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

Introduction: The Emergency Medical Treatment and Labor Act (EMTALA), a federal law enacted in 1986, is intended to prevent inadequate, delayed, or denied treatment of emergency medical or emergency psychiatric conditions by Medicare-participating hospitals when individuals present to dedicated emergency departments (EDs). EMTALA requires all patients seeking evaluation for an emergency medical condition (EMC) at a dedicated ED to have an appropriate medical screening exam (MSE), stabilization of identified EMCs, and an appropriate transfer if specialized services are needed for stabilization.

Methods: We obtained summaries of all EMTALA-related civil monetary penalties (CMPs) between 2002–2023 from the Office of the Inspector General (OIG) and reviewed them for instances where patients arrived or departed with law enforcement officers (LEOs). In this article, we describe the characteristics of these CMPs. 

Results: Of 260 EMTALA-related CMPs, 15 (5.8%) were identified as having involved patients arriving to or departing from an ED with LEOs. Among these, nine (60%) involved patients arriving to the ED with LEOs, of whom five (55.6%) were transported to alternate facilities by LEOs at the direction of ED staff without receipt of an appropriate MSE. Overall, eight (88.9%) of nine patients arriving with LEOs involved psychiatric concerns. Four cases were identified as having involved patients discharged from but not arriving to the ED with LEOs. Of these, two involved patients brought to the ED for evaluation of psychiatric conditions and discharged to jail without appropriate MSE after becoming disruptive. Two involved patients with psychiatric issues sent to jail without appropriate MSE/stabilization, some due to hospital policies pertaining to alcohol intoxication. Two involved patients without noted psychiatric concerns escorted from the ED with the assistance of LEOs after reported to be “resistant” or “aggressive.” One returned to the ED in cardiac arrest, and another was subsequently diagnosed with bacterial meningitis. 

Conclusion: Overall, 5.8% of EMTALA-related CMPs involved patients arriving to or departing from the ED with LEOs; most of these involved patients with psychiatric emergencies. In many cases, LEOs were advised to either transport patients to an alternate medical facility without an appropriate MSE, or disruptive or intoxicated patients with noted psychiatric concerns were discharged to jail without adequate MSE or stabilization. Findings indicate a need for education surrounding EMTALA requirements to provide MSEs and, if needed, stabilizing treatment prior to discharge or transfer for all patients presenting to the ED, regardless of LEO involvement.

N/A

Introduction: Definitive airway management is crucial for severely injured trauma patients when basic pre-hospital interventions fail to provide adequate oxygenation and ventilation. Endotracheal intubation by emergency medical service (EMS) personnel is often necessary before reaching the emergency department (ED). While some studies suggest that advanced airway protocols in the pre-hospital setting improve survival in patients with severe head injuries, others indicate potential complications and adverse outcomes associated with pre-hospital intubation. In this study we aimed to evaluate whether trauma patients who underwent intubation by EMS in the field experienced different hospital outcomes compared to those intubated by physicians in the ED. Specifically, it assessed the impact of pre-hospital intubation on the number of days requiring mechanical ventilation, intensive care unit length of stay (ICU LOS), and overall hospital LOS.

Methods: We conducted a retrospective chart review at a single, level II trauma center from January 1, 2019–December 31, 2023, involving trauma patients requiring intubation. Patients were divided into two groups: 608 patients ED department (ED ETT). Primary outcomes included days on mechanical ventilation, while secondary outcomes included ICU and hospital LOS. An independent t-test was performed to compare the differences in mean ventilator days, ICU LOS, and hospital LOS between the two groups, accepting P-value of <0.10 as significant.

Results: The study included 1,010 patients, with a mean age of 55.5 years in the ED group and 52.5 years in the pre-hospital group. No statistically significant differences were found in mean ventilator days (4.1 ± 4.6 days for the ED group and 4.1 ± 5.7 days for the pre-hospital group), ICU LOS (5.8 ± 6.1 days in the ED ETT group vs 5.6 ± 7.4 days in the pre-hospital ETT group), or overall hospital LOS (10.1 ± 13.6 days in the ED group vs 10.2 ± 17.5 days in the pre-hospital group). 

Conclusion: These findings indicate no significant differences in patient outcomes between those intubated pre-hospital and those intubated in the ED. Further research is needed to make modifications to airway management protocols in the pre-hospital setting.

Objectives: Barriers to healthcare in rural areas can delay treatment in pediatric patients who have experienced poisoning. We compared emergency medical services (EMS) response times and EMS-reported delays in responding to pediatric poisoning incidents between rural and urban settings using the 2021 National Emergency Medical Services Information System (NEMSIS). 

Methods: The NEMESIS defines rural areas as locations with a population of <50,000, not part of metropolitan areas, while all other locations are classified as urban (metropolitan) areas. In this study we included 11,911 patients (12% rural) <18 years of age who were transported by EMS with a first-responder primary impression of poisoning. We compared study variables using rank-sum tests and chi-square tests. Multivariable analysis of outcomes included quantile regression and logistic regression for continuous data and categorical data, respectively.

Results: The median total prehospital time by EMS was 40 minutes (interquartile range 29-57), and the most common type of delay was scene delay (6%). On multivariable quantile regression, patients transported by rural EMS agencies experienced 6.6 minutes (95% confidence interval 5-8, P<0.001) longer prehospital time than those transported by urban agencies. There were no differences between rural and urban EMS agencies in the occurrence of dispatch, response, scene, and transportation delays. 

Conclusion: These results elucidate the need for equitable allocation of resources and training to enhance rural EMS responders. The additional nearly seven minutes translates into greater risk for the human body to remain physiologically unstable and not be optimally treated. Therefore, by integrating targeted interventions to rural pediatric populations, better care can be achieved across all geographic regions. Further research must be conducted to ascertain the specific factors, aside from delays, that result in the disparity between rural and urban prehospital response time.

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.

Background: We aimed to clarify the current challenges involved in introducing and operating mobile stroke units (MSU) in new regions, considering the social background of regions with MSUs.

Methods: We conducted a questionnaire survey on the operational and financial status of all active MSU programs worldwide as of March 2023, and investigated the demographic, economic, and healthcare backgrounds of areas with and without active MSUs. We compared the data for the two groups at the country, state, or city level. We then correlated data gathered from the survey and the investigation.

Results: Of the 33 MSU programs contacted, 19 (59%) responded. The responding programs treated a range of 52-1,663 (median 781) patients at an MSU per year. The most commonly reported hours of operation were  eight hours every weekday (5, 26%). The majority had four staff on board (11, 58%). No physicians were on board in six MSUs (32%). The catchment area radius ranged from 5-250 (median 22) kilometers. The start-up costs and subsequent annual operation costs of an MSU ranged from $0.7-1.8 million (median 1.0) and $0.7 -1.7 (median 1.0) million US dollars, respectively. Reimbursement was obtained by eight (47%), with full reimbursement by two (12%). A negative gross financial balance was reported in eight MSUs (53%, of 15), and a financial challenge was reported in 17 (94%, of 18). Compared to the non-MSU group at the country level, active MSU groups had a significantly higher population, nominal gross domestic product, healthcare access and quality index, and physician density. They also had significantly lower age-standardized stroke incidence rates and age-standardized stroke disability-adjusted life year rate. The MSU operation time was significantly positively correlated with age-standardized stroke incidence rate and negatively with physician density.

Conclusion: Despite facing serious financial problems, mobile stroke units currently operate around the world. However, the social context of MSUs appears relatively advanced. For future implementation of MSUs, cost-saving strategies and reimbursements should be addressed, and national or regional social backgrounds should be considered.

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: 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: 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: The massive 2020 blast in Beirut, Lebanon, caused by improperly stored ammonium nitrate, was one of the most powerful non-nuclear explosions in history, Following the blast, head injuries emerged as a predominant presentation to the emergency department (ED). Blast-induced head injuries can lead to mild traumatic brain injuries (mTBI) mediated via primary blast overpressure without direct head trauma. The recovery process from mTBIs can be prolonged and affected by several factors. If symptoms persist for more than three months, patients should be evaluated for post-concussion syndrome (PCS). While clinical blast-injury studies have focused on repetitive blast exposure, this study evaluates a cohort exposed to a single blast. We hypothesized that a single blast exposure is sufficient to induce PCS symptoms similar to those exposed to repetitive blasts.

Methods: This cross-sectional study explores PCS in patients presenting to the ED of a tertiary-care center following the Beirut blast. Patients were identified through medical charts, contacted by phone, and consented to participate at least three months post-blast (beginning in November 2020). We used the Rivermead Post-Concussion Questionnaire (RPQ) to assess for PCS. We analyzed the association of PCS with patients and injury characteristics.

Results: Of 370 patients presenting to the ED, 145 (58.5%) completed the study questionnaire. Mean age was 39.8 ± 15.4 years, and 40% were females. Head trauma (46.9%) was the most common presentation. A total of 112 patients (77.2%) met the criteria for PCS, with a median RPQ score of 25 (interquartile range 18.75). After adjusting for injury types and distance from the blast, younger patients (adjusted odds ratio [aOR] 0.972, 95% confidence interval [CI] 0.947-0.998) and females (aOR 2.836, 95% CI 1.114-7.220) were more likely to suffer from PCS. 

Conclusion: Our study revealed a remarkably high prevalence of PCS among survivors of the Beirut blast, with younger individuals and females disproportionately affected. This highlights the need for age- and sex-specific rehabilitation and support programs. However, the study was limited by incomplete patients records and contact information, leading to the exclusion of a significant number of patients who initially presented to the ED. Ultimately, this study underscores the crucial role of robust public health preparedness and specialized care pathways against future large-scale catastrophes. Further assessment, including neurobiomarker evaluation, will be conducted on these survivors.

Background: Acute aortic dissections (AAD) have a high morbidity and mortality rate. Treatment for type B aortic dissection includes strict systolic blood pressure (SBP) and heart rate (HR) control per the American Heart Association (AHA) guidelines. However, predictors of successful emergency department (ED) management of SBP have not been well studied. 

Methods: We retrospectively analyzed the records of adult patients presenting to any regional ED with type B AAD between 2017–2020 with initial SBP >120 mmHg and HR >60 beats per minute (bpm) and were subsequently transferred to our quaternary center. Primary outcome was SBP <120 mmHg based on both the 2010 and 2022 AHA guidelines and HR <60 bpm (based on the 2010 guideline), or HR <80 (2022 guideline). We used random forest (RF) algorithms, a machine-learning tool that uses clusters of decision trees to predict a categorical outcome, to identify predictors of achieving HR and SBP goals prior to ED departure, defined as the time point at which patients left the referring ED to come to our institution. 

Results: The analysis included 134 patients. At the time of ED departure, 26 (19%) had SBP <120 mmHg, 96 (67%) received anti-impulse therapy, and 40 (28%) received beta-blocker or vasodilator infusions specifically. The RF algorithm identified higher triage SBP and treatment with intravenous labetalol as the top predictors for SBP >120 mmHg at ED departure, contrary to AHA guidelines. Pain management with higher total morphine equivalent unit, as well as shorter time to computed tomography as predictors for HR <60 bpm and <80 bpm, were in concert with AHA guidelines.

Conclusion: Many patients with type B AAD did not achieve hemodynamic parameters in line with 2010 or 2022 AHA guidelines while being in the ED prior to transferring to a quaternary care center for further evaluation and management. Patients with higher heart rate and systolic blood pressure on ED arrival were less likely to achieve goals at the time of departure from the referring EDs. Those receiving more pain medications prior to transfer were more likely to meet certain AHA goals.

Objectives: Emergency pericardiocentesis is a critical but infrequently performed procedure in emergency medicine, necessitating effective training modalities for emergency physicians. In this scoping review we aimed to identify existing literature on simulation of ultrasound-guided pericardiocentesis in human cadavers. 

Methods: We carried out a scoping review based on a search on the use of sonography on human cadavers. The following databases were searched: MEDLINE; EMBASE; CENTRAL; BIOSIS Previews; and Web of Science Core Collection. Additionally, we performed a gray literature search. Title and abstract screening were done by a single reviewer, and full-text review was performed by two independent reviewers. Studies included were limited to those published in English or German, focusing specifically on ultrasound-guided pericardiocentesis training models in human cadavers, with no restrictions on publication year or outcomes.

Results: Our search strategy yielded 9,821 publications and 1,440 reports were assessed for eligibility. Ultimately, four studies met the inclusion criteria. All were conducted in the USA; two used soft-embalmed cadavers, one reported using fresh frozen cadavers, and one did not specify the cadaver type used. All studies accessed the pericardial sac using large-bore catheters or peripheral lines, filling it with (colored) water for simulation.

Conclusions: Evidence on ultrasound-guided emergency pericardiocentesis simulation on human cadavers remains limited, but based on the four studies we reviewed human cadavers could be used for (emergency) pericardiocentesis simulation.

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: The current literature on the use of real-time ultrasound-guidance for lumbar punctures (LP) is limited. Two techniques have been described: the paramedian sagittal oblique (PSO); and the transverse interlaminar (TL) approach. Our objectives in this study were to compare the procedure outcomes between these two techniques and assess the ability of emergency physicians to perform ultrasound-guided LPs.

Methods: This was a prospective study whose participants included emergency physicians. Participants were randomized into either Group P (PSO technique) or Group T (TL technique). After a didactic session, participants then performed an ultrasound-guided LP on a training manikin, during which we collected procedure data. A survey was administered after completion of the procedure. 

Results: A total of 31 participants were included, 16 in Group P and 15 in Group T. Most participants (90.3%) successfully performed the procedure, without a statistical difference between Group P and Group T (15/16 vs 13/15, P = 0.95). Group T required a longer average time to complete the procedure (176.7 ± 140.4 seconds [s] vs 311.2 ± 202.3 s, P = 0.04). There was no statistically significant difference between Group P and Group T with regard to average time needed to obtain the required ultrasound view (18.3 ± 14.6 s vs 35.1 ± 32.9 s, P = 0.09); number of needle redirections; total number of needle passes; first puncture success; number of participants who advanced the needle without visualization of the tip (13/16 vs 14/15, P = 0.64); penetration of the anterior dura; and needle contact with bone. The Likert-style questionnaire responses (reported on a 1-10 scale) revealed no difference between Group P and Group T as to perceived difficulty of finding the required ultrasound view (3 [interquartile range (IQR) 2-5) vs 5 (IQR 3-6.5), P = 0.10), perceived difficulty of needle tracking, or rating of the needle view when entering the intrathecal space. However, Group T reported a higher overall perceived level of difficulty (4 [IQR 3-5] vs 6 (IQR 5.5-7.5), P= 0.01). 

Conclusion: This study suggests emergency physicians can be trained to use ultrasound-guidance for lumbar puncture in the simulation setting without significantly prohibitive training. Both techniques were performed with high success rates. There may be a preference for implementing the paramedian sagittal oblique approach over the transverse interlaminar.

Introduction: A mass gathering is defined as an event that has the potential to strain the resources of the local health system. An onsite physician for mass gatherings can mitigate the strain on the local health infrastructure. One factor affecting onsite medical usage and patient presentation rates is the heat index, which is a calculated value of perceived heat exposure that combines air temperature and relative humidity. In this study we asked whether there was a positive association between heat index and patient presentation rates for onsite medical care at a bounded (large event in an enclosed location) professional stadium sporting event. We hypothesized that a positive correlation exists between these two variables and assess whether it might surpass current onsite resources.

Methods: We performed a prospective observational study with patients seeking medical care at a baseball stadium in a large northeastern city in the United States. The onsite physician collected information on patients who presented during games held at the stadium. Data on game attendance, temperature in degrees Fahrenheit (F), humidity, and heat index were collected using government and professional organization websites. We assessed the correlation between heat index and patient presentation rate with the Pearson product-moment correlation (PPMC) per 100,000 attendees at the game. 

Results: A total of 81 baseball games occurred at the studied stadium from April–September 2023, with eight games excluded due to incomplete data. The heat index ranged from 46°F to 91°F, with a mean (± SD) of 70.8°F (± 10.4°F). The number of patients varied from 0-5 per game, with a mean of 1.92 (± 1.13), and stadium attendance ranged from 25,007 to 47,295, with a mean of 40,824. The patient presentation rate per 100,000 in attendance was 5.04 (± 2.13). The PPMC was calculated to be 0.37 (P < .01), indicating a positive correlation between heat index and patient presentation rates. The most common reasons for seeking medical care were lightheadedness and musculoskeletal complaints. 

Conclusion: In this study we found that the heat index was moderately associated with higher patient presentation rates at bounded mass gathering baseball events. No additional resources were needed, but this correlation could aid future event medical planning efforts as the climate continues to evolve.

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: The use of coronary artery bypass grafting (CABG) for primary revascularization during the acute care of ST-elevation myocardial infarction (STEMI) patients has declined significantly in the past decade; but there is little data to determine whether there has been a change in the use of CABG for STEMI patients treated by emergency medical services (EMS). In this study we described the incidence of urgent or emergent CABG for STEMI patients treated in a large, regionalized cardiac care system.

Methods: We obtained data obtained for patients transported by EMS between January 2011– December 2022 who were diagnosed with acute STEMI on prehospital or emergency department (ED) electrocardiogram and taken for primary diagnostic catheterization. All STEMI patients were transported by EMS to one of 34 STEMI receiving centers (SRC) in a regionalized cardiac care system, all of which are required to maintain onsite cardiac surgery as a condition of their SRC designation. Patients were considered to have undergone urgent or emergent CABG if it was performed within 72 hours of the primary diagnostic cardiac catheterization. We excluded patients if no diagnostic catheterization was performed or if CABG was performed >72 hours after diagnostic catheterization. The primary outcome was the incidence of urgent or emergent CABG. Patients were further stratified by time between diagnostic catheterization and CABG (<24 hours, 24-48 hours, 48-72 hours).

Results: A total of 28,349 patients were transported by EMS and diagnosed with an acute STEMI during the study period. Only 384 (1.35%) patients underwent CABG within 72 hours of diagnostic catheterization: 268 (0.95%) underwent CABG in <24 hours; 71 (0.25%) in 24-48 hours, and 45 (0.16%) in 48-72 hours. The median age of patients undergoing CABG was 64 years (interquartile range 58-72). Twenty-eight (7.3%) experienced prehospital cardiac arrest, and eight (2.1%) required vasopressors. Prior to undergoing CABG, 137 patients (36%) underwent primary percutaneous coronary intervention. The proportion of patients undergoing CABG within 72 hours remained relatively stable between 2011–2022 at 1.19% and 1.96%, respectively. 

Conclusion: Urgent or emergent CABG remained infrequently performed for acute STEMI patients after primary diagnostic catheterization. There was little change in the percentage of STEMI patients who received CABG within 72 hours of diagnostic catheterization over the past decade. These findings suggest that regional or local policies requiring on-site cardiac surgery at SRCs may be reconsidered.

n/a

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.

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.

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: 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: Resuscitation with low-titer O+ whole blood improves the outcomes of patients with hemorrhagic shock. Recently, some emergency medical services (EMS) agencies have started to carry blood in the field. However, there exists no standardized training program to teach paramedics the fundamentals of blood administration. This study describes one EMS system’s experience with implementing a novel, whole blood educational curriculum. 

Methods: We used Kern’s six-step framework to develop a novel curriculum to provide paramedics the requisite knowledge to safely administer blood in the field. The course included an asynchronous component as well as an in-person, skills competency verification. The asynchronous portion was open to any paramedic, but only paramedic supervisors were eligible for the in-person skills check as they are the ones tasked with administering blood in the field. The course was evaluated through survey and performance outcome measurements. 

Results: Fifty-three (26.5%) of 200 total paramedics at a combined career and volunteer fire department enrolled in the asynchronous course, and 31 (58.5%) completed the pre- and post-course survey. Of participating paramedic supervisors, 20 of 20 (100%) finished both portions of the course. Survey answers were based on a 5-point Likert scale. We reported results as a mean, with 5 corresponding to “strongly comfortable” or “strongly agree.” There was a statistically significant increase in the number of respondents who felt overall comfortable in administering blood from 3.51 to 4.16 (P = 0.003). Additionally, there was an increase in the number of paramedics who reported feeling comfortable performing the procedure of a blood transfusion from 3.11 to 4.13 (P = <0.001). Nearly all participants (30/31) would recommend the course to someone else. In the first three months of carrying blood in the field, there were 12 units of blood transfused and no protocol deviations or safety events. 

Conclusion: This study provides a model for the successful creation and implementation of a prehospital blood transfusion educational program using Kern’s framework. The curriculum was implemented in a single EMS system with senior paramedics, which may limit generalizability.

Objective: Emergency medical dispatch is intended to ensure that emergency medical services (EMS) allocate appropriate resources for the treatment of patients with status epilepticus (SE). However, it is unclear whether dispatch algorithms accurately identify those patients having a seizure-related medical emergency and how dispatch algorithms influence what prehospital resources are allocated for the encounter.

Methods: We performed a cross-sectional analysis of prehospital encounters for SE using data from the 2019 ESO Data Collaborative. We included patients who were ≥18 years of age, had an EMS diagnostic impression of SE, and did not have a cardiac arrest. We examined the dispatch-determined complaint designated by the emergency medical dispatch (EMD) code, dispatch-determined level of acuity (A, B, C, D), ambulance response, and training level of the responding prehospital professional.

Results: Of the 18,515 patient encounters for SE with an EMD code, 8,279 (44.9%) were women, and the mean age was 40.0 years (SD 19.7). There were 13,829 (75%) encounters that received a dispatch code for seizures/convulsions and 4,686 (25%) with a dispatch code for a non-seizure-related condition. Among encounters for SE identified by dispatch as seizures/convulsions, 6,412 (46.4%) were designated high acuity, 6,626 (63.6%) were designated low acuity, and the majority received emergent ambulance responses (98.1% among those designated high acuity and 81.8% among those designated low acuity) and an Advanced Life Support-trained responder (93.7% among those designated high acuity and 92.7% among those designated low acuity). Median response times were similar for all acuity levels (9.1, 8.8, 9.1, and 8.3 minutes for A-D, respectively). 

Conclusion: Approximately one-fourth of SE cases were categorized as a non-seizure related condition at dispatch, and fewer than half received the highest acuity determinant code. Despite this, dispatch-assigned acuity did not have a strong relationship with the ambulance response or training level of the EMS responder or response time, suggesting that use of dispatch algorithms might be further optimized and highlighting a potential area to improve quality of EMS care.

Background: During the COVID-19 pandemic, rapid, at-home testing for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) was inconsistently available. Consequently, for some patients, emergency departments (ED) became the preferred site to access COVID-19 testing. To improve operational efficiency, our ED implemented a “COVID-19 Test” chief concern (CC). Our primary objective in this analysis was to broadly assess the utilization of the new “COVID-19 Test” CC and associated clinical care. 

Methods: We conducted a retrospective analysis of ED encounters from an academic ED and an affiliated, community-based ED of all patients after the establishment of a CC of “COVID-19 Test” from October 11, 2021–July 31, 2022. The data were extracted from the electronic health record. We calculated descriptive demographic statistics and ran a univariate and multivariate logistic regression with additional diagnostic or therapeutic interventions (binary) as the outcome variable to generate odds ratios (OR) and 95% confidence intervals (CI). 

Results: A total of 320 patients were assigned a “COVID-19 Test” CC by a triage nurse. This was 0.5% of all ED encounters in this time frame. Of those, 45% were found to be SARS-CoV-2 positive. Admission or repeat ED visit at 72 hours occurred in 5.3% of patients. Nearly half (46.9%) of patients assigned a “COVID-19 Test” CC underwent additional ED interventions. Patients on Medicaid and those who self-identified as Black or Hispanic/Latino were disproportionately represented in the “COVID-19 Test” CC group as compared to the overall ED population. In multivariate analysis, an Emergency Severity Index of 1, 2 or 3 was associated with significantly higher odds of receiving additional interventions compared to ESI of 4 or 5 (adjusted OR: 46.85; 95% CI 13.28-165.26; P <0.001). 

Conclusion: Patients assigned a chief concern of “COVID-19 Test” had a high COVID-19 positivity rate, often underwent additional ED interventions, and were at low risk of return ED visits or admission. Minoritized and low-income patients were disproportionately represented in the “COVID-19 Test” CC group, highlighting potential disparities in access to at-home COVID-19 testing and implementation of this CC.

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.

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: 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. 

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.

Introduction: Point-of-care ultrasound (POCUS) is integral to emergency medicine (EM) training. It is unclear how EM residents use POCUS and how these skills are maintained as they progress in residency training. The purpose of this study was to evaluate resident use of POCUS at various timepoints in EM training.

Methods: This was a retrospective cohort study of EM residents at a single, three-year training program between July 1, 2014–June 30, 2022. Residents were included if they had completed three consecutive years of training and an ultrasound rotation in their postgraduate year (PGY)-1. The following time points were assessed: PGY-1 rotation and 3-, 6-, 12-, 18-, and 24-months post-rotation. Number of scans, accuracy of interpretation, acceptability for credit, and percentage of technically limited studies (TLS) were collected at each point. We analyzed performance characteristics using mixed-effects binomial logistic regression with time as a fixed effect and resident as a random effect. Models were fit separately for each performance characteristic and likelihood ratio tests were performed to determine whether performance varied over time.

Results: A total of 65 residents were included with a total of 13,229 exams performed during the study period. Cardiac and focused assessment with sonography in trauma examinations were performed most commonly. Overall accuracy of all exams during the examination period was 97.1% (95% confidence interval [CI] 96.2-98.0%), TLS was 14.5% (95% CI 9.7-20.6%), and acceptability was 82.9% (95% CI 76.3-88.2%). Trend over time (3, 6, 12, 18, and 24 months) found no differences in accuracy (P = 0.84), TLS (P = 0.20), or acceptability (P = 0.28). Further analyses by individual exam types also showed no significant differences in accuracy, acceptability, nor TLS.

Conclusion: Accuracy, acceptability, and percentage of technically limited scans did not significantly vary over time, suggesting that POCUS skills are maintained from PGY-1 rotation to each time point evaluated in this study.

Background: Point-of-care ultrasound (POCUS) is widely used in emergency medicine (EM) and increasingly throughout healthcare. Prior studies have revealed disparities in the use of imaging in the emergency department (ED) based on sociodemographic factors; however, the association between these factors and POCUS use is unknown. Our aim was to compare the odds of receiving POCUS in the ED based on patient race and ethnicity, language, sex, and type of insurance.

Methods: We reviewed electronic health records (EHR) matched to a departmental POCUS database from November 2021–June 2023 at an academic Level I trauma center. We included ED patients diagnosed with an International Classification of Diseases code mapped to chest or flank pain, who had a cardiac troponin obtained, or had been evaluated as a trauma activation or alert. Our primary outcome was whether a patient received transthoracic echocardiography (cardiac), renal, or focused assessment with sonography in trauma. Predictor variables were race/ethnicity group (non-Hispanic [NH] White, NH Black, Hispanic, other), patient language, sex assigned at birth, and insurance type as recorded in the EHR. We performed descriptive analyses and logistic regression (adjusted odds ratio [aOR], 95% confidence interval [CI]) controlling for body mass index, age, comorbidities, and triage hypotension or tachycardia.

Results: Of the 25,389 ED patients meeting inclusion criteria, 79.5% were NH White, 95.3% listed English as their primary language, 51.5% were female, and 33.4% had private payor insurance. After adjusting for confounding, patients had lower odds of receiving POCUS if they were “other” race/ethnicity as compared to NH White (aOR 0.65, CI 0.42-0.99, P = .04), female as compared to male (aOR 0.81, CI 0.69-0.94, P = .007), or if they had Medicare (aOR 0.67, CI 0.54-0.84, P <.001) or Medicaid (aOR 0.66, CI 0.52-0.83, P = .001) as compared to private payors. 

Conclusion: Overall, patients of female sex and patients with Medicaid or Medicare had lower odds of receiving point-of-care ultrasound in the ED. Although we did not find a difference in POCUS use among non-Hispanic White, NH Black, and Hispanic patients, patients belonging to other race/ethnicity categories had lower odds of receiving POCUS compared to NH White patients.

Background: Transesophageal echocardiography (TEE) has been introduced in resuscitative scenarios in recent decades, with a growing number of emergency physicians learning, performing, and studying resuscitative TEE.

Objective: Our goal was to characterize publishing trends regarding TEE use in emergency medicine (EM) and to investigate the increasing interest in potential applications of TEE in emergency departments (ED).

Methods: We retrieved published research associated with the use of TEE in EM from the Web of Science database from inception to December 31, 2023. We analyzed trends based on the number of articles published annually. To systematically map trends related to TEE in emergency medicine (EM), we extracted data on the number of unique EM TEE practitioners, institutions performing EM TEE, study topics, and other characteristics from research articles and case reports. To better reflect research trends, we exclusively conducted subgroup analysis on the research articles. We used linear regression analysis to analyze trends and conducted checkpoints on the timelines.

Results: Of the 964 titles and abstracts screened, we included 99 eligible published articles after careful review. Articles related to EM TEE increased from one article in 1991 to 20 articles in 2023, and the rate of publication has increased rapidly since 2018 (+12.4 publications per year, 95% confidence interval [CI] 9.8-15.0, P<0.001). The number of EM TEE practitioners and EM TEE-performing institutions underwent a rapid expansion with an inflection point between 2018–2020, with a rate of +91.7 practitioners per year and +36.5 institutions per year. Subgroup analysis revealed a similar trend in the published research articles. The most common indications for EM TEE were cardiac arrest (72.7%), shock (13.1%), and procedural guidance (11.1%). The United States published the majority of EM TEE-related articles (51.5%). 

Conclusion: The present study highlights that TEE-related articles in EM continue to accelerate. Among the indications for TEE, cardiac arrest remains the most frequently discussed. This scoping review provides insights into the expanding interest and applications of TEE in the field of EM.

Background: End-tidal carbon dioxide (EtCO2) has been regarded as the gold standard for assessing the effectiveness of cardiopulmonary resuscitation (CPR). However, the clinically observed limitations of EtCO2 influenced by ventilation during CPR suggest the need to implement a new, non-invasive hemodynamic monitoring method to evaluate and optimize CPR effectiveness in real time.

Methods: For this prospective study we enrolled 31 cardiac arrest (CA) patients who presented to the emergency department (ED) and 13 healthy volunteers as point-of-care ultrasound (POCUS) controls. Two physicians not involved in the resuscitation team performed POCUS of the bilateral carotid and femoral arteries during chest compression within the first 10 minutes of CPR. The clinical data and presumed CA cause were recorded. We observed the arterial pulse and measured the peak systolic velocity (PSV). The EtCO2 values during POCUS were also recorded. We explored the correlation between arterial PSV and EtCO2.

Results: The mean age of the patients was 69 ± 2 years, and 22 were male. Of 25 patients who experienced out-of-hospital cardiac arrest, 18 had an average no/low-flow time >30 minutes before ED arrival. Five patients achieved return of spontaneous circulation (ROSC). We found no significant difference in arterial PSV between ROSC and non-ROSC patients. The PSV of the left femoral artery was most consistently and positively correlated with EtCO2 in CA patients (R2 0.35, P=0.003).

Conclusion: Detection of arterial peak systolic velocity by point-of-care ultrasound, especially of the left femoral artery, might be a feasible method for non-invasive, real-time monitoring of chest compression effectiveness during CPR.

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.

Introduction: Sexual minorities, including lesbian, gay, bisexual, asexual, pansexual, and others make up 4.0 to 5.4% of the North American population. Stigmatization and minority stress can lead to poorer health status in sexual minorities, and a previous scoping review showed gaps in the emergency medicine (EM) literature for care of sexual minorities. In this review we sought to examine existing guidelines for the care of sexual minorities that made recommendations relevant to care in the emergency department (ED).

Methods: Using the PRISMA criteria, we performed a systematic search of OVID Medline, EMBASE, CINAHL, and the grey literature for clinical practice guidelines (CPG) and best practice statements (BPS) published until July 31, 2022. Articles were included if they were in English, included medical care of sexual minority populations of any age, in any setting, region, or nation, and were of national or international scope. Exclusion criteria included primary research studies, systematic or narrative reviews or otherwise non-CPG or BPS statements, editorials or letters to the editor, articles of regional or individual hospital scope, non-medical articles, or if a more recent version of the CPG or BPS existed. We identified, recorded, and assessed for quality all recommendations relevant to using the AGREE-II and AGREE-REX tools. Inter-rater reliability was assessed using the interclass correlation coefficient. We coded recommendations for the relevant point of care while in the ED (triage, registration, rooming, investigations, etc).

Results: We excluded 2,413 of 2,534 unique articles. Only nine articles contributed 11 ED-relevant recommendations. Seven of the nine articles were found to be of moderate to high quality; 6 of 11 recommendations were identified as high quality and adaptable. They included recommendations for screening, testing, and care of HIV+ sexual minority populations, and general or trauma care for men who have sex with men and sexual minority populations in general.

Conclusion: This is the most comprehensive review of guidance documents for care of sexual minority populations to date. It identifies 11 actionable recommendations for the ED and identifies opportunities for community-led development of comprehensive clinical practice guidelines for care of sexual minority populations in the ED. 

N/A

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.

Introduction: Gender minorities, including transgender, intersexual and non-binary (TIN) individuals, are at risk of receiving suboptimal care in emergency departments due to clinicians’ limited knowledge and formal training in TIN-specific needs. Little evidence is available regarding emergency medical service (EMS) responders, including paramedics (EMT-P), emergency medical technicians (EMT) ,and prehospital emergency physicians (EP). Therefore, in this study we aimed to explore the experiences and knowledge, attitudes, and education/training needs of EMS professionals in Germany regarding the care of TIN patients.

Methods: In April 2023, we electronically surveyed EMTs, EMT-Ps and prehospital EPs from ambulance stations across Germany. Participants completed a questionnaire consisting of 15 closed-ended items assessing their experience and knowledge, attitudes, and education/training needs regarding the care of TIN patients. We used standard descriptive statistics and tested for group differences using the chi-square test.

Results: Of the 2,925 potential respondents, 906 completed the survey and were eligible for further analysis (response rate: 31%). Of these, 218 (24%) were  prehospital EPs and 688 (76%) were EMTs and EMT-Ps, the latter two being significantly younger and less experienced. Almost half of the respondents reported having experience in caring for TIN patients as EMS responders (45% of EMTs/EMT-Ps vs 40% of prehospital EPs) but demonstrated significant gaps in non-medical and medical knowledge. Attitudes toward TIN patients were generally positive, but there were discrepancies between perceived comfort and actual communication behavior, with up to 25% of respondents overall avoiding questions they would ask non-TIN patients. Most respondents had no formal training in the appropriate management of TIN patients: only 7% of EMTs/EMT-Ps and 5% of  prehospital EPs indicated having received such training during their professional or medical training. Our survey showed that 63% of EMTs/EMT-Ps and 62% of prehospital EPs agreed that there is an urgent need to increase awareness for TIN patients among EMS responders.

Conclusion: Despite generally positive attitudes toward transexual, intersexual and non-binary patients, EMS responders in Germany demonstrated deficits in knowledge and clinical preparedness to care for this vulnerable patient population, indicating that the care of TIN patients has not yet become routine in EMS and highlighting a strong need for improved education and training.

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: Adverse childhood experiences (ACEs) and exposure to community violence are public health issues linked to negative mental and physical health outcomes. The emergency department (ED) can play a critical role in the care of patients with a history of trauma exposure. Unfortunately, patients’ experiences often go unidentified, leading to missed opportunities to address and prevent further harm. 

Methods: We administered a 22-question survey of trauma exposure in ED patients to 1) identify the prevalence of exposure to community violence and ACEs and resulting post-traumatic stress disorder (PTSD) symptoms, and 2) determine perceived social service needs. This self-administered survey study was conducted on a convenience sample of 267 adult patients at one academic hospital in Chicago, IL, between July 2018–December 2019. This ED sees approximately 70,000 patients annually. These were fluent English-speaking patients who were non-critically ill or altered and chosen randomly after being assigned to an ED room, typically during regular business hours based on research associate availability. They were not offered compensation for study participation. The survey included demographic information and questions modified from the Adverse Childhood Experiences Study questionnaire, the 54-item Survey of Exposure to Community Violence, and the Primary Care PTSD screen. Participants were also asked to identify resources to address their exposure to trauma. 

Results: Of 268 surveys, 267 were completed; 88% of participants endorsed exposure to ACEs or community violence (95% confidence interval [CI] 84.1-91.9%, p < 0.001 compared to general US population rate of 61%). A total of 53.6% of respondents endorsed exposure to at least one ACE (95% CI, 47.6-59.6%), and 15.7% were exposed to ≥4 ACE (95% CI, 11.3-20.1%). The most commonly endorsed categories of ACE were “emotional neglect” (30.3%, 95% CI 24.8%-35.8%); “emotional abuse” (25.8%, 95% CI 20.6%-31.1%); and “exposure to family substance use” (21%, 95% CI 16.1%-25.9%). When asked about personal experience with violence in the community, 47.9% said they had been shoved, kicked or punched (95% CI 41.9%-53.9%), 8% had been stabbed (95% CI 4.8%-11.3%), and 6.7% had been shot (95% CI 3.7%-9.7%). Among the survey participants, 26.2% said they had seen someone die from violence either in their home or in their neighborhood (95% CI 20.9%-31.5%). ZIP Code analysis indicates that most patients resided in neighborhoods near our ED and were likely to utilize it for medical care. Of respondents with exposure to trauma 38% asked for resources through their primary care clinic (95% CI 32.2%-43.8%), while 77.4% asked for resources through faith-based organizations (95% CI 72.4%-82.4%).

Conclusion: These findings suggest that most respondents in the ED have experienced trauma, and many are interested in community and clinical resources. These results demonstrate the need for trauma-informed screening in the ED and support for institutional and community-level interventions to address patient experiences

Introduction: Pain is a common chief complaint in the emergency department (ED), and there are known disparities in the management of pain among racial/ethnic minorities, women, and older adults. Transgender and gender diverse (TGD) individuals comprise another under-represented patient population in emergency medicine and are also at risk of disparities in care. To measure and evaluate the magnitude of care inequities among TGD individuals, first we need to be able to accurately identify the right cohort and comparison groups. The primary objective of this study was to establish an accurate and generalizable process for identifying TGD patients through the electronic health record (EHR). Secondary objectives included creating and validating a method for matching and comparing of TGD patients to cisgender patients. 

Methods: This was a retrospective, observational cohort study that included patients presenting to Mayo Clinic EDs with a chief complaint of abdominal pain across four states (MN, WI, AZ, FL) between July 1, 2018–November 15, 2022. Patients ≥12 years of age were included. Patients’ sex assigned at birth and gender identity was extracted from the EHR via patient-provided registration fields. Two independent investigators independently reviewed each medical record of the identified TGD patient to validate the accuracy of pulled gender identity. Discrepancies were resolved by a third reviewer. Each transgender patient was matched to cisgender GBQ males (gay, bisexual, queer), cisgender LBQ (lesbian, bisexual, queer) females, cisgender heterosexual males, and cisgender heterosexual females using propensity score (PS) matching. We calculated the PS values using a multivariable logistic regression model where being transgender was the outcome, and covariates in the model included age, site, mental health history, and gastrointestinal history.

Results: We initially identified 300 patients as TGD based on electronic data pull. An additional 1,000 patients were also included in the cohort for matching purposes. The agreement between electronic and manual review was 99.9%, and the kappa was 0.998 (95% confidence interval 0.994-1.000). We were able to match patients except for GBQ males due to low numbers. There is a significant difference in age between groups (P <0.001) with GBQ males being older than other groups.

Conclusion: The methodology for identifying transgender and gender diverse patients in the EHR was accurate compared to manual review of gender identity. The TGD patients were able to be well matched, except to GBQ males. This provides a validated method to identify TGD patients in the EHR and further study disparities they may receive in care.

Introduction: Patients who prefer to communicate in a language other than English are vulnerable to the consequences of medical communication barriers. Studies of non-English language preferred (NELP) and English language preferred (ELP) patients have shown differences in rates of hospital admission and wait times—factors known to be related to increased costs and lower patient satisfaction. However, few studies include languages other than Spanish or account for patient acuity level. 

Methods: We performed a retrospective cohort study at an urban, Level I trauma center from January–December 2020. Patients were grouped by language preference, with NELP languages grouped into three categories: Spanish; Chinese (Mandarin, Cantonese, Taishanese, Taiwanese, and Zhongshan-Chinese dialect); and other (all other remaining languages). We extracted age, sex, race, ethnicity, language preference, emergency department (ED) discharge disposition, and Emergency Severity Index Score (ESI) from the electronic health record. The primary outcome was the hospital admission rate. Secondary outcomes were the time from patient arrival to placement in the treatment room and the time from patient arrival to disposition. We analyzed data with chi-square tests, logistic, and linear regressions.

Results: Of the 58,079 unique ED encounters, 26.4% (15,307) patients identified as NELP. Within NELP patient encounters, 75.0% preferred Spanish, 13.9% preferred Chinese, and 11.1% preferred another language. After adjusting for age and acuity, Spanish language- and Chinese language-preferred patients were at 16% and 14% higher odds of admission, respectively (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.10-1.23 and OR 1.14, CI 1.02-1.27 respectively), compared to ELP patients. NELP patients waited an average 5.4 minutes longer to be roomed (95% CI 4.46-6.29) and 15.6 minutes longer until disposition (95% CI 12.62-18.54, P<0.05). This discrepancy was greater for patients triaged at lower acuities, with ESI 5 Spanish language- and Chinese language-preferred patients waiting an average of 50.3 and 90.6 minutes longer than ELP patients until disposition (95% CI 17.67-83.57; and 95% CI 24.31-81.57 respectively).

Conclusion: After adjusting for acuity level and age, non-English language preferred patients were at higher odds of admission and experienced disparate wait times, especially at lower acuity levels. Further investigation is needed to understand the causes of these differences and mitigate these health inequities.

Objectives: The purpose of this study was to evaluate the impact of the Discussing Anti-Racism and Equity (DARE) curriculum on individual physician knowledge and practice, as well as on perceptions of group culture.

Methods: DARE was a longitudinal multimodal curriculum targeted at pediatric and adult emergency medicine (EM) trainees and faculty, made up of 12 lectures/workshops, three  simulations, five book clubs, and two movie screenings. We used a multiphase, parallel convergent mixed-methods approach. Focus groups before and after DARE explored prior education, antiracism attitudes and behaviors, perceived impact of intervention curriculum, and perceptions of departmental medical culture. We elucidated themes using thematic analysis. Surveys of trainees and attendings evaluated individual attitudes and practices related to equity and antiracism.

Results: We held nine focus groups with a total of 52 participants. Half of participants were EM residents (26), and half were faculty (12 pediatric EM and 14 general EM). Four major themes emerged around antiracism education and DARE. Both trainees and faculty reported a lack of standardized or effective prior education, although trainees are beginning to report increased exposure in medical school. Participants reported an overall positive impact of DARE on individual knowledge and practice, with continued room for improvement. Focus groups particularly highlighted a perceived shift in departmental antiracist culture post-DARE. Finally, future curricular aims were elucidated. A total of 56 surveys showed significant improvement in all realms of antiracism medical- practice questions when posed as retrospective pre-post questions (P < 0.01). 

Conclusion: The DARE curriculum increased individual antiracism awareness and cultivated culture shift among the targeted clinician group. Focus groups provided clear next steps for ongoing and expanded education.

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.

n/a

Objectives: We sought to determine whether atorvastatin administration attenuates the inflammatory response and improves clinical outcomes in acute influenza. 
Methods: We conducted a randomized double-blind trial administering atorvastatin 40 milligrams or placebo to adults with confirmed influenza for five days between December 2013–May 2018. Patients were primarily enrolled in the emergency department (ED) at an urban, tertiary-care center. Serum was obtained at enrollment and 72 hours for the primary outcome, change in interleukin (IL-6). Patients reported severity of influenza symptoms over 10 days. We used linear mixed-effects models for the primary comparisons. 

Results: Of the 116 enrolled patients, 59 received atorvastatin and 57 received placebo. Groups were well-matched including baseline influenza symptom scores and receipt of an antiviral medication. There was no difference between groups in the change in interleukin-6 (IL-6) levels (P=0.468). However, there were significant differences in the overall influenza symptom scores, favoring faster resolution in the atorvastatin group (P=0.05). For patients presenting within 48 hours of symptom onset, resolution was faster for the overall score (P <0.001) and for the fever (P=0.001), sore throat (P=0.005) and headache (P=0.006) components. No safety concerns were identified. 

Conclusion: Atorvastatin administration in acute influenza appears safe. We did not find attenuation of IL-6 with atorvastatin. Patients receiving atorvastatin reported improvement in their clinical symptoms at a faster rate than those in the placebo group, particularly in patients presenting within 48 hours of symptom onset. This trial is registered at ClinicalTrials.gov, Identifier: NCT02056340. 

Background: Plasma adiponectin (APN) levels might be affected by age. In this study we aimed to study the association between plasma APN levels and age and the effects of APN levels on mortality in age-stratified septic patients.

Methods: We conducted this single-center, retrospective study with 173 patients with sepsis and 57 controls. Physical and demographic characteristics were recorded, and blood samples were collected to measure plasma APN levels. Using this data, we determined the association between plasma APN levels and age, and the effect of plasma APN levels on mortality in age-stratified septic patients.

Results: We stratified patients into three age groups: < 60 years (middle age); 60-80 years (advanced age); and elderly (≥ 80 years). Plasma APN levels increased with increasing age in both the control group and the sepsis group. Mortality also increased with age: 12.3% in the < 60 group; 24.6% in those 60-80 years of age; and 36.2% in elderly patients >80 years (P<0.001). In middle-aged and advanced-age patients, APN levels were found to be associated with 28-day mortality based on the receiver operating characteristic curve analysis. Furthermore, APN levels remained independently associated with 28-day mortality in patients < 80 years. However, in elderly patients the APN levels showed no significant association with 28-day mortality. 

Conclusion: We found a positive association between plasma adiponectin levels and age in septic patients. Low circulating levels of APN were associated with 28-day mortality in septic patients < 80 years of age. We found no significant association between APN and mortality in sepsis patients who were > 80 years of age.

Introduction: Bacteremia, a common disease but difficult to diagnose early, may result in significant morbidity and mortality without prompt treatment. We aimed to develop machine-learning (ML) algorithms to predict patients with bacteremia from febrile patients presenting to the emergency department (ED) using data that is readily available at the triage.

Methods: We included all adult patients (≥18 years of age) who presented to the emergency department (ED) of National Taiwan University Hospital (NTUH), a tertiary teaching hospital in Taiwan, with the chief complaint of fever or measured body temperature more than 38°C, and who received at least one blood culture during the ED encounter. We extracted data from the Integrated Medical Database of NTUH from 2009–2018.The dataset included patient demographics, triage details, symptoms, and medical history. The positive blood culture result of at least one potential pathogen was defined as bacteremia and used as the binary classification label. We split the dataset into training/validation and testing sets (60-to-40 ratio) and trained five supervised ML models using K-fold cross-validation. The model performance was evaluated using the area under the receiver operating characteristic curve (AUC) in the testing set.

Results: We included 80,201 cases in this study. Of them, 48120 cases were assigned to the training/validation set and 32,081 to the testing set. Bacteremia was identified in 5,831 (12.1%) and 3,824 (11.9%) cases of the training/validation set and test set, respectively. All ML models performed well, with CatBoost achieving the highest AUC (.844, 95% confidence interval [CI] .837-.850), followed by extreme gradient boosting (.843, 95% CI .836-.849), gradient boosting (.842, 95% CI .836-.849), light gradient boosting machine (.841, 95% CI .834-.847), and random forest (.828, 95% CI .821-.834).

Conclusion: Our machine-learning model has shown excellent discriminatory performance to predict bacteremia based only on clinical features at ED triage. It has the potential to improve care quality and save more lives if successfully implemented in the ED. 

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: The COVID-19 pandemic impacted the way medical students seek residency positions. In 2020, the Accreditation Council for Graduate Medical Education advocated for virtual interviews. Most emergency medicine (EM) interviews in 2023 remained virtual, and this format will persist for the foreseeable future. Since students are not evaluating programs in person in most cases, residency websites are crucial for prospective residents. Resident wellness is critical for resident training and important to prospective residents; it follows that programs must be transparent about resident wellness on websites. In this study we aimed to quantify the number of EM programs with wellness pages on their websites and identify themes portrayed on those pages. 

Methods: We analyzed residency website wellness pages from EM websites based on the 2022 directory of the Electronic Residency Application Service. We independently coded wellness statements through an inductive process. Codes were revised iteratively to consensus and organized into themes. 

Results: We identified 278 (100%) EM residency websites. Of these websites, 57 (20.5%) had a wellness page, 45 (16.2%) linked to an institutional page that discussed wellness, 169 (60.8%) discussed wellness themes on their website in areas other than a wellness page, and 69 (24.8%) had no direct mention of wellness anywhere on their website. Using this information, we identified themes including community involvement, growth and development, nutrition and health, psychological well-being, social and relaxation activities, wellness culture and environment, wellness curriculum, wellness structure and resources, and work-life integration. 

Conclusion: Most EM program websites do not include a wellness page. Of the programs that do, we identified important themes. The absence of dedicated wellness pages on most EM websites suggests an opportunity for programs to better communicate their wellness initiatives to applicants, helping them identify programs that align with their values.

Introduction: The transition to virtual interviews over the past four years has been associated with changes to the ways that applicants collect information on residency programs. 

Methods: Our program collected free-response data from questionnaires completed by applicants prior to their virtual interview days over the course of four recruitment cycles. We performed a descriptive analysis of these responses to identify the frequency with which students have been accessing various resources to learn about programs, and to learn how that has changed over time. 

Results: Our findings over four years and 322 applicants (of 391 surveyed, response rate 82%) indicated that the three most common sources of information were individual program websites, the Emergency Medicine Resident’s Association (EMRA) Match website, and Instagram. These sources were reported more frequently than personal experience, word of mouth, and advice from mentors. Other online resources were rarely used. 

Conclusion: These findings may help program leaders to direct their limited time and attention towards marketing their programs through online resources most commonly used by applicants.

Introduction: Research literacy is an important competency for all clinicians, but developing resident enthusiasm for it is difficult. At one academic emergency medicine (EM) residency program, we designed an innovative program to help residents improve literacy skills within a community of practice and use research literature to address clinical problems. 

Methods: A six-member faculty core team surveyed residents to assess their baseline experience with evidence-based medicine (EBM) and level of engagement with the medical literature. Interested residents joined an iterative curriculum development process that drew on previous EBM pedagogical experience and literacy theory. We developed a semi-structured approach that prioritizes using the reference frame of clinical applicability rather than research methodology. We held 90-120 minute sessions three times a year as part of the regular residency didactic conference; post-session evaluations with quantitative and qualitative elements were used to adjust subsequent didactics to refine the approach. 

Results: An average of 48 residents were in the EM training program during the nine sessions conducted during the study period. At baseline, residents had a high degree of exposure to EBM during medical school (94% of respondents) but low confidence in reading the medical literature (25%) or applying research to practice (10%). In contrast, they reported the novel program equipped them with skills to interpret literature and led to collective practice improvement. We found engagement was highest when residents led sessions based on inquiries that emerged out of their own training experience. Other positive factors included well-facilitated discussions between residents, relating questions to data-driven review of local practice patterns and addressing findings from free open access medical education (FOAMed) sources. The initial stages required significant team effort to design the pilot sessions, but later sessions were developed following the trajectory of resident inquiries using a minimally structured faculty consensus process and required less than 12 total faculty hours of commitment. 

Conclusion: An innovative program centered on residents’ practice-based queries of research literature appears to enhance learner enthusiasm for development of research literacy. Further development is needed to validate the overall effectiveness and generalizability of this approach.

N/A

N/A