Western Journal of Emergency Medicine最新文献

Introduction: In 2024, the American Board of Emergency Medicine (ABEM) announced the launch of a new certifying exam that emergency medicine (EM) residency graduates must pass to achieve specialty certification. To date, there are no comprehensive curricula published in the available literature to aid residents in exam preparation.

Methods: In this pre-post pilot study, 44% (24/55) of postgraduate year 1 (PGY-1) through PGY-4 EM residents at a single site participated in a four-hour simulated certifying exam curriculum. Learners were asked to complete a four-point Likert scale survey rating self-reported preparedness (very unlikely - very likely) to take the ABEM Certifying Exam, as well as comfort with the ABEM tested competencies, preceding and following the simulation session.

Results: Survey respondents (n = 21; 87.5%) reported an improvement in overall preparedness to take the ABEM Certifying Exam, yielding a pre-post mean difference score of +1.2 (1.9 [unlikely] pre to 3.1 [likely] post, P < .001). Additionally, there was an improvement in all ABEM-tested competencies; pre-post mean difference score ranged from +0.5 (3.0 pre to 3.5 post) for patient-centered communication to +1.1 (2.2 pre to 3.3 post) for clinical decision-making (P < .001 for all competencies).

Conclusion: Given the critical need, and self-reported improvement in preparedness, EM training programs nationwide could consider incorporating a similar simulation curriculum into their didactic experience to help better prepare their learners for the new ABEM Certifying Exam.

Introduction: In this study we sought to to assess the extent to which emergency physicians adhered to an institutional protocol for rapid chest pain assessment that incorporates a high sensitivity troponin I (hs-TnI) assay. We also sought to characterize clinical outcomes stratified by protocol adherence.

Methods: We conducted a retrospective cohort study that included all adult patients presenting to five major metropolitan hospital emergency departments (ED) with suspected cardiac chest pain who had at least one troponin measured. The study period was November 9, 2020-June 20, 2022. The primary outcome was protocol adherence for indeterminate-risk and high-risk patients, as defined by the protocol in use at the time of each patient's presentation to hospital. Adjusted odds ratios (aOR) are reported with associated 95% confidence intervals.

Results: A total of 14,027 patients were included in the study, among whom 8,962 (63.9%) were classified as low risk, 4,064 (29.0%) as indeterminate risk, and 1,001 (7.1%) who were in the high-risk/rule-in group. Overall, 35.9% of patients had care that adhered to the chest pain pathway protocol-22.1% of indeterminate-risk patients and 91.6% of high-risk/rule-in patients. Protocol adherence among indeterminate-risk patients was 6.6% when the initial troponin was in the range of 4-19 nanograms per liter (ng/L) and 75.4% for initial troponin levels 20-99 ng/L. Male sex was most strongly associated with protocol adherence; among those receiving adherent care, 65.8% were male compared to 34.2% female (aOR 1.67; 95% CI, 1.46-1.91). Patients in the non-adherent group with an initial troponin 4-19 ng/L experienced a significantly higher incidence of major adverse cardiac events (4.5% vs 1.7%, P < .001), compared to those in the low-risk group.

Conclusion: Adherence to proposed assessment protocols for patients presenting to the ED with chest pain was low. This lack of adherence appears to disproportionally affect females and is associated with poor outcomes. Improving adherence to evidence-based guidelines in this setting is urgently needed.

Introduction: First-generation antihistamines are frequently used in the emergency department (ED) but are discouraged in older adults due to increased adverse drug effects. Whether concerns about adverse drug effects apply to the ED is uncertain, as ED-specific data are limited, and risks with single-dose administration may differ from risks with chronic use. In this study we assessed frequency of use, adverse drug effects, and indications of first-generation antihistamines administered to older adults during ED visits.

Methods: This retrospective cohort study identified adults ≥ 65 years of age who received first-generation antihistamines from January 1-December 31, 2022 in the ED at a single, urban, academic medical center. Abstractors blinded to study hypotheses identified indications for use and adverse effects through chart review. Indications other than severe allergic reactions and continuation of home use were classified as potentially inappropriate. We evaluated sex, age ≥ 85, history of cognitive impairment, drug received, and number of doses for association with adverse drug effects by regression analysis.

Results: First-generation antihistamines were administered in 261 encounters (3% of geriatric ED encounters). Median patient age was 71 (range 65-107, interquartile range [IQR] 67-77) and 60.5% were female. Adverse drug effects occurred in 15% of encounters, with delirium (n = 20, 7.7%) and urinary retention (n = 11, 4.2%) being the most common. On multivariate analysis, patient age ≥ 85, history of cognitive impairment, and receipt of multiple doses were associated with elevated risk of adverse drug effects, with risk ratios of 5.5 (95% CI, 2.7-11.4), 3.1 (95% CI, 1.8-5.4), and 1.9 (95% CI, 1.1-3.6), respectively. Indications were classified as potentially inappropriate in 92% of encounters. Diphenhydramine was most used in patients with headache (n = 53, 30.1% of doses) and history of iodinated contrast media reaction (n = 46, 26.1% of doses), while hydroxyzine was most used for anxiety (n = 51, 60% of doses). The kappa value between abstractors was 0.84, indicating excellent agreement.

Conclusion: Emergency department use of first-generation antihistamines in older adults, especially those ≥ 85 years of age and with prior cognitive impairment, was associated with infrequent but clinically significant harm. Most use was potentially inappropriate. Prophylactic use of diphenhydramine for patients with a prior reaction to iodinated contrast media emerged as a common indication.

Introduction: Effective resuscitation leadership is a critical competency for emergency physicians, with evidence correlating strong leadership with improved team performance and patient outcomes during resuscitations. Despite its importance, the extent and nature of structured resuscitation leadership education in emergency medicine (EM) residency training remains unclear.

Methods: We conducted a voluntary, anonymous, needs assessment survey of United States (US) EM residency programs between August-October 2021. The survey assessed for the presence, content, and methods of formal resuscitation leadership curricula within these programs. We used descriptive statistics to analyze responses.

Results: Of the 261 US EM residency programs invited to participate, 80 responded (30.7%). Nineteen programs (23.8%) reported offering resuscitation leadership training through formal curricula, with considerable variation in both educational methods and content. Additionally, 68.4% of responding programs offered external generalized leadership development opportunities through partnerships with hospitals, universities, community organizations, and research entities.

Conclusion: A minority of surveyed US EM residency programs incorporate formal resuscitation leadership training into their curricula with significant variance in curricular content and educational methods. Given the critical role of resuscitation leadership in EM, our findings highlight the need for further research to evaluate the effectiveness of existing curricula and educational approaches.

Introduction: Patients with acute stroke may occasionally present as trauma activations, particularly after being found down or sustaining falls. This atypical presentation can delay diagnosis and treatment. Our objective in this study was to compare time to brain imaging, use of reperfusion therapies, and clinical outcomes, including discharge disposition and mortality, between patients with acute stroke presenting as code trauma activations and those presenting as code stroke activations.

Methods: We conducted a retrospective review of all trauma activations at our Level I trauma center from January 2018-December 2024. Patients diagnosed with acute stroke on initial trauma imaging after trauma evaluation formed the code trauma activation (CTA) group. These patients were compared to all patients diagnosed with acute stroke after a code stroke activation (CSA) in 2024. The primary outcome was door-to-imaging time; secondary outcomes included door-to-intervention time, discharge disposition, and mortality.

Results: There were 208 CSA patients and 198 CTA patients. The CTA patients were older (75.3 vs 70.3 years of age, P < .001) and had a higher percentage of hemorrhagic stroke (43.9% vs 14.4%, P < .001). The CTA patients had a higher National Institutes of Health Stroke Scale score (14.44 vs 9.67, P < .001). Despite minimal injuries (mean Injury Severity Score 3.3), CTA patients experienced longer times to initial brain imaging (47.4 vs 24.8 minutes, P < .001). Mean door-to-thrombolysis (50.3 vs 43.7 minutes, P = .19) and door-to-puncture time (98 vs 82 minutes, P =.18) did not differ significantly. The CTA patients had lower rates of discharge home (23.2% vs 42.8%, P < .001) and higher mortality (24.2% vs 12%, P < .001). On multivariate analysis, trauma activation itself was not independently associated with mortality (OR 1.57, CI, 0.53-4.27, P =.42). Age, stroke severity scores, hemorrhagic stroke, and early imaging were independently associated with mortality after acute stroke.

Conclusion: Acute stroke patients presenting as trauma activations face significant delays in imaging and lower rates of thrombolytic treatment, despite low injury burden. While trauma activation designation was not independently associated with mortality, delays in imaging and higher hemorrhage prevalence were strongly linked to worse outcomes. These findings highlight modifiable workflow opportunities, particularly streamlined imaging and early stroke recognition in low-impact trauma presentations, to improve delivery of care.

Introduction: Maricopa County, Arizona, experienced its largest West Nile virus outbreak in 2021, with 1,487 cases and 101 deaths, in the midst of the COVID-19 pandemic. We sought to describe initial presentations of emergency department (ED) patients ultimately diagnosed with West Nile virus and determine how often patients presented to the ED before their diagnosis. To assist with disease recognition during future outbreaks, we examined in detail cases where emergency physicians initially did not suspect West Nile virus.

Methods: We reviewed records from May-December 2021 for patients with a positive West Nile virus result and at least one ED visit within 15 days. Data included age, sex, race, Emergency Severity Index (ESI) score, number of ED visits, chief complaint, vital signs, blood or cerebrospinal fluid (CSF) testing, diagnosis, and disposition. We excluded cases with only immoglobulin G-positive results or outpatient tests, leaving 147 cases.

Results: Among 147 ED West Nile virus cases, the median patient age was 67 years, with patients being predominantly male (66.7%) and White (97.3%). The most common presenting chief complaints included fever (23.8%), headache (17.7%), and generalized weakness (11.6%). Emergency physicians initiated testing for the virus in 63 cases (42.9%). Patients dispositioned (n = 84, either discharged or admitted) from the ED without initiation of testing tended to be older (median 73 vs 62 years, P < .001), with higher triage respiratory rate (mean 19.4 vs 18.3 breaths per minute, P = .05) and lower triage oxygen saturation (median 96% vs 97%; P =.02). Emergency physicians predominantly performed CSF testing (n = 42 patients) over serum testing (n = 21 patients). Patients tested via CSF had lower ESI scores than those tested via serum (ESI score of 1-2 45.3% vs 14.3%, P = .03).

Conclusion: Emergency physicians did not initiate testing in 57.1% of initial ED encounters of patients ultimately found to have West Nile virus. During West Nile virus outbreaks, emergency physicians should stay vigilant for less acute presentations, such as generalized weakness in elderly patients, along with typical presentations including fever and headache, to avoid delayed diagnosis.

Introduction: As part of a quality improvement initiative, our emergency department (ED) implemented a community advisory council consisting of leaders from five community-based organizations (CBO) that provide services for survivors of intimate partner violence. We used qualitative interviews with participants from the organizations to evaluate the council by identifying factors that promoted and hindered their engagement in this partnership between the community and the ED as well as best practices for future collaborations METHODS: We conducted five, 30-minute semi-structured interviews, one for each CBO representative on the council. Interview questions were based on validated toolkits for evaluating community-based participatory research. We conducted thematic analysis using a barriers and facilitators framework.

Results: Our focus on building relationships within the community advisory council facilitated collaboration between the ED and the CBOs. We identified structural barriers to and facilitators of the relationship-building process, as well as four behaviors that promoted relationship-building within the council. These behaviors included a joint problem-solving orientation, a culture of curiosity, shared empathy between emergency clinicians and CBO members, and a deeper understanding of barriers to caring for survivors of intimate partner violence in the ED. Themes regarding the impact of the council included the results of tangible projects as well as cultural shifts in the ED as perceived by leaders of the CBOs.

Conclusion: We share a case study of a collaboration between the ED and community-based organizations that illustrates barriers to and facilitators of engagement by leaders of these organizations in community-healthcare partnerships. The ED is a short but meaningful stop in recovery for many survivors, and a warm handoff to a CBO can be an essential next step in their care. When rooted in mutually respectful, trusting relationships, ED-CBO partnerships have the potential to enable survivor-centered, quality improvement efforts that work to improve the continuum of care between the ED and the community.