We incorporated an 8-hour standardized substance use disorder (SUD) curriculum and X-waiver training into our emergency medicine (EM) residency. We sought to assess whether the implementation of the standardized SUD curriculum and X-waiver training affected graduated EM residents' comfort with treating SUD and prescribing practices, as well as their view of their future career paths. Physicians who completed their EM residency at our hospital from 2016-2022 were invited to complete the survey in 2023. The primary outcome measure was the proportion of surveyed graduates who reported comfort and confidence in treating patients with SUD, measured by affirmative responses to survey items. The secondary outcome measure was the proportion of surveyed graduates reporting that participation in the SUD curriculum and X-waiver training during residency influenced their career plans, measured by affirmative responses to career-related survey items. For each outcome measure, we compared percentages of affirmative responses between physicians who completed residency prior to and after the implementation of the SUD curriculum and X-waiver training. Among 81 graduated EM residents invited to complete the survey, 63 (78.8%) responded. We grouped them based on whether they had completed residency prior to the addition of the standardized SUD curriculum (pre-curriculum, 2016-2017) or after (post-curriculum, 2018-2022). Of the 63 participants, 17 were pre- and 46 were post-curriculum residents. Of the pre-curriculum residents, 58.8% prescribed buprenorphine in their practice after residency, compared to 76.1% of the post-curriculum residents (Fisher exact test, P = .22, odds ratio [OR] 0.46, 95% confidence interval, 0.12-1.76). Of the post-curriculum graduates, 93.5% noted that they were better prepared to treat patients with SUDs than their peers compared to 88.2% of the pre-curriculum graduates (Fisher exact test, P = .605, OR .529, 95% CI, 0.055-6.909), and 69.6% believed the training impacted their careers professionally and increased their interest in helping patients with opioid use disorder. Overall, a greater proportion of EM graduates who had been X waiver-trained in a substance use disorder curriculm during residency training at our institution prescribed buprenorphine to their patients than those who had not undergone specific training. Although the X-waiver is no longer a requirement, our SUD curriculum and training remain relevant for buprenorphine prescribing and may offer some opportunities for EM residents to develop their careers.
Intimate partner violence (IPV) represents a pervasive and costly public health issue. Many IPV victims seek care in the emergency department (ED) due to injuries or related medical complaints; yet a substantial number of cases remain undetected. The challenge lies in implementing effective screening tools within the demanding environment of an ED. In this study we aimed to assess the efficacy of two brief IPV screening tools- the single question, "Have you been hit, kicked, punched, or otherwise hurt by someone in the past year?" and the 4-item Ongoing Violence Assessment Tool-and to compare them to the more comprehensive Index of Spouse Abuse, a validated 30-item survey that is considered the gold standard for IPV assessment. Our objective was to identify improved strategies for IPV screening in the busy ED setting. In this prospective study, every third English-speaking female patient 18-55 years of age presenting to our ED triage was invited to participate. Each participating patient was sequentially assigned to either the single question or the ongoing assessment screening group. Both groups completed feedback surveys about their experiences and the Index of Spouse Abuse survey. We used chi-square tests to compare categorical variables, and we used frequency tables to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of each IPV screening tool. We compared test characteristics between the Ongoing Violence Asessment Tool or the single question screening tool to the Index of Spouse Abuse using the Fisher exact test. Mean duration was compared using two-tailed Student t-tests. The primary outcome was the sensitivity and specificity of the single question assessment. and the 4-item Ongoing Violence Assessment Tool, using the Index of Spouse Abuse as the gold standard for IPV screening. Secondary outcomes were to record the length of time needed to screen with the single question assessment and the Ongoing Violence Assessment Tool and to collect participant feedback on the two screening tools. A total of 400 participants were enrolled in the study and completed the designated surveys. Screening time was significantly shorter in the single question group (median 6 seconds) compared to the ongoing assessment group (median13 seconds; P < .001). Feedback surveys did not reveal significant differences between the two groups. When compared to the Index of Spouse Abuse, the single question tool exhibited sensitivity of 53.3% and specificity of 94.1%, while the ongoing assessment demonstrated slightly higher sensitivity levels of 75.0% and lower specificity of 92.8%. For the single question assesssment, the positive predictive value was 42.1% and negative predictive value was 96.1%. For the Ongoing Violence Assessment Tool, the positive predictive value was 40.1% and the negative predictive value was 98.2%. The 7-second reduction in overall IPV screening time for the single question compared to the 4-item Ongoing Violence Assessment Tool likely has little clinical benefit, especially with its low sensitivity. Further studies are needed to identify the optimal screening tool for intimate partner violence in the emergency department.
During endotracheal intubation, equipment setup typically includes the patient monitor fixed at the head of the bed behind the back of the operator. Inability to directly visualize the patient monitor may result in delayed recognition of desaturation. Our primary aim in this study was to measure the association between patient monitor position and the time to recognition of a desaturation event during endotracheal intubation. We performed a randomized crossover trial of emergency medicine residents across two Accreditation Council for Graduate Medical Education-accredited programs. Subjects were asked to perform direct and video-assisted laryngoscopy once on a difficult airway trainer in a simulation. The sequence of laryngoscopy modality (direct vs video-assisted) and monitor position (head vs left vs right of bed) were randomized prior to each attempt. The simulated patient's peripheral capillary oxygen saturation (SpO2) was programmed to begin at 100% and decrease at a rate of 1% per second 10 seconds after the start of the subject's attempt. The primary outcome measure was time to operator recognition of hypoxia defined as the observed period during which the simulated SpO2 was < 90%. Secondary outcomes were operator failure to visualize a desaturation event. We rendered Kaplan-Meier curves illustrating the time to visualization of hypoxia and performed a Cox regression adjusting for laryngoscopy modality and total number of previous intubations performed. Using multivariable linear regression, we modeled the association between time to recognition of hypoxia in seconds and patient monitor position with similar adjustments. To assess differences in the number of observed failure events between study arms, we used chi-squared or Fisher exact tests. The threshold for statistical significance was a two-sided P < 0.05. We observed 68 attempts by 34 subjects. Twenty-two (32.5%), 22 (32.5%), and 24 (35%) intubations were performed with the monitor positioned at the head, left, and right, respectively. The median times to recognition of hypoxia were 37 seconds [sec] (95% CI, 25-86 sec) for the head, 32 sec (95% CI, 18-50 sec) for the left, and 23 sec (95% CI, 19-34 sec) for the right groups, respectively. Cox regression demonstrated hazard ratios of 2.7 and 3.2 for the left and right groups when compared to the head group, and these findings were statistically significant (P = .04 and P = 0.03, respectively). We found no statistically significant associations between time to recognition of hypoxia and laryngoscopy modality or total number of previous intubations (P = .82 and .21, respectively). Failure rates across head, left, and right groups were similar, at 36%, 59%, and 50%, respectively (P = .30). Positioning of the patient monitor at the head of the bed results in delayed visualization of desaturation events during simulated direct and video-assisted laryngoscopy across different levels of experience. Ideally, the patient monitor should be positioned on the side of the bed and within the operator's direct line of sight. Further research is warranted to assess how equipment setup may impact procedural performance, operator ergonomics, and patient safety.
As public access to tetrahydrocannabinol (THC) products expands under state legalization, there is concern for increased use in adolescents under 18 years of age and its subsequent effects. Adverse effects of THC use have been documented such as epilepsy, lethargy, somnolence, and respiratory insufficiency. Additional concern has been raised regarding whether potential increases in THC intoxications presented to the emergency department (ED) would demand a simultaneous increase in resource utilization, like lab testing and hospital admission. Previous studies on the relationship between marijuana and pediatric use demonstrated mixed results, with others indicating an increase in co-ingestion rates when pediatric patients use marijuana. To investigate whether the incidence of THC use in pediatrics increased post-recreational marijuana legalization in 2020 (RML) and if the incidence of co-ingestion in these cases differed significantly from the pre-RML data. This was a retrospective cohort study examining positive urine drug screens (UDS) in pediatrics during an emergency department visit at a community hospital during fixed time periods in 2019 and 2020, on either side of Illinois' legalization of recreational marijuana on January 1st, 2020. Pediatric subjects were defined as those younger than 18 years of age and older than four weeks of age at the time of UDS collection with valid, complete, and reported laboratory results. UDS screens analyzed in this study were collected in the ED of a suburban community hospital from pediatric charts housed on the electronic medical record, where there was a clinical indication for UDS collection and regardless of disposition. UDS may have been obtained for either medical or psychiatric concerns, but the reason for the UDS or patient visit was not collected or analyzed. UDS was considered positive if either amphetamines, benzodiazepines, opiates, Phencyclidine (PCP), cocaine, or barbiturates were identified as present in the urine sample and negative if none of these substances were detected in the urine sample. Both negative and positive UDS were assessed using chi-square and odds ratios to investigate these differences and compare across sex. There were 169 patients with a mean age of 14 years included. Mean age in 2019 (14.1 ± 3.2 years) was comparable to mean age in 2020 (14.7 ± 2.0 years) (two-sample t-test: 0.143 > 0.05). Sex demographics were also not significantly different between cohorts, with 53.4% being female in 2019 and 50.6% in 2020 (chi-square: 0.1318; significance: 0.1318 > 0.05). Between the two time periods, we found no significant difference in pediatric presentation to the ED with THC positive testing (2019: 16 positive UDS of 88 collected [18.18%]; 2020: 17 positive UDS of 81 collected [20.99%]; chi square: 0.211; Significance: 0.646 > 0.05; odd ratio between group: 1.195 [CI 95%: 0.558-2.559]) nor correlation with demographic data. We found a nonsignificant positive association between pediatric THC ingestion and co-ingestion of other substances (amphetamines, benzodiazepines, opiates and cocaine) pre-RML and a nonsignificant negative association post-RML (2019: 1.092 [CI 95%: 0.742-1.606]; 2020: 0.913 [CI 95%: 0.627-1.330]). These findings indicate that THC usage among pediatric patients with positive UDS did not increase with state legalization, nor did co-ingestion rates. There was also no difference in rates of positive or negative UDS between patient sex. This must be considered clinically when anticipating potential co-ingestions while interacting with children who may be using street drugs. Additionally, this data suggests that legalization of recreational marijuana does not significantly change the rate of children presenting to the ED with positive drug screens and can be used by hospital administration and state representatives to anticipate healthcare demands following large-scale drug reclassifications. Further investigation is warranted to evaluate these findings in a larger, multi-center study.
Traumatic injuries are the leading cause of death in the U.S. of persons < 45 years of age, with 5-10% of all traumas caused by penetrating neck injuries (PNI). The neck contains several large blood vessels that supply the brain; thus, exsanguination is the leading cause of fatality in PNI. Vascular neck trauma is common in assaults, motor vehicle accidents, battlefields, and sporting events, particularly in ice hockey. There is a general lack of guidance on prehospital management of these injuries, and educating first responders, medics, and sports trainers on how to manage these complex injuries is challenging due to high costs, limited availability, and ethical considerations regarding use of cadavers or live animals. Here, we describe the development of a prehospital PNI-hemorrhage curriculum paired with a novel hands-on simulator and its pilot implementation with a group of professional hockey athletic trainers. We conducted a literature review to understand previously proposed algorithms for PNI, traumatic life support, combat trauma, and massive hemorrhage. Concepts from each of these algorithms were considered when determining the key steps of managing a PNI and how these should differ from previously proposed algorithms. We developed a synthetic medical simulator and training curriculum in conjunction with the National Hockey League (NHL) to create a training program for athletic trainers and team physicians to improve rapid response. The simulator was designed using computed tomography of a human neck and was fabricated to mimic the material properties of human tissue. The algorithm for prehospital management of PNI was developed in three fundamental steps: 1) identify venous vs arterial bleeding patterns; 2) control the hemorrhage; and 3) transfer the patient to a trauma center. The synthetic medical simulator allowed for the simulation of arterial and venous bleeding and was used to train 180 NHL athletic trainers and physicians at their annual meeting in 2024. Voluntary quantitative and qualitative post-training feedback obtained from 46% of trainers who participated was very positive (overall rating 4.7/5). Penetrating neck injuries are high-risk events that first responders are generally undertrained to manage due to their rarity. Simulation is effective to potentially improve the outcomes of these scenarios, and the use of synthetic medical simulators is cost effective. We developed a novel algorithm, medical simulator, and training curriculum for the management of PNI in conjunction with the NHL for training athletic trainers and physicians.
Emergency department (ED) closures have become increasingly common across health systems worldwide, reflecting mounting pressures from staffing shortages, resource constraints, and rising patient demand. Closures, whether temporary or permanent, pose potential risks to timely access to emergency care and may significantly impact patient outcomes and healthcare system performance. Despite growing attention from policymakers and the public, academic evidence on real-world impacts of ED closures remains fragmented. In this scoping review we compiled and summarized the current literature directly addressing the impacts of ED closures. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews criteria, we conducted a search of PubMed.gov, the Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases for papers published in English after the year 2000 that directly addressed ED closures. We screened these papers by title and abstract. This search yielded 15 studies for which we then conducted a forward and backward citation search, ultimately producing 22 unique papers. Data from these papers were initially extracted into a spreadsheet and then organized into thematic tables based on the impacts they discussed. Our search yielded 1,725 papers, and we ultimately included 22 of these (1.3%). Most studies were observational or quasi-experimental, covering 147 unique ED closures, with some analyzing all United States closures (thousands). We found that we could organize the papers into four themes determined by the impact of ED closures had on the following: 1) patient outcomes (eg, mortality, likelihood of acute myocardial infarction treatment) (n = 14); 2) equity-deserving populations (n = 6); 3) alternate EDs that remain open (n = 10); and 4) on healthcare networks as a whole, including emergency medical services (n = 5). Most of the papers were observational or quasi-experimental in design and drew data from a wide scale of closures, from single-site to national ED closures (> 500 sites). The largest proportion (40%) of studies were based in the U.S. The literature demonstrated mixed and context-dependent impacts of ED closures. The ED closures consistently adversely affected mortality rates of patients with time-sensitive conditions when travel times or distances exceeded certain thresholds. Closures also disproportionately affected equity-deserving populations. However, the negative impacts were often mitigated in the long term, and were less pronounced in well-resourced systems capable of adaptation. There are key gaps in the literature regarding impacts on conditions that are not time sensitive, on marginalized populations, and on broader system-level performance, which should guide future research.
It is not known whether skin color influences inclusion of substance use on medical students' differential diagnoses for a simulated cardiac arrest. Our objective in this study was to investigate whether the presence of a dark-skinned or light-skinned manikin in the lab correlated with their decision to include substance use on the differential as a possible cause of cardiac arrest. In this study at a single institution, all fourth-year medical students in an emergency medicine course participated in a manikin-based cardiac arrest simulation case. The simulation sessions alternated between the use of a light-skinned and a dark-skinned manikin. Both were adult sized. After the first shock was delivered, students individually documented their differential diagnosis for the cause of the cardiac arrest on deidentified, free-text research forms. We excluded forms if they were blank, had been completed by a non-medical student, or could not be associated with the skin color of the manikin used. The primary outcome measure was how often students included substance use as a cause of cardiac arrest anywhere in their differential diagnoses. We compared the relationship between manikin skin color and the students' consideration of substance use as a cause of cardiac arrest, using the Fisher exact test. Of 270 eligible participants, 271 surveys were returned; 75 (27.7%) were excluded. Of the remaining 196 surveys, 96 were associated with the light-skinned and 100 with the dark-skinned manikin. Among the 100 respondents using the dark-skinned manikin, one student (1%) listed substance use as the leading diagnosis, while none (0%) of the students using the light-skinned manikin listed substance use as the leading diagnosis. In each group, only 20% of students (n = 39 total) listed substance use anywhere on the differential diagnosis (P = 1.00). Among fourth-year medical students participating in a simulated cardiac arrest, we found no correlation between manikin skin color and the inclusion of substance use on their differential for cardiac arrest. Overall, their decision to include substance use in their differentials was low regardless of skin color, suggesting the need to improve their awareness of substance use as a potential cause of cardiac arrest.
Emergency department (ED) boarding of critically ill patients awaiting intensive care unit (ICU) admission has been associated with delays in time-sensitive interventions, prolonged lengths of stay (LOS), increased crowding, and higher incidence of morbidity and mortality. To address this, our institution implemented an ED critical care consult team in 2020 and established a resuscitation and emergency critical care fellowship in 2022. The critical care consult team, staffed by emergency physicians with additional resuscitation or critical care training, provides consultative support for resuscitations and the management of boarding critically ill patients 10 hours per day, with the dual goals of improving clinical care and optimizing patient flow. The primary outcome of this study was to evaluate the rate of patients downgraded from their initial admission level of care (ICU, Intermediate care) to a lesser intensity of care (intermediate, ward, home). Secondary outcomes included ED, ICU, and hospital LOS. We conducted a retrospective chart review of all patients ≥ 18 years old with ICU or intermediate care admission orders placed between November 1-30, 2024. Patients were sequentially identified via the electronic health record, and clinical and quality assurance data were collected in a REDCap database. During the study period, the ED critical care consult team was active on 73% of days, staffed primarily by resuscitation and emergency critical care fellows. Of 372 eligible patients, 18% (68/372) were managed by the critical care consult team after initial assessment by primary emergency physician staff, while 82% (304/372) served as controls and did not have involvement with the critical care consult team. Patients evaluated by the team had higher acuity, with 30.9% presenting with an Emergency Severity Index (ESI) score 1 compared to 4.6% in the control group. Despite this, the downgrade rate was significantly higher in the ED3CT cohort (29.4% vs 11.8%, p=0.001). No differences were observed in ED (0.62 days vs 0.60 days, P = .80), ICU (5.1 days vs. 5.2 days, P = .93), or hospital LOS (9.7 days vs 10.8 days, P = .68). These findings suggest that ED-based critical care physicians, including fellows in training, may facilitate earlier identification of patients suitable for lower levels of care despite initially higher acuity. While there was no change in ED, ICU, and hospital length of stay, it is possible that this is related to systemic problems with hospital bed availability. The high rate of downgrades highlights the benefits of ED-based critical care physicians advancing care of critically ill patients boarding in the ED.
Penicillin allergy is one of the most reported drug allergies, but studies have shown that patients who report an allergy frequently do not have a significant reaction when challenged. Avoidance of penicillin or beta-lactam antibiotics in these patients results in increased hospitalization costs, suboptimal antibiotic therapy, and risk for subsequent infection with multidrug resistant organisms. This was a single-center, retrospective chart review that included patients ≥ 18 years of age with documented penicillin allergy who presented to the emergency department (ED) over a one-year period. Clinical pharmacy specialists in the ED reviewed and stratified patient allergy risk. Patients with low-risk allergy histories who were to be admitted and gave formal consent were given an oral amoxicillin challenge and then observed in the ED for at least one hour. Patients who were eligible for challenge but were to be discharged from the ED were given the option to be seen in the allergy clinic. The primary outcome was the incidence of adverse reactions related to the oral amoxicillin challenge for patients. An exploratory secondary outcome was the average length of stay (LOS) in the ED for oral amoxicillin-challenged patients compared to the average LOS for non-oral amoxicillin-challenged patients. We performed descriptive statistics on all variables. A total of 144 patients received an allergy assessment in the ED, 20 who received an oral amoxicillin challenge and 124 who did not. Baseline characteristics were similar in both groups. The average total LOS in the oral amoxicillin-challenged patients was a non-significant 36 minutes longer compared to the non-challenged patients (P = 0.4). Of 144 patients, 71 (49%) had their penicillin allergy removed as a result of the challenge.. One patient experienced a mild and self-limited reaction to the oral amoxicillin challenge (0.7%; 95% CI, 0.02-3.8%). An ED pharmacist-led, penicillin de-labeling protocol was safe and feasible. A secondary exploratory analysis showed no significant difference in length of stay between patients who received the oral amoxicillin challenge in the ED vs those who did not. Performing a proper penicillin allergy evaluation in the ED can have lasting benefits for patients and antimicrobial stewardship.
In-situ simulation offers a realistic training environment with a higher level of fidelity compared to other simulation models. It is associated with enhanced knowledge retention and a higher level of composure during real clinical encounters. One common barrier to undertaking in-situ simulation is the concern that it contributes to a delay in providing patient care. In this study we gave patients in the waiting room seven hypothetical emergency medical scenarios, two of which were training simulation scenarios, and we asked them how long they would be willing to delay their care if the different scenarios were actually occurring in the emergency department (ED). Our objective was to investigate whether patients in the ED waiting room would be willing to delay their care if they knew that there were simulation training scenarios occurring. This was a prospective convenience sample of participants conducted at a Level 1 trauma centre. Participants completed a survey that presented seven hypothetical scenarios, including two in-situ simulation scenarios. They were then asked to indicate the amount of additional wait time they would deem acceptable for each scenario. Responses to the two in-situ simulation scenarios indicated that 342 (40%) and 335 (40.5%) of the 827 study participants, respectively, were willing to wait > 40 minutes for these to occur. In contrast, and after controlling for age, sex, waiting time, and time of recruitment, subjects reported they would tolerate shorter wait times for simulation scenarios than for real patient-care scenarios. [Willingness to wait > 40 minutes for the five real scenarios ranged from 70.5-79.9%, P < .05). While patients demonstrated lower tolerance for simulation-related delays than for routine clinical care, our results showed that most were still willing to wait up to an additional hour to allow in-situ simulation to proceed. These findings indicate that in-situ simulation is broadly acceptable to patients and supports its continued use in clinical settings.
Rural areas in the United States have higher mortality rates than urban regions, particularly from emergency care-sensitive conditions. Air medical ambulances (medevacs) are critical to emergency care access in the rural U.S., but limited data hinder the ability to study this critical system. In Alaska, medevac services often represent the sole method for connecting Alaska Native patients in remote clinics to physician emergency medical care. This study characterizes medevac use and timing between tribally administered village clinics and hospitals in Northwest Alaska. Our objective in this study was to describe the use and timing of medevacs and investigate how medevac decision-making impacts medevac transport times. We conducted a retrospective cohort analysis of medevac transfers between 2020-2024 from 11 Alaskan village clinics within the Maniilaq Association, which serves ~8,000 people over 35,862 square miles.We included 1,579 medevacs representing 1,119 unique patients flying from remote clinics to a central critical access hospital hub.. Our primary outcome measure was the association between short medevac decision times (< 60 minutes), and short total medevac times (< 180 minutes). We measured "flight time," "decision time," and "ground time" (time spent waiting for an aircraft to become available) as key components of total medevac time. A total of 1,579 medevacs were deployed for predominantly Alaska Native (96.8%) patients, of whom 22.2% had traumatic injuries. Between 4.1-7.9% of community members in the region are transported by medevac each year. Median medevac time was 262 minutes (interquartile range [IQR] 196-402 [101-4,142]) from activation call to arrival at the critical access hospital. No medevacs were < 100 minutes. "Ground time" was the longest phase of medevac encounters overall (median ground time 105 minutes (IQR 81-187]) vs median decision time 75 minutes (IQR 42-130) or median flight time 44 minutes (IQR 35-77). We found no association between short medevac decision times and short medevac response time (P = .93). Medevac decision-making was the longest phase in only 6% of the shortest total medevacs (< 190 minutes), but it was the longest phase in 40% of the longest total medevacs ( > 400 minutes). We found four key themes: 1) no medevacs were < 100 minutes. Independent of human or system factors,atients cannot be transferred from a village clinic to a critical access hospital within the "golden hour" of emergency care; 2) short medevac decision times were not significantly associated with short overall medevac times; 3) the longest phase in a medevac transfer was "ground time"; and 4) in the subset of the longest total medevacs, medevac decision-making was much more likely to be the longest phase than in the shortest total medevacs. This emergency transfer system is not responsive to patient condition and suggests that medevac decision support may help for a subset of encounters.
Ultrasound-guided nerve blocks (UGNB) are an effective and safe method of pain control that are increasingly used for pain management in the emergency department (ED). However, performing these procedures is often time-intensive due to the need to locate and gather necessary supplies. Our ED recently implemented use of a nerve block cart, which contains all the supplies needed for performing a nerve block. Our objective in this quality improvement study was to assess whether the presence of an ED nerve block supply cart was associated with an increase in the number of UGNBs performed. We conducted a retrospective review of point-of-care ultrasound examinations performed in a single academic quaternary-care community ED over 22 months, looking at 11-month time periods before and after implementation of an ED nerve block supply cart in March 2023. Our primary outcome measure was documentation of a UGNB, and our secondary outcome measure was the type of UGNB performed. We reviewed 14,321 ultrasound exams over 22 months-11 months pre-cart (6,853) and 11 months post-cart (7,468) implementation. We noted a statistically significant increase in the number of UGNBs, from 21 performed in the pre-cart period (0.31% of all ultrasound exams [95% CI, 0.17-0.43%], to 50 UGNBs in the post-cart period (0.67% of all ultrasound exams [95% CI, 0.46-0.86%], P < .01). The fascia iliaca block was the most common UGNB performed in both the pre- (52.4%) and post-cart (62.0%) periods. We found that the deployment of an ED nerve block supply cart was associated with an increased number of ultrasound-guided nerve blocks performed by emergency clinicians in our hospital.
Emergency departments (ED) in the United States serve as a safety net for millions, including those with limited English proficiency (LEP). Eight percent of individuals living in the United States have LEP, placing them at risk for language barriers that can adversely affect the quality and safety of their care. Many hospitals lack language-concordant care, especially at the time of discharge. Miscommunication at discharge can lead to adverse health outcomes, including medication errors, poor compliance, and unnecessary return visits to the ED. Our objectives in this study were to evaluate the quality and safety of artificial intelligence (AI)-generated translations of physician-written, patient-specific ED discharge instructions and to assess performance across varying levels of instruction complexity. Emergency physicians wrote free-form discharge instructions, representing patient-specific guidance, which are typically provided at the time of ED discharge. Four topics were selected: abdominal pain; chest pain; wrist fracture; and vaginal bleeding in pregnancy. These instructions were intentionally developed to vary in linguistic complexity and were assessed using the Flesch Reading Ease and Flesch-Kincaid Grade Level scales. Instructions were translated into Albanian, Brazilian Portuguese, and Vietnamese using the AI-based translation tools ChatGPT-4, Microsoft Copilot, and Google Translate. Translations were evaluated for semantic and syntactic accuracy. Criteria included adequacy, fluency, meaning, and severity on a 5-point scale (1 = lowest accuracy, 5 = highest accuracy). Preference and formality were rated on a 3-point scale (1 = lowest, 3 = highest). The primary outcome was the quality and safety of AI-generated translations of patient-specific discharge instructions. Secondary outcomes included the ability to handle varying instruction complexity. Professional medical translators primarily responsible for the written translation of medical text evaluated and scored the translations for accuracy and quality metrics. Overall adequacy, fluency, meaning, and severity scores were similar across models. ChatGPT-4 (3.79), Microsoft Copilot (3.60), and Google Translate (3.50), showed no statistically significant differences. Albanian translation was an exception, with ChatGPT-4 scoring significantly higher (3.75) than Google Translate (3.19) (P < .001). There were no other significant differences observed for Brazilian Portuguese or Vietnamese. ChatGPT-4 was also found to be the highest rated for Albanian and Brazilian Portuguese. Both Microsoft Copilot and Google Translate produced a total of five potentially harmful translation errors, whereas none were identified for ChatGPT-4. Miscommunication during discharge can lead to negative patient outcomes. This study evaluated ChatGPT-4, Microsoft Copilot, and Google Translate in translating ED instructions into Albanian, Brazilian Portuguese, and Vietnamese. ChatGPT-4 performed best overall and produced no harmful translations, and significantly outperformed Google Translate in Albanian. While AI-based translation tools show promise, human oversight remains necessary to mitigate risks from translation inaccuracies.
Point-of-care ultrasound (POCUS) can expedite patient diagnoses and improve procedural safety in emergency department (ED) patients. Nevertheless, clinical POCUS use lags in many ED sites nationwide, with only 40% of community physicians using POCUS according to a study from 2019-2021. We studied the impact of a multifaceted clinical POCUS intervention to address barriers and increase clinical POCUS use. We conducted a prospective cohort study at a single academic hospital that included ED attendings, residents, and advance practice clinicians (APC). A multifaceted four-week intervention for emergency clinicians from December 2023-January 2024 addressed barriers to POCUS use identified on a pre- and post-intervention survey. The intervention included POCUS education during clinical shifts by ultrasound faculty, clinical POCUS workflow demonstration during resident conference/faculty meetings, and QR code reference files on machines for a total of two hours of additional training per clinician. The primary outcome was the number of clinical ED POCUS performed during the 18 months pre-intervention and 12 months post-intervention. Secondary outcomes were POCUS workflow knowledge exam scores and POCUS revenue. We analyzed clinical POCUS numbers from July 2022-December 2024 using an interrupted time series model. Forty-two of 99 emergency clinicians (42.4%) responded to surveys pre-intervention and 28 post-intervention (28.3%). Fifty-six physicians/APCs (56.6%) participated in the in-person POCUS intervention (17 attendings, 34 residents, 5 APCs). The unadjusted number of POCUS exams performed increased from 6,708 pre-intervention (18 months) to 11,600 post-intervention (12 months). After controlling for the underlying secular trend, we saw no effect of the intervention with no significant increase in overall number of POCUS exams performed per 100 ED patients after the intervention (mean level change = -0.81, 95% CI, -2.43 to 0.82; P = .33). Neither was there an increase in the slope of the secular trend post-intervention (difference in slope, β = 0.00, 95% CI, -0.10 to 0.10; P = .98 for post-intervention, β = 0.02, 95% CI, -0.08 to 0.12 for sustainability period). Monthly POCUS revenue increased ~$55,000 in total billed and $10,000 reimbursed (~16% reimbursement). This was the professional component only that was billed by the physician and not the technical component covering equipment and maintenance. Post-intervention mean knowledge scores were 88% correct (standard deviation 12.0) with 16/22 participants (72.7%) passing the assessment (score > 90%). A multifaceted intervention was not shown to improve clinical point-of-care ultrasound use and revenue when accounting for an underlying sustained secular upward trend in number of POCUS exams performed per 100 emergency department patients throughout the study period. Future interventions directed toward low POCUS users and identification of clinical POCUS champions may improve clinical POCUS use.
The transition from resident to junior faculty in academic emergency medicine (EM) may be shaped not only by formal training and institutional policies but also by the "unwritten curriculum," a set of norms and expectations embedded in institutional culture. However, the unwritten curriculum and its potential to impact junior faculty development remains largely unexplored. Little is known about how junior faculty perceive, experience, and navigate these informal expectations, or the formal and informal structures that influence this process. In this study we aimed to explore junior faculty members' experiences with the unwritten curriculum in academic EM, with a focus on how they interpret and navigate institutional norms and identify supports and barriers encountered during their early faculty development. Within their first five years, EM faculty at academic institutions distinct from their residency training sites completed an anonymous, iteratively developed survey designed to explore experiences with the unwritten curriculum, informed by Schlossberg's transition theory framework. The primary analytic focus was identification of themes describing how junior faculty perceive and navigate implicit institutional norms. Open-ended responses underwent thematic analysis using a structured codebook, applied by two independent reviewers with consensus-based coding and adjudication by a third when disagreements arose. A total of 35 junior faculty members completed the survey. All participants indicated influence of the unwritten curriculum on their professional development. Major themes identified include the unspoken importance of mentorship and peer guidance; implicit expectations and norms surrounding engagement, productivity, and visibility; work-life integration; cultural adjustment; scholarly output; and gaps in onboarding, feedback, and role clarity. Participants emphasized challenges in navigating departmental politics, understanding hierarchical nuances, and balancing unspoken expectations for committee involvement and informal social participation. Additionally, unclear feedback processes, inconsistent evaluation expectations, and cultural norms for active engagement were noted as barriers to integration and professional growth. Junior faculty in academic EM described the unwritten curriculum as a meaningful influence on their early faculty experience. Within this sample, participants highlighted mentorship, feedback transparency, and structured faculty development as potential mechanisms to support navigation of implicit expectations during the transition to junior faculty. These findings reflect individual perceptions rather than program characteristics and should be interpreted within the context of the study's scope.
Telehealth continues to reshape healthcare delivery in the United States. Recognizing its growing importance and the need for advances in education, the Association of American Medical Colleges released telehealth competencies in 2021, and the Accreditation Council of Graduate Medical Education (ACGME) recently proposed a structured telemedicine experience as part of all emergency medicine (EM) residencies. Despite these efforts, it is unclear whether EM residencies have adopted these new educational mandates. Our primary objective in this study was to understand whether (and how) U.S. EM residencies have implemented telehealth education. We developed a cross-sectional, national survey to describe existing telehealth curricula among ACGME-accredited EM residencies. Program directors were surveyed via email. Our primary outcome measure was the percentage of residencies with existing telehealth curricula. Secondary outcomes assessed telehealth curricula emphases, implementation barriers, and telehealth's perceived importance to EM training. Of 282 U.S.-based EM residencies, 67 programs responded (24% response rate). Of these, only five (7.5%) reported having a formal telehealth curriculum. Programs with curricula were likely to teach real-time telehealth skills (80%) and focus on data collection (80%), patient safety (80%), and communication (60%). Programs without curricula identified prioritization of other curricula (76%), insufficient faculty expertise (65%), and limited infrastructure (50%) as barriers. We also found that 61% of programs viewed telehealth education as of limited importance to EM training. At the same time, program directors expressed interest in the development of asynchronous telehealth content from trusted national EM organizations (60%). Formal telehealth curricula remain the exception rather than the rule among U.S. EM residencies. Despite accreditation bodies urging its adoption, telehealth education faces multiple barriers, including limited faculty expertise, lack of telehealth infrastructure, and low perceived education importance. Our research suggests that national organizations may play a key role in providing early telehealth education while programs adapt to these new educational requirements.
Excessive environmental heat exposure is clearly associated with an increased likelihood that individual patients will suffer adverse health outcomes. Such heat exposure also strains healthcare systems via increased utilization, a burden which can challenge systems' capacities. Health impacts vary geographically with urban heat islands potentially contributing to higher temperatures and greater health risks. However, those most vulnerable to this exposure are not well identified. Our objective in this novel study was to compare and quantify differences in emergency medical services (EMS) use by selected patients during hot days in Rhode Island. Patients were recruited from low socioeconomic residential locations, stratified by whether they accessed EMS from within one of the state's "urban heat islands," or from other locations without "heat island" effects. We also compared selected patient demographic characteristics, and other EMS run data, between events associated with EMS access from these two types of areas. This retrospective, cross-sectional cohort study evaluated how the probability of an EMS encounter varied in response to daily mean temperature and the urban heat island status of the encounter location. We aggregated EMS dispatch data, daily mean temperature, urban heat island classification and the Area Deprivation Index of the encounter location. A quasi-Poisson regression model assessed the relationship between EMS encounter frequency and potential risk factors including daily temperature, urban heat island status, year, day of the week, sex, age, and relevant interaction terms. The model was restricted to low socioeconomic, residential encounter locations to reduce confounding (noted elsewhere by year) and focus on the target population. The primary outcome was the rate ratio (RR) of EMS encounters for urban heat island locations vs locations without an urban heat island effect, in response to summer temperatures. Secondary outcomes included RRs of EMS encounters stratified by age, sex, weekday vs weekend, and year. Higher temperatures were associated with increased EMS call rates across all demographic subgroups. A 5 °F (2.8 °C) increase in mean daily temperature was associated with an increase in an overall EMS encounter rate of 1.5% (RR, 1.015; 95% CI, 1.005-1.031, P = .004). On a weekday in 2021, at 75 °F degrees, 68 EMS encounters would be predicted for the residential, low socioeconomic status locations in the state while at 95 °F, 73 EMS encounters would be expected. The EMS rates were consistently higher in urban heat islands across all study years, after accounting for daily temperature, year, day of the week, demographic characteristics, population size and interactions between age, sex, urban heat island and weekday vs weekend. The largest relative increase in EMS encounters was observed in 2019, with rates 34% higher in urban heat islands compared to locations without an urban heat island effect (RR, 1.34; 95% CI, 1.27-1.42). The smallest increase occurred in 2020 (RR, 1.12; 95% CI, 1.06-1.18). In residential and low socioeconomic locations, living in an urban heat island increased the probability of an EMS encounter, highlighting potential compounding effects of social and environmental vulnerability. As climate change intensifies extreme heat events, locationally targeted interventions may be critical in reducing heat-related health impacts.
Stroke is a significant cause of mortality and long-term disability in the United States. Reduced time to thrombolytic therapy may lower stroke-related morbidity and mortality. The integration of a mobile stroke unit (MSU) into emergency medical service (EMS) systems of care has been focused in large metropolitan areas. A MSU may reduce the time from first medical contact (FMC) to thrombolytic therapy versus traditional care models, but this value must be evaluated in the context of the logistic and operational challenges of non-metropolitan EMS systems. To determine the impact of integrating an MSU into a large suburban EMS system with specific attention to key time metrics, logistics, and patient safety. We conducted a retrospective observational study of MSU dispatches by a County 911 emergency communication center (ECC) across a large suburban EMS system involving multiple agencies between August 1st, 2019, and July 31st, 2024. The MSU is a specialty ambulance with computerized tomography and telemedicine consultation capable of prehospital treatment of patients with thrombolytics. Criteria to dispatch the MSU were defined by the ECC caller-interrogation protocols for stroke and dispatcher discretion. Time metrics in minutes were reviewed for all incidents by the MSU, including dispatch to on-scene, and times from on-scene to key milestones such as imaging by computed tomography, neurology telemedicine consultation, thrombolytic therapy, and transport to the stroke center. Demographic data were obtained on those who received tPA and who were transported. Data are presented as a median with interquartile ranges (IQR). Over a five-year period, the MSU had 1,752 dispatches, of which 717 patients were transported to the emergency department. The median time on scene before initiating transport to a comprehensive stroke center was 21 minutes (IQR 18-24). The median arrival to CT scan was 9 minutes (IQR 7 - 11), median FMC to neurology telemedicine consultation was 14 minutes (IQR 12 - 17), and dispatch to thrombolytic therapy was 38 min (IQR 31-43). A total of 91 patients (4%) received thrombolytics prehospital and FMC to thrombolytic therapy had a median time of 26 minutes (IQR 22 - 31). An equal number of men (47%) and women received thrombolytics (p value = 0.602) and the median age was 73. (IQR 64.5-83). The median time from reported last known well to thrombolytic was 71 minutes (IQR 53-136). We describe the successful integration of an MSU into a suburban EMS system involving multiple agencies with rapid FMC to thrombolytic administration time. Time metrics for each step to thrombolytic administration were consistent with little variance; no patient received thrombolytics beyond the 270 minutes safety limit. Of the 1,752 dispatches, 91 patients received thrombolytics. This should initiate further discussion on the clinical, financial, and operational impact of MSU care in suburban communities.
Emergency department (ED) encounters are common for pregnant individuals in the United States. Radiological imaging is frequently ordered for diagnostics in the ED but generally avoided during pregnancy. This study examines missed pregnancy documentation and the association of pregnancy documentation with radiological imaging among individuals who have an ED encounter while pregnant. We used a retrospective cohort of pregnant individuals who had a live birth in an urban county in Indiana 2022-2023. We pulled all ED encounters occurring between 42-279 days of gestation (N = 4,597) that did not occur within five days of delivery. Our primary outcome measure was pregnancy documentation in the patient's electronic health record and receipt of radiological imaging (radiograph and computed tomography) of the chest, abdomen or spine. We used descriptive statistics and logistic regressions for the analysis. Pregnancy was not documented in 273 of the 4,597 encounters (5.9%). A larger percentage of encounters with missed pregnancy documentation occurred with non-Hispanic Black patients (162/273, 59.3%) compared to non-Hispanic White patients (75/273, 27.5%); (odds ratio 1.70, 95% CI, 1.21-2.41) for non-Hispanic Blacks relative to non-Hispanic Whites. Radiological imaging occurred in 147 of the 4,324 encounters with a documented pregnancy (3.4%), compared with 30 of the 273 encounters where the pregnancy was not documented (11.0%). Missed pregnancy documentation was associated with 2.11 times (95%CI, 1.30-3.42) the odds of receiving radiological imaging when adjusted for confounders. Missed pregnancy documentation occurred in 5.9% of emergency encounters with pregnant patients. While this is uncommon, it is still significantly associated with receipt of radiological imaging. Disparities in odds of pregnancy documentation in the ED may contribute to differences in maternal outcomes and highlights the necessity of ensuring equitable care for all pregnant individuals.
Emergency front-of-neck access may serve as a life-saving intervention when facing patients with difficult airways. Cricothyrotomy consists of needle and surgical techniques and is performed in approximately 0.2-0.5% of all airway management attempts. Our primary aim in this study was to compare procedural completion time and first-pass success of needle and surgical approaches to cricothyrotomy by civilian and military practitioners using a human cadaver model. Emergency medicine (EM) attendings and residents and U.S. Air Force Pararescue specialists were randomized to perform either a needle or surgical cricothyrotomy on an unfixed human cadaver a single time following a 30-minute didactic session about both procedure types. We recorded procedural completion time, first-pass success, frequency and type of observed complications, and subject level of training. Our primary outcome measure was procedural completion time. Secondary outcome measures included first-pass success and complication rates. We used a Wilcoxon signed-rank test to compare the difference in median completion times between needle and surgical groups. We performed a Cox regression analysis to evaluate the relationship between technique and procedural completion time while adjusting for subject level of training. Chi-squared or Fisher exact tests were used to compare unadjusted first-pass success and complication frequencies between needle and surgical groups. Multivariable logistic regression analysis modeling the association between technique and first-pass success and complication events while adjusting for subject level of training was performed. A total of 99 subjects were enrolled, and 19 (19%), 68 (69%), and 12 (12%) were classified as EM attending, EM resident, and Pararescue specialist, respectively; 51 (52%) and 48 (48%) were randomized into the needle and surgical groups, respectively. The median time to procedural completion was shorter in the needle group than the surgical group (56.5 seconds [sec], 95% confidence interval, 54-66 sec vs 65 sec, 95% CI, 59-73 sec, respectively). The difference in median completion times was 8 sec (95% CI, -1.0 to 17 sec, P = .08). The hazard ratio comparing completion time of surgical to needle cricothyrotomy while adjusting for level of training was 1.41 (95% CI, 0.93-2.13, P = .11). First-pass success and complication rates were similar between the needle and surgical groups (94% vs 94%, P = .32, and 27% vs 33%, P = .52, respectively). The adjusted odds ratios comparing the likelihoods of first-pass success and complication between surgical and needle groups while adjusting for level of training were 1.06 (95% CI, 0.20-5.54, P = .95) and 1.40 (95% CI, 0.55-3.56, P = .48), respectively. In this study using unfixed human cadavers, needle and surgical cricothyrotomy demonstrated comparable performance regarding procedural completion time, first-pass success, and complication rates. The 8-second difference in median completion time between groups was not found to be statistically significant and is unlikely to be clinically significant given the typical oxygen reserves in an apneic patient. These findings suggest that for practitioners in civilian and military settings, both needle and surgical cricothyrotomy remain viable options for emergency front-of-neck access, assuming adequate operator-level procedural proficiency and access to necessary equipment.