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Open Access Publications from the University of California

Volume 20, Issue 6, 2019

Volume 20, Issue 6, 2019

Societal Impact on Emergency Care

Barriers to Accessing Acute Care for Newly Arrived Refugees

Introduction: Over the past decade, the number of refugees arriving in the United States (U.S.) has increased dramatically. Refugees arrive with unmet health needs and may face barriers when seeking care. However, little is known about how refugees perceive and access care when acutely ill. The goal of this study was to understand barriers to access of acute care by newly arrived refugees, and identify potential improvements from refugees and resettlement agencies.

Methods: This was an in-depth, qualitative interview study of refugees and employees from refugee resettlement and post-resettlement agencies in a city in the Northeast U.S. Interviews were audiotaped, transcribed, and coded independently by two investigators. Interviews were conducted until thematic saturation was reached. We analyzed transcripts using a modified grounded theory approach.

Results: Interviews were completed with 16 refugees and 12 employees from refugee resettlement/post-resettlement agencies. Participants reported several barriers to accessing acute care including challenges understanding the U.S. healthcare system, difficulty scheduling timely outpatient acute care visits, significant language barriers in all acute care settings, and confusion over the intricacies of health insurance. The novelty and complexity of the U.S. healthcare system drives refugees to resettlement agencies for assistance. Resettlement agency employees express concern with directing refugees to appropriate levels of care and report challenges obtaining timely access to sick visits. While receiving emergency department (ED) care, refugees experience communication barriers due to limitations in consistent interpretation services.

Conclusion: Refugees face multiple barriers when accessing acute care. Interventions in the ED, outpatient settings, and in resettlement agencies, have the potential to reduce barriers to care. Examples could include interpretation services that allow for clinic phone scheduling and easier access to interpreter services within the ED. Additionally, extending the Refugee Medical Assistance program may limit gaps in insurance coverage and avoid insurance-related barriers to seeking care.

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Emergency Department Administration

Time Cost of Standardized Nursing Screens in the Emergency Department

Introduction: Various policies require that screening questions be asked of all patients who present to the emergency department (ED). No studies have previously examined the potential time costs of standardized screens. Our objective was to analyze the time nursing spent conducting standardized nursing screens and calculate the corresponding time cost.

Methods: This was a prospective observational study of ED registered nurses (RN) performing triage assessments on adults presenting to the ED. A study author timed nurses while the RN asked five pre-selected questions from their current triage protocol. The time cost of each question was determined by multiplying the length of time spent asking the question each year by the mean hourly wage of RNs at the study hospital. (T/3,600) x V x S; T = mean time per question (in seconds); V = annual patient volume; S = mean hourly RN wage.

Results: We observed 200 triage assessments. During the triage assessments, 130 patients (65%) were asked about pneumococcal vaccine status; 161 (80.5%) about tetanus vaccine status; 184 (92%) about medication allergies; 172 (86%) about influenza vaccine; and 73 (36.5%) about recent travel. The mean time spent per question ranged from 4.37-6.26 seconds. The estimated annual time used to ask the five questions in the study ED is 590.73 hours, which equates to $20,675.50 in nursing costs per year.

Conclusion: There are potential monetary and time costs of standardized screening questions in the ED. The values heavily impact time and cost efficiency in the ED and could be redirected to more pertinent patient care. The required screening questions often have an unclear utility on the care that the patient receives in the ED. Further studies are needed to determine cost effectiveness of required ED screenings.

Health Outcomes

Musculoskeletal Injuries and Outcomes Pre- and Post- Emergency Medicine Training Program

Introduction: Musculoskeletal injuries (MSI) comprise a large portion of the trauma burden in low- and middle-income countries (LMIC). Rwanda recently launched its first emergency medicine training program (EMTP) at the University Teaching Hospital-Kigali (UTH-K), which may help to treat such injuries; yet no current epidemiological data is available on MSI in Rwanda.

Methods: We conducted this pre-post study during two data collection periods at the UTH-K from November 2012 to July 2016. Data collection for MSI is limited and thus is specific to fractures. We included all patients with open, closed, or mixed fractures, hereafter referred to as MSI. Gathered information included demographics and outcomes including death, traumatic complications, and length of hospital stay, before and after the implementation of the EMTP.

Results: We collected data from 3609 patients. Of those records, 691 patients were treated for fractures, and 674 of them had sufficient EMTP data measured for inclusion in the analysis of results (279 from pre-EMTP and 375 from post-EMTP). Patient demographics demonstrate that a majority of MSI cases are male (71.6% male vs 28.4% female) and young (64.3% below 35 years of age). Among mechanisms of injury, major causes included road traffic accidents (48.1%), falls (34.2%), and assault (6.0%). There was also an observed association between EMTP and trends of the three primary outcomes: a reduction of death in the emergency department (ED) from those with MSI by 89.9%, from 2.51% to 0.25% (p = 0.0077); a reduction in traumatic complications for MSI patients by 71.7%, from 3.58% to 1.01% (p = 0.0211); and a reduction in duration of stay in the ED among those with MSI by 52.7% or 2.81 days on average, from 5.33 to 2.52 days (p = 0.0437).

Conclusion: This study reveals the current epidemiology of MSI morbidity and mortality for a major Rwandan teaching hospital and the potential impacts of EM training implementation among those with MSI. Residency training programs such as EMTP appear capable of reducing mortality, complications, and ED length of stay among those with MSI caused by fractures. Such findings underscore the efficacy and importance of investments in educating the next generation of health professionals to combat prevalent MSI within their communities.

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Emergency Department Operations

Predicting Emergency Department “Bouncebacks”: A Retrospective Cohort Analysis

Introduction: The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored.

Methods: This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 – June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit.

Results: Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 – 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 – 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 – 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 – 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 – 1.528; Medicare OR 1.601; 95% CI, 1.583 – 1.620).

Conclusion: Previous ED use – even a single previous visit – was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.

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Critical Care

Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review

Heart failure is a common presentation to the emergency department (ED), which can be confusedwith other clinical conditions. This review provides an evidence-based summary of the currentED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heartfailure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea,orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heartsound, or extremity edema. However, physical examination findings are often not sensitive or specific.ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liverfunction tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriureticpeptides do not significantly change ED treatment, mortality, or readmission rates, although they maydecrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and severalother conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound,which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cavasize. These modalities, combined with clinical assessment and gestalt, are recommended.

Health Policy Analysis

Impact of Global Budget Revenue Policy on Emergency Department Efficiency in the State of Maryland

Introduction: On January 1, 2014, the State of Maryland implemented the Global Budget Revenue (GBR) program. We investigate the impact of GBR on length of stay (LOS) for inpatients in emergency departments (ED) in Maryland.

Methods: We used the Hospital Compare data reports from the Centers for Medicare and Medicaid Services (CMS) and CMS Cost Reports Hospital Form 2552-10 from January 1, 2012–March 31, 2016, with GBR hospitals from Maryland and hospitals from West Virginia (WV), Delaware (DE), and Rhode Island (RI). We implemented difference-in-differences analysis and investigated the impact of GBR implementation on the LOS or ED1b scores of Maryland hospitals using a mixed-effects model with a state-level fixed effect, a hospital-level random effect, and state-level heterogeneity.

Results: The GBR impact estimator was 9.47 (95% confidence interval [CI], 7.06 to 11.87, p-value<0.001) for Maryland GBR hospitals, which implies, on average, that GBR implementation added 9.47 minutes per year to the time that hospital inpatients spent in the ED in the first two years after GBR implementation. The effect of the total number of hospital beds was 0.21 (95% CI, 0.089 to 0.330, p-value = 0 .001), which suggests that the bigger the hospital, the longer the ED1b score. The state-level fixed effects for WV were -106.96 (95% CI, -175.06 to -38.86, p-value = 0.002), for DE it was 6.51 (95% CI, -8.80 to 21.82, p-value=0.405), and for RI it was -54.48 (95% CI, -82.85 to -26.10, p-value<0.001).

Conclusion: Our results indicate that GBR implementation has had a statistically significant negative impact on the efficiency measure ED1b of Maryland hospital EDs from January 2014 to April 2016. We also found that the significant state-level fixed effect implies that the same inpatient might experience different ED processing times in each of the four states that we studied. [West J Emerg Med.

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Patient Communication

Efficacy of a Short Role-Play Training on Breaking Bad News in the Emergency Department

Introduction: Breaking bad news (BBN) in the emergency department (ED) represents a challenging and stressful situation for physicians. Many medical students and residents feel stressed and uncomfortable with such situations because of insufficient training. Our randomized controlled study aimed to assess the efficacy of a four-hour BBN simulation-based training on perceived self-efficacy, the BBN process, and communication skills.

Methods: Medical students and residents were randomized into a 160-hour ED clinical rotation without a formal BBN curriculum (control group [CG], n = 31) or a 156-hour ED clinical rotation and a four-hour BBN simulation-based training (training group [TG], n = 37). Both groups were assessed twice: once at the beginning of the rotation (pre-test) and again four weeks later. Assessments included a BBN evaluation via a simulation with two actors playing family members and the completion of a questionnaire on self-efficacy. Two blinded raters assessed the BBN process with the SPIKES (a delivery protocol for delivering bad news) competence form and communication skills with the modified BBN Assessment Schedule.

Results: Group-by-time effects adjusted by study year revealed a significant improvement in TG as compared with CG on self-efficacy (P < 0.001), the BBN process (P < 0.001), and communication skills (P < 0.001). TG showed a significant gain regarding the BBN process (+33.3%, P < 0.001). After the training, students with limited clinical experience prior to the rotation showed BBN performance skills equal to that of students in the CG who had greater clinical experience.

Conclusion: A short BBN simulation-based training can be added to standard clinical rotations. It has the potential to significantly improve self-efficacy, the BBN process, and communication skills.

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International Medicine

Status of Emergency Signal Functions in Myanmar Hospitals: A Cross-Sectional Survey

Introduction: Low- and middle-income countries (LMICs) have a large percentage of globalmortality and morbidity rates from non-communicable diseases, including trauma. Theestablishment and development of emergency care systems is crucial for addressing thisproblem. Defining gaps in the resources and capacity to provide emergency healthcare in LMICsis essential for proper design and operation of ECS (emergency care services) reinforcementprograms. Myanmar has particular challenges with road access for providing timely emergencymedical care, and a shortage of trained health workers. To examine the ECS capacity in Myanmar,we used the Emergency Care Assessment Tool (ECAT), which features newly developed toolsfor assessing sentinel conditions and signal functions (key interventions to address morbidity andmortality) in emergency care facilities.

Methods: ECAT is composed of six emergent sentinel conditions and corresponding signalfunctions. We surveyed a total of nine hospitals in five states in Myanmar. A constructed surveysheet was delivered by e-mail, and follow-up interviews were conducted via messenger to clarifyambiguous answers.

Results: We categorized the nine participating institutions according to predefined criteria:four basic-level hospitals; four intermediate-level; and one advanced-level hospital. All basichospitals were weak in trauma care, and two of 12 signal functions were unavailable. Half of theintermediate hospitals showed weakness in trauma care, as well as critical care such as shockmanagement. Only half had a separate triage area for patients. In contrast, all signal functions andresources listed in ECAT were available in the advanced-level hospital.

Conclusion: Basic-level facilities in Myanmar were shown to be suboptimal in traumamanagement, with critical care also inadequate in intermediate facilities. To reinforce signalfunctions in Myanmar health facilities, stakeholders should consider expanding critical functionsin selected lower-level health facilities. A larger scale survey would provide more comprehensivedata to improve emergency care in Myanmar.

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Technology in Emergency Medicine

Identifying Emergency Department Symptom-Based Diagnoses with the Unified Medical Language System

Introduction: Many patients who are discharged from the emergency department (ED) with asymptom-based discharge diagnosis (SBD) have post-discharge challenges related to lack of adefinitive discharge diagnosis and follow-up plan. There is no well-defined method for identifyingpatients with a SBD without individual chart review. We describe a method for automated identificationof SBDs from ICD-10 codes using the Unified Medical Language System (UMLS) Metathesaurus.

Methods: We mapped discharge diagnosis, with use of ICD-10 codes from a one-month period ofED discharges at an urban, academic ED to UMLS concepts and semantic types. Two physicianreviewers independently manually identified all discharge diagnoses consistent with SBDs. Wecalculated inter-rater reliability for manual review and the sensitivity and specificity for our automatedprocess for identifying SBDs against this “gold standard.”

Results: We identified 3642 ED discharges with 1382 unique discharge diagnoses that correspondedto 875 unique ICD-10 codes and 10 UMLS semantic types. Over one third (37.5%, n = 1367) of EDdischarges were assigned codes that mapped to the “Sign or Symptom” semantic type. Inter-raterreliability for manual review of SBDs was very good (0.87). Sensitivity and specificity of our automatedprocess for identifying encounters with SBDs were 84.7% and 96.3%, respectively.

Conclusion: Use of our automated process to identify ICD-10 codes that classify into the UMLS “Signor Symptom” semantic type identified the majority of patients with a SBD. While this method needsrefinement to increase sensitivity of capture, it has potential to automate an otherwise highly timeconsumingprocess. This novel use of informatics methods can facilitate future research specific topatients with SBDs.

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Identifying and Overcoming Barriers to Resident Use of Point-of-Care Ultrasound

Introduction: Emergency medicine residency programs have rigorous point-of-care ultrasound (POCUS) curricula. However, this training does not always readily translate to routine use in clinical decision-making. This study sought to identify and overcome barriers that could prevent resident physicians from performing POCUS during clinical shifts.

Methods: This was a two-step process improvement study. First, a survey was deployed to all residents of a three-year academic residency program to identify barriers to clinical use of POCUS. This survey identified the perceived lack of a uniform documenting protocol as the most important barrier to performing POCUS on shift. Second, as an intervention to overcome this barrier, a streamlined documentation protocol was developed and presented to residents. The primary outcome was the number of patients who had POCUS used in medical decision-making one year before and after intervention. Secondary outcomes were the level of training of residents performing exams and whether faculty overseeing exams were trained through an ultrasound fellowship program.

Results: POCUS use by residents increased from 82 to 223 patients before and after the intervention, respectively. Per resident, this translates to an absolute increase from 2.2 (95% confidence intervall [CI], 1.4, 3) to 5.8 (95% CI, 4, 7.6) or 3.6 (95% CI, 1.8, 5.4) exams/resident over the study period. We observed no significant difference in the proportions of scans attributable to the resident level of training (χ2 = 0.5, p = 0.47). The proportion of exams by non-ultrasound fellowship trained faculty increased significantly more compared to fellowship trained faculty (χ2 = 19, p<0.0001); however, both ultrasound fellowship trained and non-ultrasound fellowship trained faculty increased the absolute number of exams performed.

Conclusion: A key perceived barrier to resident-performed POCUS is unfamiliarity with documenting ultrasounds for medical decision-making. Educating residents in person about a POCUS documentation protocol may help overcome this barrier. Incorporating resident input and motivation into POCUS incentivization may increase utilization. Future studies in optimizing POCUS on shift will need to focus on streamlining documentation, addressing time constraints, and faculty support for resident-performed POCUS.

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Vitamin D Deficiency and Long-Term Cognitive Impairment Among Older Adult Emergency Department Patients

Introduction: Approximately 16% of acutely ill older adults develop new, long-term cognitive impairment (LTCI), many of whom initially seek care in the emergency department (ED). Currently, no effective interventions exist to prevent LTCI after an acute illness. Identifying early and modifiable risk factors for LTCI is the first step toward effective therapy. We hypothesized that Vitamin D deficiency at ED presentation was associated with LTCI in older adults.

Methods: This was an observational analysis of a prospective cohort study that enrolled ED patients ≥ 65 years old who were admitted to the hospital for an acute illness. All patients were enrolled within four hours of ED presentation. Serum Vitamin D was measured at enrollment and Vitamin D deficiency was defined as serum concentrations <20 mg/dL. We measured pre-illness and six-month cognition using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine whether Vitamin D deficiency was associated with poorer six-month cognition adjusted for pre-illness IQCODE and other confounders. We incorporated a two-factor interaction into the regression model to determine whether the relationship between Vitamin D deficiency and six-month cognition was modified by pre-illness cognition.

Results: We included a total of 134 older ED patients; the median (interquartile range [IQR]) age was 74 (69, 81) years old, 61 (46%) were female, and 14 (10%) were nonwhite race. The median (IQR) vitamin D level at enrollment was 25 (18, 33) milligrams per deciliter and 41 (31%) of enrolled patients met criteria for vitamin D deficiency. Seventy-seven patients survived and had a six-month IQCODE. In patients with intact pre-illness cognition (IQCODE of 3.13), Vitamin D deficiency was significantly associated with worsening six-month cognition (β-coefficient: 0.43, 95% CI, 0.07 to 0.78, p = 0.02) after adjusting for pre-illness IQCODE and other confounders. Among patients with pre-illness dementia (IQCODE of 4.31), no association with Vitamin D deficiency was observed (β-coefficient: -0.1;, 95% CI, [-0.50-0.27], p = 0.56).

Conclusion: Vitamin D deficiency was associated with poorer six-month cognition in acutely ill older adult ED patients who were cognitively intact at baseline. Future studies should determine whether early Vitamin D repletion in the ED improves cognitive outcomes in acutely ill older patients.


Risk Factors Associated with Emergency Department Recidivism in the Older Adult

Our objective was to review risk factors predictive of older adult recidivism in the emergency department. Certain risk factors and themes commonly occurred in the literature. These recurring factors included increasing age, male gender, certain diagnoses (abdominal pain, traumatic injuries, and respiratory complaints), psychosocial factors (depression, anxiety, poor social support, and limited health literacy), and poor general health (cognitive health and physical functioning). Many of the identified risk factors are not easily modifiable posing a significant challenge in the quest to develop and implement effective intervention strategies.


An Academic Relative Value Unit System: Do Transparency, Consensus, and Accountability Work?

Introduction: Academic medicine continues to struggle in its efforts to compensate scholarly productivity. Academic achievements receive less recognition compared to clinical work, evidenced by a lack of reduced clinical hours or financial incentive. Core departmental education responsibilities are often distributed inequitably across academic departments. An approach using an incentive program, which emphasizes transparency, equity, and consensus may help academic departments share core education responsibilities and reward scholarly activity.

Methods: We launched a two-stage approach to confront the inequitable distribution of educational responsibilities and to recognize the scholarly work among our faculty. In the first stage, baseline education expectations were implemented for all faculty members, which included accountability procedures tied to a financial incentive. The second stage involved the creation of an aAcademic rRelative vValue uUnit (ARVU) system which contained additional activities that were derived and weighted based on stakeholder consensus. The points earned in the ARVU system were applied towards additional financial incentive at academic year-end. We compared education contributions before and after implementation as well as total points earned in the ARVU system.

Results: In the first year of implementing education expectations, 87% of faculty fulfilled requirements. Those with a heavier clinical load made up the majority of deficient faculty. Those who did not meet education expectations were notified and had their year-end incentive reduced to reflect this. Faculty conference attendance increased by 21% (P<.001) and the number of resident assessments completed increased by 30% (P<.001) compared to the previous year. To date, faculty across the department have logged a total of 1,240 academic activities in the database, which will be converted into financial bonus amounts at year-end.

Conclusion: We have seen significant increases in faculty participation in educational activities and learner assessments as well as documentation of activities in the ARVU system. A similar system using different specialty-specific activities may be generalizable and employed at other institutions.

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The Standardized Letter of Evaluation Narrative: Differences in Language Use by Gender

Introduction: Prior research demonstrates gender differences in language used in letters of recommendation. The emergency medicine (EM) Standardized Letter of Evaluation (SLOE) format limits word count and provides detailed instructions for writers. The objective of this study is to examine differences in language used to describe men and women applicants within the SLOE narrative.

Methods: All applicants to a four-year academic EM residency program within a single application year with a first rotation SLOE available were included in the sample. We used the Linguistic Inquiry and Word Count (LIWC) program to analyze word frequency within 16 categories. Descriptive statistics, chi-squared, and t-tests were used to describe the sample; gender differences in word frequency were tested for using Mann-Whitney U tests.

Results: Of 1117 applicants to the residency program, 822 (82%) first-rotation SLOEs were available; 64% were men, and 36% were women. We did not find a difference in baseline characteristics including age (mean 27 years), top 25 schools (22.5%), Alpha Omega Alpha Honor Medical Society rates (13%), and having earned advanced degrees (10%).  The median word count per SLOE narrative for men was 171 and for women was 180 (p = 0.15). After adjusting for letter length, word frequency differences between genders were only present in two categories: social words (women: 23 words/letter; men: 21 words/letter, p = 0.02) and ability words (women: 2 words/letter; men: 1 word/letter, p = 0.04). We were unable to detect a statistical difference between men and women applicants in the remaining categories, including words representing communal traits, agentic traits, standout adjectives, grindstone traits, teaching words, and research words.

Conclusion: The small wording differences between genders noted in two categories were statistically significant, but of unclear real-world significance. Future work is planned to evaluate how the SLOE format may contribute to this relative lack of bias compared to other fields and formats.

Emergency Medical Services

Safety of Tiered-Dispatch for 911 Calls for Abdominal Pain

Introduction: Many dispatch systems send Advanced Life Support (ALS) resources to patientscomplaining of abdominal pain even though the majority of these incidents require only Basic LifeSupport (BLS). With increasing 911-call volume, resource utilization has become more important toensure that ALS resources are available for time-critical emergencies. In 2015, a large, urban firedepartment implemented an internally developed, tiered-dispatch system. Under this system, patientsreporting a chief complaint of abdominal pain received the closest BLS ambulance dispatched aloneemergency if located within three miles of the incident. The objective of this study was to determine thesafety of BLS-only dispatch to abdominal pain by determining the frequency of time-sensitive events.

Methods: This was a retrospective review of electronic health records of one emergency medicalservice provider agency from May 2015-2018. Inclusion criteria were a chief complaint of abdominalpain from a first- or second-party caller, age over 15, and the patient was reported to be alert andbreathing normally. The primary outcome was the prevalence of time-sensitive events, includingcardiopulmonary resuscitation (CPR), defibrillation, or airway management. Secondary outcomeswere hypotension (systolic blood pressure < 90 mmHg); or a prehospital 12 lead-electrocardiogram(ECG) demonstrating ST-elevation myocardial infarction (STEMI) criteria or a wide complex arrhythmia.Descriptive statistics were used.

Results: During the study period, there were 1,220,820 EMS incidents, of which 33,267 (2.72%) metinclusion criteria. The mean age was 49.9 years (range 16-111, standard deviation [SD] 19.6); 14,556patients (56.2%) were female. Time-sensitive events occurred in seven cases (0.021%), mean age was75.3 years (range 30-86, SD18.7); 85.7% were female. Airway management was required in sevencases (0.021%), CPR in six cases (0.018%), and defibrillation in one case (0.003%). Two of the seven(28.6%) cases involved dispatch protocol deviations. Hypotension was present in 240 (0.72%) cases;six (0.018%) cases had 12-lead ECGs meeting STEMI criteria; and no cases demonstrated widecomplex arrhythmia.

Conclusion: Among adult 911 patients with a dispatch chief complaint of abdominal pain, time-sensitiveevents were exceedingly rare. Dispatching a BLS ambulance alone appears to be safe.

Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System

Introduction: Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure.

Methods: Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge.

Results: We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success.

Conclusion: Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.

ACOEP Original Research (by Invitation Only)

Incidence of Clostridium difficile Infection After Sepsis Protocol Antibiotics

Introduction: The management of sepsis includes the prompt administration of intravenous antibiotics.There is concern that sepsis treatment protocols may be inaccurate in identifying true sepsis andexposing patients to potentially harmful antibiotics, sometimes unnecessarily. This study was designed toinvestigate those concerns by focusing on in-hospital Clostridium difficile infection (CDI), which is a knowncomplication of exposure to antibiotics.

Methods: Our emergency department (ED) recently implemented a protocol to help combat sepsis andincrease compliance with the 2017 Sepsis CMS Core Measures (SEP-1) guidelines. In this single-center,retrospective cohort analysis we queried the electronic health record to gather data on nosocomial CDIand antibiotics prescribed over a five-year period to analyze the effect of the introduction of a sepsisprotocol order set. The primary goal of this study was to measure the hospital-wide CDI rate for threeyears prior to implementation of the sepsis bundle, and then compare this to the hospital-wide CDI rate twoyears post-implementation. As a secondary outcome, we compared the number of antibiotics prescribed inthe ED 12 months prior to administration of the sepsis protocol vs 12 months post-initiation.

Results: Over the course of five years, the hospital averaged 9.4 nosocomial CDIs per 10,000 patienthours. Prior to implementation of the sepsis bundle, the average CDI rate was 11.6 (±1.11, 95%) and afterimplementation the average rate dropped to 6.2 (±1.27, 95%, p<0.01). The mean number of antibioticsordered per patient visit was 0.33 (±0.015, 95%) prior to bundle activation, and, following sepsis bundleactivation, the rate was 0.38 (±0.019, 95%, p<0.01). This accounted for 38% of all ED patient visitsreceiving antibiotics, a 5% increase after the sepsis bundle was introduced.

Conclusion: In this study, we found that CDI infections declined after implementation of a sepsisbundle. There was, however an increase in the number of patients being exposed to antibiotics afterthis hospital policy change. There are more risks than just CDI with antibiotic exposure, and thesewere not measured in this study. Subsequent studies should focus on the ongoing effects of timed,protocolized care and the associated risks.

ACOEP Abstracts (by Invitation Only)

Reducing Substance Use by an Emergency Department Intervention

Introduction: Substance use and misuse is prevalent in emergency department (ED) patients. We set out to determine substance use reduction rates after a brief ED intervention for patients with tobacco, alcohol, or drug use.

Methods: In this pilot prospective study, we approached a convenience sample of subjects in 2 EDs in PA during scheduled provider nonclinical times. One site was a trauma center while the other was a smaller community hospital. Subjects had to be ≥18 yo, have capacity to answer survey questions and participate in the program interventions, could not be critically ill, and had to be willing to participate. Participating subjects admitted to definitions of unhealthy use of one or more of: tobacco products, alcohol, street drugs, or addictive prescription drugs. Subjects received a structured survey and intervention tool that was previously validated (Project ASSERT), a brief intervention based on motivational interviewing, and referral to treatment, which took on average 5-10 minutes1. The intervention was carried out by a medical student, Emergency Medicine (EM) Resident, or an Addiction Recovery Specialist (a licensed social worker and certified recovery specialist with lived substance use disorder experience). These providers had training in Project ASSERT prior to the study start. Phone follow-up was used to determine current substance use by the patient. Subjects received no financial incentives.

Results: One-hundred ninety-one patients were recruited (105 for tobacco usage, 54 for alcohol, and 32 for drugs). At follow-up, 16/105 tobacco users (15.0%) reported stopping smoking, 51 (48.6%) a decrease in the number of cigarettes per day, and 32 (30.5%) attempting to quit. Of 54 patients in the high-risk alcohol utilization group, 40 (74.1%) reported either a decrease in the number of days per week of drinking, or a decrease in the number of drinks per day. Of the 32 patients who used drugs, 25 (78.1%) reported a decrease in usage.

Conclusion: In this pilot study involving medical students, EM residents and drug counselors at 2 EDs, we found that a brief intervention to patients with unhealthy tobacco, alcohol, and drug use resulted in overall decreased use. A more robust study, with a larger patient sample size is indicated.

Teamwork between Engineering and Medicine: Collaborative Training in the Emergency Department

Introduction: Entrustable Professional Activities (EPAs) 9 and 13 are to “collaborate as a member of an interprofessional team” and to “identify system failures thereby contributing to a culture of safety and improvement.” Addressing EPA 9, an interprofessional initiative was begun using a project team between two university programs: medical education and health systems engineering. Addressing EPA 13, this team set out to provide diagnostic analytics for Length of Stay (LOS) delays in the Emergency Department (ED).

Methods: This project was performed in 2018 at an ED with 42 beds, an annual census of 70,000, and a 38% admission rate. Two healthcare systems engineering students and a medical student performed on-site observations to identify specific bottlenecks that could contribute to ED LOS. This data and data generated from the electronic medical record were analyzed and correlated with observations. Factors (44) that affect ED processes were analyzed, including time interval metrics such as arrival to triage, arrival to admit, disposition to departure, and bed request to admit.

Results: Patients had an average LOS of 5.9 hours. A total of 4,940 adult, non-psychiatric cases presented; 1,599 (32.4%) of these were admitted. Process evaluation (Figure, mean and median minutes) showed differences between day (7a-7p) and night (7p-7a) flow patterns. These quantitative results (EPA 13) were determined by the interprofessional collaborative work efforts of the students (qualitatively, the outcome of EPA 9).This project demonstrated a synergistic educational experience that allowed the blending of medical education with process engineering, ultimately improving knowledge gaps of both. This unique process allowed for diagnostics to be performed that were necessary for the ED and simultaneously provided a stronger foundation for QI undertakings for both engineering and medical students.

Conclusion: Medical students can benefit from working alongside systems engineers, allowing them to see the value of using tools (simulation modeling, statistical analysis, process flow mapping, etc.) to uncover evidence-based improvements to a variety of medical processes. Healthcare systems engineering students can gain valuable experience in a complex medical environment. Looking for solutions to the disparity between flow during the day and night is an opportunity for future study.

Scenario-based Pilot Testing of EMS Provider Interpretation of a Novel Pediatric Triage Protocol

Introduction: Pediatric care is increasingly concentrated in a small number of hospitals. No widely operative triage protocols guide emergency medical services’ (EMS) pediatric destination decision for non trauma patients. The PDTree tool is an evidence-based protocol validated by expert consensus, which was developed to assist EMS providers’ in choosing a pediatric destination facility capable of definitive care. The PDTree defines four tiers of pediatric care (specialty/trauma center, comprehensive pediatric facility, regional pediatric facility and closest ED), and matches patients by condition and EMS assessment.

Objective: To pilot test the PDTree tool with practicing EMS providers for accuracy of interpretation and performance across the range of practice levels and prior experience

Methods: Maryland EMS providers voluntarily participated in online testing. Demographic data included certification level, location of primary EMS jurisdiction, and years of experience. Providers were provided with a copy of the PDTree tool and presented 14 patient scenarios; each scenario was written to match one condition description in the PDTree tool with a clear recommendation for destination facility capability level. For each scenario, providers were asked to name their most likely destination, and to select the level of care suggested by their interpretation of the PDTree tool.

Results: 100 providers (52 ALS, 48 BLS) completed the electronic pilot test. Providers named a destination hospital with appropriate capabilities in 60% of scenarios. Providers’ interpretation of the PDTree’s advised destination level agreed with the intended response for 71% of scenarios. Greater than 90% agreement was seen for burns, witnessed child abuse, and cervical spine injury. Less than 50% agreement was seen for shock and a non distressed child with a tracheostomy. Rates of agreement differed for diabetic ketoacidosis and non distressed medically complex child based on provider level, and for elbow injury with deformity with years of experience (Chi Square p value = 0.01 and p value = 0.04, respectively).

Conclusion: EMS providers accurately interpreted the PDTree tool to determine the advised destination for a majority of pediatric scenarios. Future evaluation will focus on conditions with lower rates of agreement to determine if educational interventions or tool alterations are required. Virtual pilot testing using clinical vignettes is a reasonable first step in assessing the usability of a novel clinical decision-making tool.

Acknowledgement: Funding was provided by a grant from the United States Health Resources and Service Administration (HRSA-16-053: PDTree: A Tool for Prehospital Pediatric Destination Choice).

The Incidence of Septic Patients Identified Using a Sepsis Order Bundle

Introduction: Sepsis order sets improve compliance with the established guidelines, but clinicians must be careful to initiate these protocols on appropriate patients. Many conditions can mimic sepsis as defined by SEP-1 (two or more SIRS* criteria and a suspected infection) such as trauma, COPD, etc. SEP-1 criteria alone can lead to initiating a sepsis protocol without true infection based solely on vital signs.

Objective: To assess the incidence of patients who had a sepsis order set, but an infection was not discovered during their hospital course.

Methods: This study is a single-center retrospective chart review of all “SIRS positive” patients >21 years old who presented to a busy community ED who had the sepsis order set initiated from the emergency department in 2017. A total of 1577 encounters met inclusion criteria. The discharge diagnoses were reviewed to identify unique diagnoses. Similar diagnoses (e.g. RLQ abdominal pain and abdominal pain) were grouped together into the more generalized diagnosis. Several of the unique discharge diagnoses (161) were vague and required individual chart review by two people.

Results: Two hundred fifty-one unique discharge diagnoses were identified and then categorized as infectious or not. Conditions which may be inflammatory versus infectious (e.g. diverticulitis), but are classically treated with antibiotics were counted as infectious. One hundred sixty-one charts were reviewed by two physicians, of which, 130 (81%) were identified as having an infectious condition (K = 0.87). The most common sepsis mimic was abdominal pain, followed by COPD, and cough. A third (33.6%) did not have an infection identified.

Conclusion: SEP-1 criteria for diagnosis and treating sepsis are not specific, with one-third false positives. Identification criteria with higher specificity is needed, and may reduce healthcare expense.

*SIRS (Systemic Inflammatory Response Syndrome) is defined as temperature > 38C° or < 36C°, heart rate > 90 beats per minute, respiratory rate > 20 or PaCO2 < 32 mmHg, and WBC > 12k or < 4k/mm3.

Attitudes, Behavior & Knowledge of Emergency Medicine Healthcare Providers Regarding LGBT+ Patient Care

Introduction: There is evidence that healthcare providers are lacking in knowledge and confidence when it comes to treating LGBT+ patients.

Objective: To assess providers’ LGBT+ health-care knowledge, willingness to treat LGBT+ patients, communication behaviors, and whether there is a need for additional training. This involved an assessment that measured respondents’ knowledge of LGBT+ patients’ reluctance to communicate with providers, risk for certain cancers, and risk for suicide. Secondary outcomes assessed providers’ attitudes and practices toward LGBT+ patients.

Methods: 16 physicians and 24 nurses in the emergency department of an urban Level 1 trauma center were asked to participate in a survey regarding LGBT+ health. The survey was modified from published work and included questions about transgender patients. The effects of age, gender, and type of provider were contrasted with their willingness to treat and knowledge of LGBT+ healthcare. Descriptive statistics, Fisher’s exact test, and the Wilcoxon rank-sum and Kruskal-Wallis tests were used. This study was approved by the IRB and all data was de-identified.

Results: Compared to nurses, physicians were 9.0 (95% CI: 2.09–38.79) times more likely to agree with the statement “LGBT+ patients avoid accessing healthcare due to difficulty communicating with providers” (p=.003). Further, providers under the age 45 had a higher level of agreement with the statement “There should be more education in health professional schools on LGBT+ health needs” (p=.03) and with “being listed as an LGBT-friendly provider” (p=.001), as did nurses (p = .04) and those who identify as LGBT+ or know someone who identifies as LGBT+ (p=.005). Finally, respondents reported higher agreement to the statement “There should be educational events at my hospital about LGBT+ health needs” (Mdn=4, IQR=3–5) than to “I am well informed on the health needs of the LGBT patients” (Mdn=2, IQR=2–3).

Conclusions: There is a need and desire for educational events at the professional school and provider level, in addition it is recommended to conduct an educational intervention.