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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 Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Head Trauma

Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Head Trauma

(2013)

Introduction: Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.

Methods: We surveyed pediatric and general emergency physicians (EP), pediatric neurosurgeons (PNSurg), general neurosurgeons (GNSurg), pediatric surgeons (PSurg) and trauma surgeons regarding care of two hypothetical patients: Case 1: a 9-year-old who fell 10 feet and Case 2: an 11-month-old who fell 5 feet.  We presented various CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis adjusting for hospital and ED characteristics and clinician experience. Pediatric EPs served as the reference group.

Results: Of 2,341 eligible surveyed, 715 (31%) responded. Most would discharge children with linear skull fractures (Case 1, 71%; Case 2, 62%). Neurosurgeons were more likely to discharge children with small subarachnoid hemorrhages (Case 1 PNSurg OR 6.87, 95% CI 3.60, 13.10; GNSurg OR 6.54, 95% CI 2.38, 17.98; Case 2 PNSurg OR 5.38, 95% CI 2.64, 10.99; GNSurg OR 6.07, 95% CI 2.08, 17.76). PSurg were least likely to discharge children with any CT finding, even linear skull fractures (Case 1 OR 0.14, 95% CI 0.08, 0.23; Case 2 OR 0.18, 95% CI 0.11, 0.30). Few respondents (<6%) would discharge children with small intraventricular, subdural, or epidural bleeds.

Conclusion: Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings. [West J Emerg Med. 2013;14(1):29-36.]

Cover page of Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Abdominal Trauma

Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Abdominal Trauma

(2013)

Introduction: Children with blunt abdominal trauma (BAT) are often hospitalized despite no intervention. We identified factors associated with emergency department (ED) disposition of children with BAT and differing computed tomography (CT) findings.

Methods: We surveyed pediatric and general emergency physicians (EPs), pediatric and trauma surgeons regarding care of two hypothetical asymptomatic patients: a 9-year-old struck by a slow-moving car (Case 1) and an 11-month-old who fell 10 feet (Case 2). We presented various abdominal CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis, adjusting for hospital and ED characteristics, and clinician experience. Pediatric EPs served as the reference group.

Results: Of 2,003 eligible surveyed, 636 (32%) responded. For normal CTs, 99% would discharge in Case 1 and 88% in Case 2. Prominent specialty differences included: for trace intraperitoneal fluid (TIF), 68% would discharge in Case 1 and 57% in Case 2. Patients with TIF were less likely to be discharged by pediatric surgeons (Case 1: OR 0.52, 95% CI 0.32, 0.82; Case 2: OR 0.49, 95% CI 0.30, 0.79). Patients with renal contusions were less likely to be discharged by pediatric surgeons (Case 1: OR 0.55, 95% CI 0.32, 0.95) and more likely by general EPs (Case 1: OR 1.83, 95% CI 1.25, 2.69; Case 2: OR 2.37, 95% CI 1.14, 4.89).

Conclusion: Substantial variation exists between specialties in reported hospitalization practices of asymptomatic children after abdominal trauma with minor CT findings. Better evidence is needed to guide disposition decisions. [West J Emerg Med. 2013;14(1):37-46.]

Cover page of Humanistic Charting: Empowering Person-centered Emergency Care Through Reimagining the Electronic Health Record.

Humanistic Charting: Empowering Person-centered Emergency Care Through Reimagining the Electronic Health Record.

(2025)

OBJECTIVES: The rise in health care standardization has increased the focus on documentation, subsequently leading to the depersonalization of patient care. Humanistic Charting attempts to enhance person-centered care (PCC) by streamlining the integration of a patients narrative into the electronic health record (EHR), while reducing a clinicians administrative workload. The Humanistic Charting Tool (HCT) transitions the collection and documentation of person-centric data to patients, empowering them to convey their values, preferences, and individuality. METHODS: We carried out a pilot study in an academic emergency department (ED) at the University of California, San Francisco, between February and April 2023, involving 6 clinicians and 29 adult patients using the HCT. Clinicians reviewed HCT entries prior to patient encounters. The feasibility and impact of HCT were assessed using surveys and interviews pre- and postuse. The statistical significance of patient and clinician responses was assessed with 2-sided paired t tests. RESULTS: The HCT was met with high patient satisfaction, with notable improvements in patient-rated care experience metrics post-HCT implementation, such as respect for patient preferences and clinician availability. The HCT received excellent Net Promoter Scores from both patients (52) and clinicians (83). Clinicians observed that the HCT promoted a humanistic care approach and helped alleviate burnout. CONCLUSIONS: In this pilot study, the HCT has demonstrated encouraging feasibility and promise in helping enhance PCC within the challenging ED environment. Clinicians have noted its advantages in providing deeper insights into patient histories and improving the quality of interactions, having the potential to aid in counteracting biases. This pilot study demonstrates the HCTs potential to help foster humanism and PCC in emergency settings and supports the potential for broader applicability in health care systems.

Cover page of Navigating Nonlinear Pathways: Challenges and Opportunities for Diversity, Equity, and Inclusion Leaders in Academic Emergency Medicine.

Navigating Nonlinear Pathways: Challenges and Opportunities for Diversity, Equity, and Inclusion Leaders in Academic Emergency Medicine.

(2025)

OBJECTIVES: Diversity, equity, and inclusion (DEI) leadership roles have grown in academic emergency medicine (EM). We sought to elucidate specific pathways to DEI leadership roles among current DEI leaders in academic EM. METHODS: From March to May 2023, we conducted semistructured, qualitative interviews with DEI leaders in academic EM across 5 US regions to investigate their pathways to leadership. Participants were recruited via email using Accreditation Council for Graduate Medical Education-accredited EM residency websites and the Academy for Diversity and Inclusion in EM. After recording and transcribing the interviews, we used an inductive approach to identify major themes. RESULTS: Of 56 DEI leaders contacted, 25 agreed to participate, and 21 were interviewed. The median (range) interview duration was 34 (25-63) minutes. Leadership titles included directors, chairs, vice chairs, committee chairs, chiefs, advisors, and deans. Three major themes emerged: (1) nonlinear pathways-participants reached DEI roles through informal assumption, volunteering, or self-creation, often without initial aspiration or compensation; (2) undefined roles and expectations-roles and responsibilities were often determined by leaders themselves, with advantages and disadvantages; (3) variable perceived value in promotions-participants felt DEI efforts were frequently undervalued in academic promotion, with mentorship highlighted as crucial for translating DEI activities into academic achievements. CONCLUSION: Our study provides important insights not only into the pathways to DEI leadership among current leaders in academic EM but also into the challenges and opportunities DEI leaders perceive when navigating roles, responsibilities, and academic promotion.

Cover page of Prehospital buprenorphine in treating symptoms of opioid withdrawal - a descriptive review of the first 131 cases in San Francisco, CA.

Prehospital buprenorphine in treating symptoms of opioid withdrawal - a descriptive review of the first 131 cases in San Francisco, CA.

(2025)

Objectives

Opioid use disorder (OUD) remains a common cause of overdose and mortality in the United States. Emergency medical services (EMS) clinicians often interact with patients with OUD, including during or shortly after an overdose. The aim of this study was to describe the characteristics and outcomes of patients receiving prehospital buprenorphine for the treatment of opioid withdrawal in an urban EMS system.

Methods

We performed a retrospective chart review of all initial cases of administration of buprenorphine-naloxone from April 2023 - July 2024 during the first 16 months of a program involving prehospital EMS administration of buprenorphine-naloxone by EMS clinicians to patients with OUD experiencing acute opioid withdrawal in San Francisco. The primary outcome involved reduction in Clinical Opioid Withdrawal Score (COWS) and other adverse events including worsened withdrawal (or increased COWS), nausea, patient destination, and loss to follow up were also assessed.

Results

Buprenorphine was administered to 131 patients. In 82 (62.6%) cases, patients presented in withdrawal after receiving naloxone from bystanders or EMS as a treatment for overdose. The average COWS prior to administration was 16.1 ± 6.5 and the median COWS prior to administration was 15 (IQR: 11-19). Of the 78 cases where a COWS was available, 74 (94.9%) experienced symptom improvement, with the median COWS dropping from 15 (IQR: 11-19) to 7 (IQR: 4-13) between first and last recorded values. No adverse effects were reported in prehospital records. There was one reported in-hospital incident of withdrawal in the Emergency Department presumably precipitated by buprenorphine. Data on outcomes after EMS transport were limited. Only six patients were successfully contacted at 30 day follow up, but five of these patients were in long-term OUD treatment programs, and three reported sustained abstinence from opioid use. During case review, we found two cases where physicians assisted EMS personnel in recognizing recent methadone use, but no other missed exclusion criteria requiring physician input.

Conclusions

In San Francisco, prehospital administration of buprenorphine for acute opioid withdrawal by EMS clinicians resulted in symptomatic improvement, and case review suggests administration can be safe without direct EMS physician oversight.

Cover page of Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation.

Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation.

(2024)

In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.

Cover page of Implementation of an EMS-based naloxone distribution program: A qualitative evaluation.

Implementation of an EMS-based naloxone distribution program: A qualitative evaluation.

(2024)

OBJECTIVES: We evaluated a novel leave-behind naloxone (LBN) program that allows Emergency Medical Services (EMS) personnel to distribute naloxone after an opioid overdose. Our objective was to explore EMS engagement and experiences with the program, as well as interest in education on addiction and harm reduction. We also assessed the acceptability of LBN programs among people who use drugs (PWUD). METHODS: We conducted telephone interviews with EMS personnel and residents of substance use recovery housing between February and September 2023. EMS personnel described their direct experiences with the LBN program and perceived facilitating factors and barriers to naloxone distribution. First responder interactions and support for LBN were explored with PWUD. A rapid assessment method was used to analyze the interview data. RESULTS: Eighteen of the 23 EMS participants had distributed LBN; most agreed EMS agencies should have an LBN program. Barriers included forgetting, patient acuity, patients declining, and perceived liability. Facilitators included having a clear protocol, accessible kits, and minimal documentation burden. The majority expressed interest in harm reduction education. Eight of the 11 PWUD participants reported recent involvement in an opioid overdose. The majority supported LBN and felt comfortable receiving naloxone training from EMS. CONCLUSION: In this qualitative evaluation, we found broad support for EMS-based naloxone distribution among EMS personnel and PWUD. We identified several modifiable barriers to the success of such programs, which should be the subject of future investigation. EMS and harm reduction communities should support the expansion of LBN programs across the United States.

Cover page of The San Francisco Health Systems Collaborative: Public Health and Health Care Delivery Systems Response to the Covid-19 Pandemic.

The San Francisco Health Systems Collaborative: Public Health and Health Care Delivery Systems Response to the Covid-19 Pandemic.

(2024)

The Covid-19 pandemic challenged health care delivery systems worldwide. Many acute care hospitals in communities that experienced surges in cases and hospitalizations had to make decisions such as rationing scarce resources. Hospitals serving low-income communities, communities of color, and those in other historically marginalized or vulnerable groups reported the greatest operational impacts of surges. However, cross-institutional collaborations within jurisdictions offer unique opportunities to prevent or mitigate health disparities in resource utilization and access to care. In January 2020, in response to the emerging coronavirus epidemic, the San Francisco Department of Public Health (SFDPH) and local hospital and health systems partners convened to align and coordinate medical surge planning and response. Adopting a governance structure of mutual accountability and transparency, the San Francisco Health Systems Collaborative guided local medical and public health response in the areas of medical surge, vaccination administration, testing, and therapeutics. Four principles guided the collaborative response: (1) shared priorities, (2) clear governance and accountability, (3) data transparency, and (4) operational coordination. High-level priorities established included protecting vulnerable people, protecting health care workers, and maintaining health system capacity. The governance structure consisted of three layers: local hospital and health systems CEOs coordinating with SFDPH executives; hospital chief medical and nursing officers coordinating high-level surge capacity assessments and mitigation plans; and local clinical operational managers working with public health response operational leaders to coordinate scarce resource utilization. Fluctuating with the tempo of the disease indicators and medical surge, governance and coordination were maintained through a tiered meeting and reporting system. Data visibility and transparency were key principles facilitating operational decision-making and executive-level coordination of resources, including identifying additional surge bed capacity for use systemwide, as well as ensuring efficient and equitable vaccine distribution through implementation of five mass-vaccination sites with prioritized access for vulnerable communities. Applying these four principles of shared priorities, accountability, transparency, and operational coordination and pragmatism helped the public health and individual hospital systems make contributions to the overall response that were aligned with their unique strengths and resources. Publication here represents the first official public use of the name San Francisco Health Systems Collaborative (which had served as the term used internally to refer to the group) and the first time codifying this structure. Through this coordination, San Francisco achieved one of the lowest Covid-19 death rates and had one of the highest vaccination and booster rates, compared with rates across California or the United States. Similar principles and implementation methods can be adopted by other health jurisdictions for future emergency outbreak response.

Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrests in California

(2024)

Importance

The incidence of opioid-associated out-of-hospital cardiac arrest (OA-OHCA) has grown from less than 1% of OHCA in 2000 to between 7% and 14% of OHCA in recent years; American Heart Association (AHA) protocols suggest that emergency medical service (EMS) clinicians consider naloxone in OA-OHCA. However, it is unknown whether naloxone improves survival in these patients or in patients with undifferentiated OHCA.

Objective

To evaluate the association of naloxone with clinical outcomes in patients with undifferentiated OHCA.

Design, setting, and participants

Retrospective cohort study of EMS-treated patients aged 18 or older who received EMS treatment for nontraumatic OHCA in 3 Northern California counties between 2015 and 2023. Data were analyzed using propensity score-based models from February to April 2024.

Exposure

EMS administration of naloxone.

Main outcomes and measures

The primary outcome was survival to hospital discharge; the secondary outcome was sustained return of spontaneous circulation (ROSC). Covariates included patient and cardiac arrest characteristics (eg, age, sex, nonshockable rhythm, any comorbidity, unwitnessed arrest, and EMS agency) and EMS clinician determination of OHCA cause as presumed drug-related.

Results

Among 8195 patients (median [IQR] age, 65 [51-78] years; 5540 male [67.6%]; 1304 Asian, Native Hawaiian, or Pacific Islander [15.9%]; 1119 Black [13.7%]; 2538 White [31.0%]) with OHCA treated by 5 EMS agencies from 2015 to 2023, 715 (8.7%) were believed by treating clinicians to have drug-related OHCA. Naloxone was administered to 1165 patients (14.2%) and was associated with increased ROSC using both nearest neighbor propensity matching (absolute risk difference [ARD], 15.2%; 95% CI, 9.9%-20.6%) and inverse propensity-weighted regression adjustment (ARD, 11.8%; 95% CI, 7.3%-16.4%). Naloxone was also associated with increased survival to hospital discharge using both nearest neighbor propensity matching (ARD, 6.2%; 95% CI, 2.3%-10.0%) and inverse propensity-weighted regression adjustment (ARD, 3.9%; 95% CI, 1.1%-6.7%). The number needed to treat with naloxone was 9 for ROSC and 26 for survival to hospital discharge. In a regression model that assessed effect modification between naloxone and presumed drug-related OHCA, naloxone was associated with improved survival to hospital discharge in both the presumed drug-related OHCA (odds ratio [OR], 2.48; 95% CI, 1.34-4.58) and non-drug-related OHCA groups (OR, 1.35; 95% CI, 1.04-1.77).

Conclusions and relevance

In this retrospective cohort study, naloxone administration as part of EMS management of OHCA was associated with increased rates of ROSC and increased survival to hospital discharge when evaluated using propensity score-based models. Given the lack of clinical practice data on the efficacy of naloxone in OA-OHCA and OHCA in general, these findings support further evaluation of naloxone as part of cardiac arrest care.