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Open Access Publications from the University of California

Volume 23, Issue 5, 2022

Endemic Infections

Racial and Ethnic Disparities in Hospitalization and Clinical Outcomes Among Patients with COVID-19

Introduction: The recent spread of coronavirus disease 2019 (COVID-19) has disproportionately impacted racial and ethnic minority groups; however, the impact of healthcare utilization on outcome disparities remains unexplored. Our study examines racial and ethnic disparities in hospitalization, medication usage, intensive care unit (ICU) admission and in-hospital mortality for COVID-19 patients.Methods: In this retrospective cohort study, we analyzed data for adult patients within an integrated healthcare system in New York City between February 28–August 28, 2020, who had a lab-confirmed COVID-19 diagnosis. Primary outcome was likelihood of inpatient admission. Secondary outcomes were differences in medication administration, ICU admission, and in-hospital mortality.Results: Of 4717 adult patients evaluated in the emergency department (ED), 3219 (68.2%) were admitted to an inpatient setting. Black patients were the largest group (29.1%), followed by Hispanic/Latinx (29.0%), White (22.9%), Asian (3.86%), and patients who reported “other” race-ethnicity (19.0%). After adjusting for demographic, clinical factors, time, and hospital site, Hispanic/Latinx patients had a significantly lower adjusted rate of admission compared to White patients (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.34-0.76). Black (OR 0.60; 95% CI 0.43-0.84) and Asian patients (OR 0.47; 95% CI 0.25 - 0.89) were less likely to be admitted to the ICU. We observed higher rates of ICU admission (OR 2.96; 95% CI 1.43-6.15, and OR 1.83; 95% CI 1.26-2.65) and in-hospital mortality (OR 4.38; 95% CI 2.66-7.24; and OR 2.96; 95% CI 2.12-4.14) at two community-based academic affiliate sites relative to the primary academic site.Conclusion: Non-White patients accounted for a disproportionate share of COVID-19 patients seeking care in the ED but were less likely to be admitted. Hospitals serving the highest proportion of minority patients experienced the worst outcomes, even within an integrated health system with shared resources. Limited capacity during the COVID-19 pandemic likely exacerbated pre-existing health disparities across racial and ethnic minority groups.

  • 1 supplemental ZIP

Can Urinalysis and Past Medical History of Kidney Stones Predict Urine Antibiotic Resistance?

Introduction: Urinary tract infections (UTI) are one of the most common infections encountered in the emergency department (ED) with an estimated 2-3 million annual visits.  Commonly prescribed antibiotics for UTIs have shown growing rates of resistance.  Previous studies lack direction on improving UTI treatment based on the labs available to the bedside clinician.  

Methods: We sought to determine if antibiotic resistance in UTIs was related to demographics, urinalysis, and history of renal failure or kidney stones. We conducted an analysis of 892 women ≥18 years of age discharged from the ED with a UTI diagnosis. We assessed predictors of nitrofurantoin resistance, cefazolin resistance, ciprofloxacin resistance, and trimethoprim-sulfamethoxazole resistance using unadjusted and multivariable logistic regression models.

Results: Antibiotic resistance was 13.6% for nitrofurantoin, 11.9% for cefazolin, 12.8% for ciprofloxacin, and 17.1% for trimethoprim-sulfamethoxazole. In multivariable analysis, significant independent associations with an increased likelihood of resistance to nitrofurantoin were observed for less urine blood (OR [per 1 category increase of score] 0.81; P = 0.02); greater mucous (OR [per 1 category increase of score] 1.22; P = 0.02); less specific gravity urine (OR [per 1 category increase] 0.87; P = 0.04), and presence of any history of kidney stones (OR 3.24; P = 0.01). There were no significant predictors for cefazolin resistance (all P ≥0.06); age was the only significant predictor of ciprofloxacin resistance (OR per 10 year increase] 1.10, P = 0.05), and lower specific gravity urine was significantly associated with an increased risk of resistance to trimethoprim- sulfamethoxazole (OR [per 1 category increase] 0.88, P = 0.04).

Conclusion: Women with any history of kidney stones may have bacteriuria resistant to nitrofurantoin, suggesting that providers might consider alternative antibiotic therapies in this scenario.

  • 1 supplemental ZIP

More Accessible COVID-19 Treatment Through Monoclonal Antibody Infusion in the Emergency Department

Introduction: Monoclonal antibody (MAB) infusion is the first treatment to manage coronavirus 2019 (COVID-19) in an outpatient setting. Yet increased risk of severe COVID-19 illness may occur from inequities in social determinants of health including access to quality healthcare. Given the safety-net nature of emergency departments (ED), a model that puts them at the center of MAB infusion may better reach underserved patients than models that require physician referral and distribute MAB at outpatient infusion centers. We examined characteristics of two groups of patients who received MAB infusion in the Robert Wood Johnson University Hospital (RWJUH) ED in New Brunswick, New Jersey: 1) patients who tested positive for COVID-19 in the ED and received ED infusion; and 2) patients who tested positive elsewhere and were referred to the ED for infusion. The process for the latter group was similar to the more common national model of patients testing COVID-19 positive in the community and then being referred to an infusion center for MAB therapy. 

Methods: We performed a cross-sectional retrospective health record review of all adult patients presenting to the ED from November 20, 2020–March 15, 2021 who received MAB infusion at RWJUH ED (N = 486). Patients were identified through the electronic health record system by an administrative query, with manual chart review for any additional characteristics not available through the query. We compared the two groups using chi-squared tests for categorical variables and t-tests for continuous variables.

Results: We found higher proportions of Black (18% vs 6% P < 0.001, statistically significant), Hispanic (19% vs 11% P = 0.02), Medicaid (12% vs 9% P = 0.01), and uninsured (17% vs 8% P = 0.01) patients who tested positive for COVID-19 in their ED visit and then received MAB therapy during their visit than patients tested elsewhere in the community and referred to the ED for MAB therapy.

Conclusion: These findings suggest that providing MAB infusion in the ED allows increased access for patients traditionally marginalized from the healthcare system, who may be at risk of longer disease duration and complications from COVID-19.

Prospective Case-control Study of Contact Tracing Speed for Emergency Department-based Contact Tracers

Introduction: In Snohomish County, WA, the time from obtaining a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test and initiating contact tracing is 4-6 days. We tested whether emergency department (ED)-based contact tracing reduces time to initiation and completion of contact tracing investigations. 

Methods: All eligible coronavirus disease 2019 (COVID-19)-positive patients were offered enrollment in this prospective case-control study. Contact tracers were present in the ED from 7 AM to 2 AM for 60 consecutive days. Tracers conducted interviews using the Washington State Department of Health’s extended COVID-19 reporting form, which is also used by the Snohomish Health District (SHD). 

Results: Eighty-one eligible SARS-CoV-2 positive patients were identified and 71 (88%) consented for the study. The mean time between positive COVID-19 test result and initiation of contact tracing investigation was 111 minutes with a median of 32 minutes (range: 1-1,203 minutes). The mean time from positive test result and completion of ED-based contact tracing investigation was 244 minutes with a median of 132 minutes (range: 23-1,233 minutes). In 100% of the enrolled cases, contact tracing was completed within 24 hours of a positive COVID-19 test result. For comparison, during this same period, SHD was able to complete contact tracing in 64% of positive cases within 24 hours of notification of a positive test result (P < 0.001). In the ED, each case identified a mean of 2.8 contacts as compared to 1.4 contacts identified by SHD-interviewed cases. There was no statistically significant difference between the percentage of contacts reached through ED contact tracing (82%) when compared to the usual practice (78%) (P = 0.16). 

Conclusion: When contact tracing investigations occur at the point of diagnoses, the time to initiation and completion are reduced, there is higher enrollment, and more contacts are identified.

Evaluation of an Emergency Department Influenza Vaccination Program: Uptake Factors and Opportunities

Introduction: Influenza vaccines are commonly provided through community health events and primary care appointments. However, acute unscheduled healthcare visits such as emergency department (ED) visits are increasingly viewed as important vaccination opportunities. Emergency departments may be well-positioned to complement broader public health efforts with integrated vaccination programs. 

Methods: We studied an ED-based influenza vaccination initiative in an urban hospital and examined patient-level factors associated with screening and vaccination uptake. Our analyses included patient visits to the ED from October 1, 2019-April 1, 2020.

Results: The influenza screening and vaccination program proved feasible. Of the 20,878 ED visits that occurred within the study period, 3,565 (17.1%) included a screening for influenza vaccine eligibility; a small proportion (11.5%) of the patients seen had multiple screenings. Among the patients screened eligible for the vaccine, 916 ultimately received an influenza vaccination while in the ED (43.7% of eligible patients). There was significant variability in the characteristics of patients who were and were not screened and vaccinated. Age, gender, race, preferred language, and receipt of a flu vaccine in prior years were associated with screening and/or receiving a vaccine in the ED. 

Conclusion: Vaccination programs in the ED can boost community vaccination rates and play a role in both preventing and treating current and future vaccine-preventable public health crises, although efforts must be made to deliver services equitably.

Health Equity

Horizontal Violence Toward Emergency Medicine Residents: Gender as a Risk Factor

Introduction: Horizontal violence (HV) is defined as “persistent exposure to interpersonal aggression and mistreatment from colleagues.” Our objective in this pilot, single-site study was to identify sources of HV toward emergency medicine (EM) residents, using the Negative Acts Questionnaire-Revised (NAQ-R).

Methods: In this investigation we used a descriptive cross-sectional survey design to categorize HV. All voluntary participants were residents in an Accreditation Council for Graduate Medical Education- approved, three-year academic EM residency. Data were collected via electronic survey and occurred six months into an academic year. We collected demographic information and responses to the NAQ-R in 2020. Horizontal violence is subdivided into three categories: work-related; person-related; and physical intimidation. Emergency medicine residents answered questions as they related to their interactions with residents and support staff, which included nursing.

Results: A total of 23 of 26 residents responded (89%). Participants were 56% women, 78% white, 11% Hispanic, and 89% heterosexual. Participant clinical year was 39% first-, 39% second-, and 22% third-year residents. Women reported a higher frequency of HV compared to men (1.3 vs 1.1, P =.01). By category, women indicated higher incidence of work-related violence from other residents (P = .05) and staff (P =.02). There was no difference in reported frequency of violence for interns compared to senior residents. 

Conclusion: Our pilot study demonstrated horizontal violence toward EM residents exists and is more prevalent in women.

 

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Discharge Navigator: Implementation and Cross-Sectional Evaluation of a Digital Decision Tool for Social Resources upon Emergency Department Discharge

Introduction: Many patients have unaddressed social needs that significantly impact their health, yet navigating the landscape of available resources and eligibility requirements is complex for both patients and clinicians.

 

Methods: Using an iterative design-thinking approach, our multidisciplinary team built, tested, and deployed a digital decision tool called “Discharge Navigator” (edrive.ucsf.edu/dcnav) that helps emergency clinicians identify targeted social resources for patients upon discharge from the acute care setting. The tool uses each patient’s clinical and demographic information to tailor recommended community resources, providing the clinician with action items, pandemic restrictions, and patient handouts for relevant resources in five languages. We implemented two modules at our urban, academic, Level I trauma center.

 

Results: Over the 10-week period following product launch, between 4-81 on-shift emergency clinicians used our tool each week. Anonymously surveyed clinicians (n = 53) reported a significant increase in awareness of homelessness resources (33% pre to 70% post, P<0.0001) and substance use resources (17% to 65%, P<0.0001); confidence in accessing resources (22% to 74%, P<0.0001); knowledge of eligibility criteria (13% to 75%, P<0.0001); and ability to refer patients always or most of the time (11% to 43%, P<0.0001). The average likelihood to recommend the tool was 7.8 of 10.

 

Conclusion: Our design process and low-cost tool may be replicated at other institutions to improve knowledge and referrals to local community resources.

 

Race and Other Disparate Demographic Variables Identified Among Emergency Department Boarders

Introduction: Emergency department (ED) boarding, the process of holding patients in the ED due to a lack of inpatient beds after the decision is made to admit, has profound consequences. Increased ED boarding times are associated with adverse patient outcomes, including increased mortality. While previous studies have demonstrated racial disparities with regard to ED boarding, current literature lacks insight into discrepancies that may exist among other demographic groups as it pertains to ED boarding. We sought to review ED boarding times differentiated by demographic characteristics.

Methods: We conducted a retrospective review of all ED admissions from an academic ED in the Southeast from April–September 2019. The primary outcome assessed was boarding time, defined as time from decision to admit to ED departure. Patient demographic data including race, gender, and age were collected and analyzed. We performed descriptive statistics and chi-square analyses. 

Results: The study population included 17,606 patients with a mean age of 56.3. Nearly half (49.8%) of the patients were female. Additionally, 43.8% of patients were Black and 48.6% White. For all admissions, there was no difference in mean boarding time among Black and White patients (5.2 ± 8.8 vs 5.2 ± 8.2 hours, P = 0.11). Among Emergency Severity Index (ESI) level I admissions, Black patients boarded longer than White patients (4.1 ± 0.3 vs 2.7 ± 0.3 hours, P = 0.009). Black patients also boarded significantly longer than White patients for psychiatric admissions (22.7 ± 23.7 vs 18.5 ± 19.4 hours, P <0.05). For all admissions, males boarded longer than females (5.5 ± 8.5 vs 4.9 ± 8.2 hours, P <.0001). Patients older than 75 boarded for less time (3.8 ± 6.2 hours) compared to younger groups (15-24: 6.4 ± 10.8 hours; 25-44: 6.6 ± 10.8; 45-64: 5.0 ± 7.6; and 64-75: 4.7 ± 6.7; all P <.05). 

Conclusion: This analysis demonstrated significant differences in ED boarding times between races among psychiatric and ESI I admissions, gender, and age. This data provides insight into differences in ED boarding times among demographic groups and provides a focal point for examining possible factors contributing to the observed differences.

A Structural Competency Framework for Emergency Medicine Research: Results from a Scoping Review & Consensus Conference

Introduction: The application of structural competency and structural vulnerability to emergency medicine (EM) research has not been previously described despite EM researchers routinely engaging structurally vulnerable populations. The purpose of this study was to conduct a scoping review and consensus-building process to develop a structurally competent research approach and operational framework relevant to EM research.

Methods: We conducted a scoping review focused on structural competency and structural vulnerability. Results of the review informed the development of a structural competency research framework that was presented throughout a multi-step consensus process culminating in the 2021 Society for Academic Emergency Medicine Consensus Conference. Feedback to the framework was incorporated throughout the conference.

Results: The scoping review produced 291 articles with 123 articles relevant to EM research. All 123 articles underwent full-text review and data extraction following a standardized data extraction form. Most of the articles acknowledged or described structures that lead to inequities with a variety of methodological approaches used to operationalize structural competency and/or structural vulnerability. The framework developed aligned with components of the research process, drawing upon methodologies from studies included in the scoping review. 

Conclusion: The framework developed provides a starting point for EM researchers seeking to understand, acknowledge, and incorporate structural competency into EM research. By incorporating components of the framework, researchers may enhance their ability to address social, historical, political, and economic forces that lead to health inequities, reframing drivers of inequities away from individual factors and focusing on structural factors.

  • 1 supplemental ZIP

WOMen profEssioNal developmenT oUtcome Metrics in Academic Emergency Medicine: Results from the WOMENTUM Modified Delphi Study

Introduction: To address persistent gender inequities in academic medicine, women professional development groups (PDG) have been developed to support the advancement of women in medicine. While these programs have shown promising outcomes, long-term evaluative metrics do not currently exist. The objective of this study was to establish metrics to assess women’s PDGs. 

Methods: This was a modified Delphi study that included an expert panel of current and past emergency department (ED) chairs and Academy for Women in Academic Emergency Medicine (AWAEM) presidents. The panel completed three iterative surveys to develop and rank metrics to assess women PDGs. Metrics established by the expert panel were also distributed for member-checking to women EM faculty. 

Results: The expert panel ranked 11 metrics with high to moderate consensus ranking with three metrics receiving greater than 90% consensus: gender equity strategy and plan; recruitment; and compensation. Members ranked 12 metrics with high consensus with three metrics receiving greater than 90% consensus: gender equity strategy and plan; compensation; and gender equity in promotion rates among faculty. Participants emphasized that departments should be responsible for leading gender equity efforts with PDGs providing a supportive role. 

Conclusion: In this study, we identified metrics that can be used to assess academic EDs’ gender equity initiatives and the advisory efforts of a departmental women’s PDG. These metrics can be tailored to individual departmental/institutional needs, as well as to a PDG’s mission. Importantly, PDGs can use metrics to develop and assess programming, acknowledging that many metrics are the responsibility of the department rather than the PDG.

  • 1 supplemental ZIP

Women's Health

Traumatic Injuries in Sexual Assault Patients in the Emergency Department

Introduction: The emergency department (ED) is at the forefront for treatment of sexual assault patients. Many require treatment for injuries sustained during the assault, ranging from mild to severe. Our objective in this study was to characterize types of injuries associated with sexual assault and identify associated factors.

Methods: We reviewed ED charts from an inner-city trauma center and nearby community hospital from 2019-2020 for patients age ≥13 years with a chief complaint of sexual assault. We used descriptive statistics, chi square, and logistic regression to characterize demographics and identify factors associated with trauma. 

Results: A total of 157 patients met inclusion criteria. The mean age was 27.9 years old (range 13-79 years) and 92.4% were female. Adult patients (age >18 years) comprised 77.5% of assaults vs adolescents (age 13-18 years) at 22.3%. Most patients presented to the trauma center compared to the community hospital (69.4% vs 30.6%). The assailants were reported as 61.2% acquaintance, 22.9% stranger, and 15.9% intimate partner. A forensic rape kit was performed in 92 (58.6%) cases. The patient was intoxicated with alcohol in 39 (24.8%) cases, and 22 (14%) patients reported drug-facilitated assault where an unknown substance was given to them. Alcohol (P = 0.95) and drug-facilitated assault (P = 0.64) did not change the occurrence of injuries. Fifty-seven (36.3%) patients exhibited physical trauma on presentation. Forty-five (28.6%) patients had minor injuries of abrasions, lacerations, or contusions. Major trauma was defined as fracture, brain injury, hemorrhage, strangulation, or injury requiring surgical consultation. There were 12 patients with major trauma consisting of fracture injury or nonfatal strangulation. None of the patients required admission. Sexual assault by an intimate partner (odds ratio [OR] 2.6; 95% CI: 1.1-6.5) and being an adult patient compared to adolescent (OR 3.0; 95% CI, 1.1-7.7) was significantly associated with physical trauma. Sexual assault by an intimate partner was also associated with nonfatal strangulation (OR 4.0; 95% CI, 1.1-15.4). 

Conclusion: Physical injuries that resulted from sexual assault were mostly minor and occurred in 36% of rape victims. Intimate partner violence was found to be associated with physical trauma as well as nonfatal strangulation. Overall, this study helps us to understand key factors associated with sexual violence.

Trends of Pandemic Parenting in Medical Academia

Introduction: The pandemic has been difficult on physicians, with two fifths of doctors in one survey reporting that their mental health is now worse than before the pandemic.  It is likely that a significant proportion of these physicians are parents of children necessitating childcare, as approximately 32% of the US workforce has someone in their household under the age of 14. We sought to study the impact of the coronavirus 2019 (COVID-19) pandemic on physician parents in academia. Our goal was to investigate the intersection of professional and personal challenges, as well as perceived impact on domestic life and professional development secondary to the COVID-19 pandemic. 

Methods: Using Survey Monkey, we developed a 37-question survey to address the aim of this study. Questions were grouped into four categories: demographics; impact on childcare; impact on care; and impact on mental health/wellness. Most of the questions were multiple choice with a few fill-in-the-blank options to allow participants to provide additional information related to their experiences as physicians during the pandemic. A link to the survey was disseminated via email to physicians at our home institution, Rush University Medical Center (Chicago), via our own intra- and interdepartmental communications, We used private social media accounts such as Facebook physician groups to reach out to physicians at other academic medical centers. Survey responses were voluntary and collected anonymously over an eight-week period, without identifiable data. Inclusion criteria included any physician identifying themselves as working full or full or part time in an academic facility in the US and caregivers for children <18 years.

Results: Survey respondents were mostly female (83.2%), practicing in the Midwest (61.2%), and ranked as assistant professor (59.5%). The majority of respondents had two children (65.1%) who were <11 years in age (85.6%). Most respondents worked full time with 72.8% working over 50% clinically. Childcare was disrupted for 171 of 232 respondents (73.7%); 62.9% struggled with balancing work with childcare; 81.9% worried often or very often about fulfilling their responsibilities. A vast majority, 210 of 232 respondents (90.5%) had some degree of concern about feeling overburdened by their roles. More than half (57.3%) worried that their professional advancement was impacted by the pandemic, and 53.9% considered making adjustments to their clinical workload/. Over half (51.6%) thought that increased domestic responsibilities impacted their professional advancement .  

Conclusion: In the survey, which was completed primarily by early-career women physicians practicing in a variety of specialties and geographic regions, we noted that childcare disruption amidst the pandemic was extremely prevalent. The majority of respondents reported full-time equivalent work; thus, it is reasonable to assume that significant workloads and limitations in remote work in combination with childcare constraints resulted in significant burden. A large number felt the challenges were negatively impacting their professional development and felt overburdened by their various roles.

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Behavioral Health

Stage-of-change Assessment Predicts Short-term Treatment Engagement for Opioid Use Disorder Patients Initiated on Buprenorphine

Introduction: The emergency department (ED) is an effective setting for initiating medication for opioid use disorder (MOUD); however, predicting who will remain in treatment remains a central challenge. We hypothesize that baseline stage-of-change (SOC) assessment is associated with short-term treatment retention outcomes.

Methods: This is a longitudinal cohort study of all patients enrolled in an ED MOUD program over 12 months. Eligible and willing patients were treated with buprenorphine at baseline and had addiction medicine specialist follow-up arranged. Treatment retention at 30 and 90 days was determined by review of the Prescription Drug Monitoring Program. We used uni- and multivariate logistic regression to evaluate associations between patient variables and treatment retention at 30 and 90 days.

Results: From June 2018–May 2019, 279 patients were enrolled in the ED MOUD program. Of those patients 151 (54.1%) and 120 (43.0%) remained engaged in MOUD treatment at 30 and 90 days, respectively. The odds of treatment adherence at 30 days were significantly higher for those with advanced SOC (preparation/action/maintenance) compared to those presenting with limited SOC (pre-contemplation/contemplation) (60.0% vs 40.8%; odds ratio 2.18; 95% confidence interval 1.15 to 4.1; P <0.05). At 30 days, multivariate logistic regression determined that advanced SOC, age >40, having medical insurance, and being employed were significant predictors of continued treatment adherence. At 90 days, advanced SOC, non-White race, age > 40, and having insurance were all significantly associated with higher likelihood of treatment engagement.

Conclusion: Greater stage-of-change was significantly associated with MOUD treatment retention at 30 and 90 days post index ED visit.

#WhyIDoIt: A Multidisciplinary Wellness Initiative in an Academic Emergency Department

Introduction: Healthcare clinicians in critical care settings such as the emergency department (ED) experience workplace stressors and are at high risk for burnout. This correlates with substance abuse, suicidality, career dissatisfaction, early retirement, and suboptimal patient care. Therefore, recognizing, and mitigating, burnout is critical to a healthcare worker’s health and wellbeing. While gratitude and positive psychology are shown to increase resilience and decrease burnout, no prior studies have examined specific ED care team motivators for continued career satisfaction and workplace engagement. To increase the wellness in our ED, we implemented a wellness initiative titled #WhyIDoIt. Our goal was to have all care team members share what motivates them to work in our ED.

 

Methods: Participants were asked what motivates them in the workplace. We gathered responses each February for three consecutive years, 2017-2019, at our academic Level I trauma center. Emergency department clinicians, nurses, and staff were recruited to participate at grand rounds, nursing huddles, and sign out. Participants self-selected to contribute by writing their response on a sticky note and posting it in the department. After three years of implementing this initiative, we analyzed the collected qualitative data using thematic analysis based on grounded theory. Submissions were subjectively categorized into initial themes and then reconciled into three overarching classifications.

 

Results: In total, we collected 149 responses. Themes included team work (35, 23.5%), pride in a unique skill set (26, 17.4%), helping patients in a time of need (26, 17.4%), teaching/learning opportunities (15,10.1%), humor and levity (14, 9.4%), building relationships with patients (11,7.4%), financial motivation (9, 6.0%), patient gratitude (7, 4.7%), and philosophical and moral motivators (6, 4.0%). These themes were reconciled into three overarching classifications including team-centered motivators

(76, 51%), patient-centered motivators (37, 24.8%), and reward-centered motivators (36, 24.2%).

 

Conclusion: Responses that showed the greatest motivator for ED clinicians and nurses were team-centered. This highlights the importance of relationship building and a sense of shared purpose and suggests that future workplace well-being initiatives should include strengthening and maintaining professional team relationships. [West J Emerg Med. 2022;22(X)X–X.]

 

Critical Care

The Accuracy of Sepsis Screening Score for Mortality Prediction at Emergency Department Triage

Introduction: Sepsis has a mortality rate of 10-40% worldwide. Many screening tools for sepsis prediction and for emergency department (ED) triage are controversial. This study compared the accuracy of the scores for predicting 28-day mortality in adult patients with sepsis in the triage area of the ED.

 

Methods: Adult patients who presented to the ED of a tertiary-care university hospital from January–December 2019 with an initial diagnosis of sepsis or other infection-related conditions were enrolled. We calculated predictive scores using information collected in the ED triage area. Prognostic accuracy was measured by the area under the receiver operating characteristic curve (AUROC) for predicting 28-day mortality as a primary outcome. The secondary outcomes included mechanical ventilation usage and vasopressor usage for 28 days.

 

Results: We analyzed a total of 550 patients. The 28-day mortality rate was 12.4% (n = 68). The 28-day mortality rate was best detected by the National Early Warning Score (NEWS) (AUROC = 0.770; 95% confidence interval [CI]: 0.705-0.835), followed by the quick Sequential Organ Failure Assessment (qSOFA) score (AUROC = 0.7473; 95% CI: 0.688-0.806), Search Out Severity (SOS) score (AUROC = 0.749; 95% CI: 0.685-0.815), Emergency Severity Index (ESI) triage (AUROC = 0.599; 95% CI: 0.542-0.656, and the Systemic Inflammatory Response System (SIRS) criteria (AUROC = 0.588; 95% CI: 0.522-0.654]). The NEWS also provided a higher AUROC and outperformed for 28-day mechanical ventilator usage and 28-day vasopressor usage.

 

Conclusion: The NEWS outperforms qSOFA, SOS, SIRS, and ESI triage in predicting 28-day mortality, mechanical ventilator, and vasopressor usage of a patient with sepsis who is seen at ED triage.

 

  • 2 supplemental ZIPs

Direct vs Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study

Introduction: Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways. 

Methods: We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016–December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI).

Results: Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts.

Conclusion: Analysis of the NEAR database demonstrates higher first-pass success with VL compared to DL in patients with predicted or anatomically difficult airways, and reduced rate of esophageal intubations and vomiting.

Emergency Department Operations

Pain Assessment in the Emergency Department: A Prospective Videotaped Study

Introduction: Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician’s perception of a patient’s pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment.

Methods: We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos. 

Results: A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0-6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain (correlation coefficient, 0.46; P <0.001), with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001).

Conclusion: Patients’ self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors.

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Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders

Introduction: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. 

Methods: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services.

Results: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown.

Conclusion: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Geriatrics

Geriatric Falls: Patient Characteristics Associated with Emergency Department Revisits

Introduction: Falls are the leading cause of traumatic injury among elderly adults in the United States, which represents a significant source of morbidity and leads to exorbitant healthcare costs. The purpose of this study was to characterize elderly fall patients and identify risk factors associated with seven-day emergency department (ED) revisits.

Methods: This was a multicenter, retrospective, longitudinal cohort study using non-public data from 321 licensed, nonfederal, general, and acute care hospitals in California obtained from the Department of Healthcare Access and Information from January 1–December 31, 2017. Included were patients 65 and older who had a fall-related ED visit identified by International Classification of Diseases codes W00x to W19x. Primary outcome was a return visit to the ED within a seven-day window following the index encounter. Demographics collected included age, gender, ethnicity/race, patient payer status, Charlson Comorbidity Index (CCI), psychiatric diagnoses, and alcohol/substance use disorder diagnoses. We performed multivariate logistic regression to identify characteristics associated with seven-day ED revisit.

Results: We identified a total of 2,758,295 ED visits during the study period with 347,233 (12.6%) visits corresponding to fall-related injuries. After applying exclusion criteria, 242,572 index ED visits were identified, representing 206,612 patients. Of these, 24,114 (11.7%) patients returned to an ED within seven days (revisit). Within this revisit population, 6,161 (22.6%) presented to a facility that was distinct from their index visit, and 4,970 (18.2%) were ultimately discharged with the same primary diagnosis as their index visit. Characteristics with the largest independent associations with a seven-day ED revisit were presence of a psychiatric diagnosis (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.69 to 1.80), presence of an alcohol or substance use disorder (OR 1.70; 95% CI 1.64 to 1.78), and CCI ≥ 3 (OR 2.79; 95% CI 2.68 to 2.90).

Conclusion: In this study we identified 24,114 elderly fall patients who experienced a seven-day ED revisit. Patients with multiple comorbidities, a substance use disorder, or a psychiatric diagnosis exhibited increased odds of experiencing a return visit to the ED within seven days of a fall-related index visit. These findings will help target at-risk elderly fall patients who may benefit from preventative multidisciplinary intervention during index ED visits to reduce ED revisits.

Health Outcomes

Low Rates of Lung and Colorectal Cancer Screening Uptake Among a Safety-net Emergency Department Population

Introduction: A suspected diagnosis of cancer through an emergency department (ED) visit is associated with poor clinical outcomes. The purpose of this study was to explore the rate at which ED patients attend cancer screenings for lung, colorectal (CRC), and breast cancers based on national guidelines set forth by the United States Preventive Services Task Force (USPSTF).

 

Methods: This was a prospective cohort study. Patients were randomly approached in the Eskenazi Hospital ED between August 2019–February 2020 and were surveyed to determine whether they would be eligible and had attended lung, CRC, and breast cancer screenings, as well as their awareness of lung cancer screening with low-dose computed tomography (LDCT). Patients who were English-speaking and ≥18 years old, and who were not critically ill or intoxicated or being seen for acute decompensated psychiatric illness were offered enrollment. Enrolled subjects were surveyed to determine eligibility for lung, colorectal, and breast cancer screenings based on guidelines set by the USPSTF. No cancer screenings were actually done during the ED visit.

 

Results: A total of 500 patients were enrolled in this study. More participants were female (54.4%), and a majority were Black (53.0%). Most participants had both insurance (80.2%) and access to primary care (62.8%). Among the entire cohort, 63.0% identified as smokers, and 62.2% (140/225) of the 50- to 80-year-old participants qualified for lung cancer screening. No patients were screened for lung cancer in this cohort (0/225). Only 0.6% (3/500) were aware that LDCT was the preferred method for screening. Based on pack years, 35.5% (32/90) of the patients who were 40-49 years old and 6.7% (6/90) of those 30–39 years old would eventually qualify for screening. Regarding CRC screening, 43.6% (218/500) of the entire cohort was eligible. However, of those patients only 54% (118/218) had been screened. Comparatively, 77.7% (87/112) of the eligible females had been screened for breast cancer, but only 54.5% (61/112) had been screened in the prior two years.

 

Conclusion: Many ED patients are not screened for lung/colorectal/breast cancers even though many are eligible and have reported access to primary care. This study demonstrates an opportunity and a need to address cancer screening in the ED.

 

International Medicine

Emergency Services Capacity of a Rural Community in Guatemala

Introduction: Access to emergency care is an essential part of the health system. Improving access to emergency services in low- and middle-income countries (LMIC) decreases mortality and reduces global disparities; however, few studies have assessed emergency services resources in LMICs. To guide future improvements in care, we performed a comprehensive assessment of the emergency services capacity of a rural community in Guatemala serving a mostly indigenous population.

Methods: We performed an exhaustively sampled cross-sectional survey of all healthcare facilities providing urgent and emergent care in the four largest cities surrounding Lake Atitlán using the Emergency Services Resource Assessment Tool (ESRAT).

Results: Of 17 identified facilities, 16 agreed to participate and were surveyed: nine private hospitals; four public clinics; and three public hospitals, including the region’s public departmental hospital. All facilities provided emergency services 24/7, and a dedicated emergency unit was available at 67% of hospitals and 75% of clinics. A dedicated physician was present in the emergency unit during the day at 67% of hospitals and 75% of clinics. Hospitals had a significantly higher percentage of available equipment compared to clinics (85% vs 54%, mean difference 31%; 95% confidence interval (CI) 23-37%; P = 0.004). There was no difference in availability of laboratory tests between public and private hospitals or between cities. Private hospitals had access to a significantly higher percentage of medications compared to clinics (56% vs 27%, mean difference 29%; 95% CI 9-49%; P = 0.024).

Conclusion: We found a high availability of emergency services and universal availability of personal protective equipment but a severe shortage of critical medications in clinics, and widespread shortage of pediatric equipment.

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Pediatrics

COVID-19 and Serious Bacterial Infection in Febrile Infants Less Than 60 Days Old

Introduction: The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to the coronavirus disease 2019 (COVID-19) pandemic that drastically impacted the United States. The evidence was not clear on how SARS-CoV-2 infection impacted children, given the high prevalence of SAR-CoV-2 infection. Febrile infants less than 60 days old are an ongoing challenge to risk-stratify for serious bacterial infection (SBI), including urinary tract infection (UTI), bacteremia, and meningitis. We hypothesized there would be a lower rate of SBI in SARS-CoV-2 positive febrile infants compared to those SARS-CoV-2 negative.

 

Methods: This was a retrospective chart review with a nested, age-matched, case-control study performed from March 2020–June 2021. Infants less than 60 days old presenting with fever were assigned groups based on SARS-CoV-2 infection. Blood, urine, and cerebrospinal fluid cultures were used as the gold standard to diagnose SBI. We compared overall rate of SBI as well as individual rates of SBI between each group. We performed a subgroup analysis evaluating the age group 29-60 days old.

 

Results: A total of 164 subjects met criteria for analysis: 30 COVID-19 positive and 134 COVID-19 negative subjects. Rate of SBI was 17.9% (95% confidence interval [CI]: 11.8-25.5%) in the COVID-19 negative group compared to 0% (95% CI: 0.0%-11.1%) in the COVID-19 group, which demonstrated statistical significance (p = 0.008). In the age-matched data, we found statistical significance for any SBI (p = <0.001). For individual rates of SBI, we found statistical significance for UTI (p = <0.001) and bacteremia (p = <0.001). The 29- 60 days-old subgroup analysis did not achieve statistical significance (p = 0.11).

 

Conclusion: This study demonstrated the utility of including SARS-CoV-2 infection as part of the risk stratification of febrile infants less than 60 days old. While overall there is a low incidence of bacteremia and meningitis in this age group, these results can contribute to existing literature and potentially help decrease invasive testing and exposure to broad-spectrum antibiotics.

 

Technology in Emergency Medicine

Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model

Introduction: Despite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices.

Methods: We developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model. 

Results: The estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation. 

Conclusion: In this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.

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Trauma

Blood Pressure Variability and Outcome in Traumatic Brain Injury: A Propensity Score Matching Study

Introduction: Patients with tIPH (used here to refer to traumatic intraparenchymal hemorrhagic contusion) or intraparenchymal hemorrhage face high rates of mortality and persistent functional deficits. Prior studies have found an association between blood pressure variability (BPV) and neurologic outcomes in patients with spontaneous IPH. Our study investigated the association between BPV and discharge destination (a proxy for functional outcome) in patients with tIPH.

Methods: We retrospectively reviewed the charts of patients admitted to a Level I trauma center for ≥ 24 hours with tIPH. We examined variability in hourly BP measurements over the first 24 hours of hospitalization. Our outcome of interest was discharge destination (home vs facility). We performed 1:1 propensity score matching and multivariate regressions to identify demographic and clinical factors predictive of discharge home.

Results: We included 354 patients; 91 were discharged home and 263 to a location other than home. The mean age was 56 (SD 21), 260 (73%) were male, 22 (6%) were on anticoagulation, and 54 (15%) on antiplatelet therapy. Our propensity-matched cohorts included 76 patients who were discharged home and 76 who were discharged to a location other than home. One measure of BPV (successive variation in systolic BP) was identified as an independent predictor of discharge location in our propensity-matched cohorts (odds ratio 0.89, 95% confidence interval 0.8-0.98; P = 0.02). Our model demonstrated good goodness of fit (P-value for Hosmer-Lemeshow test = 0.88) and very good discriminatory capability (AUROC = 0.81). High Glasgow Coma Scale score at 24 hours and treatment with fresh frozen plasma were also associated with discharge home.

Conclusion: Our study suggests that increased BPV is associated with lower rates of discharge home after initial hospitalization among patients with tIPH. Additional research is needed to evaluate the impact of BP control on patient outcomes.

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Violence Assessment and Prevention

A Novel Technique to Identify Intimate Partner Violence in a Hospital Setting

Introduction: Intimate partner violence (IPV) is defined as sexual, physical, psychological, or economic violence that occurs between current or former intimate partners. Victims of IPV may seek care for violence-related injuries in healthcare settings, which makes recognition and intervention in these facilities critical. In this study our goal was to develop an algorithm using natural language processing (NLP) to identify cases of IPV within emergency department (ED) settings.

Methods: In this observational cohort study, we extracted unstructured physician and advanced practice provider, nursing, and social worker notes from hospital electronic health records (EHR). The recorded clinical notes and patient narratives were screened for a set of 23 situational terms, derived from the literature on IPV (ie, assault by spouse), along with an additional set of 49 extended situational terms, extracted from known IPV cases (ie, attack by spouse). We compared the effectiveness of the proposed model with detection of IPV-related International Classification of Diseases, 10th Revision, codes.

Results: We included in the analysis a total of 1,064,735 patient encounters (405,303 patients who visited the ED of a Level I trauma center) from January 2012–August 2020. The outcome was identification of an IPV-related encounter. In this study we used information embedded in unstructured EHR data to develop a NLP algorithm that employs clinical notes to identify IPV visits to the ED. Using a set of 23 situational terms along with 49 extended situational terms, the algorithm successfully identified 7,399 IPV-related encounters representing 5,975 patients; the algorithm achieved 99.5% precision in detecting positive cases in our sample of 1,064,735 ED encounters. 

Conclusion: Using a set of pre-defined IPV-related terms, we successfully developed a novel natural language processing algorithm capable of identifying intimate partner violence.