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

Introduction: Effective out-of-hospital administration of naloxone in opioid overdoses is dependent on timely arrival of naloxone. Delays in emergency medical services (EMS) response time could potentially be overcome with drones to deliver naloxone efficiently to the scene for bystander use. Our objective was to evaluate a mathematical optimization simulation for geographical placement of drone bases in reducing response time to opioid overdose.

Methods: Using retrospective data from a single EMS system from January 2016–February 2019, we created a geospatial drone-network model based on current technological specifications and potential base locations. Genetic optimization was then used to maximize county coverage by drones and the number of overdoses covered per drone base. From this model, we identified base locations that minimize response time and the number of drone bases required.

Results: In a drone network model with 2,327 opioid overdoses, as the number of modeled drone bases increased the calculated response time decreased. In a geospatially optimized drone network with four drone bases, response time compared to ambulance arrival was reduced by 4 minutes 38 seconds and covered 64.2% of the county.

Conclusion: In our analysis we found that in a mathematical model for geospatial optimization, implementing four drone bases could reduce response time of 9–1–1 calls for opioid overdoses. Therefore, drones could theoretically improve time to naloxone delivery.

Introduction: Persons experiencing homelessness (PEH) use emergency medical services (EMS) at disproportionately high rates relative to housed individuals due to several factors including disparate access to healthcare. Limited access to care is compounded by higher rates of substance use in PEH. Despite growing attention to the opioid epidemic and housing crisis, differences in EMS naloxone administration by housing status has not been systematically examined. Our objective in this study was to describe EMS administration of naloxone by housing status in the City of Los Angeles.

Methods: This was a 12-month retrospective, cross-sectional analysis of electronic patient care reports (ePCRs) for all 9–1–1 EMS incidents attended by the Los Angeles Fire Department (LAFD), the sole EMS agency for the City of Los Angeles during the study period, January-December 2018. During this time, the City had a population of 3,949,776 with an estimated 31,825 (0.8%) PEH. We included in the study individuals to whom LAFD responders had administered naloxone. Housing status is a mandatory field on ePCRs. The primary study outcome was the incidence of EMS naloxone administration by housing status. We used descriptive statistics and logistic regression models to examine patterns by key covariates.

Results: There were 345,190 EMS incidents during the study period. Naloxone was administered during 2,428 incidents. Of those incidents 608 (25%) involved PEH, and 1,820 (75%) involved housed individuals. Naloxone administration occurred at a rate of 19 per 1,000 PEH, roughly 44 times the rate of housed individuals. A logistic regression model showed that PEH remained 2.38 times more likely to receive naloxone than their housed counterparts, after adjusting for gender, age, and respiratory depression (odds ratio 2.38, 95% confidence interval 2.15–2.64). The most common impressions recorded by the EMS responders who administered naloxone were the same for both groups: overdose; altered level of consciousness; and cardiac arrest. Persons experiencing homelessness who received naloxone were more likely to be male (82% vs 67%) and younger (41.4 vs 46.2 years) than housed individuals.

Conclusion: In the City of Los Angeles, PEH are more likely to receive EMS-administered naloxone than their housed peers even after adjusting for other factors. Future research is needed to understand outcomes and improve care pathways for patients confronting homelessness and opioid use.

Introduction: Patients present to the emergency department (ED) relatively commonly with traumatic closed proximal interphalangeal joint (PIPJ) dislocations, an orthopedic emergency. There is a paucity of teaching models and training simulations for clinicians to learn either the closed dislocated dorsal or volar interphalangeal joint reduction technique. We implemented a teaching model to demonstrate the utility of a novel reduction model designed from three-dimensional (3D) printable components that are easy to connect and do not require further machining or resin models to complete.

Methods: Students watched a two-minute video and a model demonstration by the authors. Learners including emergency medicine (EM) residents and physician assistant fellows assessed model fidelity, convenience, perceived competency, and observed competency.

Results: Seventeen of 21 (81%) participants agreed the model mimicked dorsal and volar PIPJ dislocations. Nineteen of 21 (90%) agreed the model was easy to use, 21/21 (100%) agreed the dorsal PIPJ model and 20/21 (95%) agreed the volar PIPJ model improved their competency.

Conclusion: Our 3D-printed, dorsal and volar dislocation reduction model is easy to use and affordable, and it improved perceived competency among EM learners at an academic ED.

Objectives: Prior research has demonstrated that men and women emergency medicine (EM) residents receive similar numerical evaluations at the beginning of residency, but that women receive significantly lower scores than men in their final year. To better understand the emergence of this gender gap in evaluations we examined discrepancies between numerical scores and the sentiment of attached textual comments.

Methods: This multicenter, longitudinal, retrospective cohort study took place at four geographically diverse academic EM training programs across the United States from July 1, 2013–July 1, 2015 using a real-time, mobile-based, direct-observation evaluation tool. We used complementary quantitative and qualitative methods to analyze 11,845 combined numerical and textual evaluations made by 151 attending physicians (94 men and 57 women) during real-time, direct observations of 202 residents (135 men and 67 women).

Results: Numerical scores were more strongly positively correlated with positive sentiment of the textual comment for men (r = 0.38, P < 0.001) compared to women (r = −0.26, P < 0.04); more strongly negatively correlated with mixed (r = −0.39, P < 0.001) and negative (r = −0.46, P < 0.001) sentiment for men compared to women (r = −0.13, P < 0.28) for mixed sentiment (r = −0.22, P < 0.08) for negative; and women were around 11% more likely to receive positive comments alongside lower scores, and negative or mixed comments alongside higher scores. Additionally, on average, men received slightly more positive comments in postgraduate year (PGY)-3 than in PGY-1 and fewer mixed and negative comments, while women received fewer positive and negative comments in PGY-3 than PGY-1 and almost the same number of mixed comments.

Conclusion: Women EM residents received more inconsistent evaluations than men EM residents at two levels: 1) inconsistency between numerical scores and sentiment of textual comments; and 2) inconsistency in the expected career trajectory of improvement over time. These findings reveal gender inequality in how attendings evaluate residents and suggest that attendings should be trained to provide all residents with feedback that is clear, consistent, and helpful, regardless of resident gender.

Introduction: Hospitalizations during the coronavirus 2019 (COVID-19) pandemic peaked in New York in March–April 2020. In the months following, emergency department (ED) volumes declined. Our objective in this study was to examine the effect of this decline on the procedural experience of emergency medicine (EM) residents compared to the pre-pandemic period.

Methods: We conducted this multicenter, retrospective cohort study of patients seen and key procedures performed by EM residents at hospitals spanning three Accreditation Committee for Graduate Medical Education-approved EM residencies in New York City and Nassau County, NY. We obtained numbers of procedures performed during May–July 2020 and compared them to the same time period for 2019 and 2018. We a priori classified critical care procedures—cardioversion, central lines, chest tubes, procedural sedation, and endotracheal intubation. We also studied “fast-track” procedures—fracture/joint reduction, incision and drainage (I&D), laceration repairs, and splints.

Results: Total number of critical care procedures in the months following the COVID-19 peak decreased from 694 to 606 (−12.7%, 95% confidence interval [CI] 10.3–15.4%), compared to an increase from 642 to 694 (+8.1%, 95% CI 6.1–10.5%) the previous year (difference −9.3%). Total number of fast-track procedures decreased from 5,253 to 3,369 (−35.9%, 95% CI 34.6–37.2%), compared to a decrease from 5,333 to 5,253 (−1.5%, 95% CI 1.2–1.9%) the year before (difference −36.3%). Specific critical care procedures performed in 2020 compared to the mean of 2019 and 2018 as follows: cardioversion −33.3%; central lines +19.0%; chest tubes −27.9%; procedural sedation −30.8%; endotracheal intubation −13.8%. Specific fast-track procedures: reductions +33.3%; I&D −48.6%; laceration repair −17.3%; and splint application −49.8%.

Conclusion: Emergency medicine residents’ critical and fast-track procedural experience at five hospitals was reduced during the months following the COVID-19 peak in comparison to a similar period in the two years prior. Training programs may consider increasing simulation-lab and cadaver-lab experiences, as well as ED and critical care rotations for their residents to offset this trend.

Introduction: Ensuring high-quality scholarly output by graduate medical trainees can be a challenge. Within many specialties, including emergency medicine (EM), it is unclear what constitutes appropriate resident scholarly activity. We hypothesized that the quantity and quality of scholarly activity would improve with a clearer guideline, including a point system for eligible scholarly activities.

Methods: A resident Scholarly Activity Guideline was implemented for EM residents in a university setting. The guideline consists of a point system in which point values, ranging from 1–10, are assigned to various types of scholarly activities. Residents must earn at least 10 points and present their work to meet their scholarly graduation requirement. We tracked scholarly activities for graduates from the classes of 2014–2020, with the guideline being implemented for the class of 2016. In a blind analysis, we compared median total points per resident, mean counts of the Boyer model of scholarship components per resident, and mean counts of significant scholarly output per resident before vs after the guideline was implemented. Significant scholarly output was defined as an implemented protocol,a research project with data collection and analysis, a research abstract presentation, or an oral abstract presentation.

Results: Among 64 residents analyzed, 48 residents used the guideline. We found that median points per resident increased after the guideline was implemented (median, interquartile range: before 7 [7], after 11 [10, 13], P = 0.002). Post-guideline scholarly activities were found to represent more of Boyer’s components of scholarship [mean before 0.81 [SD 0.40], mean after 1.52 [SD 0.71], mean difference 0.71, 95% confidence interval [CI] 0.332 ± 1.09, P < 0.001. There was no difference in the mean significant scholarly output per resident (mean before 1.38 [SD 1.02], mean after 1.02 [SD 1.00], mean difference 0.35, 95% CI 0.93 ± 0.23, P = 0.23).

Conclusion: Implementation of a Scholarly Activity Guideline point system significantly increased the quantity and, by one of two measures, increased the quality of scholarly output in our program. Our point-based guideline successfully incorporated traditional and modern forms of scholarship that can be tailored to resident interests.

Charcot neuroarthropathy (CN) is a rare but serious sequela of diabetes and other diseases that cause peripheral neuropathy. It is most commonly characterized by degeneration of the foot and/or ankle joints leading to progressive deformity and altered weight-bearing. If left untreated, the deformities of CN lead to ulceration, infection, amputation, and even death. Because of the associated peripheral neuropathy and proprioception deficits that accompany CN, patients typically do not perceive the onset of joint destruction. Moreover, in the hands of the untrained clinician, the initial presentation of CN can easily be mistaken for infection, osteoarthritis, gout, or inflammatory arthropathy. Misdiagnosis can lead to the aforementioned serious sequelae of CN. Thus, an early accurate diagnosis and off-loading of the involved extremity, followed by prompt referral to a specialist trained in the care of CN are crucial to prevent the late-term sequelae of the disease. The purpose of this article was to create an opportunity for enhanced understanding between orthopedic surgeons and emergency physicians, to improve patient care through the optimization of diagnosis and early management of CN in the emergent setting.

Keywords: Charcot neuroarthropathy; Charcot foot; diabetes mellitus; midfoot collapse; emergency.

Background: Prehospital emergency medical services (EMS) are the main gateway for trauma patients. Recent advances in point-of-care testing and the development of early warning scores have allowed EMS to improve patient classification. We aimed to identify patients presenting with major trauma involving life-saving interventions (LSI) using the modified Sequential Organ Failure Assessment (mSOFA) score in the prehospital scenario, and to compare these results with those of other trauma scores.

Methods: This was a prospective, ambulance-based, multicenter, training-validation study in trauma patients who were treated in a prehospital setting and subsequently transported to a hospital. The study involved six Advanced Life Support units, 38 Basic Life Support units, and four hospitals. The primary outcome was LSI performed at the scene or en route and intensive care unit (ICU) admission and all-cause two-day in-hospital mortality. We collected epidemiological variables, creatinine, lactate, base excess, international normalized ratio, and vital signs. Discriminative power (area under the receiver operating characteristic curve [AUC]), calibration (observed vs predicted outcome agreement), and decision-curve analysis (DCA, clinical utility) were used to assess the reliability of the mSOFA in comparison to other scores.

Results: Between January 1, 2020–April 30, 2022, a total of 763 patients were selected. The mSOFA score’s AUC was 0.927 (95% confidence interval [CI] 0.898–0.957) for LSI, 0.845 (95% CI 0.808–0.882) for ICU admission, and 0.979 (95% CI 0.966–0.991) for two-day mortality.

Conclusion: The mSOFA score outperformed the other scores, allowing a quick identification of high-risk patients. The routine implementation in EMS of mSOFA could provide critical support in the decision-making process in time-dependent trauma injuries.

Introduction: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients’ environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients’ insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel.

Methods: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory.

Results: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients’ employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures.

Conclusion: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients’ SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

Introduction: Black and Hispanic patients are frequently assigned lower acuity triage scores than White patients. This can lead to longer wait times, less aggressive care, and worse outcomes. In this study we aimed to determine whether these effects are more pronounced for patients with subjective complaints.

Methods: We performed a retrospective analysis for all adult visits between 2016-2019 at an urban academic emergency department (ED) with acuity-based pods. We determined rates of initial high-acuity triage both across all patients and among the subset located in the high-acuity pod at time of disposition (either through initial assignment or subsequent up-triage). Analysis was performed for common chief complaints categorized as subjective (chest pain, dyspnea, any pain); observed (altered mental status); numeric (fever, hypotension); or protocolized (stroke, ST-elevation myocardial infarction). We constructed logistic regression models to control for age, race, gender, method of arrival, and final disposition.

Results: We analyzed 297,355 adult ED visits. Black and Hispanic patients were less likely to be triaged to high-acuity beds (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.73-0.79 for Black, and aOR 0.87, 95% CI 0.84-0.90 for Hispanic patients). This effect was more pronounced for those with subjective chief complaints, including chest pain (aOR 0.76, 95% CI 0.73-0.79 for Black and 0.88, 95% CI 0.78-0.99 for Hispanic patients), dyspnea (aOR 0.79, 95% CI 0.68-0.92 and 0.8, 95% CI 0.72-0.99), and any pain (aOR 0.83, 95% CI 0.75-0.92 and 0.89, 95% CI 0.82-0.97, respectively). Among patients in the high-acuity pod at time of disposition, Black and Hispanic patients were disproportionately triaged to lower acuity pods on arrival (aOR 1.47, 95% CI 1.33-1.63 for Black and aOR 1.27, 95% CI 1.15-1.40 for Hispanic adults), with significant differences observed only for subjective chief complaints. No differences were observed for observed, objective, or protocolized complaints in either analysis.

Conclusion: Black and Hispanic adults, including those who ultimately required high-acuity resources, were disproportionately triaged to lower acuity pods. This effect was more pronounced for patients with subjective chief complaints. Additional work is needed to identify and overcome potential bias in the assessment of patients with subjective chief complaints in ED triage.

Introduction: In this study we examined the association of homelessness and emergency department (ED) use, considering social, medical, and mental health factors associated with both homelessness and ED use. We hypothesized that social disadvantage alone could account for most of the association between ED use and homelessness.

Methods: We used nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Emergency department use within the prior year was categorized into no use (27,674; 76.61%); moderate use (1–4 visits: 7,972; 22.1%); and high use (5 or more visits: 475; 1.32%). We used bivariate analyses followed by multivariable-adjusted logistic regression analyses to identify demographic, social, medical, and mental health characteristics associated with ED use.

Results: Among 36,121 respondents, unadjusted logistic regression showed prior-year homelessness was strongly associated with moderate and high prior-year ED use (odds ratio[OR] 2.31 and 7.34, respectively, P < 0.001). After adjusting for sociodemographic factors, the associations of homelessness with moderate/high ED use diminished (adjusted OR [AOR] 1.27 and 1.62, respectively, both P < 0.05). Adjusting for medical/mental health variables, alone, similarly diminished the association between homelessness and moderate/high ED use (AOR 1.26, P < .05 and 2.07, P < 0.001, respectively). In a final stepwise model including social and healthvariables, homelessness was no longer significantly associated with moderate or high ED usein the prior year.

Conclusion: After adjustment for social disadvantage and health problems, we found no statistically significant association between homelessness and ED use. The implications of our findings suggest that ED service delivery must address both health issues and social factors.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities.

As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments—communicable diseases, non-communicable conditions, and injuries—and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Introduction: Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT.

Methods: We conducted an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry of 2,400 LVOS patients treated at nine ESCs in the United States. We examined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale.

Results: A total of 435 patients were included in the final analysis. The mean DIDO time for patients with good outcomes was 17 minute shorter than patients with poor outcomes (122 minutes [min] vs 139 min, P = 0.04). Absolute DIDO cutoff times of ≤60 min, ≤90 min, or ≤120 min were not associated with improved functional outcomes (46.4 vs 32.3%, P = 0.12; 38.6 vs 30.6%, P = 0.10; and 36.4 vs 28.9%, P = 0.10, respectively). This held true for patients with hyperacute strokes of less than four-hour onset. Lower baseline National Institutes of Health Stroke Scale (NIHSS) score (11.9 vs 18.2, P =<.001) and younger age (62.5 vs 74.9 years (P < .001) were associated with improved outcomes. On multiple regression analysis, age (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.45–2.02) and baseline NIHSS score (OR 1.67, 95% CI 1.42–1.98) were associated with improved outcomes while DIDO time was not associated with better outcome (OR 1.13, 95% CI 0.99–1.30).

Conclusion: Although the DIDO time was shorter for patients with a good outcome, this was non-significant in multiple regression analysis. Receipt of intravenous thrombolysis and time to EVT were not associated with better outcomes, while male gender, lower age, arrival by private vehicle, and lower NIHSS score portended better outcomes. No absolute DIDO-time cutoff or modifiable factor was associated with improved outcomes for LVOS. This study underscores the need to streamline DIDO times but not to set an artificial DIDO time benchmark to meet.

Background: There are no randomized trials comparing andexanet alfa and 4 factor prothrombin complex concentrate (4F-PCC) for the treatment of factor Xa inhibitor (FXa-I)-associated bleeds, and observational studies lack important patient characteristics. We pursued this study to demonstrate the feasibility of acquiring relevant patient characteristics from electronic health records. Secondarily, we explored outcomes in patients with life-threatening FXa-I associated bleeds after adjusting forthese variables.

Methods: We conducted a multicenter, chart review of 100 consecutive adult patients with FXa-I associated intracerebral hemorrhage (50) or gastrointestinal bleeding (50) treated with andexanet alfa or 4F-PCC. We collected demographic, clinical, laboratory, and imaging data including time from last factor FXa-I dose and bleed onset.

Results: Mean (SD) age was 75 (12) years; 34% were female. Estimated time from last FXa-I dose to bleed onset was present in most cases (76%), and patients treated with andexanet alfa and 4F-PCC were similar in baseline characteristics. Hemostatic efficacy was excellent/good in 88% and 76% of patients treated with andexanet alfa and 4F-PCC, respectively (P = 0.29). Rates of thrombotic events within 90 days were 14% and 16% in andexanet alfa and 4F-PCC patients, respectively (P = 0.80). Survival to hospital discharge was 92% and 76% in andexanet alfa and 4F-PCC patients, respectively (P = 0.25). Inclusion of an exploratory propensity score and treatment in a logistic regression model resulted in an odds ratio in favor of andexanet alfa of 2.01 (95% confidence interval 0.67–6.06) for excellent/good hemostatic efficacy, although the difference was not statistically significant.

Conclusion: Important patient characteristics are often documented supporting the feasibility of a large observational study comparing real-life outcomes in patients with FXa-I-associated bleeds treated with andexanet alfa or 4F-PCC. The small sample size in the current study precluded definitive conclusions regarding the safety and efficacy of andexanet alfa or 4F-PCC in FXa-I-associated bleeds.

Introduction: Childhood obesity is a serious concern in the United States, with over one third of the pediatric population classified as obese. Abdominal pain is one of the most common chief complaints among pediatric emergency department (ED) visits. We hypothesized that overweight and obese children being evaluated in the ED for abdominal pain would have higher resource utilization than their normal and underweight peers.

Methods: This was a retrospective review of pediatric patients <18 years who presented with abdominal pain to the ED of a tertiary care center from January 1, 2014–September 3, 2020. Patients were excluded if they did not have both a height and weight recorded. We categorized patients as underweight (body mass index [BMI] <5th percentile); normal weight (BMI 5th to <85th percentile), overweight (BMI 85th to<95th percentile); or obese (BMI ≥95th percentile). Descriptive statistics were used to examine the study population. We used chi-square tests to examine the differences in patient characteristics between normal/underweight patients and overweight/obese patients. The Kruskal-Wallis test was completed for examining differences in the medians. We used multivariable logistic regression to examine visit characteristics associated with overweight/obese patients, including ED interventions, testing, and length of stay (LOS).

Results: Of the 184 subjects included in the analysis, nine (4.9%) were underweight, 108 (58.7%) werenormal weight, 21 (11.4%) were overweight, and 46 (25.0%) were obese. Patients with a BMI of ≥85th percentile were older (median 15 vs 13 years, P = 0.01). They were otherwise similar in demographics. There was no significant difference between normal/underweight and overweight/obese subjects in disposition (37% vs 43% discharge, P = 0.38), 72-hour return (7% vs 6%, P = 0.82), ED LOS (median 4.42 vs 3.95 hours, P = 0.195), or inpatient LOS (median 42.0 vs 34.2 hours, P = 0.06). There were no statistically significant differences in total number of ED tests or interventions received by overweight/obese patients compared to normal/underweight patients, and each subject received a median of six tests (interquartile range [IQR] 4–7) and two interventions (IQR 1–3).

Conclusion: Among pediatric patients presenting to the ED with abdominal pain, we found that patient characteristics and ED resource utilization (including testing, intervention, disposition, and LOS) did not differ significantly across BMI categories.

Background: Acute appendicitis (AA) is the most common abdominal surgical emergency in children and adolescents. In the year immediately following the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO), there was a precipitous decline in emergency department (ED) visits especially for surgical conditions and infectious diseases. Fear of exposure to severe acute respiratory coronavirus 2 infection resulted in delay in presentation and time to surgery, and a shift toward more conservative management.

Objective: Our goal was to compare the incidence and severity of AA before and during the COVID-19 pandemic.

Methods: Patients aged 2–18 years admitted with the diagnosis of AA to Flushing Hospital Medical Center or Jamaica Hospital Medical Center in Queens, New York, were selected for chart review. Data extracted from electronic health records included demographics, clinical findings, imaging studies, and operative and pathological findings. We calculated the Alvarado score (AS) for incidence and the American Association for the Surgery of Trauma (AAST) grade for severity. We compared patients admitted between March 1, 2018–February 29, 2020 (pre-pandemic) to patients admitted between March 1, 2020–February 28, 2021 (pandemic). We then compared pre-pandemic and pandemic groups to determine differences in pediatric AA incidence and severity.

Results: Of 239 patients diagnosed with AA, 184 (77%) were in the pre-pandemic group and 55 (23%) in the pandemic group. Incidence (number per year) of AA declined by 40%. The pandemic group had significantly greater overall AS of ≥7, indicating increased likelihood to require surgery, (P = 0.04) and higher AAST grade demonstrating increased severity (P = 0.02).

Conclusion: There was a decline in the number of AA cases seen in our pediatric EDs and admitted during the first year of the pandemic. Clinicians need to be aware of increased severity of AA at time of presentation during public health emergencies such as a pandemic, possibly due to modified patient behavior.

Introduction: Diabetes screening traditionally occurs in primary care settings, but many who are at high risk face barriers to accessing care and therefore delays in diagnosis and treatment. These same high-risk patients do frequently visit emergency departments (ED) and, therefore, might benefit from screening at that time. Our objective in this study was to analyze one year of results from a multisite, ED-based diabetes screening program.

Methods: We assessed the demographics of patients screened, identified differences in rates of newly diagnosed diabetes by clinical site, and the geographic distribution of high and low hemoglobin A1c (HbA1c) results.

Results: We performed diabetes screening (HbA1c) among 4,211 ED patients 40–70 years old, with a body mass index ≥25, and no prior history of diabetes. Of these patients screened for diabetes, 9% had a HbA1c result consistent with undiagnosed diabetes, and nearly half of these patients had a HbA1c ≥9.0%. Rates of newly diagnosed diabetes were notably higher at EDs located in neighborhoods of lower socioeconomic status.

Conclusion: Emergency department-based diabetes screening may be a practical and scalable solution to screen high-risk patients and reduce health disparities experienced in specific neighborhoods and demographic groups.

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model.

Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule.

Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture.

Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.

Introduction: Sexual Assault Nurse Examiners (SANE), who are trained to provide comprehensive and compassionate specialty care to sexual assault survivors, are increasingly used in the emergency department (ED), but there is little published literature to support their benefit. In this study we aimed to compare services offered and received by sexual assault survivors in the ED when care was provided by a SANE vs those with traditional care teams, hypothesizing that SANE utilization will be associated with improved uptake of recommended services.

Methods: This was a retrospective review examining all patient encounters in which a sexual assault was disclosed in a large, urban, adult ED between June 1, 2019–June 30, 2022. We extracted timeline information from the ED encounter, demographic information, resources offered to and accepted by the patient, clinical care data, and continuity of care data from the medical record. We used unadjusted and adjusted analyses to compare patient demographics and services offered and accepted between SANE and non-SANE encounters.

Results: We included a total of 182 encounters in the analysis, of which 130 (71.4%) involved SANEs. Demographics were similar between groups, except there was a larger proportion of cisgender men in the non-SANE group (14.0% vs 5.5%), and the timing of visits differed, with non-SANE visits more common during the overnight shift. All recommended testing, prophylaxis, and resources were offered more frequently during SANE visits, and all but one were more frequently accepted by patients during SANE visits, although not all comparisons reached statistical significance.

Conclusion: Patients who received care from a SANE were more often offered recommended services and resources and more frequently accepted them. Making SANE care available at all times to these vulnerable patients would both improve patient outcomes and allow hospitals to meet required quality metrics. States should consider expanding legislation to encourage and fund SANE coverage for all hospitals to support access to vital resources in the ED for survivors of sexual assault.

Objective: We explored individual Muslim women’s reproductive healthcare experiences, preferences, beliefs, and behaviors in the emergency department (ED) and in general.

Methods: This was a qualitative study conducted at a community ED using semi-structured interviews with a piloted interview guide. We interviewed participants awaiting care in the ED with the following criteria: female gender; English or Arabic speaking; aged ≥18 years; and self-identified as Muslim. We conducted interviews in both English and Arabic until thematic saturation was reached. Transcripts were coded using an iteratively developed codebook, maintaining intercoder agreement greater than 80%. We used an inductive thematic analysis to identify themes, and results were interpreted in the context of interview language and patient’s age.

Results: We interviewed 26 Muslim-identified female ED patients. We found that cultural representation and sensitivity among ED staff mitigated discrimination and promoted inclusion for Muslim ED patients. However, assumptions about Muslim identity also impacted the participants’ healthcare. Most participants endorsed a preference for a female clinician for their reproductive healthcare in general, but not necessarily for other areas of medicine. Clinician cultural concordance was not always preferred for participants in the ED due to fears about the loss of confidentiality. Marital status impacted beliefs about reproductive and sexual health in the context of Muslim identity. Overall, family planning was acceptable and encouraged in this patient population.

Conclusion: The themes elucidated in this study may guide clinicians in developing culturally sensitive practices when providing reproductive healthcare to the Muslim population.

Background: Treatment for partners of patients diagnosed with sexually transmitted infections (STI), referred to as expedited partner therapy (EPT), is infrequently used in the emergency department (ED). This was a pilot program to initiate and evaluate EPT through medication-in-hand (“take-home”) kits or paper prescriptions. In this study we aimed to assess the frequency of EPT prescribing, the efficacy of a randomized best practice advisory (BPA) on the uptake, perceptions of emergency clinicians regarding the EPT pilot, and factors associated with EPT prescribing.

Methods: We conducted this pilot study at an academic ED in the midwestern US between August–October 2021. The primary outcome of EPT prescription uptake and the BPA impact was measured via chart abstraction and analyzed through summary statistics and the Fisher exact test. We analyzed the secondary outcome of barriers and facilitators to program implementation through ED staff interviews (physicians, physician assistants, and nurses). We used a rapid qualitative assessment method for the analysis of the interviews.

Results: During the study period, 52 ED patients were treated for chlamydia/gonorrhea, and EPT was offered to 25% (95% CI 15%–39%) of them. Expedited partner therapy was prescribed significantly more often (42% vs 8%; P < 0.01) when the interruptive pop-up alert BPA was shown compared to not shown. Barriers identified in the interviews included workflow constraints and knowledge of EPT availability. The BPA was viewed positively by the majority of participants.

Conclusion: In this pilot EPT program, expedited partner therapy was provided to 25% of ED patients who appeared eligible to receive it. The interruptive pop-up alert BPA significantly increased EPT prescribing. Barriers identified to EPT prescribing should be the subject of future interventions to improve provision of EPT from the emergency department.