Western Journal of Emergency Medicine最新文献

Introduction: The emergency department (ED) is a safety net, caring for families who lack adequate access to food and other basic needs. The COVID-19 pandemic caused a dramatic rise in food insecurity (FI) nationally; however, little is known about the prevalence of FI among families seen in pediatric EDs (PED). In this study we aimed to determine the prevalence of FI, as well as awareness and utilization of supplemental food services, among families seen in an urban PED during the COVID-19 pandemic using an electronic screening survey.

Methods: This was a cross-sectional survey of families screened for FI in an urban PED. An electronic survey was advertised to all families via posters placed in patient rooms and other locations in the PED between February-October 2022. Surveys in English and Spanish were accessed on personal electronic devices via QR codes. Six validated US Department of Agriculture household food security questions and sociodemographic questions were included. We calculated respondents' food security and performed descriptive and bivariate analyses of patient sociodemographics and responses to FI questions.

Results: Of 42,697 PED visits, 612 surveys were completed and analyzed (1.4%). Nearly 50% of respondents identified as White and non-Hispanic, with approximately 80% female. Thirty percent had a household income of <$25,000 and 32% between $25,000-<50,000. Among survey respondents, 56.7% demonstrated FI: 25% with low food security, and 31.7% with very low food security. We identified statistically significant differences in awareness and use of supplemental food services by FI status, household income, and primary language spoken.

Conclusions: Nearly 60% of survey participants in an urban pediatric ED during the COVID-19 pandemic experienced food insecurity, substantially higher than previous reports. These results support the ED's contributory role in FI screening, particularly during times of a public health crisis, and highlights the need for targeted outreach in this setting.

Background: Diversity within the physician workforce is associated with improved clinical outcomes and patient satisfaction. Despite this, the US physician workforce, particularly in emergency medicine (EM), remains relatively homogeneous. Of all Black medical school students in the US, 14% attend the four Historically Black Colleges and Universities (HBCU) that have a medical school. Unfortunately, none of these schools are affiliated with an academic EM program. Because of this, there is less professional mentorship focused on obtaining a career in EM and potentially less formal curricula for senior medical students doing their home sub-internship in EM.

Objectives: Our objective was to fill the gap left by the absence of an academic EM department at Howard University College of Medicine (HUCOM) by creating a collaborative educational experience for fourth-year medical students during their home EM sub-internship. The curricular objectives were to teach core principles of EM, build relationships with students, and prepare them for pursuing EM residency training.

Curricular design: Four EM academic departments collaborated to create and implement a virtual curriculum using the six-step approach to curricular development.

Impact/effectiveness: After completion of the course, five students (100%) reported strongly agreeing with the following statements. These sessions 1) helped me learn the approach to core EM topics more than I would have been able to do on my own; 2) helped me learn key skills for excelling in an EM rotation more than I would have been able to do on my own; and 3) allowed me to connect with faculty and resident mentors to learn more about the field of EM. Of these five students, 80% and 20% reported strongly agreeing and agreeing, respectively, that these sessions helped them learn about the process of applying to and selecting an EM residency program.

Introduction: Hyperkalemia, a potentially life-threatening electrolyte disturbance, is commonly encountered in the Emergency Department (ED). However, the frequency of factitious hyperkalemia, an artificially elevated potassium level in hyperkalemic ED patients, is unknown. This study aims to detect the rate of factitious hyperkalemia among patients with a potassium concentration of ≥5.0 mmol/l in an all-comer ED population.

Methods: This retrospective, monocentric chart review analyzed data of 2,440 ED patients who presented with a potassium concentration of ≥5.0 mmol/L in their initial whole blood or plasma sample, who also underwent a repeat potassium measurement on the same day. Two groups were established based on potassium levels in the initial and repeat blood tests: 1) True hyperkalemia, characterized by consistently elevated potassium levels in both the initial and repeat samples; and 2) Factitious hyperkalemia, defined by an elevated initial potassium level while the repeat blood test showed a normal potassium level. A subset of factitious hyperkalemia was spurious hyperkalemia. In spurious hyperkalemia, the initial blood sample showed an elevated potassium level with evidence of hemolysis, but a repeat test revealed a normal potassium level without evidence of hemolysis.

Results: Of the 2,440 patients, 1,576 (65%) had true hyperkalemia and 864 (35%) factitious hyperkalemia. Among the 864 patients with factitious hyperkalemia, 597 (69%) displayed hemolysis in their initial blood sample, indicating spurious hyperkalemia due to in-vitro hemolysis.

Conclusion: These data show that about one third of all hyperkalemic blood samples drawn in the ED were due to factitious hyperkalemia. The leading cause of factitious hyperkalemia was spurious hyperkalemia due to in-vitro hemolysis.

Introduction: While many aspects of emergency medicine (EM) residency training are standardized among residents within a single residency program, there is no standard for the distribution of chief complaints (CC) that residents should see over the course of residency. This could result in substantial variability in each resident's clinical exposure. Our objective in this study was to explore EM residents' clinical exposure to CCs to determine whether substantial variation exists. If such variation exists, this could suggest the need for curricular reform to address gaps in resident clinical exposure during training.

Methods: This was a retrospective observational study of EM residents who graduated in the years 2016-2021 at a single, university-affiliated emergency department (ED) in the midwestern United States. All patient encounters where a CC was logged were included and categorized into 1 of 20 clinical domains based on the 2016 American Board of Emergency Medicine Model of Clinical Practice. We calculated descriptive statistics for the top 10 most encountered domains for comparison among residents.

Results: We included a total of 228,916 patient encounters from 69 residents in the analysis. Residents were involved in an average of 3,323 distinct patient encounters during the study period. The overall interquartile range for patient encounters was 523. The three CC domains with the broadest interquartile variation were abdominal and gastrointestinal disorders (116), musculoskeletal disorders (nontraumatic) (93), and traumatic disorders (86).

Conclusion: Within a single, three-year academic EM program, substantial variation existed among residents with regard to the variety of patient CCs seen during their residency training.

Introduction: As fentanyl has become more readily available, opioid-related morbidity and mortality in the United States has increased dramatically. Preliminary studies suggest that high-affinity, partial mu-opioid receptor agonists such as the combination product buprenorphine-naloxone may reduce mortality from overdose and promote remission. With the escalating prevalence of opioid use disorder (OUD), it is essential to evaluate the effectiveness of opioid agonists like buprenorphine-naloxone. This study examines mortality and remission rates for OUD patients prescribed buprenorphine-naloxone to determine the efficacy of this treatment toward these outcomes.

Methods: We carried out a retrospective analysis using the US Collaborative Network database in TriNetX, examining de-identified medical records from nearly 92 million patients across 56 healthcare organizations. The study spanned the years from January 1, 2017-May 13, 2022. Cohort 1 included OUD patients who began buprenorphine-naloxone treatment within one-year post-diagnosis, while Cohort 2, the control group, consisted of OUD patients who were not administered buprenorphine. The study measured mortality and remission rates within a year of the index event, incorporating propensity score matching for age, gender, and race/ethnicity.

Results: Prior to propensity matching, we identified a total of 221,967 patients with OUD. Following exclusions, 61,656 patients treated with buprenorphine-naloxone showed 34% fewer deaths within one year of diagnosis compared to 159,061 patients who did not receive buprenorphine (2.6% vs 4.0%; relative risk [RR] 0.661; 95% confidence interval [CI] 0.627-0.698; P < 0.001). The remission rate was approximately 1.9 times higher in the buprenorphine-naloxone group compared to the control group (18.8% vs 10.1%; RR 1.862; 95% CI 1.812-1.914; P < 0.001). After propensity matching, the effect on mortality decreased but remained statistically significant (2.6% vs 3.0%; RR 0.868; 95% CI 0.813-0.927; P < 0.001) and the remission rate remained consistent (18.8% vs 10.4%; RR 1.812; 95% CI 1.750-1.876; P < 0.001). Number needed to treat for benefit was 249 for death and 12 for remission.

Conclusion: Buprenorphine-naloxone was associated with significantly reduced mortality and increased remission rates for patients with opioid use disorder and should be used as a primary treatment. The recognition and implementation of treatment options like buprenorphine-naloxone is vital in alleviating the impact of OUD.

Objective: Food insecurity is a prevalent social risk among emergency department (ED) patients. Patients who may benefit from food insecurity resources may be identified via ED-based screening; however, many patients experience difficulty accessing resources after discharge. Co-locating resources in or near the ED may improve utilization by patients, but this approach remains largely unstudied. This study characterized the acceptance and use of a food voucher redeemable at a hospital food market for patients who screened positive for food insecurity during their ED visit.

Methods: This prospective cohort study, conducted at a single county-funded ED, included consecutive adult patients who presented on weekdays between 8 AM-8 PM from July-October 2022 and consented to research participation. We excluded patients who required resuscitation on arrival or could not provide written informed consent in English. Study participants completed a paper version of the two-question Hunger Vital Sign screening tool, administered by research staff. Participants who screened positive received a uniquely numbered $30 food voucher redeemable at the hospital's co-located food market. Voucher redemption was quantified through regular evaluation of market receipt records at 30-day intervals. The primary outcome was the proportion of redeemed vouchers. Secondary outcomes included the proportion of participants screening positive for food insecurity, proportion of participants accepting vouchers, and associated descriptive statistics.

Results: Of the 396 eligible individuals approached, 377 (95.2%) consented and completed food insecurity screening. Most were middle-aged (median 53 years, interquartile range 30-58 years), 191 were female (50.4%), 242 were Black (63.9%), and 343 were non-Hispanic (91.0%). Of the participants, 228 (60.2%) screened positive for food insecurity and 224 received vouchers (98.2%), of which 86 were redeemed (38.4%) a median of nine days after the ED visit.

Conclusion: A high proportion of participants screened positive for food insecurity and accepted food vouchers; however, less than half of all vouchers were redeemed at the co-located food market. These results imply ED food voucher distribution for food insecurity is feasible, but co-location of resources alone may be insufficient in addressing the social risk and alludes to a limited understanding of facilitators and barriers to resource utilization following ED-based social needs screening.

Introduction: Pre-exposure prophylaxis (PrEP) for HIV-using antiretroviral medication in non-infected individuals to prevent HIV-has immense potential to slow the spread of the virus. However, uptake has been insufficient, and stark racial disparities exist in both HIV acquisition and PrEP usage, making PrEP access a health equity issue. A promising venue to engage high-risk populations in PrEP care is the emergency department (ED); however, existing ED PrEP initiatives have been costly or have had limited success. We hypothesize that two strategies could overcome these barriers: prescribing PrEP during an ED visit and providing patients with an initial supply of PrEP medication in the ED. Here, we describe the results of a qualitative study exploring multidisciplinary emergency clinicians and HIV clinicians' needs and views about the feasibility of such an initiative.

Methods: We conducted 22 semi-structured interviews with multidisciplinary clinicians from an urban, safety-net medical center in the ED and the on-site HIV clinic that provides PrEP services. We performed thematic analysis to summarize challenges and potential solutions described by participants.

Results: Participants' responses fell into three thematic categories: operational challenges; patient-level considerations; and potential impacts. Operational challenges highlighted the difficulty of PrEP initiation in a busy ED and clinician support needs. Patient-level considerations included the complex psychosocial needs of ED patients who could benefit from PrEP. Finally, participants anticipated that an ED-based PrEP initiation program could positively impact both individual patients and public health.

Conclusion: Interviews with emergency department and HIV clinic staff revealed important considerations and potential solutions for ED-initiated PrEP workflows. Clinicians in both specialties were enthusiastic about such an initiative, which could facilitate its success. This study lays the groundwork for the future design of an efficient and innovative workflow to leverage the ED as an essential entry point into HIV prevention services.

Introduction: There are several options for receiving acute care besides emergency departments (ED), such as primary care physician (PCP) offices, urgent care centers (UCC), and telehealth services. It is unknown whether these alternative modes of care have decreased the number of ED visits for patients or whether they are considered before visiting the ED. A comprehensive study considering all potential methods of care is needed to address the evolving landscape of healthcare. Our goal was to identify any factors or barriers that may have influenced a patient's choice to visit the ED as opposed to a UCC, PCP, another local ED, or use telehealth services.

Methods: We surveyed ED patients between three hospital sites in the greater Buffalo, NY, area. The survey consisted of questions regarding the patients' reasons and rationale for choosing the ED over the alternative care options. The study also involved a health record review of the patients' diagnoses, tests/procedures, consults, and final disposition after completion of the survey.

Results: Of the 590 patients consented and surveyed, 152 (25.7%) considered seeking care at a UCC, 18 (3.1%) considered telehealth services, and 146 (24.7%) attempted to contact their PCP. On the recommendation of their PCP, patients presented to the ED 110 (20.7%) times and on the recommendation of the clinician at the UCC 54 (9.2%) times. Patients' perceived seriousness of their condition was the most common reason for their selected mode of transport to the ED and reason for choosing the ED as opposed to alternative care sites (PCP, UCC, telehealth). Based on criteria for an avoidable ED visit, 83 (14.1%) ED patients met these criteria.

Conclusion: Individuals prioritize the perceived severity of their condition when deciding where to seek emergency care. While some considered alternatives (PCP, UCC, telehealth services), uncertainties about their condition and recommendations from other clinicians led many to opt for ED care. Our findings suggest a potential gap in understanding the severity of symptoms and determining the most suitable place to seek medical care for these particular conditions.