Western Journal of Emergency Medicine最新文献

Introduction: Psychiatric conditions are common presentations to the emergency department, and their prevalence has been steadily increasing. Part of this spectrum of presentations is self-directed violence. Self-directed violence involves suicidal acts and non-suicidal self-injuries that can result in serious morbidity and mortality. This study examines characteristics and outcomes of patients who presented to US trauma centers with self-inflicted injuries and identifies factors associated with survival to hospital discharge in this patient population.

Methods: We extracted data in a retrospective, observational manner from the 2020 National Trauma Data Bank (NTDB) 2020. The NTDB includes data from over 900 trauma centers (900/2,294 total trauma centers in the United States, 39.2%). We performed a descriptive analysis of characteristics, injury patterns and outcomes. All variables were tabulated by outcome (died: yes/no). We then conducted a multivariable logistic regression using a stepwise technique to identify factors associated with the patients' survival to hospital discharge.

Results: A total of 12,824 patients with self-inflicted injuries were included in this analysis. Their median age was 35 years (interquartile range 25-50), and they were mostly males (74.7%) and White (69.6%). Patients were mostly transported by ground ambulance (78.9%) to Level I (60.6%) and Level II (33.5%) trauma centers. Most patients had a pre-existing condition (70.2%). These included mental/personality disorder (48.2%), alcohol use disorder (11.5%), and substance use disorder (17.7%). The most common mechanism of injury was penetrating trauma (71.6%), followed by blunt trauma (18.0%) and burns (1%). Cutting/piercing was the most common penetrating mechanism (60%) compared with firearm-related trauma (40%). Severe injury (Injury Severity Score ≥ 16) was present in 32.8% of patients. A positive alcohol screen and/or a positive drug screen were reported in 30.2% and 31.2% of patients, respectively. Most patients were admitted to hospital (86%). Overall mortality rate at hospital discharge was 21.7%. We identified Important factors associated with survival to hospital discharge in this patient population.

Conclusion: Patients with self-inflicted injuries treated at US trauma centers have high rates of injury severity and a high mortality rate. This study sheds light on the complex and resource-intensive care needed for this vulnerable patient population.

Introduction: Patients who frequently use the emergency department (ED) make up 8% of ED patients annually but account for up to 28% of all ED visits. Frequent ED utilization has been associated with mental health disorders. However, the association between social determinants of health (SDoH) and frequent ED use is not as well understood. Our objective was to identify associations between frequent ED use and mental health disorders and SDoH among patients visiting 19 Upper Midwest EDs in an integrated health system.

Methods: We conducted a cross-sectional analysis of adult patients presenting to the 19 EDs from July 1, 2020-June 30, 2021. Using odds ratios (OR) and 95% confidence intervals obtained from multivariable logistic regression models, we characterized associations between mental health disorders (based on ICD-10 groupings) and 10 SDoH with frequent ED utilization (defined as ≥6 ED visits per year).

Results: A total of 228,814 visits among 134,452 patients were eligible for inclusion. After accounting for clinical features and mental health risk factors, the following had the strongest association with frequent ED use: unmet transportation needs (OR 1.73); high risk for financial resources (OR 1.52); food insecurity (OR 1.58); smoking tobacco (OR 1.31); and physical inactivity (OR 1.23). The top mental health risk factors for frequent ED utilization were adult personality and behavioral disorders (OR 4.0) and anxiety, stress and non-psychotic disorders (OR 3.35).

Conclusion: We found strong associations between mental illness and SDoH and frequent ED use. The strongest SDoH risk factors included unmet transportation needs, financial resource risk, and food insecurity. The top two mental health risk factors were adult personality and behavioral disorders as well as anxiety and stress disorders, with differences that persisted when analyzed independently as well as when adjusting for other mental health risk factors. By understanding the interaction between social determinants of health and mental health disorders researchers can better address root causes and improve health outcomes among this vulnerable population.

Introduction: Despite prior efforts to improve well-being in emergency medicine, clinician burnout in the specialty is rising. In this study we examined the acceptability and feasibility of using a method called "experience sampling" to explore factors important to clinician experience in emergency departments (ED). Experience sampling enables the measuring of work experience in real time, with more granular detail than in usual burnout surveys. The approach may reveal new opportunities for improving work experience in emergency medicine at a critical time.

Methods: We conducted this pilot study in a large, urban, academic, quaternary care ED. Iterative multidisciplinary focus groups were used to generate a brief, experience-sampling tool that was comprised of three different surveys to assess emergency clinician experience before, during, and after shifts. These were deployed using a smartphone application to a convenience sample of 11 clinicians (three attending physicians, two residents, five physician assistants, and one registered nurse) during four shifts each. A post-pilot survey was also sent to all participants to evaluate their experience of using the tool. Our primary outcome measures were feasibility, assessed by the survey response rates during the pilot, and acceptability, assessed by participant sentiment as expressed in the post-pilot surveys. Secondary outcomes were quantitative- and qualitative-experience data collected using the tool.

Results: The overall response rates for pre-shift, on-shift, and post-shift surveys were 79%, 73%, and 91%, respectively. All participants responded to the post-pilot survey and indicated they would be willing to use the experience-sampling tool again in the future. Many participants noted that the simple and open-ended on-shift questions were relatively easy to complete; some also said on-shift survey questions could present added difficulty during busy shifts. Four participants said the exercise of completing surveys itself improved on-shift experience by prompting reflection. Common themes associated with positive experiences included manageable patient volumes, excellent teamwork, interesting cases, adequate staffing, and feeling able to provide adequate care. Common themes associated with negative experiences included crowding, inadequate staffing, feeling overwhelmed, complex patient cases, difficult disposition plans, and feeling unable to provide adequate care.

Conclusion: Experience sampling is an acceptable and feasible method for measuring clinician experience in a busy academic ED. Further studies could potentially use this approach to identify targets for reducing burnout in emergency medicine.

Introduction: The Tijuana River, which affects southern San Diego Beaches, is severely contaminated with untreated sewage. Exposure to pathogens can lead to various health problems, commonly gastrointestinal (GI) illnesses. We aimed to look for any relationship between Tijuana River flow rates and ocean pollution levels and levels of diarrhea at a nearby Emergency Department (ED).

Methods: In this retrospective study that spanned the 2023 dry season and included Hurricane Hillary, we compared Tijuana River flow rates and fecal bacterial counts on the southern San Diego County coastline to the number of visits to a nearby ED, specifically a 225-patient sample size, with the chief complaint of diarrhea, a potential waterborne illness.

Results: In late August of 2023, after Hurricane Hillary made landfall as a tropical storm in Baja California, Mexico, there was a large increase in the Tijuana River flow rate and a correspondingly significant increase in diarrhea cases at 3.25 times the mean, from a mean of 4.25 cases per week to 14 cases the week of Hurricane Hillary.

Conclusion: We found a significant correlation between Tijuana River transboundary flow rates and Emergency Department case levels of diarrhea, a known waterborne illness, in the summer of 2023.

Introduction: Past patient data from health information exchanges (HIE) can enhance physician-patient interactions, although how and how often is unclear. We sought to determine how and how often past medical records provided by an HIE impacts current decision-making by emergency physicians.

Methods: We identified qualifying emergency department (ED) visits between September 24-26, 2022. The primary feature of a qualifying visit was a separate ED visit within three days prior at a separate hospital system. Fifty-five charts with essential details of each patient's most recent visit were reviewed in duplicate by 22 emergency medicine residents. Reviewers accessed prior medical records for each patient via an HIE clinical viewer. The primary outcome was the influence of knowledge from prior records on interactions during the most recent visit, measured with 11 Likert-scale ratings. Reviewer agreement was used as an indicator of confidence.

Results: Reviewers most frequently agreed that the information from the prior visit was valuable "a moderate amount" (25% of all reviewer pairs) and agreed that the information would cause them to change their approach (69%). They would adjust treatment protocols because of understanding what had been tried previously (67%) and ask the patient different questions (78%). There was also agreement that they would further compare laboratory tests or imaging between visits (67%) and better understand patient behavioral patterns (73%).

Conclusion: Access to patients' previous medical records (diagnoses, imaging reports, discharge reports, etc) via HIEs impacts how emergency physicians communicate with patients, evaluate cases, and make medical decisions.