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Open Access Publications from the University of California

Volume 22, Issue 2, 2021

WestJEM Volume 22 Issue 2 - March

Health Outcomes

Persistent and Widespread Pain Among Blacks Six Weeks after MVC: Emergency Department-based Cohort Study

Introduction: Blacks in the United States experience greater persistent pain than non-Hispanic Whites across a range of medical conditions, but to our knowledge no longitudinal studies have examined the risk factors or incidence of persistent pain among Blacks experiencing common traumatic stress exposures such as after a motor vehicle collision (MVC). We evaluated the incidence and predictors of moderate to severe axial musculoskeletal pain (MSAP) and widespread pain six weeks after a MVC in a large cohort of Black adults presenting to the emergency department (ED) for care.

Methods: This prospective, multi-center, cohort study enrolled Black adults who presented to one of 13 EDs across the US within 24 hours of a MVC and were discharged home after their evaluation. Data were collected at the ED visit via patient interview and self-report surveys at six weeks after the ED visit via internet-based, self-report survey, or telephone interview. We assessed MSAP pain at ED visit and persistence at six weeks. Multivariable models examined factors associated with MSAP persistence at six weeks post-MVC.

Results: Among 787 participants, less than 1% reported no pain in the ED after their MVC, while 79.8 (95% confidence interval [CI], 77.1 – 82.2) reported MSAP and 28.3 (95% CI, 25.5 – 31.3) had widespread pain. At six weeks, 67% (95% CI, 64, 70%) had MSAP and 31% (95% CI, 28, 34%) had widespread pain. ED characteristics predicting MSAP at six weeks post-MVC (area under the curve  = 0.74; 95% CI, 0.72, 0.74) were older age, peritraumatic dissociation, moderate to severe pain in the ED, feeling uncertain about recovery, and symptoms of depression.

Conclusion: These data indicate that Blacks presenting to the ED for evaluation after MVCs are at high risk for persistent and widespread musculoskeletal pain. Preventive interventions are needed to improve outcomes for this high-risk group.

Emergency Department Patients Who Leave Before Treatment Is Complete

Introduction: Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system.

Methods: This retrospective, multicenter study examined all encounters from January 1–December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. 

Results: During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system.

Conclusion: In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.

The Utility of Pain Scale to Assess Verifiable vs Non- Verifiable Pain in United States Emergency Departments

Introduction: We sought to examine the utility of self-reported pain scale by comparing emergency department (ED) triage pain scores of self-reported but non-verifiable painful conditions with those of verifiable painful conditions using a large, nationally representative sample.

Methods: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2015. Verifiable painful conditions were identified based on the final diagnoses in the five included International Classification of Diseases 9th revision codes. Non-verifiable painful conditions were identified by the five main reasons for visit. Only adults 18 years of age or older were included. The primary outcome variable was the pain scale from 0 to 10 at triage. We performed descriptive and multivariate analyses to investigate the relationships between the pain scale and whether the painful condition was verifiable, controlling for patient characteristics.

Results: There were 55 million pain-related adult ED visits in 2015. The average pain scale was 6.49. For verifiable painful diagnoses, which were about 24% of the total visits, the average was 6.27, statistically significantly lower than that for non-verifiable painful conditions, 6.56. Even after controlling for the confounding of patient characteristics and comorbidities, verifiable painful diagnoses still presented less pain than those with non-verifiable painful complaints. Older age, female gender, and urban residents had significantly higher pain scores than their respective counterparts, controlling for other confounding factors. Psychiatric disorders were independently associated with higher pain scores by about a half point. 

Conclusion: Self-reported pain scales obtained at ED triage likely have a larger psychological component than a physiological one. Close attention to clinical appropriateness and overall patient comfort are more likely to lead to better health outcomes and patient experiences than focusing on self-reported pain alone.

Four-factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors versus Warfarin in Life-threatening Bleeding

Introduction: Factor Xa (fXa) inhibitor reversal for life-threatening bleeding is controversial due to a lack of high-quality evidence. The purpose of this study was to determine the hemostatic efficacy of four-factor prothrombin complex concentrate (4F-PCC) for the reversal of fXa inhibitors compared to warfarin for life-threatening bleeding.

Methods: This was a multicenter, retrospective cohort study at two academic medical centers between January 1, 2014–December 31, 2019, which included patients who presented to the emergency department with a life-threatening bleed necessitating anticoagulation reversal with 4F-PCC. The primary endpoint was achievement of hemostatic efficacy after 4F-PCC administration.

Results: Of the 525 patients who had an order for 4F-PCC during the study period, 148 patients met the criteria for inclusion (n = 48 fXa inhibitor group; n = 100 warfarin group). Apixaban (52.1%) and rivaroxaban (45.8%) were the most commonly used fXa inhibitors. Effective hemostasis was similar between groups (79.2% fXa inhibitor group vs 85% warfarin group, p = 0.38). This was consistent across all types of bleeding. Thrombotic events were rare in both groups (2% vs 3%). 

Conclusion: This multicenter, retrospective cohort study demonstrated that using 4F-PCC for treatment of life-threatening bleeding produced effective hemostasis in patients on fXa inhibitors and warfarin.

Diagnostic Uncertainty in Dyspneic Patients with Cancer in the Emergency Department

Objective: Dyspnea is the second most common symptom experienced by the approximately 4.5 million patients with cancer presenting to emergency departments (ED) each year. Distinguishing pneumonia, the most common reason for presentation, from other causes of dyspnea is challenging. This report characterizes the diagnostic uncertainty in patients with dyspnea and pneumonia presenting to an ED by establishing the rates of co-diagnosis, co-treatment, and misdiagnosis.

Methods: Visits by individuals ≥18 years old with cancer who presented with a complaint of dyspnea were identified using the National Hospital Ambulatory Medical Care Survey between 2012-2014 and analyzed for rates of co-diagnosis, co-treatment (treatment or diagnosis for >1 of pneumonia, chronic obstructive pulmonary disease [COPD], and heart failure), and misdiagnosis of pneumonia. Additionally, we assessed rates of diagnostic uncertainty (co-diagnosis, co-treatment, or a lone diagnosis of dyspnea not otherwise specified [NOS]) .

Results: Among dyspneic cancer visits (1,593,930), 15.2% (95% confidence interval [CI], 11.1-20.5%) were diagnosed with pneumonia, 22.5% (95% CI, 16.7-29.7%) with COPD, and 7.4% (95% CI 4.7-11.4%) with heart failure. Dyspnea NOS was diagnosed in 32.3% (95% CI, 25.7-39.7%) of visits and as the only diagnosis in 23.1% (95% CI, 16.3-31.6%) of all visits. Co-diagnosis occurred in 4.0% (95% CI, 2.0-7.6%) of dyspneic adults with cancer and co-treatment in 12.1% (95% CI, 7.5-18.9%). Agreement between emergency physician and inpatient documentation for presence of pneumonia was 57.7% (95% CI, 37.0-76.1%).

Conclusion: Diagnostic uncertainty remains a significant concern in patients with cancer presenting to the ED with dyspnea. Clinical uncertainty among dyspneic patients results in both misdiagnosis and under-treatment of patients with pneumonia and cancer.

Effect of Blood Pressure Variability on Outcomes in Emergency Patients with Intracranial Hemorrhage

Introduction: Patients with spontaneous intracranial hemorrhage (sICH) have high mortality and morbidity, which are associated with blood pressure variability. Additionally, blood pressure variability is associated with acute kidney injury (AKI) in critically ill patients, but its association with sICH patients in emergency departments (ED) is unclear. Our study investigated the association between blood pressure variability in the ED and the risk of developing AKI during sICH patients’ hospital stay.

Methods: We retrospectively analyzed patients with sICH, including those with subarachnoid and intraparenchymal hemorrhage, who were admitted from any ED and who received an external ventricular drain at our academic center. Patients were identified by the International Classification of Diseases, Ninth Revision (ICD-9). Outcomes were the development of AKI, mortality, and being discharged home. We performed multivariable logistic regressions to measure the association of clinical factors and interventions with outcomes.

Results: We analyzed the records of 259 patients: 71 (27%) patients developed AKI, and 59 (23%) patients died. Mean age (± standard deviation [SD]) was 58 (14) years, and 150 (58%) were female. Patients with AKI had significantly higher blood pressure variability than patients without AKI. Each millimeter of mercury increment in one component of blood pressure variability, SD in systolic blood pressure (SBPSD), was significantly associated with 2% increased likelihood of developing AKI (odds ratio [OR] 1.02, 95% confidence interval [CI], 1.005-1.03, p = 0.007). Initiating nicardipine infusion in the ED (OR 0.35, 95% CI, 0.15-0.77, p = 0.01) was associated with lower odds of in-hospital mortality. No ED interventions or blood pressure variability components were associated with patients’ likelihood to be discharged home.

Conclusion: Our study suggests that greater SBPSD during patients’ ED stay is associated with higher likelihood of AKI, while starting nicardipine infusion is associated with lower odds of in-hospital mortality. Further studies about interventions and outcomes of patients with sICH in the ED are needed to confirm our observations.

  • 3 supplemental files

Evidence-Based Heatstroke Management in the Emergency Department

Introduction: Climate change is causing an increase in the frequency and intensity of extreme heat events, which disproportionately impact the health of vulnerable populations. Heatstroke, the most serious heat-related illness, is a medical emergency that causes multiorgan failure and death without intervention. Rapid recognition and aggressive early treatment are essential to reduce morbidity and mortality. The objective of this study was to evaluate current standards of care for the emergent management of heatstroke and propose an evidence-based algorithm to expedite care.

Methods: We systematically searched PubMed, Embase, and key journals, and reviewed bibliographies. Original research articles, including case studies, were selected if they specifically addressed the recognition and management of heatstroke in any prehospital, emergency department (ED), or intensive care unit population. Reviewers evaluated study quality and abstracted information regarding demographics, scenario, management, and outcome.

Results: In total, 63 articles met full inclusion criteria after full-text review and were included for analysis. Three key themes identified during the qualitative review process included recognition, rapid cooling, and supportive care. Rapid recognition and expedited external or internal cooling methods coupled with multidisciplinary management were associated with improved outcomes. Delays in care are associated with adverse outcomes. We found no current scalable ED alert process to expedite early goal-directed therapies.

Conclusion: Given the increased risk of exposure to heat waves and the time-sensitivity of the condition, EDs and healthcare systems should adopt processes for rapid recognition and management of heatstroke. This study proposes an evidence-based prehospital and ED heat alert pathway to improve early diagnosis and resource mobilization. We also provide an evidence-based treatment pathway to facilitate efficient patient cooling. It is hoped that this protocol will improve care and help healthcare systems adapt to changing environmental conditions.

  • 2 supplemental files

Norepinephrine in Septic Shock: A Systematic Review and Meta-analysis

Introduction: Most experts recommend norepinephrine as the first-line agent in septic shock. Our objective was to determine the effectiveness and safety of norepinephrine in patients with septic shock.

Methods: We searched the Cochrane Central Register of Controlled Trials and Epistemonikos, as well as MEDLINE from 1966 till August 2019. Screening of full texts, evaluation for eligibility, and data extraction were done by four independent reviewers. We estimated risk ratios (RR) and mean differences (MD) using a random-effects model with 95% confidence intervals (CI). The primary outcomes included the number of participants who achieved the target mean arterial pressure (MAP), time to achieve the target MAP, and number of participants with all-cause 28-day mortality. The secondary outcomes included the length of stay in the intensive care unit, length of hospital stay, incidence of arrhythmia and myocardial infarction, vasopressor-free days, and number of participants with all-cause 90-day mortality.

Results: We identified 11 randomized controlled trials with a total of 4,803 participants. There was no difference in the number of participants who achieved the target MAP between those patients receiving norepinephrine and other vasopressors (RR 1.44; 95% CI, 0.32 to 6.54; P = 0.640; I2 = 94%; two trials, 116 participants). There was no significant difference in time to achieve the target MAP (MD -0.05; 95%, CI, -0.32 to 0.21; P = 0.690; I2 = 26%; two trials, 1763 participants) and all-cause 28-day mortality (RR 0.95; 95% CI, 0.89 to 1.02; P = 0.160; I2 = 0%; seven trials, 4,139 participants). Regarding the secondary outcome, norepinephrine may significantly reduce the incidence of arrhythmia as compared to other vasopressors (RR 0.64; 95% CI, 0.42 to 0.97; P = 0.030; I2 = 64%; six trials, 3974 participants). There was no difference in the incidence of myocardial infarction (RR 1.28; 95% CI, 0.79 to 2.09), vasopressor-free day (RR 0.46; 95% CI, -1.82 to 2.74) and all-cause 90-day mortality (RR 1.08; 95% CI, 0.96 to 1.21) between norepinephrine and vasopressors.

Conclusion: In minimizing the occurrence of an arrhythmia, norepinephrine is superior to other vasopressors, making it safe to be used in septic shock. However, there was insufficient evidence concerning mortality and achievement of the target MAP outcomes.

  • 1 supplemental file

Health Equity

Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department

Introduction: Our objective was to determine the proportion of patients in our emergency department (ED) who are unhoused or marginally housed and when they typically present to the ED.

Methods: We surveyed patients in an urban, safety-net ED from June–August 2018, using a sampling strategy that met them at all times of day, every day of the week. Patients used two social needs screening tools with additional questions on housing during sampling shifts representing two full weeks. Housing status was determined using items validated for housing stability, including PRAPARE, the Accountable Health Communities Survey, and items from the United States Department of Health and Human Services. Propensity scores estimated differences among respondents and non-respondents.

Results: Of those surveyed, 35% (95% confidence interval [CI], 31-38) identified as homeless and 28% (95% CI, 25-31) as unstably housed. Respondents and non-respondents were similar by propensity score. The average cumulative number of homeless and unstably housed patients arriving per daily 8-hour window peaks at 7 AM, with 46% (95% CI, 29-64) of the daily aggregate of those reporting homelessness and 44% (95% CI, 24-64) with unstable housing presenting over the next eight hours.

Conclusion: The ED represents a low-barrier contact point for reaching individuals experiencing housing challenges, who may interact rarely with other institutions. The current prevalence of homelessness and housing instability among urban ED patients may be substantially higher than reported in historical and national-level statistics. Housing services offered within normal business hours would reach a meaningful number of those who are unhoused or marginally housed.

  • 1 supplemental file

A Model Partnership: Mentoring Underrepresented Students in Medicine (URiM) in Emergency Medicine

Introduction: Creating a racially and ethnically diverse workforce remains a challenge for medical specialties, including emergency medicine (EM). One area to examine is a partnership between a predominantly white institution (PWI) with a historically black college and university (HBCU) to determine whether this partnership would increase the number of underrepresented in medicine (URiM) in EM who are from a HBCU.

Methods: Twenty years ago Emory Department of Emergency Medicine began its collaboration with Morehouse School of Medicine (MSM) to provide guidance to MSM students who were interested in EM. Since its inception, our engagement and intervention has evolved over time to include mentorship and guidance from the EM clerkship director, program director, and key faculty.

Results: Since the beginning of the MSM-Emory EM partnership, 115 MSM students have completed an EM clerkship at Emory. Seventy-two of those students (62.6%) have successfully matched into an EM residency program. Of those who matched into EM, 22 (32%) have joined the Emory EM residency program with the remaining 50 students matching at 40 other EM programs across the nation.

Conclusion: Based on our experience and outcomes with the Emory-MSM partnership, we are confident that a partnership with an HBCU school without an EM residency should be considered by residency programs to increase the number of URiM students in EM, which could perhaps translate to other specialties.

Geographically Indexed Referral Databases to Address Social Needs in the Emergency Department

Introduction: Unmet health-related social needs (HRSN) are among the drivers of disparities in morbidity and mortality during public health emergencies such as the novel coronavirus 2019 (Covid-19) pandemic. Although emergency departments (ED) see a high volume of patients with HRSN, ED providers have limited time to complete detailed assessments of patients’ HRSN and are not always able to provide up-to-date and comprehensive information to patients on available community resources. Electronic, geographically indexed resource database systems have the potential to provide an efficient way for emergency physicians to rapidly identify community resources in settings where immediate social work consultation is not accessible.

Methods: We conducted a systematic review of papers examining the use of geographically indexed resource database systems in healthcare to better understand how these services can be used in emergency care. We then conducted simulated, standardized searches using two nationally available databases (211 and Aunt Bertha), applied to a single metropolitan area (Boston).

Results: Our systematic review found that most public health and screening interventions using nationally available databases have focused on chronic care needs. A small subset of publications demonstrated that these databases were mobilized during disasters to successfully aid vulnerable populations during Hurricanes Katrina and Rita. A total of 408 standardized searches were conducted to identify community resources related to four domains of social needs (food, transportation, housing, and utilities). Although 99% of the resources identified by both databases were relevant to the search domains queried, a significant proportion of the resources identified by each database were restricted to a specific demographic (eg, veterans).

Conclusion: Our findings demonstrate that geographically indexed referral databases may be an effective tool to help ED providers connect patients to nearby community resources during public health emergencies. We recommend that EDs select a referral database based on the greatest number of resources that are not demographically restricted.

  • 1 supplemental file

Language Barriers and Timely Analgesia for Long Bone Fractures in a Pediatric Emergency Department

Introduction: Long bone fractures are common painful conditions often managed in the pediatric emergency department (PED). Delay to providing effective pediatric pain management is multifactorial. There is limited information regarding how the issue of language spoken impacts the provision of adequate and timely institution of analgesia. We sought to determine whether there is a difference between English-speaking and non-English speaking patients with respect to time to pain management for long bone fractures in a multi-ethnic urban PED.

Methods: We conducted a retrospective cohort study of consecutive cases over 29 months of children <18 years old who presented to the PED with a first-time long bone fracture. A correlation of multiple clinical variables with timeliness to providing analgesia as a primary outcome was determined. We performed regression analysis to eliminate confounding and to determine the magnitude of each variable’s effect on the outcome.

Results: We analyzed a total of 753 patient cases (power 0.95). Regression analysis showed that the variable of English vs non-English language spoken was the most significant predictor of timeliness to pain management (p < 0.001). There was a significant difference in median time to triage measurement of pain score (1 minute vs 4 minutes for English vs non-English speakers [p < 0.001]); median time to initial analgesia (4 minutes vs 13 minutes for English vs non-English speakers (p < 0.001]); and median time to opioid analgesia (32 minutes vs 115 minutes for English vs non-English speakers (p < 0.001]), respectively. All measurements of time were from the creation of a patient’s electronic health record. Just 30% of all patients received an opioid analgesic for treatment of long bone fractures, including only 37% with moderate triage pain scores.

Conclusion: Delay to receiving analgesic medications in pediatric patients with long bone fractures can be augmented by language barriers. Time to providing analgesia for long bone fractures is significantly delayed in non-English speaking families, contributing to disproportionate care in the PED. Furthermore, use of opioid analgesia for fractures in children remains poor.

Endemic Infections

Who Stayed Home Under Safer-at-Home? Impacts of COVID-19 on Volume and Patient-Mix at an Emergency Department

Introduction: To describe the impact of COVID-19 on a large, urban emergency department (ED) in Los Angeles, California, we sought to estimate the effect of the novel coronavirus 2019 (COVID-19) and “safer-at-home” declaration on ED visits, patient demographics, and diagnosis-mix compared to prior years.

Methods: We used descriptive statistics to compare ED volume and rates of admission for patients presenting to the ED between January and early May of 2018, 2019, and 2020.

Results: Immediately after California’s “safer-at-home” declaration, ED utilization dropped by 11,000 visits (37%) compared to the same nine weeks in prior years. The drop affected patients regardless of acuity, demographics, or diagnosis. Reductions were observed in the number of patients reporting symptoms often associated with COVID-19 and all other complaints. After the declaration, higher acuity, older, male, Black, uninsured or non-Medicaid, publicly insured, accounted for a disproportionate share of utilization.

Conclusion: We show an abrupt, discontinuous impact of COVID-19 on ED utilization with a slow return as safer-at-home orders have lifted. It is imperative to determine how this reduction will impact patient outcomes, disease control, and the health of the community in the medium and long terms.

  • 1 supplemental file

Clinical Features of Emergency Department Patients from Early COVID-19 Pandemic that Predict SARS-CoV-2 Infection: Machine-learning Approach

Introduction: Within a few months coronavirus disease 2019 (COVID-19) evolved into a pandemic causing millions of cases worldwide, but it remains challenging to diagnose the disease in a timely fashion in the emergency department (ED). In this study we aimed to construct machine-learning (ML) models to predict severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection based on the clinical features of patients visiting an ED during the early COVID-19 pandemic.

Methods: We retrospectively collected the data of all patients who received reverse transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 at the ED of Baylor Scott & White All Saints Medical Center, Fort Worth, from February 23–May 12, 2020. The variables collected included patient demographics, ED triage data, clinical symptoms, and past medical history. The primary outcome was the confirmed diagnosis of COVID-19 (or SARS-CoV-2 infection) by a positive RT-PCR test result for SARS-CoV-2, and was used as the label for ML tasks. We used univariate analyses for feature selection, and variables with P<0.1 were selected for model construction. Samples were split into training and testing cohorts on a 60:40 ratio chronologically. We tried various ML algorithms to construct the best predictive model, and we evaluated performances with the area under the receiver operating characteristic curve (AUC) in the testing cohort.

Results: A total of 580 ED patients were tested for SARS-CoV-2 during the study periods, and 98 (16.9%) were identified as having the SARS-CoV-2 infection based on the RT-PCR results. Univariate analyses selected 21 features for model construction. We assessed three ML methods for performance: of the three methods, random forest outperformed the others with the best AUC result (0.86), followed by gradient boosting (0.83) and extra trees classifier (0.82).

Conclusion: This study shows that it is feasible to use ML models as an initial screening tool for identifying patients with SARS-CoV-2 infection. Further validation will be necessary to determine how effectively this prediction model can be used prospectively in clinical practice.

Violence Assessment and Prevention

Emergency Physician Survey on Firearm Injury Prevention: Where Can We Improve?

Introduction: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention.The aim of this study was to describe EPs’ beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED).

Methods: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons’ Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate.

Results: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home.

Conclusions: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

  • 1 supplemental file

California ACEP Firearm Injury Prevention Policy

Firearm-related deaths and injuries are a serious public health problem in California and the United States. The rate of firearm-related deaths is many times higher in the US than other democratic, industrialized nations, yet many of the deaths and injuries are preventable. The California American College of Emergency Physicians Firearm Injury Prevention Policy was approved and adopted in 2013 as an evidence-based, apolitical statement to promote harm reduction. It recognizes and frames firearm injuries as a public health epidemic requiring allocation of robust resources, including increased governmental funding of high-quality research and the development of a national database system. The policy further calls for relevant legislation to be informed by best evidence and expert consensus, and advocates for legislation regarding the following: mandatory universal background checks; mandatory reporting of firearm loss/theft; restrictions against law-enforcement or military-style assault weapons and high capacity magazines; child-protective safety and storage systems; and prohibitions for high-risk individuals. It also strongly defends the right of physicians to screen and counsel patients about firearm-related risk factors and safety. Based upon best-available evidenced, the policy was recently updated to include extreme risk protection orders, which are also known as gun violence restraining orders.


Patterns and Predictors of Firearm-related Spinal Cord Injuries in Adult Trauma Patients

Introduction: Firearm-related spinal cord injuries are commonly missed in the initial assessment as they are often obscured by concomitant injuries and emergent trauma management. These injuries, however, have a significant health and financial impact. The objective of this study was to examine firearm-related spinal cord injuries and identify predictors of presence of such injuries in adult trauma patients.

Methods: This retrospective cohort study examined adult trauma patients (≥16 years) with injuries from firearms included in the 2015 United States National Trauma Data Bank. We performed descriptive and bivariate analyses and compared two groups: patients with no spinal cord injury (SCI) or vertebral column injury (VCI); and patients with SCI and/or VCI. Predictors of SCI and/or VCI in patients with firearm-related injuries were identified using a multivariate logistic regression analysis.

Results: There were 34,898 patients who sustained a firearm-induced injury. SCI and/or VCI were present in 2768 (7.9%) patients. Patients with SCI and/or VCI had more frequently severe injuries, higher Injury Severity Score (ISS), lower mean systolic blood pressure, and lower Glasgow Coma Scale (GCS). The mortality rate was not significantly different between the two groups (14.7%, N = 407 in SCI and/or VCI vs 15.0%, N = 4,811 in no SCI or VCI group). Significant general positive predictors of presence of SCI and/or VCI were as follows: university hospital; assault; public or unspecified location of injury; drug use; air medical transport; and Medicaid coverage. Significant clinical positive predictors included fractures, torso injuries, blood vessel or internal organ injuries, open wounds, mild (13-15) and moderate GCS scores (9 – 12), and ISS ≥ 16.

Conclusion: Firearm-induced SCI and/or VCI injuries have a high burden on affected victims. The identified predictors for the presence of SCI and/or VCI injuries can help with early detection, avoiding management delays, and improving outcomes. Further studies defining the impact of each predictor are needed.

  • 1 supplemental file

Collaboration and Decision-Making on Trauma Teams: A Survey Assessment

Introduction: Leadership, communication, and collaboration are important in well-managed trauma resuscitations. We surveyed resuscitation team members (attendings, fellows, residents, and nurses) in a large urban trauma center regarding their impressions of collaboration among team members and their satisfaction with patient care decisions.

Methods: The Collaboration and Satisfaction About Care Decisions in Trauma (CSACD.T) survey was administered to members of ad hoc trauma teams immediately after resuscitations. Survey respondents self-reported their demographic characteristics; the CSACD.T scores were then compared by gender, occupation, self-identified leader role, and level of training.

Results: The study population consisted of 281 respondents from 52 teams; 111 (39.5%) were female, 207 (73.7%) were self-reported White, 78 (27.8%) were nurses, and 140 (49.8%) were physicians. Of the 140 physician respondents, 38 (27.1%) were female, representing 13.5% of the total surveyed population. Nine of the 52 teams had a female leader. Men, physicians (vs nurses), fellows (vs attendings), and self-identified leaders trended toward higher satisfaction across all questions of the CSACD.T. In addition to the comparison groups mentioned, women and general team members (vs non-leaders) gave lower scores.

Conclusion: Female residents, nurses, general team members, and attendings gave lower CSACD.T scores in this study. Identification of nuances and underlying causes of lower scores from female members of trauma teams is an important next step. Gender-specific training may be necessary to change negative team dynamics in ad hoc trauma teams.

  • 1 supplemental file

Women's Health

Point-of-care Ultrasound to Evaluate Breast Pathology in the Emergency Department

Introduction: As physician-performed point-of-care ultrasound (POCUS) becomes more prevalent in the evaluation of patients presenting with various complaints in the emergency department (ED), one application that is significantly less used is breast ultrasound. This study evaluates the utility of POCUS for the assessment of patients with breast complaints who present to the ED and the impact of POCUS on medical decision-making and patient management in the ED.

Methods: This was a retrospective review of ED patients presenting with breast symptoms who received a POCUS examination. An ED POCUS database was reviewed for breast POCUS examinations. We then reviewed electronic health records for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of the POCUS study on patient care and disposition.

Results: We included a total of 40 subjects (36 females, 4 males) in the final analysis. Most common presenting symptoms were breast pain (57.5%) and a palpable mass (37.5%). “Cobblestoning,” ie, dense bumpy appearance, was the most common finding on breast POCUS, seen in 50% of the patients. Simple fluid collections were found in 37.5% of patients.

Conclusion: Our study findings illustrate the utility of POCUS in the evaluation of a varietyof breast complaints in the ED.

Coding of Sexual Assault by Emergency Physicians: A Nationally Representative Study

Introduction: Sexual assault is a public health problem that affects many Americans and has multiple long-lasting effects on victims. Medical evaluation after sexual assault frequently occurs in the emergency department, and documentation of the visit plays a significant role in decisions regarding prosecution and outcomes of legal cases against perpetrators. The American College of Emergency Physicians recommends coding such visits as sexual assault rather than adding modifiers such as “alleged.”

Methods: This study reviews factors associated with coding of visits as sexual assault compared to suspected sexual assault using the 2016 Nationwide Emergency Department Sample.

Results: Younger age, female gender, a larger number of procedure codes, urban hospital location, and lack of concurrent alcohol use are associated with coding for confirmed sexual assault.

Conclusion: Implications of this coding are discussed.


Emergency Medicine Intern Education for Best Practices in Opioid Prescribing

Introduction: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing.

Methods: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education programincluded opioid prescribing guidelines for common ED disease states associated with moderate pain,clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes.

Results: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4,305 vs 749) were reduced, P <0.01. There were no differences in selection of opioid product or total morphine milligram equivalents prescribed when an opioid was used.

Conclusion: An opioid reduction education program targeting EM interns was associated with a reduction in opioid prescribing in the ED and at discharge. This may be an effective way to influence early prescribing patterns and best practices of EM interns.

Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department

Objectives: Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED).

Methods: We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations.

Results: Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: “in-series”; “in-parallel modeling”; and “in-parallel supervision.”

Conclusions: Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study.


Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost

Background: Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms.

Methods: This was a retrospective chart review of two cohorts. We identified ED charts from six-month periods prior to and after adoption of our HEART score-based protocol. Patients in whom an electrocardiogram and troponin were ordered were eligible for inclusion. We analyzed data for patients with typical symptoms (chest pain) and atypical symptoms both together and separately.

Results: We identified 1546 charts in the pre-adoption cohort and 1623 in the post-adoption cohort that met criteria. We analyzed the first 900 charts in each group. Discharges from the ED increased (odds ratio [OR[1.56, P<.001), and admissions for cardiac workup decreased (OR 0.46, P <.001). ED length of stay was 17 minutes shorter (P = .01). Stress testing decreased (OR 0.47, P<.001). We estimate a cost savings for our hospital system of over $4.5 million annually. There was no significant difference in inpatient length of stay or catheterization rate. When analyzing typical and atypical patients separately, these results held true.

Conclusion: After adoption of a HEART score-based protocol, discharges from the ED increased with a corresponding decrease in admissions for cardiac evaluations as well as cost. These effects were similar in patients presenting without chest pain but with presentations concerning for ACS.

Examining the Timeliness of ST-elevation Myocardial Infarction Transfers

Introduction: Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI.

Methods: We conducted a retrospective analysis of interfacility transfers from emergency departments (ED) to a single percutaneous coronary intervention center between 2011–2014. We included emergency department (ED) patients transferred to the percutaneous coronary intervention center and excluded scene transfers and those given fibrinolytics. We calculated descriptive statistics and used multivariable linear regression to model the association of variables with ED time intervals (arrival to electrocardiogram [ECG], ECG-to-EMS activation, and ECG-to-STEMI alert) adjusting for patient age, gender, mode of arrival, weekday hour presentation, facility transfers in the past year, and transferring facility distance.

Results: We identified 159 patients who met inclusion criteria. Subjects were a mean of 59 years old (standard deviation 13), 22% female, and 93% White; 59% arrived by private vehicle, and 24% presented after weekday hours. EDs transferred a median of 9 STEMIs (interquartile range [IQR] 3, 15) in the past year and a median of 65 miles (IQR 35, 90) from the percutaneous coronary intervention center. Median ED length of stay was 65 minutes (IQR 51, 85). Among component intervals, arrival to ECG was 6%, ECG-to-EMS activation 32%, and ECG-to-STEMI alert was 49% of overall ED length of stay. Only 18% of transfers had EMS activation earlier than STEMI alert. ECG-to-EMS activation was shorter in EDs achieving length of stay ≤60 minutes compared to those >60 minutes (12 vs 31 minutes, P<0.001). Multivariable modeling showed that after-hours presentation was associated with longer ECG-to-EMS activation (adjusted relative risk [RR] 1.05, P<0.001). Female gender (adjusted RR 0.81, P<0.001), prior facility transfers (adjusted RR 0.84, P<0.001), and initial ambulance presentation (adjusted RR 0.93, P = 0.02) were associated with shorter ECG-to-EMS activation.

Conclusion: In STEMI transfers, faster EMS activation was more likely to achieve a shorter ED length of stay than a rapid, percutaneous coronary intervention center STEMI alert. Large-scale quality improvement efforts such as the American Heart Association’s Mission Lifeline that were designed to regionalize STEMI have improved the timeliness of reperfusion, but major gaps, particularly in interfacility transfers, remain. While the transferring EDs are recognized as the primary source of delay during interfacility STEMI transfers, the contributions to delays at transferring EDs remain poorly understood.

Emergency Medical Services

Suicide Among the EMS Occupation in the United States

Introduction: Suicide claimed 47,173 lives in 2017 and is the second leading cause of death for individuals 15-34 years old. In 2017, rates of suicide in the United States (US) were double the rates of homicide. Despite significant research funding toward suicide prevention, rates of suicide have increased 38% from 2009 to 2017. Recent data suggests that emergency medical services (EMS) workers are at a higher risk of suicidal ideation and suicide attempts compared to the general public. The objective of this study was to determine the proportionate mortality ratio (PMR) of suicide among firefighters and emergency medical technicians (EMT) compared to the general US working population.

Methods: We analyzed over five million adult decedent death records from the National Occupational Mortality Surveillance database for 26 states over a 10-year non-consecutive period including 1999, 2003–2004, and 2007–2013. Categorizing firefighters and EMTs by census industry and occupation code lists, we used the underlying cause of death to calculate the PMRs compared to the general US decedent population with a recorded occupation.

Results: Overall, 298 firefighter and 84 EMT suicides were identified in our study. Firefighters died in significantly greater proportion from suicide compared to the US.working population with a PMR of 172 (95% confidence interval [CI], 153-193, P<0.01). EMTs also died from suicide in greater proportion with an elevated PMR of 124 (95% CI, 99-153), but this did not reach statistical significance. Among all subgroups, firefighters ages 65-90 were found to have the highest PMR of 234 (95% CI, 186-290), P<0.01) while the highest among EMTs was in the age group 18-64 with a PMR of 126 (95% CI, 100-156, P<0.05).

Conclusion: In this multi-state study, we found that firefighters and EMTs had significantly higher proportionate mortality ratios for suicide compared to the general US working population. Firefighters ages 65-90 had a PMR more than double that of the general working population. Development of a more robust database is needed to identify EMS workers at greatest risk of suicide during their career and lifetime.

Ethical and Legal Issues

Emergency Department and Urgent Care Medical Malpractice Claims 2001–15

Introduction: This study reviews malpractice, also called medical professional liability (MPL), claims involving adult patients cared for in emergency departments (ED) and urgent care settings.

Methods: We conducted a retrospective review of closed MPL claims of adults over 18 years, from the Medical Professional Liability Association’s Data Sharing Project database from 2001–2015, identifying 6,779 closed claims. Data included the total amount, origin, top medical specialties named, chief medical factors, top medical conditions, severity of injury, resolution, average indemnity, and defense costs of closed claims.

Results: Of 6,779 closed claims, 65.9% were dropped, withdrawn, or dismissed. Another 22.8% of claims settled for an average indemnity of $297,709. Of the 515 (7.6%) cases that went to trial, juries returned verdicts for the defendant in 92.6% of cases (477/515). The remaining 7.4% of cases (38/515) were jury verdicts for the plaintiff, with an average indemnity of $816,909. The most common resulting medical condition cited in paid claims was cardiac or cardiorespiratory arrest (10.4%). Error in diagnosis was the most common chief medical error cited in closed claims. Death was the most common level of severity listed in closed (38.5%) and paid (42.8%) claims. Claims reporting major permanent injury had the highest paid-to-closed ratio, and those reporting grave injury had the highest average indemnity of $686,239.

Conclusion: This retrospective review updates the body of knowledge surrounding medical professional liability and represents the most recent analysis of claims in emergency medicine. As the majority of emergency providers will be named in a MPL claim during their career, it is essential to have a better understanding of the most common factors resulting in MPL claims.

Behavioral Health

Nobody Wants to Be Narcan’d: A Pilot Qualitative Analysis of Drug Users’ Perspectives on Naloxone

Introduction: Bystander naloxone distribution is an important component of public health initiatives to decrease opioid-related deaths. While there is evidence supporting naloxone distribution programs, the effects of increasing naloxone availability on the behavior of people who use drugs have not been adequately delineated. In this study we sought to 1) evaluate whether individuals’ drug use patterns have changed due to naloxone availability; and 2) explore individuals’ knowledge of, access to, experiences with, and perceptions of naloxone.

Methods: We conducted a pilot study of adults presenting to the emergency department whose medical history included non-medical opioid use. Semi-structured interviews were conducted with participants and thematic analysis was used to code and analyze interview transcripts.

Results: Ten participants completed the study. All were aware of naloxone by brand name (Narcan) and had been trained in its use, and all but one had either currently or previously possessed a kit. Barriers to naloxone administration included fear of legal repercussions, not having it available, and a desire to avoid interrupting another user’s “high.” Of the eight participants who reported being revived with naloxone at least once during their lifetime, all described experiencing a noxious physical response and expressed a desire to avoid receiving it again. Furthermore, participants did not report increasing their use of opioids when naloxone was available.

Conclusions: Participants were accepting of and knowledgeable about naloxone, and were willing to administer naloxone to save a life. Participants tended to use opioids more cautiously when naloxone was present due to fears of experiencing precipitated withdrawal. This study provides preliminary evidence countering the unsubstantiated narrative that increased naloxone availability begets more high-risk opioid use and further supports increasing naloxone access.

Provider Workforce

The Psychological Impact of COVID-19 on Hospital Staff

Introduction: The coronavirus 2019 (COVID-19) pandemic has created a mental health crisis among hospital staff who have been mentally and physically exhausted by uncertainty and unexpected stressors. However, the mental health challenges and complexities faced by hospital staff in the United States has not been fully elucidated. To address this gap, we conducted this study to examine the prevalence and correlates of depression and anxiety among hospital staff in light of the COVID-19 pandemic.

Methods: The design is a single-center, cross-sectional, online survey evaluating depression and anxiety among all hospital employees (n = 3,500) at a safety-net hospital with a moderate cumulative COVID-19 hospitalization rate between April 30–May 22, 2020. We assessed depression with the Patient Health Questionnaire-9. Anxiety was measured with the Generalized Anxiety Disorder-7 scale. Logistic regression analyses were calculated to identify associations with depression and anxiety.

Results: Of 3,500 hospital employees, 1,246 (36%) responded to the survey. We included 1,232 individuals in the final analysis. Overall, psychological distress was common among the respondents: 21% and 33% of staff reported significant depression and anxiety, respectively, while 46% experienced overwhelming stress due to COVID-19. Notably, staff members overwhelmed by the stress of COVID-19 were seven and nine times more likely to suffer from depression and anxiety, respectively. In addition to stress, individuals with six to nine years of work experience were two times more likely to report moderate or severe depression compared to those with 10 or more years of work experience. Moreover, ancillary staff with direct patient contact (odds ratio [OR] 8.9, confidence interval (CI), 1.46, 173.03) as well as administrative and ancillary staff with indirect patient contact (OR 5.9, CI, 1.06, 111.01) were more likely to be depressed than physicians and advanced providers.

Conclusion: We found that a considerable proportion of staff were suffering from psychological distress. COVID-19-associated depression and anxiety was widespread among hospital staff even in settings with comparatively lower COVID-19 hospitalization rates. Ancillary staff, administrative staff, staff with less job experience, and staff overwhelmed by the stress of COVID-19 are particularly susceptible to negative mental health outcomes. These findings will help inform hospital policymakers on best practices to develop interventions to reduce the mental health burden associated with COVID-19 in vulnerable hospital staff.

Research Publishing

Emergency Medicine Journal Editorial Boards: Analysis of Gender, H-Index, Publications, Academic Rank, and Leadership Roles

Introduction: Our goal in this study was to determine female representation on editorial boards of high-ranking emergency medicine (EM) journals. In addition, we examined factors associated with gender disparity, including board members’ academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years.

Methods: In this retrospective study, we examined EM editorial boards with an impact factor of 1 or greater according to the Clarivate Journal Citations Report for a total of 16 journals. All board members with a doctor of medicine or doctor of osteopathic medicine degree, or international equivalent were included, resulting in 781 included board members. We analyzed board members’ gender, academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years.

Results: Gender disparity was clearly notable, with men holding 87.3% (682/781) of physician editorial board positions and women holding 12.7% (99/781) of positions. Only 6.6% (1/15) of included editorial board chiefs were women. Male editorial board members possessed higher h-indices, total citations, and more publishing years than their female counterparts. Male board members held a greater number of departmental leadership positions, as well as higher academic ranks.

Conclusion: Significant gender disparity exists on EM editorial boards. Substantial inequalities between men and women board members exist in both the academic and departmental realms. Addressing these inequalities will likely be an integral part of achieving gender parity on editorial boards.

Critical Care

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

Introduction: The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).

Methods: We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014–June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway  characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE.

Results: A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = - 10.3%, 95% confidence interval (CI), - 14.8% to - 5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = - 10.7%, 95% CI, - 17.3% to - 4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = - 21.4%, 95% CI, - 27.0% to - 16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 - 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 - 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 - 0.33].

Conclusion: FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials.

Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock

Introduction: The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy.

Methods: This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups.

Results: A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm.

Conclusion: In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used.

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Transfer of Patients with Spontaneous Intracranial Hemorrhage who Need External Ventricular Drain: Does Admission Location Matter?

Introduction: Patients with spontaneous intracranial hemorrhage (sICH) are associated with high mortality and require early neurosurgical interventions. At our academic referral center, the neurocritical care unit (NCCU) receives patients directly from referring facilities. However, when no NCCU bed is immediately available, patients are initially admitted to the critical care resuscitation unit (CCRU). We hypothesized that the CCRU expedites transfer of sICH patients and facilitates timely external ventricular drain (EVD) placement comparable to the NCCU.

Methods: This is a pre-post study of adult patients transferred with sICH and EVD placement. Patients admitted between January 2011–July 2013 (2011 Control) were compared with patients admitted either to the CCRU or the NCCU (2013 Control) between August 2013–September 2015. The primary outcome was time interval from arrival at any intensive care units (ICU) to time of EVD placement (ARR-EVD). Secondary outcomes included time interval from emergency department transfer request to arrival, and in-hospital mortality. We assessed clinical association by multivariable logistic regressions.

Results: We analyzed 259 sICH patients who received EVDs: 123 (48%) CCRU; 81 (31%) 2011 Control; and 55 (21%) in the 2013 Control. The groups had similar characteristics, age, disease severity, and mortality. Median ARR-EVD time was 170 minutes [106-311] for CCRU patients; 241 minutes [152-490] (p < 0.01) for 2011 Control; and 210 minutes [139-574], p = 0.28) for 2013 Control.  Median transfer request-arrival time for CCRU patients was significantly less than both control groups. Multivariable logistic regression showed each minute delay in ARR-EVD was associated with 0.03% increased likelihood of death (odds ratio 1.0003, 95% confidence interval, 1.0001-1.006, p = 0.043).

Conclusion: Patients admitted to the CCRU had shorter transfer times when compared to patients admitted directly to other ICUs. Compared to the specialty NCCU, the CCRU had similar time interval from arrival to EVD placement. A resuscitation unit like the CCRU can complement the specialty unit NCCU in caring for patients with sICH who require EVDs.

Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation

Introduction: Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment.

Methods: On January 14, 2019, as part of a ventilator-associated pneumonia prevention bundle in our ED-based ICU, we began providing RTs with tape measures and created a best practice advisory reminding them to record patient height. We then retrospectively collected data on patient height and tidal volumes before and after the intervention.

Results: We evaluated 51,404 tidal volume measurements in 1,826 patients over the 4 year study period; of these patients, 1,579 (86.5%) were pre-intervention and 247 (13.5%) were post-intervention. The intervention was associated with a odds of the patient’s height being measured were 10 times higher post-intervention (25.1% vs 3.2%, P <0.05). After the bundle was initiated, we observed a significantly higher percentage of patients ventilated with mean tidal volumes less than 8 cubic centimeters per kilogram (93.9% vs 84.5% P < 0.05).

Conclusion: Patients in an ED-ICU environment were ventilated with a lung-protective strategy more frequently after an intervention reminding RTs to measure actual patient height and providing a tape measure to do so. A significantly higher percentage of patients had height measured rather than estimated after the intervention, allowing for more accurate determination of ideal body weight and calculation of lung-protective ventilation volumes. Measuring all mechanically ventilated patients’ height with a tape measure is an example of a simple, low-cost, scalable intervention in line with guidelines developed to improve the quality of care delivered to critically ill ED patients.

Emergency Department Operations

Prospective Observational Multisite Study of Handover in the Emergency Department: Theory versus Practice

Introduction: The handover process in the emergency department (ED) is relevant for patient outcomes and lays the foundation for adequate patient care. The aim of this study was to examine the current prehospital to ED handover practice with regard to content, structure, and scope.

Methods: We carried out a prospective, multicenter observational study using a specifically developed checklist. The steps of the handover process in the ED were documented in relation to qualification of the emergency medical services (EMS) staff, disease severity, injury patterns, and treatment priority.

Results: We documented and evaluated 721 handovers based on the checklist. According to ISBAR (Identification, Situation, Background, Assessment, Recommendation), MIST (Mechanism, Injuries, Signs/Symptoms, Treatment), and BAUM (Situation [German: Bestand], Anamnesis, Examination [German: Untersuchung], Measures), almost all handovers showed a deficit in structure and scope (99.4%). The age of the patient was reported 339 times (47.0%) at the time of handover. The time of the emergency onset was reported in 272 cases (37.7%). The following vital signs were transferred more frequently for resuscitation room patients than for treatment room patients: blood pressure (BP)/(all comparisons p < 0.05), heart rate (HR), oxygen saturation (SpO2) and Glasgow Coma Scale (GCS). Physicians transmitted these vital signs more frequently than paramedics BP, HR, SpO2, and GCS. A handover with a complete ABCDE algorithm (Airway, Breathing, Circulation, Disability, Environment/Exposure) took place only 31 times (4.3%). There was a significant difference between the occupational groups (p < 0.05).

Conclusion: Despite many studies on handover standardization, there is a remarkable inconsistency in the transfer of information. A “hand-off bundle” must be created to standardize the handover process, consisting of a uniform mnemonic accompanied by education of staff, training, and an audit process.

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Sports Medicine

Rising Trends in Wrestling-associated Injuries in Females Presenting to US Emergency Departments

Introduction: Wrestling is one of the fastest-growing sports among females in the United States (US). However, female wrestling injuries remain poorly characterized. In this study we describe historical and projected national estimates of female wrestling injuries, and compare injury characteristics with those of male wrestlers.

Methods: We queried the National Electronic Injury Surveillance System (NEISS) database (2005-2019) to compare national weighted estimates and injury characteristics of male vs female wrestlers presenting to US emergency departments (ED) and projected annual female wrestling injuries expected by 2030.

Results: Our analyses demonstrated a significant (P < 0.001) increase in female wrestling injuries between 2005 (N = 1500; confidence interval [CI], 923 – 2,078) and 2019 (N = 3,404; CI 2,296 – 4,513). Linear regression (R2 = 0.69; P < 0.001) projected 4,558 (CI, 3104 – 6033) such injuries in 2030. Of female wrestling injuries 50.1% (CI, 44.1 – 56.2) occurred in patients 14-18 years of age. Compared with age-matched males, female wrestlers were significantly less likely to present with fractures (Female [F]: 10.6%; CI 7.5% – 13.7%; Male [M]: 15.7%; CI 14.7% – 16.7%; P = 0.003) or head/neck injuries (F: 18.5%; CI 13.2% – 23.9%; M: 24.6%; CI 23.2% – 26.0%; P = 0.018), and significantly more likely to present with strains/sprains (F: 48.8%; CI, 41.2% – 56.3%; M: 34.4%; CI 31.6% – 37.1%; P < 0.001).

Conclusion: Males and females possess distinctly unique physiology and anatomy, such as variances in ligamentous and muscular strength, which may help to explain differences in wrestling injury characteristics. Prompt management of injuries and specific training strategies aimed at prevention may help to reduce the projected increase of female wrestling-associated injuries as the popularity of the sport continues to rise.

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Patient Communication

“I wanted to participate in my own care”: Evaluation of a Patient Navigation Program

Introduction: Patient navigation programs can help people overcome barriers to outpatient care. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for US Medicaid-enrolled frequent ED users.

Methods: We conducted a mixed-methods evaluation of patient experiences and satisfaction with an ED-PN program for patients who visited the ED more than four times in the prior year. Participants were Medicaid-enrolled, English- or Spanish-speaking, New Haven-CT residents over the age of 18. Pre-post ED-PN intervention surveys and post-ED-PN individual interviews were conducted. We analyzed baseline and follow-up survey responses as proportions of total responses. Interviews were coded by multiple readers, and interview themes were identified by consensus.

Results: A total of 49 participants received ED-PN. Of those, 80% (39/49) completed the post-intervention survey. After receiving ED-PN, participants reported high satisfaction, fewer barriers to medical care, and increased confidence in their ability to coordinate and manage their medical care. Interviews were conducted until thematic saturation was reached. Four main themes emerged from 11 interviews: 1) PNs were perceived as effective navigators and advocates; 2) health-related social needs were frequent drivers of and barriers to healthcare; 3) primary care utilization depended on clinic accessibility and quality of relationships with providers and staff; and 4) the ED was viewed as providing convenient, comprehensive care for urgent needs.

Conclusions: Medicaid-enrolled frequent ED users receiving ED-PN had high satisfaction and reported improved ability to manage their health conditions.

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Patient Safety

Central Venous Catheter Adverse Events Are not Associated with Crowding Indicators

Objective: Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).

Methods: We conducted a retrospective observational study from 2008–2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU.

Results: Of 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08).

Conclusion: In a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

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International Medicine

Performance of Prognostication Scores for Mortality in Injured Patients in Rwanda

Introduction: While trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda.

Methods: A retrospective, randomly sampled cohort of ED patients presenting with injury was accrued from August 2015–July 2016. Primary outcome was 14-day mortality and secondary outcome was overall facility-based mortality. We evaluated summary statistics of the cohort. Bootstrap regression models were used to compare areas under receiver operating curves (AUC) with associated 95% confidence intervals (CI).

Results: Among 617 cases, the median age was 32 years and 73.5% were male. The most frequent mechanism of injury was road traffic incident (56.2%). Predominant anatomical regions of injury were craniofacial (39.3%) and lower extremities (38.7%), and the most common injury types were fracture (46.0%) and contusion (12.0%). Fourteen-day mortality was 2.6% and overall facility-based mortality was 3.4%. For 14-day mortality, TEWS had the highest accuracy (AUC = 0.88, 95% CI, 0.76–1.00), followed by RTS (AUC = 0.73, 95% CI, 0.55–0.92), and then KTS (AUC = 0.65, 95% CI, 0.47–0.84). Similarly, for facility-based mortality, TEWS (AUC = 0.89, 95% CI, 0.79–0.98) had greater accuracy than RTS (AUC = 0.76, 95% CI, 0.61–0.91) and KTS (AUC = 0.68, 95% CI, 0.53–0.83). On pairwise comparisons, RTS had greater prognostic accuracy than KTS for 14-day mortality (P = 0.011) and TEWS had greater accuracy than KTS for overall (P = 0.007) mortality. However, TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101).

Conclusion: In this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar ED environments.

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Patient Satisfaction

Intensive Cryotherapy in the Emergency Department (ICED): A Randomized Controlled Trial

Introduction: Pain control is an essential component of musculoskeletal injury treatment in the emergency department (ED). We evaluated the most effective type of cryotherapy for analgesia of acute musculoskeletal injury and the impact on opioid utilization.

Methods: This was a prospective, randomized, single-blind controlled trial of adult ED patients who presented with acute musculoskeletal pain. Patients were randomized to either intensive targeted cryotherapy (crushed wetted ice in a plastic bag) or agitated chemical cold pack applied to the injury site for 20 minutes. All other diagnostic and therapeutic orders were at the discretion of the treating physician. Visual analog pain scores were measured at the time of cryotherapy application, at 20 minutes (time of cryotherapy removal), and at 60 minutes (40 minutes after removal).

Results: We enrolled 38 patients, 17 randomized to intensive targeted cryotherapy and 21 to chemical cold packs, with well-matched demographics. The intensive targeted cryotherapy group achieved significantly greater pain relief at 20 minutes (2.1 [95% confidence interval (CI), 1.3 – 2.9] vs 0.9 [95% CI, 0.3 – 1.5], P < 0.05) and at 60 minutes (2.7 [95% CI, 1.6 – 3.7] vs 1.2 [95% CI, 0.6 – 1.7], P < 0.05), number need to trial (NNT) = 3.2. Opioid administration in the ED was significantly lower in the intensive targeted cryotherapy group (1 [6%] vs 7 [33%], P < 0.05), NNT = 3.6. Those who received a discharge opiate prescription had significantly higher 60-minute pain scores (7.3 ± 2.2 vs 4.1 ± 2.7, P < 0.05).

Conclusion: Intensive targeted cryotherapy provided more effective analgesia than chemical cold packs for acute musculoskeletal injuries in the ED and may contribute to lower opioid usage.


Telephonic Medical Toxicology Service in a Low- Resource Setting: Setup, Challenges, and Opportunities

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.