity, defined as body mass index (BMI) >30.

Results: Of those patients who tested positive, 18 died during hospitalization (9%), 36 (17%) required mechanical ventilation, and 94 (45%) were admitted. Each of the primary outcomes was significantly associated with a BMI >30 (mortality OR = 6.29, 95% confidence interval [CI], 1.76-22.46, p = 0.0046; mechanical ventilation OR = 6.01, 95% CI, 2.5-14.48, p = 0.0001; admission OR 2.61, 95% CI, 1.49-4.58, p = .0008).

Conclusion: Obesity appears to be an independent risk factor for poor outcomes in young patients with COVID-19. Future studies examining the clinical characteristics and risk factors of COVID-19 patients across large, diverse populations will strengthen our understanding of this novel and complex disease.

The Next Pandemic: Prepare for “Disease X”

The organism that will cause the next pandemic, which WHO labels “Disease X,” probably already exists. The COVID-19 pandemic will, slowly, and with some hiccups and many tragedies, pass into memory. This coronavirus may disappear and later recur, continue endemically under vaccine control, or simply attenuate and vanish. The economy and healthcare systems will return to a new normal, some parts more quickly than others. Like the multiple plagues humanity has endured since our ancestors gathered into cities, it will generate recriminations for slow and misguided responses, profiteering, and over- or under reacting to economic, social, and healthcare events that will, retrospectively, be obvious. The individuals and organizations most culpable for exacerbating the disaster will escape responsibility while they scapegoat others and try to re-write history. Heroes, whether individuals who helped provide clear risk communication and leadership or groups that persevered in the face of fear and life-threatening danger will emerge. Without fanfare, most will return to their normal jobs, scarred but proud of their efforts. As they have before, pundits and scholars will write endlessly about the pandemic’s cause, effects, and ways to ameliorate the next pandemic’s brutal destruction of lives and ways of life. The problem is, we have done all this before and seemed not to have learned the lessons our predecessors taught.

Brief Review of Chloroquine and Hydroxychloroquine Toxicity and Management

As of April 21, 2020, more than 2.5 million cases of coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, have been reported in 210 countries and territories, with the death toll at 171,810. Both chloroquine and hydroxychloroquine have gained considerable media attention as possible therapies, resulting in a significant surge in demand. In overdose, both medications can cause severe, potentially life-threatening effects. Here, we present a brief overview of the pharmacology of chloroquine and hydroxychloroquine, manifestations of toxicity, and treatment considerations.

A Multidisciplinary Intubation Algorithm for Suspected COVID-19 Patients in the Emergency Department

Introduction: Intubation of patients suspected of having coronavirus disease 2019 (COVID-19) is considered to be a high-risk procedure due to the aerosolization of viral particles. In an effort to minimize the risk of exposure and optimize patient care, we sought to develop, test, provide training, and implement a standardized algorithm for intubating these high-risk patients at our institution.

Methods: We developed an initial intubation algorithm, incorporating strategic use of equipment and incorporating emerging best practices. By combining simulation-based training sessions and rapid-cycle improvement methodology with physicians, nurses, and respiratory therapists, and incorporating their feedback into the development, we were able to optimize the process prior to implementation. Training sessions also enabled the participants to practice the algorithm as a team. Upon completion of each training session, participants were invited to complete a brief online survey about their overall experience.

Results: An algorithm and training system vetted by simulation and actual practice were developed. A training video and dissemination package were made available for other emergency departments to adopt. Survey results were overall positive, with 97.92% of participants feeling confident in their role in the intubation process, and many participants citing the usefulness of the multidisciplinary approach to the training.

Conclusion: A multidisciplinary, team-based approach to the development and training of a standardized intubation algorithm combining simulation and rapid-cycle improvement methodology is a useful, effective process to respond to rapidly evolving clinical information and experiences during a global pandemic.

  • 1 supplemental file

Point-of-care Lung Ultrasound Is More Sensitive than Chest Radiograph for Evaluation of COVID-19

Introduction: Current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR.

Methods: This was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations.

Results: We identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations.

Conclusion: Among patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.

  • 5 supplemental videos
  • 1 supplemental file

Identifying Patients at Greatest Risk of Mortality due to COVID-19: A New England Perspective

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly since December 2019, resulting in a pandemic that has, as of May 24, 2020, yielded over 5.3 million confirmed cases and over 340,000 deaths.1 As businesses move to safely reopen and frontline healthcare workers (HCW) continue to face this crisis, it is essential that health officials know who in the population is at the greatest risk of mortality if hospitalized and, therefore, has the greatest need to protect themselves from being infected. We examined the factors that increase the risk of mortality among hospitalized COVID-19 patients.

Methods: This was a retrospective cohort study including confirmed COVID-19 patients admitted to the four Trinity Health of New England hospitals (THONE) in Connecticut and Massachusetts who either died or were discharged between March 1–April 22, 2020. Demographics, comorbidities, and outcomes of care were extracted from the electronic health record. A model of in-hospital mortality was made using a generalized linear model with binomial distribution and log link.

Results: The analysis included 346 patients: 229 discharged and 117 deceased. The likelihood of in-hospital mortality was increased for patients who were aged 60 or older (relative risk [RR] = 2.873; 95% confidence interval [CI], 1.733-4.764; p = <0.001), had diabetes (RR = 1.432; 95% CI,1.068-1.921; p = 0.016), or had chronic obstructive pulmonary disease (COPD) (RR = 1.410; 95% CI, 1.058-1.878; p = 0.019). Hyperlipidemia had a protective effect, reducing the likelihood of mortality (odds ratio = 0.745; 95% CI, 0.568-0.975; p = 0.032). Sensitivity and specificity of the model were 51.4% and 88.4%, respectively.

Conclusions: Being age 60 or older or having a history of diabetes or COPD are the most useful risk factors associated with mortality in hospitalized COVID-19 patients. As states ease stay-at-home orders, risk factors of severe disease can be used to identify those more likely to have worse outcomes if infected and hospitalized and, therefore, who in particular should continue to follow public health guidelines for avoiding infection: stay home if possible; practice physical distancing; and wear a facemask.

Predictors of Mortality in Adult Population Admitted with COVID-19: A Retrospective Cohort Study from New York City

Introduction: Rapid spread of coronavirus disease 2019 (COVID-19) in the United States, especially in New York City (NYC), led to a tremendous increase in hospitalizations and mortality. There is very limited data available that associates outcomes during hospitalization in patients with COVID-19.

Methods: In this retrospective cohort study, we reviewed the health records of patients with COVID-19 who were admitted from March 9–April 9, 2020, to a community hospital in NYC. Subjects with confirmed reverse transcriptase-polymerase chain reaction (RT-PCR) of the nasopharyngeal swab for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were included. We collected data related to demographics, laboratory results, and outcome of hospitalization. Outcome was measured based on whether the patient was discharged home or died during hospitalization.

Results: There were 888 consecutive admissions with COVID-19 during the study period, of which 513 were excluded with pending outcome or incomplete information. We included a total of 375 patients in the study, of whom 215 (57%) survived and 160 (43%) died during hospitalization. The majority of patients were male (63%) and of Hispanic origin (66%) followed by Blacks (25%), and others (9%). Hypertension (60%) stands out to be the most common comorbidity followed by diabetes mellitus (47%), cardiovascular disease (17%), chronic kidney disease (17%), and human immunodeficiency virus/acquired immunodeficiency syndrome (9%). On multiple regression analysis, increasing odds of mortality during hospitalization was associated with older age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01-1.06 per year increase; p < 0.0001), admission D-dimer more than 1000 nanograms per milliliter (ng/mL) (OR 3.16; 95% CI, 1.75-5.73; p<0.0001), admission C-reactive protein (CRP) levels of more than 200 milligrams per liter  (mg/L) (OR 2.43; 95% CI, 1.36-4.34; p = 0.0028), and admission lymphopenia (OR 2.63; CI, 1.47-4.69; p 0.0010).

Conclusion: In this retrospective cohort study originating in NYC, older age, admission levels of D-dimer of more than 1000 ng/mL, CRP of more than 200 mg/L and lymphopenia were associated with mortality in individuals hospitalized for COVID-19. We recommend using these risk factors on admission to triage patients to critical care units or surge units to maximize the use of surge capacity beds.

Novel Barrier Enclosure for Both Aerosol and Droplet Protection Model

Emergency physicians are on the front lines of treating patients with highly infectious respiratory diseases. Personal protective equipment is one defense against contamination from droplet and aerosol secretions. Intubation is a procedure that greatly can increase provider’s risk of exposure. Utilization of an intubation box has been discussed and recommended on social media platforms. There has been scant literature demonstrating the effectiveness of such devices. This study aimed to determine degree of droplet contamination to the intubator utilizing a novel barrier enclosure with a fluorescent simulated respiratory contagion. This model confirmed both added protection to the providers preforming intubation, and reduction of spread of the droplets when such a device is applied to patient care.

  • 2 supplemental videos

Emergency Department-based Hepatitis A Vaccination Program in Response to an Outbreak

Introduction: The Philadelphia Department of Public Health (PDPH) declared a public health emergency due to hepatitis A in August 2019.1 Our emergency department (ED) serves a population with many of the identified risk factors for hepatitis A transmission. This study examines the impact of an ED-based hepatitis A vaccination program, developed in partnership with the PDPH, on incidence of hepatitis A infection and hospital admission.

Methods: We conducted a retrospective review of all ED visits in the 12-week period centered around the implementation of the ED-based hepatitis A vaccination program. All adult patients presenting to the ED were offered vaccination, with vaccines supplied free of charge by the PDPH. We compared the incidence of diagnosis and of hospital admission for treatment of hepatitis A before and after implementation of the program.

Results: There were 10,033 total ED visits during the study period, with 5009 of them prior to the implementation of the vaccination program and 5024 after implementation. During the study period, 669 vaccines were administered. Before the vaccination program began, 73 patients were diagnosed with hepatitis A, of whom 67 were admitted. After implementation of the program, 38 patients were diagnosed with hepatitis A, of whom 31 were admitted.

Conclusion: A partnership between an ED and the local public health department resulted in the vaccination of 669 patients in six weeks in the midst of an outbreak of a vaccine-preventable illness, with a corresponding drop in ED visits and hospital admission for acute hepatitis A.

Fever Incidence Is Much Lower in the Morning than the Evening: Boston and US National Triage Data

Introduction: In this observational study, we evaluated time-of-day variation in the incidence of fever that is seen at triage. The observed incidence of fever could change greatly over the day because body temperatures generally rise and fall in a daily cycle, yet fever is identified using a temperature threshold that is unchanging, such as ≥38.0° Celsius (C) (≥100.4° Fahrenheit [F]).

Methods: We analyzed 93,225 triage temperature measurements from a Boston emergency department (ED) (2009-2012) and 264,617 triage temperature measurements from the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2002-2010), making this the largest study of body temperature since the mid-1800s. Boston data were investigated exploratorily, while NHAMCS was used to corroborate Boston findings and check whether they generalized. NHAMCS results are nationally representative of United States EDs. Analyses focused on adults.

Results: In the Boston ED, the proportion of patients with triage temperatures in the fever range (≥38.0°C, ≥100.4°F) increased 2.5-fold from morning to evening (7:00-8:59 PM vs 7:00-8:59 AM: risk ratio [RR] 2.5, 95% confidence interval [CI], 2.0-3.3). Similar time-of-day changes were observed when investigating alternative definitions of fever: temperatures ≥39.0°C (≥102.2°F) and ≥40.0°C (≥104.0°F) increased 2.4- and 3.6-fold from morning to evening (7:00-8:59 PM vs 7:00-8:59 AM: RRs [95% CIs] 2.4 [1.5-4.3] and 3.6 [1.5-17.7], respectively). Analyses of adult NHAMCS patients provided confirmation, showing mostly similar increases for the same fever definitions and times of day (RRs [95% CIs] 1.8 [1.6-2.1], 1.9 [1.4-2.5], and 2.8 [0.8-9.3], respectively), including after adjusting for 12 potential confounders using multivariable regression (adjusted RRs [95% CIs] 1.8 [1.5-2.1], 1.8 [1.3-2.4], and 2.7 [0.8-9.2], respectively), in age-group analyses (18-64 vs 65+ years), and in several sensitivity analyses. The patterns observed for fever mirror the circadian rhythm of body temperature, which reaches its highest and lowest points at similar times.

Conclusion: Fever incidence is lower at morning triages than at evening triages. High fevers are especially rare at morning triage and may warrant special consideration for this reason. Studies should examine whether fever-causing diseases are missed or underappreciated during mornings, especially for sepsis cases and during screenings for infectious disease outbreaks. The daily cycling of fever incidence may result from the circadian rhythm.

  • 1 supplemental PDF

Rabies Vaccination Compliance and Reasons for Incompletion

Introduction: Rabies is a fatal disease with a 91% mortality rate in the United States. Current treatment of rabies consists of post-exposure prophylaxis treatment involving a complicated vaccination regimen. Studies conducted in other countries have found that patients do not complete their rabies vaccination treatment due to forgetting about their treatment, lack of time for visits, and the financial burden of treatment. However, little is known about why patients do not complete the rabies series in the US. The objective of this study was to determine the reasons why patients in the US do not complete rabies treatment.

Methods: We performed a retrospective study to evaluate rabies post-exposure prophylaxis completion in the emergency department of an academic suburban hospital between June 2014–  July 2017. Further review was performed for patients who received inadequate vaccination to determine the cause of treatment incompletion. We conducted additional follow-up by phone survey for those patients who did not complete their rabies treatment but had no explanation for discontinuation available in the medical chart review.

Results: Results indicated 198 patients received rabies post-exposure treatment during the inclusion period. Of these, 145 patients completed the rabies vaccination regimen. Reasons for treatment incompletion were found for 29 patients, and 24 patients were lost to follow-up. Of the 29 patients for which discontinuation was assessed, 23 patients (79.3%) stopped treatment due to appropriate reasons – either the animal involved tested negative for the rabies virus or the patient had prior rabies treatment and only required two booster shots. Reasons for not completing the series when medically indicated included the patient deciding to not return for treatment, lack of awareness of the full vaccination regimen, and the patient declining initiation of rabies vaccination.

Conclusion: Most patients in the US discontinue their rabies vaccination treatment for appropriate reasons; however, there is a proportion of patients who discontinue rabies vaccination when further treatment is medically indicated. This subset of patients is particularly at risk of rabies-related mortality, and additional measures need to be taken to ensure increased treatment compliance.

Behavioral Health

Management of Agitation During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.

Prevalence and Predictors of Driving after Prescription Opioid Use in an Adult ED Sample

Introduction: Prescription opioid use and driving is a public health concern given the risks associated with drugged driving, but the issue remains under-studied. We examined the prevalence and correlates of driving after taking prescription opioids (DAPO) among adults seeking emergency department (ED) treatment.

Methods: Participants (aged 25-60) seeking ED care at a Level I trauma center completed a computerized survey. Validated instruments measured prescription opioid use, driving behaviors, and risky driving. Patients who reported past three-month prescription opioid use and drove at least twice weekly were administered an extended study survey measuring DAPO, depression, pain, and substance use.

Results: Among participants completing the screening survey (n = 756; mean age = 42.8 [standard deviation {SD} =10.4]), 37.8% reported past three-month prescription opioid use (30.8% of whom used daily), and 14.7% reported past three-month DAPO. Of screened participants, 22.5% (n = 170) were eligible for the extended study survey. Unadjusted analyses demonstrated that participants reporting DAPO were more likely to use opioids daily (51.1% vs 15.9%) and had higher rates of opioid misuse (mean Current Opioid Misuse Measure score 3.4 [SD = 3.8] vs 1.1 [SD = 2.1]) chronic pain (80.7% vs 42.7%), and driving after marijuana or alcohol use (mean intoxicated driving score 2.1 [SD = 1.3] vs 0.3 [SD = 0.8]) compared to patients not reporting DAPO (all p<0.001). Adjusting for age, gender, employment, and insurance in a logistic regression model, participants reporting DAPO were more likely to report a chronic pain diagnosis (odds ratio [OR] = 3.77, 95% confidence interval [CI], 1.55-9.17), daily opioid use (OR = 3.81, 95% CI, 1.64-8.85), and higher levels of intoxicated driving (OR = 1.62, 95% CI, 1.07-2.45). Alcohol and marijuana use, depression, and opioid misuse were not associated with DAPO in adjusted analyses.

Conclusion: Nearly one in six adult patients seeking ED care reported DAPO. The ED may be an important site for interventions addressing opioid-related drugged driving.

Current Understanding of the Neurobiology of Agitation

Introduction: Managing agitation in the clinical setting is a challenge that many practitioners faceregularly. Our evolving understanding of the etiological factors involved in aggressive acts has betterinformed our interventions through pharmacologic and behavioral strategies. This paper reviews theliterature on the neurobiological underpinnings of aggressive behaviors, linking psychopathology withproposed mechanisms of action of psychiatric medications shown to be effective in mitigating agitation.

Methods: We performed a review of the extant literature using PubMed as a primary database.Investigation focused on neurobiology of agitation and its relation to the current evidence base forparticular interventions.

Results: There are well-established pathways that can lead to increased autonomic response andthe potential for violence. Psychopathology and substance-induced perceptual distortions may leadto magnification and overestimation of environmental threat, heightening the potential for aggression.Additional challenges have arisen with the advent of several novel drugs of abuse, many of whichlead to atypical clinical presentations and which can elude standard drug screens. Our interventionsstill lean on the evidence base found in Project BETA (Best Practices in Evaluation and Treatmentof Agitation). Although not a new drug and not included in the Project BETA guidelines, ketamineand its use are also discussed, given its unique pharmacology and potential benefits when otherprotocoled interventions have failed.

Conclusion: Aggression can occur due to manifold reasons in the clinical setting. Having aninformed understanding of the possible determinants of agitation can help with more tailoredresponses to individual patients, limiting the unnecessary use of medications or of interventions thatcould be deemed forceful.

Technology in Emergency Medicine

Telehealth Solutions for In-hospital Communication with Patients Under Isolation During COVID-19

The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis that has quickly overwhelmed our healthcare system. It has led to significant shortages in personal protective equipment (PPE), ventilators, and intensive care unit beds across the nation. As the initial entry point for patients with suspected COVID illness, emergency departments (ED) have had to adapt quickly to prioritize the safety of patients and providers while still delivering optimal, timely patient care. COVID-19 has presented many challenges for the ED that also extend to all inpatient services. Some of these key challenges are the fundamental tasks of communicating with patients in respiratory isolation while minimizing PPE usage and enabling all patients who have been affected by hospitals’ visitor restrictions to connect with their families. We discuss the design principles behind implementing a robust in-hospital telehealth system for patient-provider and patient-family communication, provide a review of the strengths and weaknesses of potential videoconferencing options, and deliver concise, step-by-step guides for setting up a secure, low-cost, user-friendly solution that can be rapidly deployed.

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Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception in Children Presenting to the Emergency Department: A Systematic Review and Meta-analysis


Ileocolic intussusception is a common cause of pediatric bowel obstruction in youngchildren but can be difficult to diagnose clinically due to vague abdominal complaints. If left untreated,it may cause significant morbidity. Point-of-care ultrasound (POCUS) is a rapid, bedside method ofassessment that may potentially aid in the diagnosis of intussusception. The purpose of this systematicreview and meta-analysis was to determine the diagnostic accuracy of POCUS for children withsuspected ileocolic intussusception by emergency physicians (EP).


We conducted a systematic search on PubMed, Embase, CINAHL, LILACS, the Cochranedatabases, Google Scholar, as well as conference abstracts, and assessed bibliographies of selectedarticles for all studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children.We dual extracted data into a predefined worksheet and performed quality analysis with the QUADAS-2tool. Data were summarized and a meta-analysis was performed


Six studies (n = 1303 children) met our inclusion criteria. Overall, 11.9% of children hadintussusception. POCUS was 94.9% (95% confidence interval [CI], 89.9% to 97.5%) sensitive and 99.1%(95% CI, 94.7% to 99.8%) specific with a likelihood ratio (LR)+ of 105 (95% CI, 18 to 625) and a LR− of0.05 (95% CI, 0.03 to 0.10).


POCUS by EPs is highly sensitive and specific for the identification of intussusception forchildren presenting to the emergency department.

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A Novel Multimodal Approach to Point-of-Care Ultrasound Education in Low-Resource Settings

Point-of-care ultrasound (POCUS) enables physicians to make critical diagnosis and treatment decisions at the bedside. However, access to and expertise with this technology remain limited in Peru. Establishing longitudinal POCUS educational curriculums in remote, low-resource settings can be challenging due to geographical distances, encumbering the ability to provide ongoing hands-on support. Previously described educational interventions have focused on training individual users on clinical applications of POCUS, rather than training physicians how to teach POCUS, thereby limiting scalability and sustainable impact. We therefore describe our experiences establishing the first ultrasound fellowship curriculum in Peru, which incorporates tele-ultrasonography to circumvent traditional geographical barriers.

Visual Estimation of Tricuspid Annular Plane Systolic Excursion by Emergency Medicine Clinicians

Introduction: Tricuspid annular plane systolic excursion (TAPSE) is an established echocardiographic marker of right ventricular (RV) systolic function. The objective of this study was to evaluate whether emergency clinicians can visually estimate RV function using TAPSE in a set of video clips compared to a reference standard M-mode measurement.

Methods: Emergency clinicians were shown a five-minute educational video on TAPSE. Participants then viewed 20 apical four-chamber point-of-care ultrasound (POCUS) echocardiography clips and recorded their estimate of TAPSE distance in centimeters (cm), as well as whether TAPSE was normal (>1.9 cm), borderline (1.5-1.9 cm), or abnormal (<1.5 cm). We calculated sensitivity, specificity, and overall accuracy of visual TAPSE categorization using M-mode measurement as the criterion standard. Participants also reported their comfort with assessing TAPSE on a five-point Likert scale before and after participation in the study.

Results: Among 70 emergency clinicians, including 20 postgraduate year 1-4 residents, 22 attending physicians, and 28 physician assistants (PA), the pooled sensitivity and specificity for visual assessment of TAPSE was 88.6% (95% confidence interval, 85.4-91.7%) and 81.6% (95% CI, 78.2-84.4%), respectively. The sensitivity and specificity for the clips in which the measured TAPSE was <1.5 cm or >1.9 cm was 91.4% (95% CI, 88.4-94.3%) and 90.8% (95% CI, 87.7-93.9%), respectively. There was no significant difference in sensitivity (p = 0.27) or specificity (p = 0.55) between resident and attending physicians or between physicians and PAs (p = 0.17 and p = 0.81). Median self-reported comfort with TAPSE assessment increased from 1 (interquartile range [IQR] 1-2) to 3 (IQR 3-4) points after participation in the study.

Conclusion: A wide range of emergency clinicians demonstrated fair accuracy for visual estimation of TAPSE on previously recorded POCUS echocardiography video clips. These findings should be considered hypothesis generating and warrant validation in larger, prospective studies.


Novice Physician Ultrasound Evaluation of Pediatric Tricuspid Regurgitant Jet Velocity

Introduction: Pulmonary hypertension, associated with high mortality in pediatric patients, is traditionally screened for by trained professionals by measuring a tricuspid regurgitant jet velocity (TRJV). Our objective was to test the feasibility of novice physician sonographers (NPS) to perform echocardiograms of adequate quality to exclude pathology (defined as TRJV > 2.5 meters per second).

Methods: We conducted a cross-sectional study of NPS to assess TRJV by echocardiogram in an urban pediatric emergency department. NPS completed an educational course consisting of a didactic curriculum and hands-on workshop. NPS enrolled a convenience sample of patients aged 7-21 years. Our primary outcome was the proportion of echocardiograms with images of adequate quality to exclude pathology. Our secondary outcome was NPS performance on four image elements. We present descriptive statistics, binomial proportions, kappa coefficients, and logistic regression analysis.

Results: Eight NPS completed 80 echocardiograms. We found 82.5% (95% confidence interval [CI], 74.2-90.8) of echocardiograms had images of adequate quality to exclude pathology. Among image elements, NPS obtained a satisfactory, apical 4-chamber view in 85% (95% CI, 77.1-92.9); positioned the color box accurately 65% (95% CI, 54.5-75.5); optimized TRJV color signal 78.7% (95% CI, 69.8-87.7); and optimized continuous-wave Doppler in 55% (95% CI, 44.1-66.0) of echocardiograms.

Conclusion: NPS obtained images of adequate quality to exclude pathology in a majority of studies; however, optimized acquisition of specific image elements varied. This work establishes the basis for future study of NPS assessment of TRJV pathology when elevated pulmonary pressures are of clinical concern.


Fall Prevention Knowledge, Attitudes, and Behaviors: A Survey of Emergency Providers

Introduction: Falls are a frequent reason geriatric patients visit the emergency department (ED). To help providers, the Geriatric Emergency Department Guidelines were created to establish a standard of care for geriatric patients in the ED. We conducted a survey of emergency providers to assess 1) their knowledge of fall epidemiology and the geriatric ED guidelines; 2) their current ED practice for geriatric fall patients; and 3) their willingness to conduct fall-prevention interventions.

Methods: We conducted an anonymous survey of emergency providers including attending physicians, residents, and physician assistants at a single, urban, Level 1 trauma, tertiary referral hospital in the northeast United States.

Results: We had a response rate of 75% (102/136). The majority of providers felt that all geriatric patients should undergo screening for fall risk factors (84%, 86/102), and most (76%, 77/102) answered that all geriatric patients screened and at risk for falls should have an intervention performed. While most (80%, 82/102) answered that geriatric falls prevention was very important, providers were not willing to spend much time on screening or interventions. Less than half (44%, 45/102) were willing to spend 2-5 minutes on a fall risk assessment and prevention, while 46% (47/102) were willing to spend less than 2 minutes.

Conclusion: Emergency providers understand the importance of geriatric fall prevention but lack knowledge of which patients to screen and are not willing to spend more than a few minutes on screening for fall interventions.  Future studies must take into account provider knowledge and willingness to intervene.

Emergency Medical Services

Home-based Testing for SARS-CoV-2: Leveraging Prehospital Resources for Vulnerable Populations

Introduction: Expanded testing for SARS-CoV-2 is critical to characterizing the extent of community spread of COVID-19 and to identifying infectious cohorts. Unfortunately, current facility-based testing compounds shortcomings in testing availability, neglecting those who are frail or physically unable to travel to a testing facility.

Methods: We developed an emergency medical service (EMS)-based home testing and evaluation program, leveraging existing community EMS resources. This program has kept vulnerable populations out of the emergency department, reduced cost, and improved access to care.

Results: Our EMS-based testing program can test approximately 15 homebound patients per day. Through April 2020 our program had performed 477 home-based tests. Additionally, we have recently undertaken several mass testing operations, testing up to 900 patients per testing site.

Conclusion: Facility-based SARS-CoV-2 testing requires that a patient physically present to a facility for a nasopharyngeal swap to be collected. Unfortunately, access may be limited for patients that are homebound, chronically ill, or without a means of private transportation. By leveraging existing EMS infrastructure in new ways, our community has been able to keep almost 500 vulnerable patients in their home. Using EMS, we can strengthen the healthcare system’s response to the evolving COVID-19 pandemic and support at-risk populations, including those that are underserved, homebound, and frail.

Recommendations for Prehospital Airway Management in Patients with Suspected COVID-19 Infection

In light of the rapid spread of coronavirus disease 2019 (COVID-19) across the United States, the Centers for Disease Control and Prevention (CDC) and hospitals nationwide have developed new protocols to address infection control as well as the care of critical patients. Airway management has been particularly difficult; the challenge of quickly establishing an airway in patients must be balanced by the risk of aerosolizing respiratory secretions and putting the provider at risk of infection. Significant attention has been given to developing protocols for the emergency department and critical care units, but little guidance regarding establishing airway and respiratory support for patients in the prehospital setting has been made available. While some of the recommendations can be extrapolated from hospital guidelines, other factors such as environment and available resources make these protocols unfeasible. Through review of current literature the authors established recommendations regarding airway management and the provision of respiratory support to patients developing respiratory failure related to COVID-19.

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care

Introduction: We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California.

Methods: We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations.

Results: PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol.

Conclusion: Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.


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Rural Interfacility Emergency Department Transfers: Framework and Qualitative Analysis

Introduction: Interfacility transfers from rural emergency departments (EDs) are an important means of access to timely and specialized care.

Methods: Our goal was to identify and explore facilitators and barriers in transfer processes and their implications for emergency rural care and access. Semi-structured interviews with ED staff at five rural and two urban Veterans Health Administration (VHA) hospitals were recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to identify themes and construct a conceptual framework.

Results: From 81 interviews with clinical and administrative staff between March–June 2018, four themes in the interfacility transfer process emerged: 1) patient factors; 2) system resources; and 3) processes and communication for transfers, which culminate in 4) the location decision. Current and anticipated resource limitations were highly influential in transfer processes, which were described as burdensome and diverting resources from clinical care for emergency patients. Location decision was highly influenced by complexity of the transfer process, while perceived quality at the receiving location or patient preferences were not reported in interviews as being primary drivers of location decision. Transfers were described as burdensome for patients and their families. Finally, patients with mental health conditions epitomized challenges of emergency transfers.

Conclusion: Interfacility transfers from rural EDs are multifaceted, resource-driven processes that require complex coordination. Anticipated resource needs and the transfer process itself are important determinants in the location decision, while quality of care or patient preferences were not reported as key determinants by interviewees. These findings identify potential benefits from tracking transfer boarding as an operational measure, directed feedback regarding outcomes of transferred patients, and simplified transfer processes.

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Critical Care

Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover

Introduction: The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times.

Methods: An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED.

Results: A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm -11:30 pm (372) and 2:31 pm -3:30 pm (365). The minimum was placed between 7:31 am – 8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6-1,434; interquartile range 144-174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am - 5:30 am (120 minutes [min]), 12:31 pm - 1:30 pm (145 min), and 9:31 pm - 10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am - 8:30 am (177 min), 4:31 pm - 5:30 pm (218 min), and 11:31 pm - 12:30 am (179 min).

Conclusion: ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients’ outcomes by minimizing ED provider handoffs.

The Utility of Color Doppler to Confirm Endotracheal Tube Placement: A Pilot Study

Introduction: Grayscale ultrasound (US) imaging has been used as an adjunct for confirming endotracheal tube (ETT) placement in recent years. The addition of color Doppler imaging (CDI) has been proposed to improve identification but has not been well studied. The aim of this study was to assess whether CDI improves correct localization of ETT placement.

Methods: A convenience sample of emergency and critical care physicians at various levels of training and experience participated in an online assessment. Participants viewed US video clips of patients, which included either tracheal or esophageal intubations captured in grayscale or with CDI; there were five videos of each for a total of 20 videos. Participants were asked to watch each clip and then assess the location of the ETT.

Results: Thirty-eight subjects participated in the online assessment. Levels of training included medical students (13%), emergency medicine (EM) residents (50%), EM attendings (32%), and critical care attendings (5%). The odds ratio of properly assessing tracheal placement using color relative to a grayscale imaging technique was 1.5 (p = 0.21). Regarding the correct assessment of esophageal placement, CDI had 1.4 times the odds of being correctly assessed relative to grayscale (p = 0.26). The relationship between training level and correct assessments was not significant for either tracheal or esophageal placements.

Conclusion: In this pilot study we found no significant improvement in correct identification of ETT placement using color Doppler compared to grayscale ultrasound; however, there was a trend toward improvement that might be better elucidated in a larger study.

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Decrease in Trauma Admissions with COVID-19 Pandemic

Introduction: The COVID-19 pandemic has led to social distancing and decreased travel in the United States. The impact of these interventions on trauma and emergency general surgery patient volume has not yet been described.

Methods: We compared trauma admissions and emergency general surgery (EGS) cases between February 1–April 14 from 2017-2020 in five two-week time periods. Data were compared across time periods with Poisson regression analysis.

Results: There were significant decreases in overall trauma admissions (57.4% decrease, p<0.001); motor vehicle collisions (MVC) (80.5% decrease, p<0.001); and non-MVCs (45.1% decrease, p<0.001) from February–April 2020. We found no significant change in EGS cases (p = 0.70). Nor was there was a significant change in trauma cases in any other year 2017-2019.

Conclusion: The COVID-19 pandemic’s burden of disease correlated with a significant decrease in trauma admissions, with MVCs experiencing a larger decrease than non-MVCs.


Documentation Displaces Teaching in an Academic Emergency Department

Introduction: Adverse effects of administrative burden on emergency physicians have been described previously, but the impact of electronic health record documentation by academic emergency attendings on resident education is not known. In this observational study of a quaternary care, academic emergency department, we sought to assess whether the amount of time attending physicians spent on documentation affected the amount of time they spent teaching.

Methods: A fourth-year emergency medicine (EM) resident observed 10 attending physicians over 42 hours during 11 shifts, recording their activities every 30 seconds. Activity categories were developed iteratively by the study team and validated through co-observation by an EM education fellow with a kappa of 0.89. We used regression analysis to assess the relationship between time spent documenting and time spent teaching, as well as the relationship between these two activities and all other attending activity categories.

Results: Results demonstrate that time spent documenting was significantly and specifically associated with less time spent teaching, controlling for patient arrivals per hour; every minute spent on documentation was associated with 0.48 fewer minutes spent teaching (p<0.05). Further, documentation time was not strongly associated with time spent on any other activity including patient care, nor did any other activity significantly predict teaching time.

Conclusion: Findings suggest that academic attendings may face a trade-off between their documentation and teaching duties. Further study is needed to explore how administrative expectations placed on academic emergency physicians might interfere with trainee education.

Assessment of Emergency Medicine Residents’ Clinical Reasoning: Validation of a Script Concordance Test

Introduction: A primary aim of residency training is to develop competence in clinical reasoning. However, there are few instruments that can accurately, reliably, and efficiently assess residents’ clinical decision-making ability. This study aimed to externally validate the script concordance test in emergency medicine (SCT-EM), an assessment tool designed for this purpose.

Methods: Using established methodology for the SCT-EM, we compared EM residents’ performance on the SCT-EM to an expert panel of emergency physicians at three urban academic centers. We performed adjusted pairwise t-tests to compare differences between all residents and attending physicians, as well as among resident postgraduate year (PGY) levels. We tested correlation between SCT-EM and Accreditation Council for Graduate Medical Education Milestone scores using Pearson’s correlation coefficients. Inter-item covariances for SCT items were calculated using Cronbach’s alpha statistic.

Results: The SCT-EM was administered to 68 residents and 13 attendings. There was a significant difference in mean scores among all groups (mean + standard deviation: PGY-1 59 + 7; PGY-2 62 + 6; PGY-3 60 + 8; PGY-4 61 + 8; 73 + 8 for attendings, p < 0.01). Post hoc pairwise comparisons demonstrated that significant difference in mean scores only occurred between each PGY level and the attendings (p < 0.01 for PGY-1 to PGY-4 vs attending group). Performance on the SCT-EM and EM Milestones was not significantly correlated (r = 0.12, p = 0.35). Internal reliability of the exam was determined using Cronbach’s alpha, which was 0.67 for all examinees, and 0.89 in the expert-only group.

Conclusion: The SCT-EM has limited utility in reliably assessing clinical reasoning among EM residents. Although the SCT-EM was able to differentiate clinical reasoning ability between residents and expert faculty, it did not between PGY levels, or correlate with Milestones scores. Furthermore, several limitations threaten the validity of the SCT-EM, suggesting further study is needed in more diverse settings.

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Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Conference Didactic Planning and Structure: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. To our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. This paper offers expert guidelines for didactic instruction from members of the Council of Emergency Medicine Residency Directors Best Practices Subcommittee, based on best available evidence. Programs can use these recommendations to further optimize their resident conference structure and content. Recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. Authors also recommend following the Model of Clinical Practice of Emergency Medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism.

Research Publishing

A Review of Journal Impact Metrics and Characteristics to Assist Emergency Medicine Investigators with Manuscript Submission Decisions

Introduction: A crucial, yet subjective and non-evidence-based, decision for researchers is where to submit their original research manuscripts. The approach of submitting to journals in descending order of impact factor (IF) is a common but imperfect strategy. The validity of the IF as a measure of journal quality and significance is suspect, and a number of other journal impact scores have emerged, such that no one scale is universally accepted. Furthermore, practical considerations, such as likelihood of manuscript acceptance rates and times for decisions, may influence how authors prioritize journals. In this report, we sought to 1) review emergency medicine (EM) journal impact metrics, and 2) provide a comprehensive list of pertinent journal characteristics that may influence researchers’ choice of submission.

Methods: We systematically reviewed five impact metrics (IF, H Index, CiteScore, Source-Normalized Impact per Paper, and SCImago Journal Rank) and other relevant characteristics of 20 EM journals.

Results: We found good to excellent agreement in ordinal rankings of four of the journal impact metrics, as measured by the Spearman rank correlation coefficient. The median acceptance rate for original research manuscripts in the EM category was 25% (interquartile range [IQR] 18, 31%), and the median initial decision time was 33 days (IQR 18, 56 days). Fourteen EM journals (70%) accepted brief reports, and 15 (75%) accepted case reports/images.

Conclusion: We recommend replication, expansion, and formalization of this repository of information for EM investigators in a continuously updated, open-access forum sponsored by an independent organization.

Consensus Guidelines for Digital Scholarship in Academic Promotion

Introduction: As scholarship moves into the digital sphere, applicant and promotion and tenure (P&T) committee members lack formal guidance on evaluating the impact of digital scholarly work. The P&T process requires the appraisal of individual scholarly impact in comparison to scholars across institutions and disciplines. As dissemination methods evolve in the digital era, we must adapt traditional P&T processes to include emerging forms of digital scholarship.

Methods: We conducted a blended, expert consensus procedure using a nominal group process to create a consensus document at the Council of Emergency Medicine Residency Directors Academic Assembly on April 1, 2019.

Results: We discussed consensus guidelines for evaluation and promotion of digital scholarship with the intent to develop specific, evidence-supported recommendations to P&T committees and applicants. These recommendations included the following: demonstrate scholarship criteria; provide external evidence of impact; and include digital peer-review roles. As traditional scholarship continues to evolve within the digital realm, academic medicine should adapt how that scholarship is evaluated. P&T committees in academic medicine are at the epicenter for supporting this changing paradigm in scholarship.

Conclusion: P&T committees can critically appraise the quality and impact of digital scholarship using specific, validated tools. Applicants for appointment and promotion should highlight and prepare their digital scholarship to specifically address quality, impact, breadth, and relevance. It is our goal to provide specific, timely guidance for both stakeholders to recognize the value of digital scholarship in advancing our field.

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Health Outcomes

Practice Gap in Atrial Fibrillation Oral Anticoagulation Prescribing at Emergency Department Home Discharge

Introduction: Current U.S. cardiology guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in selected patients with atrial fibrillation (AF), but no formal AF OAC recommendations exist to guide emergency medicine clinicians in the acute care setting. We sought to characterize emergency department (ED) OAC prescribing practices after an ED AF diagnosis.

Methods: This retrospective study included index visits for OAC-naive patients ≥18 years old who were discharged home from the ED at an urban, academic, tertiary hospital with a primary diagnosis of AF from 2012-2014. Five hypothesis-blinded, chart reviewers abstracted data from patient problem lists and medical history in the electronic health record to assess stroke (CHA2DS2-VASc) and bleeding risk (HAS-BLED). The primary outcome was the provision of an OAC prescription at discharge in OAC-naive patients with high stroke risk. Descriptive statistics and multivariable logistic regression assessed associations between OAC prescription and patient characteristics.

Results: We included 138 patient visits in our analysis, of whom 39.9% (n = 55) were low stroke risk (CHA2DS2-VASc = 0 in males and 1 in females), 15.9% (n = 22) were intermediate risk (CHA2DS2-VASc = 1 in males), and 44.2% (n = 61) were high risk (CHA2DS2-VASc ≥ 2). Of patients with high stroke risk and low-to-intermediate bleeding risk (n = 57), 80.7% were not prescribed an OAC at discharge. Cardiology consultation and female gender, but not stroke risk (CHA2DS2-VASc score), were predictors of an ED provider prescribing an OAC to an OAC-naive AF patient at ED discharge.

Conclusion: The majority of OAC-eligible patients were discharged home without an OAC prescription. In OAC-naive patients discharged home from the ED, cardiology consultation and female gender were associated with OAC prescription. Our findings suggest that access to expert opinion may improve provider comfort with OAC prescribing and highlight the need for improved guidelines specific to ED-management of AF.

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Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

Introduction: Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.

Methods: This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.

Results: We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.

Conclusion: The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.


Necrotizing Fasciitis Within 72 hours After Presentation with Skin and Skin Structure Infection

Introduction: A small percentage of patients with skin infections later develop necrotizing fasciitis (NF). Diagnostic testing is needed to identify patients with skin infections at low risk of NF who could be discharged from the emergency department (ED) after antibiotic initiation. Elevated lactate has been associated with NF; existing estimates of the frequency of NF are based on retrospective reviews, and cases often lack testing for lactate. We present the incidence of patients with skin infections who developed NF and their baseline lactates.

Methods: In four phase-3 trials, 2883 adults with complicated or acute bacterial skin and skin structure infections were randomized to dalbavancin or comparator, with early and late follow-up visits through Day 28. We prospectively collected baseline plasma lactates in one trial to assess an association with NF.

Results: NF was diagnosed in 3/2883 patients (0.1%); all three survived. In the study with prospectively collected baseline lactates (n = 622), 15/622 (2.4%) had a lactate ≥4 millimoles per liter (mmol/L), including 3/622 (0.5%) with a lactate ≥7 mmol/L. NF was not seen in patients with a lactate <4 mmol/L; NF was seen in 1/15 (6.7%) with a lactate ≥4 mmol/L, including 1/3 (33.3%) with lactate ≥7 mmol/L.

Conclusions: NF incidence within 72 hours of antibiotic initiation in patients with complicated or acute bacterial skin and skin structure infections was extremely low (0.1%) and occurred in 6.7% with a lactate ≥4 mmol/L. Lactate <4 mmol/L can be used to identify patients at low risk of NF who could be safely discharged from the ED after antibiotic initiation.

Population Health and Social Emergency Medicine

Social Determinants of Hallway Bed Use

Introduction: Hallway beds in the emergency department (ED) produce lower patient satisfaction and inferior care. We sought to determine whether socioeconomic factors influence which visits are assigned to hallway beds, independent of clinical characteristics at triage.

Methods: We studied 332,919 visits, across 189,326 patients, to two academic EDs from 2013-2016. We estimated a logistic model of hallway bed assignment, conditioning on payor, demographics, triage acuity, chief complaint, patient visit frequency, and ED volume. Because payor is not generally known at the time of triage, we interpreted it as a proxy for other observable characteristics that may influence bed assignment. We estimated a Cox proportional hazards model of hallway bed assignment on length of stay.

Results: Median patient age was 53. 54.0% of visits were by women. 42.1% of visits were paid primarily by private payors, 37.1% by Medicare, and 20.7% by Medicaid. A total of 16.2% of visits were assigned to hallway beds. Hallway bed assignment was more likely for frequent ED visitors, for lower acuity presentations, and for psychiatric, substance use, and musculoskeletal chief complaints, which were more common among visits paid primarily by Medicaid. In a logistic model controlling for these factors, as well as for other patient demographics and for the volume of recent ED arrivals, Medicaid status was nevertheless associated with 22% greater odds of assignment to a hallway bed (odds ratio 1.22, [95% confidence interval, CI, 1.18-1.26]), compared to private insurance. Visits assigned to hallway beds had longer lengths of stay than roomed visits of comparable acuity (hazard ratio for departure 0.91 [95% CI, 0.90-0.92]).

Conclusion: We find evidence of social determinants of hallway bed use, likely involving epidemiologic, clinical, and operational factors. Even after accounting for different distributions of chief complaints and for more frequent ED use by the Medicaid population, as well as for other visit characteristics known at the time of triage, visits paid primarily by Medicaid retain a disproportionate association with hallway bed assignment. Further research is needed to eliminate potential bias in the use of hallway beds.

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Food Insecurity and Insulin Use in Hyperglycemic Patients Presenting to the Emergency Department

Introduction: The prevalence of food insecurity (FI) and insulin rationing among patients with diabetes who present to the emergency department (ED) is unclear. We examined the prevalence of food insecurity and subtherapeutic insulin use among patients who presented to the ED with a blood glucose level of greater than 250 milligrams per deciliter.

Methods: This was a single-center, cross-sectional survey of clinically stable, hyperglycemic adults in the ED for food insecurity using the Hunger Vital Sign screening tool. Patients who were insulin dependent were asked about insulin usage and rationing.

Results: Of the 85 eligible patients, 76 (89.4%) were enrolled; 35 (46%) screened positive for food insecurity. Food insecure patients were 1.9 times more likely to be hospitalized than non-food insecure patients (relative risk = 1.90 [1.21-2.99], p<.01). Food insecure patients were younger than non-food insecure patients (50.4 vs 57.5 p<.02), and had significantly higher hemoglobin A1c (HgbA1c) levels (11.2% vs 9.9% p = 0.04). Of the 49 patients prescribed insulin, 17 (34.6%) stated they had used less insulin during the prior week than had been prescribed, and 21 (42.9%) stated they had used less insulin during the prior year than had been prescribed. Food insecure patients were more likely to have used less insulin than prescribed in the prior year (odds ratio = 3.60 [1.09-11.9], p = 0.04).

Conclusion: Our exploratory findings suggest almost half of clinically stable adults presenting to our inner-city ED with hyperglycemia experience food insecurity. More than one-third of those prescribed insulin used less than their prescribed amount in the prior year.

Patient and Community Organization Perspectives on Accessing Social Resources from the Emergency Department: A Qualitative Study

Introduction: Social risks adversely affect health and are associated with increased healthcare utilization and costs. Emergency department (ED) patients have high rates of social risk; however, little is known about best practices for ED-based screening or linkage to community resources. We examined the perspectives of patients and community organizations regarding social risk screening and linkage from the ED.

Methods: Qualitative interviews were conducted with a purposive sample of ED patients and local community organization staff. Participants completed a brief demographic survey, health literacy assessment, and qualitative interview focused on barriers/facilitators to social risk screening in the ED, and ideas for screening and linkage interventions in the ED. Interviews were conducted in English or Spanish, recorded, transcribed, and coded. Themes were identified by consensus.

Results: We conducted 22 interviews with 16 patients and six community organization staff. Three categories of themes emerged. The first related to the importance of social risk screening in the ED. The second category encompassed challenges regarding screening and linkage, including fear, mistrust, transmission of accurate information, and time/resource constraints. The third category included suggestions for improvement and program development. Patients had varied preferences for verbal vs electronic strategies for screening. Community organization staff emphasized resource scarcity and multimodal communication strategies.

Conclusion: The development of flexible, multimodal, social risk screening tools, and the creation and maintenance of an accurate database of local resources, are strategies that may facilitate improved identification of social risk and successful linkage to available community resources.

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