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

Introduction

The decision to discharge a patient from the hospital with confirmed or suspected COVID-19 is fraught with challenges. Patients who are discharged home must be both medically stable and able to safely isolate to prevent disease spread. Socioeconomically disadvantaged patient populations in particular may lack resources to safely quarantine and are at high risk for COVID-19 morbidity.

Methods

We developed a telehealth follow-up program for emergency department (ED) patients who received testing for COVID-19 from April 24 to June 29, 2020 and were discharged home. Patients who were discharged with a pending COVID-19 test received follow up calls on Days 1, 4 and 8. The objective of our program was to screen and provide referrals for health-related social needs (HRSNs); conduct clinical screening for worsening symptoms; and deliver risk-reduction strategies for vulnerable individuals. Retrospective chart review was conducted on all patients in this cohort to collect demographic information, testing results, and outcomes of clinical symptom and HRSN screening. Our primary outcome measurement was the need for clinical reassessment and referral for an unmet HRSN.

Results

From April 24th to June 29th, 2020, we made calls to 1,468 patients tested for COVID-19 and discharged home. On Day 4, we reached 67.0% of the 1,468 patients called. Of these, 15.9% were referred to a PA out of concern for clinical worsening and 12.4% were referred to an ED Patient Navigator for HRSNs. On Day 8, we reached 81.8% of the 122 patients called. Of these, 19.7% were referred to a PA for clinical reassessment and 14.0% of patients were referred to an ED Patient Navigator for HRSNs. Our intervention reached 1,069 patients, of which 12.6% required referral for HRSNs and 1.3% (n=14) were referred to the ED or Respiratory Illness Clinic due to concern for worsening clinical symptoms.

Conclusion

In this patient population, the demand for interventions to address social needs was as high as the need for clinical reassessment. Similar ED-based programs should be considered to help support patients’ interdependent social and health needs, beyond those related to COVID-19.

Introduction: People experiencing homelessness have high rates of social needs when presenting for emergency department (ED) services, but less is known about patients with housing instability who do not meet the established definitions of homelessness.

Methods: We surveyed patients in an urban, safety-net ED from June–August 2018. Patients completed two social needs screening tools and responded to additional questions on housing. Housing status was determined using validated questions about housing stability.

Results: Of the 1,263 eligible patients, 758 (60.0%) completed the survey. Among respondents, 40% identified as Latinx, 39% Black, 15% White, 5% Asian, and 8% other race/ethnicities. The median age was 42 years (interquartile range [IQR]: 29-57). and 54% were male. Of the 758 patients who completed the survey, 281 (37.1%) were housed, 213 (28.1%) were unstably housed, and 264 (34.8%) were homeless. A disproportionate number of patients experiencing homelessness were male (63.3%) and Black (54.2%), P <0.001, and a disproportionate number of unstably housed patients were Latinx (56.8%) or were primarily Spanish speaking (49.3%), P <0.001. Social needs increased across the spectrum of housing from housed to unstably housed and homeless, even when controlling for demographic characteristics.

Conclusion: Over one in three ED patients experience homelessness, and nearly one in three are unstably housed. Notable disparities exist by housing status, and there is a clear increase of social needs across the housing spectrum. Emergency departments should consider integrating social screening tools for patients with unstable housing.

ABSTRACT

Introduction. The coronavirus 2019 (COVID-19) pandemic caused significant disruptions in daily life. Given the role that social determinants of health play in the overall well-being of individuals and populations, we wanted to determine the effects of the COVID-19 pandemic on our patient population in the emergency department (ED).

Methods: We adapted the Centers for Medicare and Medicaid Services social risk assessment to assess changes to participants’ social situations throughout the COVID-19 pandemic from January 2020–February 2021. The survey was administered within the ED to individuals selected by a convenience sample of patients who were stable enough to complete the form.

Results: We received 200 (66%) responses from the 305 patients approached. Worsened food access was reported by 8.5% (17) of respondents, while 13.6% (27) reported worsened food concern since the onset of the COVID-19 pandemic. The odds of worsened food access were higher among non-Whites (adjusted odds ratio [aOR] 19.17, 95% confidence interval [CI] 3.33-110.53) and females (aOR 9.77, CI 1.51-63.44). Non-Whites had greater odds of worsened food concern (aOR 15.31, CI 3.94-59.54). Worsened financial difficulty was reported by 24% (48) of respondents. The odds of worsened financial difficulty were higher among females (aOR 2.87, 95% CI 1.08-7.65) and non-Whites (aOR 10.53, CI 2.75-40.35).

Conclusion: The COVID-19 pandemic has worsened many of the social determinants of health found within communities. Moreover, vulnerable communities were found to be disproportionately affected as compared to their counterparts. Understanding the challenges faced by our patient populations can serve as a guide on how to assist them more comprehensively.

Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting.

Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health.

Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting?

Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

Wealthy nations must step up support for Africa and vulnerable countries in addressing past, present and future impacts of climate change

Introduction: Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients’ self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States.

Methods: This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019–December 31, 2020. We collected demographic and clinical information, including patients’ race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient’s race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival.

Results: We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival. 

Conclusion: Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.

ABSTRACT

Introduction: Emergency department (ED) staff are at a high risk for compassion fatigue (CF) due to a work environment that combines high patient acuity, violence, and other workplace stressors. This multi-faceted syndrome has wide-ranging impacts which, if left untreated, can lead to adverse mental health conditions including depression, anxiety, and substance use disorders. However, the majority of studies examining CF look solely at clinicians; as a result, there is no information on the impact of CF across other roles that are involved in supporting patient care. We conducted this study to establish the prevalence of CF across both clinical and non-clinical roles in the adult ED setting.

Methods: For this single institution cross-sectional study, all full- and part-time ED staff members who worked at least 50% of their shifts in the ED or within the adult trauma service line were eligible to participate. Using the Professional Quality of Life (ProQOL-5) scale, which measures CF via compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS), we assessed for group differences between roles using non-parametric one-way ANOVA.

Results: A total of 152 participants (response rate = 38.0%) completed the survey. This included attending physicians (n = 15, 9.7%), resident/fellow physicians (n = 23, 15.1%), staff nurses (n = 54, 35.5%), emergency technicians (n = 21, 13.8%), supportive clinical staff (n = 28, 18.4%), and supportive ancillary staff (n = 11, 7.2%). Across all roles, the majority of respondents had average levels of BO (median = 25.0, IQR 20.0 – 29.0) and STS (median = 23.0, IQR 18.0 – 27.0) coupled with high levels of CS (median = 38.0, IQR 33.0 – 43.0). There was a difference in CS by role (p = .01), with nurses reporting lower CS than attending physicians. STS also differed by role (p = .01), with attending physicians reporting lower STS than both emergency technicians and nurses. Group differences were not seen in BO.

Objectives: Although factors related to a return visit to the emergency department (ED) have been reported, only few studies have examined “high-risk” ED revisits with serious adverse outcomes. This study aimed to describe the incidence and trend of high-risk ED revisits in United States EDs and to investigate factors associated with these revisits.

Methods: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010–2018. Adult ED revisits within 72 hours of a previous discharge were identified using a mark on the Patient Record Form. High-risk revisits were defined as revisits with serious adverse outcomes, including intensive care unit admissions, emergency surgery, cardiac catheterization, or cardiopulmonary resuscitation (CPR) during the return visit. Analyses used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design.

Results: Over the 9-year study period, there were an estimated 37,700,000 revisits, and the proportion of revisits in the entire ED population decreased slightly from 5.1% in 2010 to 4.5% in 2018 (P for trend = 0.02). By contrast, there were an estimated 827,000 high-risk ED revisits, and the proportion of high-risk revisits in the entire ED population remained stable at approximately 0.1%. The mean age of these high-risk revisit patients was 57 years, and 43% were men. Approximately 6% of the patients were intubated, and 13% received CPR. Most of them were hospitalized, and 2% died in the ED. Multivariable analysis showed older age (65+ years), Hispanic ethnicity, daytime visits, and arrival by ambulance during the revisit were independent predictors of high-risk revisits.

Introduction

Critically ill patients are frequently transferred from other hospitals to the Emergency department (ED) of tertiary hospitals. Due to the unforeseen transfer, the ED length of stay (LOS) of the patient is likely to be prolonged along with other adverse effects. The present study aimed to confirm whether the establishment of an organized unit called the Emergency Transfer Coordination Center (ETCC) to systematically coordinate emergency transfers is effective in reducing the ED LOS of transferred critically ill patients.

Methods

The present study is a retrospective observational study focusing on patients who were transferred from other hospitals and admitted to the intensive care unit (ICU) of the ED in a tertiary hospital located in northwestern Seoul, the capital city of South Korea from January 2019 to December 2020. The exposure variable of the study was ETCC approval before transfer and ED LOS was the primary outcome. Propensity score matching was used for comparison between the group with ETCC approval and the control group.

Results

Participants comprised 1097 patients admitted to the ICU after being transferred from other hospitals, of which, 306 patients (27.9%) were transferred with ETCC approval. The median ED LOS in the ETCC approved group was significantly reduced to 277 minutes compared to 385 minutes in the group without ETCC approval. ETCC had a greater effect on reducing evaluation time than boarding time, which was the same for populations with different clinical features.

Conclusion

ETCC can be effective in systematically reducing critical patients’ ED LOS who are transferred from other hospitals to tertiary hospitals suffering from severe crowding.

Introduction: Knowledge about the relationship between symptoms, diagnoses, and mortality in emergency department (ED) patients is essential for the emergency physician to optimize treatment, monitoring, and flow. In this study, we investigated the association between symptoms and discharge diagnoses; symptoms and mortality; and we then analyzed whether the association between symptoms and mortality was influenced by other risk factors.

Methods: This was a population-based, multicenter cohort study of all non-trauma ED patients ≥18 years who presented at a hospital in the Region of Southern Denmark between January 1, 2016–March 20, 2018. We used multivariable logistic regression to examine the association between symptoms and mortality adjusted for other risk factors.

Results: We included 223,612 ED visits with a median patient age of 63 and even distribution of females and males. The frequency of the chief complaints at presentation were as follows: non-specific symptoms (19%); abdominal pain (16%); dyspnea (12%); fever (8%); chest pain (8%); and neurologic complaints (7%). Discharge diagnoses were symptom-based (24%), observational (hospital visit for observation or examination, 17%), circulatory (12%), or respiratory (12%). The overall 30-day mortality was 3.5%, with 1.7% dead within 0-7 days and 1.8% within 8-30 days. The presenting symptom was associated with mortality at 0-7 days but not with mortality at 8-30 days. Patients whose charts were missing documentation of symptoms (adjusted odds ratio [aOR] 3.5) and dyspneic patients (aOR 2.4) had the highest mortality at 0-7 days across patients with different primary symptoms. Patients ≥80 years and patients with a higher degree of comorbidity had increased mortality from 0-7 days to 8-30 days (aOR from 24.0 to 42.7 and 1.9 to 2.8, respectively).

Conclusion: Short-term mortality was more strongly associated with patient-related factors than with the primary presenting symptom at arrival to the hospital.

Introduction: Urolithiasis causes severe acute pain and is commonly treated with opioid analgesics in the emergency department (ED). We examined opioid analgesic use after episodes of acute pain. 

Methods: Using data from a longitudinal trial of ED patients with urolithiasis, we constructed multivariable models to estimate the adjusted probability of opioid analgesic use 3, 7, 30, and 90 days after ED discharge. We used multiple imputation to account for missing data and weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. We used weighted multivariable regression to compare longitudinal opioid analgesic use for those prescribed vs not prescribed an opioid analgesic at discharge, stratified by reported pain at ED discharge. 

Results: Among 892 adult ED patients with urolithiasis, 79% were prescribed an opioid analgesic at ED discharge. Regardless of reporting pain at ED discharge, those who were prescribed an opioid analgesic were significantly more likely to report using it one, three, and seven days after the visit in weighted multivariable analysis. Among those who were not prescribed an opioid analgesic, an estimated 21% (not reporting pain at ED discharge) and 30% (reporting pain at discharge) reported opioid analgesic use at day three. Among those prescribed an opioid analgesic, 49% (no pain at discharge) and 52% (with pain at discharge) reported using an opioid analgesic at day three. 

Conclusion: Urolithiasis patients who received an opioid analgesic at ED discharge were more likely to continue using an opioid analgesic than those who did not receive a prescription at the initial visit, despite the time-limited nature of urolithiasis.

Introduction: Frostbite leads to progressive ischemia eventually causing tissue necrosis if not quickly reversed. Patients with frostbite tend to present to the emergency department (ED) for assessment and treatment. Acute management includes rewarming, pain management, and (when indicated) thrombolytic therapy. Thrombolytic therapy in severe frostbite injury may decrease rates of amputation and improve patient outcomes. Fluorescence microangiography (FMA) has been used to distinguish between perfused and non-perfused tissue. The purpose of this study was to evaluate the potential role of FMA in the acute care of patients with frostbite, specifically its role as a tool to identify perfusion deficit following severe frostbite injury, and to explore its role in time to tissue plasminogen activator (tPA).

Methods: This retrospective analysis included all patients from December 2020–March 2021 who received FMA in a single ED as part of their initial frostbite evaluation. In total, 42 patients presented to the ED with concern for frostbite and were evaluated using FMA.

Results: Mean time from arrival in the ED to FMA was 46.3 minutes. Of the 42 patients, 14 had clinically significant perfusion deficits noted on FMA and received tPA. Mean time to tPA (measured from ED arrival to administration of tPA) for these patients was 117.4 minutes. This is significantly faster than average historical times at our institution of 240-300 minutes.

Conclusion: Bedside FMA provides objective information regarding perfusion deficits and allows for faster decision-making and improved times to tPA. Fluorescence microangiography shows promise for quick and efficient evaluation of perfusion deficits in frostbite-injured patients. This could lead to faster tPA administration and potentially greater rates of tissue salvage after severe frostbite injury.

Introduction: Regional anesthesia (RA) has become a prominent component of multimodal pain management in emergency medicine (EM), and its use has increased rapidly in recent decades. Nevertheless, there is a paucity of data on how RA practice has evolved in the specialty. In this study we sought to investigate how RA has been implemented in EM by analyzing trends of published articles and to describe the characteristics of the published research.

Methods: We retrieved RA-related publications from the SciVerse Scopus database from inception to January 13, 2022, focusing on studies associated with the use of RA in EM. The primary outcome was an analysis of trend based on the number of annual publications. Other outcomes included reports of technique diversity by year, trends in the use of individual techniques, and characteristics of published articles. We used linear regression analysis to analyze trends.

Results: In total, 133 eligible publications were included. We found that overall 23 techniques have been described and results published in the EM literature. Articles related to RA increased from one article in 1982 to 18 in 2021, and the rate of publication has increased more rapidly since 2016. Reports of lower extremity blocks (60.90%) were published most frequently in ranked-first aggregated citations. The use of thoracic nerve blocks, such as the erector spinae plane block, has increased exponentially in the past three years. The United States (41.35%) has published the most RA-related articles. Regional anesthesia administered by emergency physicians (52.63%) comprised the leading field in published articles related to RA. Most publications discussed single-shot (88.72%) and ultrasound-guided methods (55.64%).

Conclusion: This study highlights that the number of published articles related to regional anesthesia in EM has increased. Although RA research has primarily focused on lower extremity blocks, clinical researchers continue to broaden the field of study to encompass a wide spectrum of techniques and indications.

Introduction: While females make up more than half of medical school matriculants, they only comprise about one third of emergency medicine (EM) residents. We examined EM residency cohorts with entering years of 2014–2017 to estimate the ratio of males to females among residents and program leadership to determine what correlation existed, if any, between program leadership and residency gender distributions. 

Methods: We identified 171 accredited EM residency programs in the United States with resident cohorts entering between 2014-2017 with publicly available data that were included in the study. The number of male and female residents and program directors were counted. We then confirmed the counts by contacting the programs directly to confirm accuracy of the data collected from program websites. 

Results: Within the included 171 programs, the overall male to female EM resident ratio was 1.78:1. Individual program ratios ranged from 0.85-8.0. Only eight programs (5.6%) had a female-predominant ratio. Among program directors, the overall male to female ratio was 2.17:1. TThe gender of the program director did not have a statistically significant correlation with the male to female ratio among its residents (P = .93). 

Conclusion: Within 171 residency programs across the US with entering cohorts between 2014-2017, the average male to female ratio among residents is nearly 2:1. No significant correlation exists between the gender distribution among a program’s leadership and its residents.

Introduction

The purpose of this study was to quantify the effects of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency departments (PEDs) across the United States (US), specifically its impact on trainee clinical education as well as patient volume, admission rates, and staffing models.

Methods

We conducted a cross-sectional study of US PEDs, targeting PED clinical leaders via a web-based REDCap questionnaire.  The survey was sent via 3 national pediatric emergency medicine distribution lists, with several follow-up reminders.

Results

There were 46 questionnaires included, completed by PED directors from 25 states.  Forty-two sites provided PED volume and admission data for early pandemic (March-July 2020), and a pre-pandemic comparison period (March-July 2019).   Mean PED volume decreased > 32% for each studied month, with a maximum mean reduction of 63.6% (April 2020).  Mean percentage of pediatric admissions over baseline also peaked in April 2020 at 38.5% and remained 16.4% above baseline by July 2020.

During the study period, 33 (71.1%) sites had decreased provider staffing at some point.  Only 3 sites (6.7%) reported decreased faculty protected time.  All PEDs reported staffing changes, including decreased mid-level use, increased on-call staff, movement of staff between PED and other units, and added tele-visit shifts.  Twenty-six sites (56.5%) raised their patient age cutoff; median was 25 years (IQR 25-28).

Of 44 sites hosting medical trainees, 37 (84,1%) reported a decrease in trainee number or elimination altogether.  Thirty (68.2%) sites had restrictions on patient care provision by trainees:  28 (63.6%) affected medical students, 12 (27.3%) affected residents and 2 (4.5%) impacted fellows.  Fifteen sites (34.1 %) had restrictions on procedures performed by medical students (29.5%), residents (20.5%), or fellows (4.5%).

Conclusion

This study highlights the marked impact of the COVID-19 pandemic on US PEDs, noting decreased patient volumes, increased admission rates, and alterations in staffing models.  During the early pandemic, educational restrictions for trainees in the PED setting disproportionately affected medical students over residents, with fellow experience largely preserved.  Our findings quantify the magnitude of these impacts on trainee pediatric clinical exposure during this period.

Introduction: Few studies have investigated the management of COVID-19 cases from the operational perspective of the emergency department (ED), We sought to compare the management and outcome of COVID-19 positive and negative patients who presented to French EDs.

Methods: We conducted a prospective, multicenter, observational study in four EDs. Included in the study were adult patients (≥18 years) between March 6–May 10, 2020, were hospitalized, and whose presenting symptoms were evocative of COVID-19. We compared the clinical features, management, and prognosis of patients according to their confirmed COVID-19 status.

Results: Of the 2,686 patients included in this study, 760 (28.3%) were COVID-19 positive. Among them, 364 (48.0%) had hypertension, 228 (30.0%) had chronic cardiac disease, 186 (24.5%) had diabetes, 126 (16.6%) were obese, and 114 (15.0%) had chronic respiratory disease. The proportion of patients admitted to intensive care units (ICU) was higher among COVID-19 positive patients (185/760, 24.3%) compared to COVID-19 negative patients (206/1,926, 10.7%; P <0.001), and they required mechanical ventilation (89, 11.9% vs 37, 1.9%; P <0.001) and high-flow nasal cannula oxygen therapy (135, 18.1% vs 41, 2.2%; P < 0.001) more frequently. The in-hospital mortality was significantly higher among COVID-19 positive patients (139, 18.3% vs 149, 7.7%; P <0.001).

Conclusion: Emergency departments were on the frontline during the COVID-19 pandemic and had to manage potential COVID-19 patients. Understanding what happened in the ED during this first outbreak is crucial to underline the importance of flexible organizations that can quickly adapt the bed capacities to the incoming flow of COVID-19 positive patients.

Introduction: Coronavirus 2019 (COVID-19) illness continues to affect national and global hospital systems, with a particularly high burden to intensive care unit (ICU) beds and resources. It is critical to identify patients who initially do not require ICU resources, but subsequently rapidly deteriorate. We investigated patient populations during COVID-19 at times of full or near full (surge) and non-full (non-surge) hospital capacity to determine the effect on those who may need a higher level of care or deteriorate quickly defined as requiring a transfer to ICU within 24 hours of admission to a non-ICU level of care and provide further knowledge on this high-risk group of patients. 

Methods: This was a retrospective cohort study of a single health system comprising four emergency departments and three tertiary hospitals in New York, New York across two different time periods (during surge and non-surge inpatient volume times during the COVID-19 pandemic).  The electronic health record was queried for all patients admitted to a non-ICU setting with unexpected ICU transfer (UIT) within 24 hours of admission. A comparison between adult patients with confirmed coronavirus 2019 and without was made during surge and non-surge time periods.

Results: During the surge time period, there was a total of 86 UITs in a one month period. Of those 60 were COVID positive patients who had a mortality rate of 63.3% and 26 were COVID negative with a 30.8 % mortality rate. During the non-surge time period, there was a total of 112 UITs, of those 24 were COVID positive with a 37.5% mortality rate and 90 were COVID negative with a 11.1% mortality rate. 

Conclusion: During surge, the mortality rate for both COVID positive and COVID negative patients experiencing an unexpected ICU transfer is significantly higher.

Introduction: Acute appendicitis is the most common non-obstetrical surgical emergency in pregnancy. Ultrasound is the imaging tool of choice, but its use is complicated due to anatomical changes during pregnancy and depends on the clinician’s expertise. In this study, our aim was to investigate the diagnostic accuracy of point-of-care ultrasound (POCUS) in suspected appendicitis in pregnant women.

Methods: We conducted a retrospective analysis of all pregnant women undergoing POCUS for suspected appendicitis between June 2010–June 2020 in a tertiary emergency department. The primary outcome was to establish sensitivity, specificity, and likelihood ratios of POCUS in diagnosing acute appendicitis, overall and for each trimester. We used histology of the appendix as the reference standard in case of surgery. If appendectomy was not performed, the clinical course until childbirth was used to rule out appendicitis. If the patients underwent magnetic resonance imaging (MRI), we compared readings to POCUS.

Results: A total of 61 women were included in the study, of whom 34 (55.7%) underwent appendectomy and in 30 (49.2%) an acute appendicitis was histopathologically confirmed. Sensitivity of POCUS was 66.7% (confidence interval [CI] 95% 47.1-82.7), specificity 96.8% (CI 95% 83.3-99.9), and positive likelihood ratio 20.7. Performance of POCUS was comparable in all trimesters, with highest sensitivity in the first trimester (72.7%). The MRI reading showed a sensitivity of 84.6% and a specificity of 100%. In the four negative appendectomies a MRI was not performed.

Conclusion: Point-of-care ultrasound showed a high specificity and positive likelihood ratio in diagnosing acute appendicitis in pregnant women in all trimesters with suspected appendicitis. In negative (or inconclusive) cases further imaging as MRI could be helpful to avoid negative appendectomy.

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Introduction: Prior to intubation, preoxygenation is performed to denitrogenate the lungs and create an oxygen reservoir. After oxygen is removed, it is unclear whether renitrogenation after preoxygenation occurs faster in the supine vs the sitting position.

Methods: We enrolled 80 healthy volunteers who underwent two preoxygenation and loss of preoxygenation procedures (one while supine and one while sitting) via bag-valve-mask ventilation with spontaneous breathing. End-tidal oxygen (ETO₂) measurements were recorded as fraction of expired oxygen prior to preoxygenation, at the time of adequate preoxygenation (ETO₂ >85%), and then every five seconds after the oxygen was removed until the ETO₂ values reached their recorded baseline.

Results: The mean ETO₂ at completion of preoxygenation was 86% (95% confidence interval 85-88%). Volunteers in both the supine and upright position lost >50% of their denitrogenation in less than 60 seconds. Within 25 seconds, all subjects had an ETO₂ of <70%. Complete renitrogenation, defined as return to baseline ETO₂, occurred in less than 160 seconds for all volunteers.

Conclusion: Preoxygenation loss, or renitrogenation, occurred rapidly after oxygen removal and was not different in the supine and sitting positions. After maximal denitrogenation in healthy volunteers, renitrogenation occurred rapidly after oxygen removal and was not different in the supine and sitting positions.

ABSTRACT

Introduction

This study aimed to assess the prevalence of risk behaviors and the impact of electronic risk behavior screening with personalized feedback among adolescents seeking care in the emergency department (ED).

Methods

Randomized control trial of tablet-based screening and feedback among adolescents presenting to the ED. Intervention youth received screening with individualized feedback. Control youth completed risk behavior screening only. All participants received 3-month online follow up surveys re-assessing health behaviors.

Results

296 subjects were enrolled and randomized. Approximately half were female (52.4%) and half white (54.4%) with a mean age of 15.4 years. The response rate at 3-month follow-up was 70.6%.  The most frequently reported risk behaviors were those negatively impacting long-term health: sleeping less than 8 hours per night (142/296=48%), drinking more than 2 sugary drinks per day (99/296=33.4%) and getting less than 3 days of physical activity per week (96/296=32.4%). The prevalence of high-risk behaviors with more immediate health consequences were depression (92/296 =31.1%); high alcohol (47/296=15.9%) or marijuana use (55/296=18.6%); texting when driving (41/296=13.8%) and inconsistent birth control or condom use (42/296=14.2%). There was no significant difference between groups in risk behavior changes from baseline to 3 months.

Conclusions

While risk behavior prevalence was high in this population, electronic personalized feedback alone was insufficient to induce change in behaviors. More research is warranted to understand the best strategies for reducing risk among youth presenting to the ED.

Introduction: The purpose of this study was to assess the added clinical value of oblique knee radiographs four-view (4V) compared to orthogonal anteroposterior (AP) and lateral radiographs in a two-view (2V) series.

Methods: We obtained 200 adult, 4V knee radiographs in 200 patients in the ED and randomly divided them into two groups with 100 series in each group. Ten reviewers — three musculoskeletal radiologists and seven orthopedic surgeons — performed radiograph analyses. These reviewers were randomly divided evenly into group one and group two. Reviewers were blinded to patient data and first reviewed 2V radiographs (AP/lateral) only, and then reviewed 4V radiographs, including AP/lateral, and two additional oblique views for the same patients at least four weeks later. Acute pathology identification and the need for further imaging was assessed for all reviewers, and clinical decision-making (operative vs nonoperative treatment, need for admission, need for additional imaging) was assessed only by the seven orthopaedic surgeon reviewers. 

Results: Mean sensitivity for pathology identification was 79% with 2V and 81% with 4V (P =0.25). Intra-observer kappa value was 0.81 (range 0.54-1.00). Additional oblique radiographs led orthopaedic reviewers to change their treatment recommendations in 62/329 patients (18.84%) (P <0.001). Eight of 329 radiographic series were identified as “critical misses.” (2.43%) (P =0.004), when pathology was reported as normal or reviewers recommended nonoperative treatment on 2V radiographs but changed their recommendation to operative management after the addition of oblique radiographs. The number needed to treat (NNT) for any treatment change and for “critical misses” was 83 and 643, respectively.  

Conclusion: Although the addition of oblique radiographs may improve a clinician’s ability to identify subtle pathologic findings not identified on 2V, it rarely leads to significant changes in treatment recommendations. Given the high NNT, limiting the usage of these oblique radiographs in the general patient population may reduce costs without significantly affecting patient care.

Introduction: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network.

Methods: We describe the challenges encountered when EMERGE proposed the development of a global Emergency Department (ED) visit registry. The proposed registry was to be a 6-month, retrospective, deidentified, parsimonious dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition.

Results: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable data taxonomies, need for language translation, varying processes for data cleaning and transfer of deidentified data, navigating numerous data protection regulations and substantial variation in each participating institution’s research infrastructure including training in research related activities. We have overcome many of these challenges through creating detailed data sharing agreements with bilateral regulatory oversight, developing relationships with and training site health informaticians to ensure secure transfer of deidentified data, and formalizing a transfer process ensuring data privacy.

Conclusions: We believe that networks like EMERGE are integral to provide the necessary platforms for education, training and research collaborations. We identified substantial challenges in data sharing and variation in local sites’ research infrastructure, and propose approaches which may overcome the data quality and access issues that we encountered.

Introduction: In response to the ongoing opioid overdose crisis, US officials urged the expansion of access to naloxone for opioid overdose reversal. Since then, emergency medical services’ (EMS) dispensing of naloxone kits has become an emerging harm reduction strategy.

Methods: We created a naloxone training and low-barrier distribution program in San Francisco: Project FRIEND (First Responder Increased Education and Naloxone Distribution). The team assembled an advisory committee of stakeholders and subject-matter experts, worked with local and state EMS agencies to augment existing protocols, created training curricula, and developed a naloxone-distribution data collection system. Naloxone kits were labeled for registration and data tracking. Emergency medical technicians and paramedics were asked to distribute naloxone kits to any individuals (patient or bystander) they deemed at risk of experiencing or witnessing an opioid overdose, and to voluntarily register those kits.

Results: Training modalities included a video module (distributed to over 700 EMS personnel) and voluntary, in-person training sessions, attended by 224 EMS personnel. From September 25, 2019–September 24, 2020, 1,200 naloxone kits were distributed to EMS companies. Of these, 232 kits (19%) were registered by EMS personnel. Among registered kits, 146 (63%) were distributed during encounters for suspected overdose, and 103 (44%) were distributed to patients themselves. Most patients were male (n = 153, 66%) and of White race (n = 124, 53%); median age was 37.5 years (interquartile range 31-47).

Conclusion: We describe a successful implementation and highlight the feasibility of a low-threshold, leave-behind naloxone program. Collaboration with multiple entities was a key component of the program’s success.