Department of Emergency Medicine (UCSF)

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.]

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.]

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 to 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.

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.

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 patient's narrative into the electronic health record (EHR), while reducing a clinician's 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 HCT's potential to help foster humanism and PCC in emergency settings and supports the potential for broader applicability in health care systems.

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.

Objectives: Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022. Methods: We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non-traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually. Results: We identified 1764 unique publications, 87 RCTs were included after title/abstract and full-text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, p = 1.0). Geographic analysis of study centers found 31 countries represented; Denmark (n = 13, 15%) and the United States (n = 9, 10%) conducted the majority of trials. Nearly all trials included adults (n = 84, 97%) and few included children (n = 9, 10%). The majority of trials focused on out-of-hospital cardiac arrest (n = 62, 71%). Thirty-eight (44%) trials used an intervention characterized as a process improvement; 28 (32%) interventions were characterized as a drug and 20 (23%) as a device. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra-arrest (53%) and post-arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days. Conclusions: Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in-hospital cardiac arrest and pediatric patients.

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.