Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

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Background: Overdose response applications and hotlines are novel overdose response technologies (ORT)/virtual harm reduction strategies that have recently emerged as a strategy to reduce the harms associated with the ongoing opioid epidemic. First responders are often the first point of contact for people who have overdosed and play a significant role in responses enacted by these services. In this study our aim was to explore the attitudes and perceptions of first responders on these novel technologies. 

Methods: We recruited 17 participants using purposive sampling through the province of Alberta between February–April 2023 including 11 paramedics, two firefighters, and five emergency communications operators. To be included in the study, participants were required to be older than 18 years of age, have the ability to communicate effectively in English, provide verbal informed consent, and work in an emergency responder role. Semi-structured interviews were conducted by two evaluators. When reviewing interview transcripts we used thematic analysis to identify key themes and subthemes. 

Results: Participants discussed their current operating procedures, their current perspectives on overdose response hotlines and apps, how they would best integrate them into their current workloads, and how to raise awareness of these services within first-responder communities. Participants were apprehensive about the integration of these services into their current workloads, including their potential benefits, and raised concerns about their efficacy within communities of people who use drugs. Key strategies were raised for the successful integration of these services into emergency responses including providing information to clients and the feasibility of overdose responses by the general public. 

Conclusion: This study’s results add to the existing literature on the toll of the overdose epidemic seen within first-response communities. Furthermore, we explored the communities’ diverse perspectives on these novel technologies, including support and concerns, and propose additional strategies for their integration into emergency responses.

Objective: While the American Diabetes Association (ADA) screening guidelines have been used widely, the way they are implemented and adapted to a particular setting can impact their practical application and usage. Our primary objective was to validate a best practice advisory (BPA) screening algorithm informed by the ADA guidelines to identify patients eligible for hemoglobin a1c (HbA1c) testing in the emergency department (ED). 

Methods: This cross-sectional study included adults presenting to a large urban medical center’s ED in May 2021. We used sensitivity, specificity, likelihood ratios, and predictive values to estimate the algorithm’s ability to correctly identify patients eligible for diabetes screening, with manual chart review as the reference standard. Eligibility criteria targeted patients at risk for diabetes who were likely unaware of their elevated HbA1c. We also calculated the area under the receiver operating characteristic curve (AUC).  

Results: In May 2021, 2,963 (77%) of the 3,850 adults admitted to the ED had a routine lab ordered. Among those, 796 (27%) had a BPA triggered, and of those 631 (79%) had an HbA1c test completed. The algorithm had acceptable sensitivity (0.69, 95% confidence interval [CI] 0.66-0.72), specificity (0.91, CI 0.89-0.92), positive predictive value (0.75, CI 0.72-0.78) and negative predictive value (0.88, CI 0.86-0.89). The positive likelihood ratio (7.39, CI 6.35-8.42 ) was adequate, and the negative likelihood ratio (0.34, CI 0.30-0.37) was informative. The AUC of 0.74 (CI 0.72-0.77) suggests that the algorithm had acceptable accuracy. 

Conclusion: Findings suggest that an electronic health record-based algorithm informed by the ADA guidelines is a valid tool for identifying patients presenting to the ED who are eligible for HbA1c testing and may be unaware of having prediabetes or diabetes. The ease of workflow integration and high yield of potentially undiagnosed diabetes and prediabetes makes the BPA algorithm an appealing method for diabetes screening within the ED. 

Introduction: Spinal epidural abscess (SEA) is a rare surgical emergency of the spine that can result in permanent neurological injury if not diagnosed and treated in a timely manner. Because early presentation can appear similar to benign back or neck pain, delays in diagnosis may be relatively common. We sought an improved understanding of the characteristics associated with SEA and frequency of delays in SEA diagnosis. 

Methods: We conducted a retrospective cohort study of adult patients with new magnetic resonance imaging-confirmed SEA from January 1, 2016–December 31, 2019 in an integrated healthcare system. We applied electronic data abstraction and focused manual chart review to describe potentially SEA-related ambulatory and emergency visits in the 30 days prior to SEA diagnosis, and patient characteristics including comorbidities, potential risk factors, and presenting signs and symptoms. We described the frequency of potential delays in diagnosis and of previously described clinical characteristics and risk factors for SEA.

Results: Spinal epidural abscess was diagnosed in 457 patients during the study period, 178 (39%) of whom were female, with median age 63 years (interquartile range 45-81 years). More than two-thirds of patients had at least one visit prior to diagnosis (323, 71%), and SEA location was most commonly the lumbar spine (235, 51%). Although over 90% of patients presented with back or neck pain or tenderness, the classic triad of back pain, fever, and neurologic symptoms was present in only 10% of patients. Diabetes mellitus and infection in the prior 90 days were common, while injection drug use, chronic steroid use, HIV infection, and solid organ transplant were rare.

Conclusion: In an integrated healthcare system, 71% of patients with spinal epidural abscess had potentially related ambulatory care or emergency visits in the 30 days prior to diagnosis. Diagnosis of SEA remains challenging, with multiple visits common before the diagnosis is clear.

Introduction: Healthcare systems typically provide multiple channels to access acute inpatient care, with the emergency department (ED) as the main route of access. The ED faces multifaceted demand and supply challenges, which implicate resource allocation and patient flow. In this study we aimed to identify factors associated with hospital admissions among ED patients in a Singapore tertiary-care hospital.

Methods: Using a retrospective cohort study of all eligible visits to a Singapore ED between  January 1–December 31, 2019, we conducted a multivariable, mixed-effect logistic regression model to study the factors associated with hospital admissions. The model accounted for patients’ demographics; triage category; arrival mode; referral source; time of ED visit; discharge diagnosis; and ED occupancy levels. 

Results: In 2019, there were 141,719 visits to the ED, with 42,238 (30%) of these visits resulting in hospital admissions. Factors associated with increased odds of hospital admissions included increasing age, being male, ethnicity (Malay vs Chinese), higher patient acuity, non-self-referred patients (vs self-referred), patient being conveyed by ambulances (vs walk-in), and category of disease. Our model demonstrated that the highest odds of inpatient admissions were attributed to the patient’s acuity (highest vs lowest acuity: odds ratio [OR] 326, 95% confidence interval [CI] 292-363), followed by patients’ age (70 and above vs 30 and below: OR 13.8, 95% CI 12.8-14.8). The ORs for all other factors with significantly increased odds of admissions were modest, ranging from 1.12-4.18. Although the ED occupancy levels at the hour of the patient’s disposition decision, the hour of the ED visit, and the month of the ED visit were significantly associated with hospital admissions, changes in the probabilities of hospital admissions across the possible range of values of these factors were marginal.

Conclusion: Our study revealed several factors significantly associated with hospital admissions, with patient acuity and age as the most important factors. Moreover, emergency physicians’ decisions to admit patients were clinically consistent and only marginally influenced by the degree of ED crowding. These findings offer invaluable insights into follow-up studies that will be crucial in shaping new policies or designing new interventions to enhance current preventive health or healthcare delivery systems to curtail the growth in inpatient-bed demand among ED patients over time.

Introduction: The emergency department (ED) is an appropriate location to screen for and address social risks among patients; however, a standardized process does not currently exist. Our objective in this study was to describe the implementation and findings of a social risk screening and resource referral program using a comprehensive screening questionnaire. 

Methods: We conducted a prospective, cohort study between July 2022–April 2023 at a single academic, urban ED in Los Angeles, CA. Trained staff on rotating shifts recruited ED patients between 6 am to midnight, with an average of 40 hours of coverage per week including weekends. Patients were excluded if they were <18 years of age, could not provide informed consent, or were deemed too medically unstable. Trained staff screened eligible consenting patients at ED bedside for social risks within 12 different domains of social determinants of health using a 19-question survey. Personalized resources were provided through an online platform or through direct communication with a social worker. Demographic data and patient responses were recorded in a deidentified database. We used a univariate logistic regression analysis to evaluate associations between demographic information and burden of social risk. 

Results: A total of 4,277 ED patients were considered for screening, and 1,677 (39.2%) were eligible: 1,473 (87.8%) patients consented to social risk screening, and 1,078 (73.2%) of them had at least one social risk as indicated by the screening questionnaire. The most commonly reported social risks were social isolation (39%) and depression (23%). Between 88.9-96.8% of patients categorized as medium social risk were successfully provided resources through the online platform. Between 80.8-100% of patients categorized into high social risk had successfully connected with a social worker while in the ED. In this sample, there were significantly higher odds of having greater than one social risk for female (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.02-1.67) and Black patients (OR 1.37, 95% CI 1.02-1.85) compared to male and White patients, respectively.

Conclusion: This study describes the findings from a comprehensive social risk screening and resource referral program at a large, urban, academic ED. The results will inform resource prioritization at the study institution. This model can serve as a basis for similar institutions to use, while individualizing their own approach.

Introduction: Emergency medical services (EMS) professionals interact with nearly every type of physician and are key stakeholders across the healthcare spectrum. However, no formal national recommendations exist for medical student education about EMS. When looking for institution-level resources to assist in writing the educational objectives and curricular content for an EMS elective for medical students, limited examples are available for guidance. We designed, implemented, and evaluated a two-week EMS elective for final-year medical students. A pragmatic description of how to create an EMS elective is detailed. 

Methods: The EMS elective involves an introductory session, an operational orientation, and six ambulance shifts. Self-directed activities and checklists encourage interdisciplinary learning between calls. Additionally, students deliver a case presentation including an example for improved interdisciplinary communication. Before and after the elective, a voluntary anonymous survey is distributed, in addition to a formal standard course evaluation. 

Results: From 2017–2022, 37 students participated in the elective. Thirty-four (92%) submitted the pre-elective survey, and 21 (57%) submitted the post-elective survey. Mann-Whitney U testing suggested an improved understanding of the capabilities of different EMS practitioner levels and of the different types of medical oversight after the elective (median pre=60%, median post=90%, U=118, P<0.001). Qualitatively, students described their experiences as “practical,” “hands-on,” and “eye-opening.”

Conclusion: An EMS elective using andragogy and intentional interdisciplinary communication seems useful in facilitating improved understanding of the fundamentals of EMS practice for final-year medical students.

Introduction: Firearm-related unintentional and suicide death rates in adolescents are higher in rural areas. In 2020, the overall rural firearm death rate was 28% higher than the urban rate. Firearm access significantly increases the risk. The study objective was to evaluate firearm exposure and storage practices in the homes of rural adolescents. 

Methods: We conducted a cross-sectional, anonymous survey of attendees at the 2021 National FFA (formerly Future Farmers of America) Convention & Exposition. Descriptive, bivariate, and multivariable logistic regression analyses were performed.

Results: A total of 3,296 adolescents 13-18 years of age participated in our survey. Overall, 87% of respondents reported having rifles/shotguns, 71% had handguns, and 69% had both rifles/shotguns and handguns in their homes. The odds of those living on farms having rifles/shotguns and handguns were 7.5 and 2 times higher, respectively, as compared to those from towns. Rifles/shotguns and handguns were stored unlocked and/or loaded at least some of the time in 63% and 64% of homes, respectively. Respondents from farms had 1.5 and 1.7 times greater odds of having rifles/shotguns and handguns stored unlocked and loaded, respectively, as compared to those from town. The South, West and Midwest had odds that were 5.9, 3.2, and 2.8 times higher for rifles/shotguns and 8.1, 5.2, and 4.3 times greater for handguns to be stored loaded and unlocked, respectively, as compared to the Northeast. Only 43% of respondents reported ammunition being locked and stored separately from firearms.

Conclusion: Most rural adolescents surveyed lived in homes with firearms, and a large proportion of those firearms were not stored safely. Firearm presence and storage differed by region and home setting. Unsafe storage practices could be contributing to the higher unintentional and suicide death rates seen in rural areas.

Introduction: Understanding characteristics of top-performing emergency medical service (EMS) agencies and hospitals can be an important tool for improving community out-of-hospital cardiac arrest (OHCA) care. We compared deidentified EMS and hospital-level variations in OHCA performance and outcomes in Ohio.

Methods: We analyzed adult OHCA data from the 2019 Ohio Cardiac Arrest Registry to Enhance Survival (Ohio CARES). We limited the analysis to EMS agencies and receiving hospitals with ≥10 OHCA episodes. The primary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge. We compared OHCA outcomes between EMS agencies using linear mixed models, with EMS agency as a random effect and adjusting for Utstein variables. We repeated the analysis by receiving hospital. We compared EMS agency population demographics, response times, and resuscitation characteristics of the top 10% of agencies against remaining agencies using chi-squared tests. 

Results: We included 2,841 OHCA among 44 EMS agencies in our analysis. The ROSC varied three-fold; mean 27.9%, range 15.8%-51.0%. Among 40 hospitals, survival varied two-fold; mean 12.9%, range 8.1%-19.0%. Top-performing EMS agencies included both medium- and large-sized agencies that tended to treat younger patients (59 vs 62 years, P<0.01) in public areas (15.7% vs 12.3%, P<0.01). There were no differences in bystander-witnessed arrest, bystander cardio-pulmonary resuscitation (CPR), or EMS response time. However, top-performing EMS agencies used less mechanical CPR (61.7% vs 76.0%, P<0.01) and were more successful in advanced airway placement (89.6% vs 74.8% P<0.01). 

Conclusions: The ROSC and survival after out-of-hospital cardiac arrest varied across EMS agencies and hospitals in Ohio. Top-performing EMS agencies exhibited unique demographic characteristics, used less mechanical CPR, and were more successful in airway placement. These variations in OHCA care and outcomes can indicate opportunities for system improvement in Ohio.

Introduction: Food insecurity (FI) remains a pervasive issue in the United States, affecting over 12.8% of households. Marginalized populations, particularly those in urban areas, are disproportionately impacted. The emergency department (ED) holds potential as a vital outreach hub, given its diverse patient population and extensive service coverage. In this study we explore the feasibility of implementing an ED-based FI screening and referral program at an urban, academic teaching hospital. We aimed to assess the prevalence of FI among ED patients and evaluate the feasibility of a three- and six-week follow-up to assess patients’ FI and related barriers to resource referral utilization.

Methods: This single-center, observational study was conducted at an urban, academic ED from 2018-2024. Initial FI screening was performed using a validated two-question survey adapted from the Hunger Vital Sign screening tool. Participants who screened positive were enrolled and completed the 10-item US Department of Agriculture Adult Food Security survey, received a food assistance guide, and were followed up at three- and six-week intervals to assess changes in FI status.

Results: Among 6,339 participants, 1,069 (16.9%) experienced FI, with the highest rates among Black non-Hispanic (24.7%) and Spanish-speaking participants (28.7%). Of the 1,069 participants who screened positive for FI, 630 (59.0%) were enrolled in the study. Of the enrolled participants, 161 (25.6%) completed the three-week follow-up phone calls, and 48 (7.6%) completed the six-week follow-up. The mean FI score for these 48 participants decreased from 6.67 (SD 2.68) at enrollment to 4.75 (SD 2.85) at the three-week follow-up (P < 0.001), and to 4.25 (SD 3.48) by the six-week follow-up (P < 0.001). Barriers to using the food resource guide, such as time constraints, transportation, and misplacement of resources, limited many participants’ engagement.

Conclusion: This study demonstrated the feasibility and effectiveness of an ED-based food insecurity screening and resource referral program, associated with a significant reduction in food insecurity scores among participants. However, barriers such as time constraints, transportation issues, and misplacement of referral materials limited engagement. Addressing these barriers through tailored follow-up and systematic support systems, including universal screening during ED intake and personalized assistance, can enhance the program’s accessibility and impact.

Objective: Heatstroke (HS) is a severe condition associated with significant morbidity and mortality. In this study we aimed to identify early risk factors that impacted the 30-day mortality of HS patients and establish a predictive model to assist clinicians in identifying the risk of death.

Methods: We conducted a retrospective cohort study, analyzing the clinical data of 203 HS patients between May 2016–September 2024. The patients were divided into two groups: those who had died within 30 days of symptom onset; and those who had survived. We analyzed the risk factors affecting 30-day mortality. A nomogram was drawn to visualize the clinical model. We used the receiver operating characteristic (ROC) curve and calibration curve to verify the accuracy of the nomogram. A decision curve analysis was also performed to evaluate the clinical usefulness of the nomogram.

Results: Within a 30-day period, 57 patients (28.08%) died. The APACHE II score, the ratio of lactate-to-albumin (LAR), and the core temperature at 30 minutes after admission were independent risk factors for death of HS patients at 30 days. The area under the ROC curve (AUC) for predicting mortality based on the APACHE II score was 0.867, with a sensitivity of 96.5% and a specificity of 61.6%. Moreover, the AUC for predicting mortality based on the LAR was 0.874, with a sensitivity of 93.0% and a specificity of 77.4%. The AUC based on the core temperature at 30 minutes after admission was 0.774, with a sensitivity of 70.2% and a specificity of 78.8%. Finally, the AUC for predicting death due to HS using the combination of these three factors was 0.928, with a sensitivity of 82.5% and a specificity of 91.8%. The calibration curve and the decision-curve analysis showed that the new nomogram had better accuracy and potential application value in predicting the prognosis of HS patients. 

Conclusion: A nomogram with these three indicators in combination—APACHE II score, lactate-to-albumin ratio, and core temperature at 30 minutes after admission—can be used to predict 30-day mortality of heatstroke patients.

Introduction: Hand sanitizer use and media coverage increased throughout the coronavirus-2019 pandemic. In this study our goal was to examine and compare the incidence, demographics, and clinical outcomes of exposures to alcohol-based hand sanitizers (ABHS) before and during the COVID-19 pandemic in the state of Florida.

Methods: We analyzed statewide data on all ABHS exposures in adults collected by the Florida Poison Information Network from March 1, 2015–February 28, 2020 (“pre-COVID-19” cohort) and during the COVID-19 pandemic from March 1, 2020–May 5, 2023 (“COVID-19” cohort). We performed descriptive, univariable, and multivariable analyses to assess changes in sex, age, medical outcome, and intentionality of the exposure in the pre-COVID-19 vs COVID-19 study periods, and we examined the factors associated with medical outcomes. 

Results: We identified 876 single-substance ingestions of ABHS, 414 in the pre-COVID-19 cohort and 462 in the COVID-19 cohort. The proportions of ABHS ingestions increased significantly during the COVID-19 pandemic in all age groups except the 25-50 age group, where it decreased. Individuals 18-24 of age and those ≥51 years showed a relative increase in both intentional and unintentional ingestions during the COVID-19 period compared to the 25-50 age group. The significant risk factors associated with more severe outcomes in exposed individuals were intentional exposures and younger age. 

Conclusion: Unintentional ingestions of alcohol-based hand sanitizers showed a relative increase during the COVID-19 pandemic, particularly in individuals 18-25 years of age and those ≥51. Both intentional ingestions and younger age increased the likelihood of moderate or severe outcomes. Harm reduction strategies targeted toward younger individuals and those with intentional ingestions should be considered during future pandemics.

Introduction: Prescribing patients buprenorphine from the emergency department (ED) is recommended by multiple organizations. However, it is unclear how best to encourage physicians to prescribe buprenorphine from the ED. Our objectives in this study were to examine the effects of a departmental-wide training initiative for emergency physicians to prescribe buprenorphine, increase buprenorphine prescribing, and decrease ED re-utilization for opioid use disorder (OUD) complications.

Methods: We performed this retrospective cohort study at an academic medical center. Beginning May 1, 2018, the ED started a buprenorphine-education initiative and tracked the proportion of clinicians who obtained buprenorphine-prescribing certification over the following 16 months. We identified adult patients referred to an addiction clinic from the ED during this period. Our primary outcome was the proportion of patients who received a buprenorphine prescription from the ED. Secondary outcomes included ED re-utilization for OUD complications and buprenorphine refills, as well as follow-up in the bridge clinic within 30 days.

Results: The proportion of physicians eligible to prescribe buprenorphine increased from 37% to 88% over the study period, and 430 patients were referred to an addiction clinic. The proportion of patients referred to a bridge program who received a buprenorphine prescription increased from 50% during the first month compared to 92% during month 16 (odds ratio 1.14, 95% confidence interval 1.08-1.21 per month). There were no statistically significant changes in any secondary outcomes.

Conclusion: Our intervention increased buprenorphine prescribing by emergency physicians. It did not decrease ED reutilization for complications related to opioid use disorder.

Introduction: Social determinants of health (SDoH) and health literacy have been demonstrated to significantly impact health outcomes. As part of a study of diabetic ketoacidosis (DKA) treatment from the emergency department (ED), we assessed the burden of SDoH and health literacy among patients with DKA to identify potentially modifiable risk factors in the development of DKA. 

Methods: This was an exploratory, prospective, cross-sectional study of adult patients with DKA in a large urban academic ED from March 2023–March 2024. We administered the Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool (SNST) and the Brief Health Literacy Screen (BHLS).

Results: Of 126 identified ED patients with confirmed DKA, 57 completed the SNST and 72 completed the BHLS. Nearly all patients (56 patients, 98%) reported at least one unmet SDoH need, and 32 (56%) patients reported five or more. The most frequently reported SDoH needs were physical activity (77%), mental health (63%), financial strain (60%), substance use (54%), and food insecurity (51%). Seventy-two patients completed the BHLS, which demonstrated high levels of health literacy, with median responses ranging from 4-5 on a Likert scale with 5 corresponding to highest health literacy.

Conclusion: Social determinants of health needs are prominent among patients who develop DKA, highlighting an opportunity for ED-based interventions to address specific SDoH factors to prevent the development of this disease. Self-reported health literacy scores were high in this patient population.

Introduction: Despite a lack of data guiding safe standards for physician productivity and supervision of non-physician practitioners (NPP), legislation dictating supervision ratios for emergency physicians (EP) has been enacted in Florida and elsewhere across the country. To inform future legislation, we aim to identify current productivity and supervision practices among practicing EPs as well as those physicians’ safety assessments of their current practices. 

Methods: We conducted a cross-sectional observational study regarding EPs’ perspectives on safe staffing and supervision models. A survey, consisting of 14 questions examining different variables affecting supervision and productivity, was used to determine physicians’ opinions on the safety of productivity and supervision models across a range of annual volumes, employers, and years of experience. We coded safety assessments as binary (yes/no) and measured productivity by patients treated per hour. Ratios of physician to supervisee (either resident physician or or NPP) were given as number of supervisees: EP.

Results: The survey response rate was 4.8% (196/4,004). On average, most EPs treated 2.6 patients per hour, regardless of years of experience, employment model, or supervision model. More than 80% of EPs felt that their current patients-per- hour practice was safe. Direct supervision represented 59% of total visits and the majority in all employment models except for community contract-management groups (CMG). A minimum of 80% of physicians felt that their current supervision practices were safe across employment models, with the notable exception of community CMGs. Most felt that a safe ratio for direct supervision of NPPs was 1:1. Over 30% reported there was no safe staffing ratio for indirect supervision. 

Conclusion: With the exception of those employed by community contract-management groups, EPs felt that their current productivity and supervision practices were safe; however, average productivity and supervision ratios are much lower than prior estimates and in current legislation governing emergency department practice. Standards of care for both productivity and supervision that take into account current practices and safety assessments should be established and considered when future policies and legislation are developed. 

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Objective: Drug overdose is the leading cause of unintentional death in the United States, and individuals identifying as BIPOC (Black, indigenous and people of color) and those of low socioeconomic status are over-represented in this statistic. The US-Mexico border faces several unique challenges when it comes to healthcare and the drug overdose crisis, due in large part to health inequities. Although the US Centers for Disease Control and Prevention recommends that overdose prevention programs address health inequities, little is known about opioid overdoses in this rural, primarily Spanish-speaking region. As emergency medical services (EMS) records collect countywide data, they represent a high-quality source for epidemiologic surveillance.

Methods: We conducted a retrospective chart review based on a local quality assurance program in which two years of EMS records were reviewed with the primary objective of characterizing patients receiving prehospital care for opioid overdoses in a rural, borderland community, and the secondary objective of characterizing EMS’s fidelity to a naloxone distribution protocol. We included electronic patient care records for analysis if they included the EMS clinician’s impression of overdose, opiate abuse, or opiate-related disorder from November 1, 2020–October 31,2022. The following data points were abstracted: date; patient initials/gender/age; police presence; response location; bystanders on scene; naloxone administration prior to EMS arrival; distribution of naloxone kit (yes/no); substance reported; and disposition. We analyzed descriptive statistics. 

Results: A total of 74 cases met inclusion criteria over two years with the majority of cases involving men (82%) with a median age of 28. Almost half of overdoses occurred at private residences (46%), and slightly more than half (57%) reported fentanyl use prior to overdose. Family or friends were usually (64%) on scene, and law enforcement was often (77%) the first 911  to arrive. Naloxone was administered on scene in almost all cases (91%), usually by EMS (44%) or law enforcement (43%). The EMS clinicians distributed naloxone kits at 61% of calls.

Conclusion: Opioid overdoses along the US-Mexico border occurred primarily among young men using illicit fentanyl in private residences. Although family/friends were often present, they rarely administered naloxone. Law enforcement was often the first 911 responder to arrive. Emergency medical services is a suitable setting for naloxone distribution programs.

Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children. Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller. Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation. Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Introduction: In the United States, 3.7 million people present to an emergency department (ED) annually with an injury related to sports or athletic activity. A prior study a decade ago revealed that 14% of life-threatening injuries presenting to EDs were sports related, with this percentage being higher in the pediatric population. However, with changes in sports participation and regulatory changes over the past decade, it is unclear whether the proportion of life-threatening sports-related injuries has changed. 

Methods: We conducted a cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS), consisting of patients from years 2009–2018. Life-threatening injuries were defined as International Classification of Diseases 9 and 10 codes for skull fracture, cervical spine fractures, intracranial hemorrhage, traumatic pneumothorax/hemothorax, liver lacerations, spleen lacerations, traumatic aortic aneurysm or rupture, gastric/duodenal rupture, heat stroke, and commotio cordis. Injuries were classified as sports related based on external cause of injury codes. We examined the relationship between demographic variables and sports-related injuries using Pearson chi-square analysis. 

Results: From the years 2009–2018 there were 256,564 observed ED visits. Of these, 646 were for life-threatening injuries, representing a national estimate of 3,456,166 patients over the 10-year period. Thirteen percent were sports related. Of the life-threatening injuries, 77.5% were injuries to the head and neck, and 9.1% of these were sports related. The proportion of life-threatening injuries due to sports and recreation was higher among pediatric patients than adult patients (30.4% vs 9.9%, P<0.001). The proportion of sports-related life-threatening injuries to the head and neck was also higher among pediatric patients than adult patients (23.3% vs 6.4%, P<0.001)  

Conclusion: A substantial proportion of life-threatening injuries occur during sports and recreation, especially among pediatric patients. Compared to a similar study a decade ago, there is a similar proportion of life-threatening injuries that are sports related, however; there does seem to be a decrease in the proportion of life-threatening sports-related injuries to the head and neck. Sports medicine physicians and sports organizations should continue to find effective ways to prevent life-threatening injuries in sports.

Introduction: Abdominal pain is the leading emergency department (ED) chief complaint in older (≥65 years of age) adults, accounting for 1.4 million ED visits annually. Ultrasound and computed tomography (CT) are high-yield tests that offer rapid and accurate diagnosis for the most clinically significant causes of abdominal pain. In this study we used nationally representative data to examine racial/ethnic differences in cross-sectional imaging for older adults presenting to the ED with abdominal pain. 

Methods: We performed a retrospective, cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to assess differences in the rate of imaging between White and Black older adults presenting to the ED for abdominal pain. Our primary outcome was the receipt of abdominal CT and/or ultrasound imaging. 

Results: Across 1,656 older adult ED visits for abdominal pain, White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal CT and/or ultrasound than Black patients: 802 of 1,197 (67.0%) White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal computed tomography and/ or ultrasound than Black patients (P=0.01).

Conclusion: This study revealed that Black older adults presenting to the ED with abdominal pain receive significantly lower levels of cross-sectional imaging (CT/ultrasound) than White patients. Our findings highlight the need for further investigations into causes of disparities while initiating quality improvement processes to assess and address site- and clinician-specific patterns of care.

Objective: The American College of Emergency Physicians recommends that transesophageal echocardiography (TEE) be used to “maintain the standard of ultrasound-informed resuscitation” in cardiac arrest. To date, no standards exist on how to train emergency physicians (EP) on TEE use in the emergency department (ED). We propose a novel educational paradigm using simulation to train EPs on the use of TEE in cardiac arrest.

Methods: A total of 63 EPs at a single-center academic teaching hospital participated in a 90-minute simulation-based education session to summarize the use of TEE in cardiac resuscitation and practice related procedural skills. The session consisted of a simulated cardiac arrest scenario using both transthoracic echocardiography (TTE) and TEE and hands-on practice on a high-fidelity TEE task trainer. Participants filled out anonymous surveys before and after the training session, which evaluated their subjective attitudes toward TEE, knowledge of its role in cardiac arrest, and perceived efficacy of the curriculum in introducing the modality.

Results: Survey results indicated fewer perceived barriers to performing TEE in resuscitation after completion of the course, with statistically significant decreases in the following: not understanding image acquisition (85.5% pre vs 27.4% post; P<0.001), interpretation (66.1% pre vs 25.8% post; P<0.001), indications (29.0% pre vs 0.0% post; P<0.001), contraindications (35.5% pre vs. 3.2% post; P<0.001), and the potential benefit for the patient (24.2% pre vs 3.2% post; P <0.001). Finally, 68% of EPs stated they were “extremely likely” to use TEE in cardiac arrest with the availability of assistance from a credentialed attending.

Conclusion: The survey responses suggest that a short, simulation-based course can generate interest in the incorporation of TEE in cardiac resuscitation as well as overcome many of the perceived barriers regarding TEE. Moreover, they suggest that the participating academic EPs would be interested in using TEE in critical patients in the future when available.

Objectives: Addressing minor yet significant frustrations, or “pebbles,” in the workplace can reduce physician burnout, as noted by the American Medical Association. These “pebbles” are small workflow issues that are relatively easy to fix but can significantly improve the workday when resolved. This quality improvement project aimed to enhance clinician well-being in an emergency department (ED) affiliated with an academic institution through human-centered design by actively engaging clinicians to identify these “pebbles” and for a dedicated team to address them.

Methods: A task force comprised of three emergency physicians collaborating with emergency medicine leadership was established. After educating clinicians about “pebbles,” clinicians were able to anonymously submit pebbles based on recall of frustrations in a baseline survey at the start of the project, as well as submit pebbles in real time by a QR code that was placed in easily noticeable areas. The task force met bimonthly to categorize, prioritize, and assign ownership of the pebbles. Progress was communicated to staff via a monthly “stop light” report. An anonymous survey assessed the impact on clinician well-being among 68 emergency clinicians within seven months of starting the project.

Results: Over seven months, 284 pebbles were submitted (approximately 40 per month). The feasibility of addressing pebbles was characterized by a color scale: green (easy to fix): 149 (53%); yellow (more complex): 111 (39%); and red (not feasible, “boulder”): 24 (8%). Categories of pebbles included the following: equipment/supply: 115 (40%); nursing/clinical: 86 (30%); process: 64 (23%); and information technology/technology: 19 (7%). A total of 214 pebbles (75%) were completed. Among 51 respondents (75% response rate), the self-reported impact on well-being of having pebbles addressed was as follows: extremely effective: 16 (31%); very effective: 25 (49%); moderately effective: 8 (16%); slightly effective: 2 (4%); and not effective 0 (0%). 

Conclusion: In addition to improving personal resilience, improving well-being in the ED involves addressing efficiency of practice. This project highlights the positive impact of resolving small, feasible issues identified by clinicians, which resulted in 80% of respondents rating the project as very to extremely effective in improving their well-being. Most pebbles were related to equipment and easily fixed, while issues involving human interactions (eg, communications between consultants and EM) were more challenging. Regular meetings and accountability facilitated progress. This approach is replicable across medical specialties and practice settings, offering a low-cost method to enhance clinician work environments and well-being.

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