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Open Access Publications from the University of California

Open Access Policy Deposits

This series is automatically populated with publications deposited by UCSF Department of Emergency Medicine researchers in accordance with the University of California’s open access policies. For more information see Open Access Policy Deposits and the UC Publication Management System.

Cover page of Significant variation in computed tomography imaging of pregnant trauma patients: a retrospective multicenter study.

Significant variation in computed tomography imaging of pregnant trauma patients: a retrospective multicenter study.

(2024)

PURPOSE: Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice. METHODS: A multicenter retrospective study (2016-2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables. RESULTS: A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1-4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8-62.5%, p < 0.001), cervical spine (11.8-75%, p < 0.001), chest (4.4-50.2%, p < 0.001), and abdomen/pelvis (0-57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5-64.3%, p < 0.001), cervical spine (16.7-75%, p < 0.001), chest (5.9-83.3%, p < 0.001), and abdomen/pelvis (0-60%, p < 0.001). There was no difference in mortality (0-2.9%, p =0.19). CONCLUSION: Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved.

Cover page of Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis.

Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis.

(2023)

BACKGROUND: Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS: We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS: Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS: In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER: NCT03112018.

Certified Medical Interpreters’ Perspectives on Relationship-Centered Communication in Safety-Net Care

(2023)

This article was migrated. The article was marked as recommended. Background: Interpreters may offer valuable perspectives on ways clinicians could improve communication skills. Relationship-centered communication (RCC) curricula are based on a framework for promoting effective communication both with patients and within health care teams. Methods: We conducted a 90-minute workshop with certified interpreters at an academically-affiliated safety-net system to solicit feedback to optimize RCC skills trainings for clinicians at a U.S. academically-affiliated safety-net system. We applied an editing analysis style to transcribed quotes to reveal opportunities to optimize RCC skills trainings to improve safety-net care for diverse populations. Results: Twenty-two Spanish-, Cantonese-, Mandarin-, Vietnamese-, and Russian-speaking interpreters participated. Overall, interpreters emphasized the importance of creating a supportive environment for safety-net patients. One Spanish-speaking interpreter added: "When they get up in the morning and go to work, they may get deported. So, that's important to create an atmosphere to help them open up. And they may tell you stuff that's directly pertinent to patient care." Thematic analysis revealed opportunities to tailor and reinforce each RCC stage. On agenda-setting and rapport-building: "We need a little background on the phone, and we don't know how many people are in the room ... Sometimes you're talking to the mom, but the doctor didn't even bother to say it.. [If] we're lost, we're bound to make mistakes." On eliciting the patient's perspective: "Start with this information so they know you're still going to give them your advice: "I'm going to let you know what I think is going on, but what do you think is going on?" On negotiating a shared plan: "[Teachback] is really important. Otherwise it puts an incredible burden on the interpreter ... I'm not sure that the patient really understood." Conclusions: Teaching RCC in partnership with medical interpreters could provide opportunities to deepen clinician RCC skills for more effective patient-interpreter-clinician interactions.

Certified Medical Interpreters’ Perspectives on Relationship-Centered Communication in Safety-Net Care

(2023)

This article was migrated. The article was marked as recommended. Background: Interpreters may offer valuable perspectives on ways clinicians could improve communication skills. Relationship-centered communication (RCC) curricula aim to promote effective communication between patients and clinicians and among members of health care teams. Methods: We conducted a 90-minute workshop with certified interpreters at an academically affiliated safety-net system to solicit feedback on content offered during RCC skills trainings. We applied an editing analysis style to transcribed quotes to reveal opportunities to optimize RCC skills trainings for application in interpreted interactions to improve safety-net care for diverse populations. Results: Twenty-two Spanish-, Cantonese-, Mandarin-, Vietnamese-, and Russian-speaking interpreters participated. Overall, interpreters emphasized the importance of creating a supportive environment for safety-net patients. One Spanish-speaking interpreter added: "When they get up in the morning and go to work, they may get deported. So, that's important to create an atmosphere to help them open up. And they may tell you stuff that's directly pertinent to patient care." Thematic analysis revealed opportunities to tailor and reinforce each RCC stage. On agenda-setting and rapport-building: "We need a little background on the phone, and we don't know how many people are in the room ... Sometimes you're talking to the mom, but the doctor didn't even bother to say it.. [If] we're lost, we're bound to make mistakes." On eliciting the patient's perspective: "Start with this information so they know you're still going to give them your advice: "I'm going to let you know what I think is going on, but what do you think is going on?" On negotiating a shared plan: "[Teachback] is really important. Otherwise it puts an incredible burden on the interpreter ... I'm not sure that the patient really understood." Conclusions: Teaching RCC in partnership with medical interpreters could provide opportunities to deepen clinician RCC skills for more effective patient-interpreter-clinician interactions.

Cover page of San Francisco’s Citywide COVID-19 Response: Strategies to Reduce COVID-19 Severity and Health Disparities, March 2020 Through May 2022

San Francisco’s Citywide COVID-19 Response: Strategies to Reduce COVID-19 Severity and Health Disparities, March 2020 Through May 2022

(2023)

San Francisco implemented one of the most intensive, comprehensive, multipronged COVID-19 pandemic responses in the United States using 4 core strategies: (1) aggressive mitigation measures to protect populations at risk for severe disease, (2) prioritization of resources in neighborhoods highly affected by COVID-19, (3) timely and adaptive data-driven policy making, and (4) leveraging of partnerships and public trust. We collected data to describe programmatic and population-level outcomes. The excess all-cause mortality rate in 2020 in San Francisco was half that seen in 2019 in California as a whole (8% vs 16%). In almost all age and race and ethnicity groups, excess mortality from COVID-19 was lower in San Francisco than in California overall, with markedly diminished excess mortality among people aged >65 years. The COVID-19 response in San Francisco highlights crucial lessons, particularly the importance of community responsiveness, joint planning, and collective action, to inform future pandemic response and advance health equity.

Patterns in Patient Encounters and Emergency Department Capacity in California, 2011-2021.

(2023)

Importance

The health care system has undergone major changes in the past decade, and emergency department (ED) crowding has worsened over time; however, the most recent patterns in ED capacity and use in California have yet to be studied.

Objective

To analyze patterns in ED capacity and utilization in California hospitals from 2011 to 2021.

Design, setting, and participants

This retrospective cohort study used data from the California Department of Health Care Access and Information and the US Census Bureau to analyze ED facility characteristics from more than 400 general acute care hospitals with more than 320 EDs in California as well as patients who presented to those EDs between January 1, 2011, and December 31, 2021.

Main outcomes and measures

Linear patterns (measured by percentage change) in total annual ED capacity (volume of hospital beds, EDs, ED treatment stations, and trauma centers) and ED use (ED visits by disposition and acuity) were assessed as primary outcomes. Patterns in ambulance diversion hours and the number of patients who left the ED without being seen were also examined as secondary outcomes. Visit acuity was categorized into 5 levels by increasing severity (minor, low to moderate, moderate, severe without threat, and severe with threat) based on California Department of Health Care Access and Information descriptions corresponding to Current Procedural Terminology codes.

Results

In the prepandemic period (2011-2019), the total population of California increased from 37 638 369 to 39 512 223 (5.0%; 95% CI, 4.1%-5.8%), then decreased to 39 237 836 in 2021 (0.7%; 95% CI, -3.9% to 2.5%). Over the entire study period (2011-2021), the total California population increased by 4.2% (95% CI, 3.3%-5.2%). From 2011 to 2019, the annual number of ED visits increased from 12 054 885 to 14 876 653 (23.4%; 95% CI, 20.0%-26.8%) before decreasing to 12 944 692 in 2021 (-13.0%; 95% CI, -33.1% to 7.1%); from 2011 to 2021, total ED visits increased by 7.4% (95% CI, 5.6%-9.1%). From 2011 to 2021, the total number of EDs decreased from 339 to 326 (-3.8%; 95% CI, -4.4% to -3.2%) and the total number of hospital beds decreased from 75 940 to 74 052 (-2.5%; 95% CI, -3.3% to -1.6%), while the number of ED treatment stations in these fewer EDs increased from 7159 to 8667 (21.1%; 95% CI, 19.7%-22.4%). The number of visits rated as severe with threat also increased, from 2 011 637 in 2011 to 3 375 539 in 2021 (67.8%; 95% CI, 59.7%-75.9%), while visits rated as minor decreased from 913 712 to 336 071 (-63.2%; 95% CI, -75.2% to -51.2%) over the same period.

Conclusions and relevance

In this cohort study, multiple measures of ED capacity did not proportionally increase with the increasing demand for services; however, the COVID-19 pandemic appears to have substantially affected some of these patterns. These findings may be helpful to policy makers and health care stakeholders when planning resource allocation of limited health care resources.

Cover page of Burden of severe infections due to carbapenem-resistant pathogens in intensive care unit.

Burden of severe infections due to carbapenem-resistant pathogens in intensive care unit.

(2023)

Intensive care units (ICU) for various reasons, including the increasing age of admitted patients, comorbidities, and increasingly complex surgical procedures (e.g., transplants), have become "the epicenter" of nosocomial infections, these are characterized by the presence of multidrug-resistant organisms (MDROs) as the cause of infection. Therefore, the perfect match of fragile patients and MDROs, as the cause of infection, makes ICU mortality very high. Furthermore, carbapenems were considered for years as last-resort antibiotics for the treatment of infections caused by MDROs; unfortunately, nowadays carbapenem resistance, mainly among Gram-negative pathogens, is a matter of the highest concern for worldwide public health. This comprehensive review aims to outline the problem from the intensivist's perspective, focusing on the new definition and epidemiology of the most common carbapenem-resistant MDROs (Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacterales) to emphasize the importance of the problem that must be permeating clinicians dealing with these diseases.

Cover page of Designing clinical guidelines that improve access and satisfaction in the emergency department.

Designing clinical guidelines that improve access and satisfaction in the emergency department.

(2023)

Clinical guidelines are evidence-based clinician decision-support tools that improve health outcomes, reduce patient harm, and decrease healthcare costs, but are often underused in emergency departments (EDs). This article describes a replicable, evidence-based design-thinking approach to developing best practices for guideline design that improves clinical satisfaction and usage. We used a 5-step process to enhance guideline usability in our ED. First, we conducted end-user interviews to identify barriers to guideline usage. Second, we reviewed the literature to identify key principles in guideline design. Third, we applied our findings to create a standardized guideline format, incorporating rapid cycle learning and iterative improvements. Fourth, we ensured the clinical validity of our updated guidelines by using a rigorous process for peer review. Lastly, we evaluated the impact of our guideline conversion process by tracking clinical guidelines access per day from October 2020 to January 2022. Our end-user interviews and review of the design literature revealed several barriers to guideline use, including lack of readability, design inconsistencies, and guideline complexity. Although our previous clinical guideline system averaged 0.13 users per day, >43 users per day accessed the clinical guidelines on our new digital platform in January 2022, representing an increase in access and use exceeding 33,000%. Our replicable process using open-access resources increased clinician access to and satisfaction with clinical guidelines in our ED. Design-thinking and use of low-cost technology can significantly improve clinical guideline visibility and has the potential to increase guideline use.

Cover page of Improvements to emergency department length of stay and user satisfaction after implementation of an integrated consult order

Improvements to emergency department length of stay and user satisfaction after implementation of an integrated consult order

(2023)

Objective

Subspecialty consultation in the emergency department (ED) is a vital, albeit time consuming, part of modern medicine. Traditional consultation requires manual paging to initiate communication. Although consult orders through the electronic health record (EHR) may help, they do not facilitate 2-way communication. However, the impact of combining these systems within the EHR is unknown. We estimated the effect of implementing an integrated paging system on ED workflow efficiency and user attitudes.

Methods

We integrated a messaging system into order entry at our tertiary care academic ED, such that placing a consult order simultaneously paged the consultant. We measured ED workflow efficiency metrics (length of stay [LOS], consult initiation time) and MD/nurse practitioner (NP)/physician assistant (PA) attitudes (perceived mis-pages, efficiency, and workflow preference) 3 months before and 6 months after the implementation.

Results

Six months after implementation, there was 25% use of the new workflow. During the pre-implementation phase, the median time to consult initiation and ED LOS were 150 and 621 minutes, respectively. Implementation of the order was associated with a 15-minute reduction in median time to consult initiation (P < 0.001), and a 52-minute reduction in median ED LOS (P < 0.001). ED MDs/NPs/PAs perceived a reduction in the rate of mis-pages, improved efficiency, and overall preferred the new workflow.

Conclusions

We consolidated steps in the ED consult workflow using an integrated consult order, which improved user satisfaction, and reduced consult initiation time and ED LOS for patients requiring a consult at an urban tertiary care ED.

Cover page of Medicinal cannabis products for the treatment of acute pain.

Medicinal cannabis products for the treatment of acute pain.

(2023)

For thousands of years, medicinal cannabis has been used for pain treatment, but its use for pain management is still controversial. Meta-analysis of the literature has shown contrasting results on the addition of cannabinoids to opioids compared with placebo/other active agents to reduce pain. Clinical studies are mainly focused on medicinal cannabis use in chronic pain management, for which the analgesic effect has been proven in many studies. This review focuses on the potential use of medical cannabis for acute pain management in preclinical studies, studies on healthy subjects and the few pioneering studies in the clinical setting.