Western Journal of Emergency Medicine最新文献

Introduction: Discrimination and bias based on race/ethnicity permeate the medical education system. Racial disparities in assessment measures can ultimately impact applicants' Match results. Few studies to date have examined the narrative portion of the emergency medicine (EM) Standardized Letter of Evaluation (SLOE) for language differences by race. In this study we aimed to determine whether there were language differences by race in the narrative portion of the EM SLOE.

Methods: This study is an analysis of word category frequencies in the narrative portion of the SLOE for applicants applying to EM residency. The sample was drawn from the students who applied to the study institution in 2022. The narrative portion of the SLOE and other applicant factors were collected from the Electronic Residency Application Service (ERAS) applications and de-identified. We compared the number of SLOEs containing predefined keywords by race using chi2 analysis. Keywords were identified in six thematic word categories: agency; standout traits; ability; grindstone habits; achievement; and compassion. We performed logistic regression to determine whether any differences remained after controlling for other factors in the application.

Results: Of 1,104 applicants to the institution, 2,288 SLOEs with self-identified race/ethnicity were available for analysis. Black and Hispanic applicants had higher proportions of SLOEs that contained a compassion word than White applicants (24.9% and 22.4% vs 16.9%, respectively). This finding persisted after controlling for other factors in the application for Black applicants (odds ratio 1.61, 95% CI 1.1-2.36]). There was no evidence of difference in word use by race across other thematic categories.

Conclusion: We found differences in the proportion of SLOEs containing compassion words in the narrative portion of the EM SLOE between Black and White applicants, with Black applicants being described with compassion language more frequently. However, we found no difference in any other word category, indicating less overall disparity than other narrative assessment studies.

Introduction: Emergency departments (ED) present unique challenges for elderly patients who often experience higher revisit rates, increased number of complications, and worse health outcomes. This study examines the impact of implementing a combined automated screening callback and Geriatric Emergency Nurse Initiative Expert (GENIE)-led callback system on reducing ED revisit rates among elderly patients.

Methods: We conducted a retrospective analysis that compared revisit rates before and after the implementation of a GENIE callback system in the ED of a large, Level 1 trauma academic center. The study cohort included 23,664 patients, and the primary outcome was revisits at three, seven, and 30 days post-discharge from the ED. Data were adjusted for the Emergency Severity Index (ESI), age group, and sex. The cost of this initiative came from a three-year grant of $650,000 from the Gary and Mary West Foundation, which included the salary for a GENIE nurse.

Results: Revisit ratios in the pre-intervention period were 4.8%, 8.9%, and 17.2% at three, seven, and 30 days after discharge, respectively. Following implementation of the callback system, those ratios decreased to 3.9%, 7.6%, and 15.2% at the corresponding time points. All reductions were statistically significant (P < .001) and remained significant after adjusting for ESI, age group, and sex.

Conclusion: The GENIE callback system effectively reduced ED revisits among elderly patients, highlighting the importance of structured follow-up communication and care. These findings support the expansion of such programs to improve patient outcomes and reduce healthcare costs.

Introduction: Take-home naloxone (THN) programs in emergency departments (ED) can reduce opioid overdose deaths by providing naloxone directly to at-risk patients before discharge. However, sustainable models that integrate reimbursement and workflow alignment remain limited.

Methods: A reimbursable ED-led THN program was developed across a large regional health system. The program used electronic health record (EHR)-integrated ordering, on-site kit dispensing, and third-party insurance billing when available. Kits were stocked in automated medication dispensing systems and supplemented by city-provided stock for uninsured patients. Pilot outcomes included kits dispensed and reimbursement rates across eight participating EDs.

Results: A total of 2,520 naloxone kits were dispensed across eight EDs between January 2019-December 2024, with a total of 6,551 encounters with decision support prompting naloxone ordering (31.6% of eligible). The proportion of kits reimbursed by insurance rose from 46% in 2019 to 95% by 2025. In total, 89.9% of kits were reimbursed either by insurance or public supply (the rest paid by the hospital system). Kit distribution grew from 99 in 2019 to 702 in 2024, reflecting expanded site participation, improved workflows, and greater staff engagement.

Conclusion: A reimbursable ED-led naloxone program can increase access to life-saving medication for patients at risk of opioid overdose. Integrating take-home naloxone distribution into EHR workflows, leveraging insurance billing, and partnering with public health agencies offers a sustainable, low-barrier model that other health systems can adopt.

Introduction: Poisoning-induced out-of-hospital cardiac arrest (P-OHCA) is a leading mortality cause; however, no specific prognostic model exists for P-OHCA. In this study we aimed to develop and validate a novel scoring system, the WAIVOR score, which identifies factors associated with survival to hospital discharge in patients with P-OHCA, including the nature of the toxic agent.

Methods: In this retrospective nationwide observational study we analyzed 4,252 South Korean adult P-OHCA cases from 2013-2023. The study population was randomly stratified into derivation (n = 2,834) and validation (n = 1,418) cohorts. Independent factors associated with survival to hospital discharge were identified through multivariable logistic regression analysis, yielding adjusted odds ratios (aOR) and 95% confidence intervals (CI). We assessed the scoring system's discriminative performance using the receiver operating characteristic curve and area under the curve (AUC) analysis, with optimal threshold determination via the Youden index.

Results: Among all patients, 291 (6.8%) survived to hospital discharge. The most frequent poisoning substances were gases/vapors (45.3%), pesticides (31.5%), and medically prescribed drugs (12.0%). Six independent factors associated with survival to hospital discharge were incorporated into the WAIVOR score (maximum 11 points): pre-hospital return of spontaneous circulation, four points (aOR 16.11, 95% CI 10.16-25.64); witnessed arrest, two points (aOR 3.86, 95% CI 2.61-5.71); age < 65 years, two points (aOR 3.34, 95% CI 2.20-5.15); female sex, one point (aOR 1.54, 95% CI 1.09-2.16); and arrest-to-emergency department intervals ≤ 30 minutes, two points (aOR 3.44, 95% CI 2.00-6.09; 31-60 minutes, one point (aOR 1.77, 95% CI 1.08-3.02); and poisoning by non-gas/non-vapor substances, one point (aOR 0.54, 95% CI 0.33-0.89). The WAIVOR score demonstrated robust discriminative performance (AUC: 0.823 and 0.739 in derivation and validation cohorts, respectively). At the optimal threshold of five points, the score demonstrated 53.6% sensitivity, 84.4% specificity, 19.8% positive predictive value, and 96.2% negative predictive value (NPV).

Conclusion: The WAIVOR score represents a practical tool whose associated factors may help assess potential for survival to hospital discharge in patients with P-OHCA. Its high NPV renders it valuable for identifying poor prognostic outcomes. However, further external validation studies are required before this score can be broadly used in decisions regarding resuscitation termination in clinical practice.

Introduction: Although humility is a key leadership trait linked to collaboration and trust, current residency application processes lack methods to identify it. By examining whether themes of humility appear in the Standardized Letters of Evaluation (SLOE) of medical students who later became emergency medicine (EM) chief residents, we sought to determine the presence of humility-related traits in SLOEs and explore their potential to inform the identification of applicants with leadership potential during residency selection.

Methods: Two independent reviewers examined 104 SLOEs (52 chief, 52 non-chief) from 2015-2021, representing 43 students (21 who later assumed chief resident positions and 22 who did not) between 2018-2024 at a single academic EM residency program. A third reviewer resolved all coding disagreements. Reviewers deductively analyzed all written comments, targeting elements associated with humility as conceptualized by Tangney (2000) and Gruppen (2015). A SLOE was categorized as containing elements of humility if at least one clearly defined construct (such as openness to feedback, recognition of limitations, or concern for others) was identified. Sections of the data displaying the most convergence of humility elements underwent open coding, revealing emerging themes.

Results: Nineteen of 21 (90.5%) chief residents had letters encompassing elements of humility compared to only 10 of 22 (45.5%) non-chief residents (P < .01). Openness was the most prominent element noted, followed by the need to make changes in performance, concern for others, and confidence. Further analysis of comments that highlighted humility uncovered several other themes including commitment and advocacy, eagerness to learn and improve, and maturity and responsibility.

Conclusion: This study highlights specific humility-related traits noted in the Standard Letters of Evaluation of fourth-year medical students who later became chief residents in emergency medicine, offering preliminary insights into how qualitative evaluation tools may capture characteristics associated with future leadership roles.

Introduction: Deimplementation is the process through which an existing practice, procedure, or protocol is discontinued. Past deimplementation efforts in emergency medical services (EMS), such as reduction of liberal oxygen administration, backboard use, and lights and sirens responses, have been slow in rates of change and had varying levels of adoption. Our objective in this study was to analyze the deimplementation of albuterol administration in the beginning of the 2019 novel coronavirus (COVID-19) pandemic for the adoption of deimplementation guidelines, rate of change, and factors leading to this change in EMS practice.

Methods: Using the 2020 National Emergency Medical Services Information System (NEMSIS) dataset, we analyzed the change in EMS calls with albuterol administration following the US Centers for Disease Control and Prevention (CDC) advisory recommending limiting aerosol-generating procedures in response to the COVID-19 pandemic.

Results: The 2020 NEMSIS dataset included 43,488,767 total records, and 449,290 (1.0%) records included at least one albuterol administration. Calls with albuterol administration dropped 61.7% in a near-linear fashion in the six weeks following the publication of the CDC's guidance (from March 8-April 18, 10,426 absolute reduction; from 16,891 to 6,465, in average calls per week with albuterol administration). In the period before the guidance, there were on average 16,891 calls with albuterol administration of 640,597 (2.6%) calls per week. In the period after the guidance, there were, on average, 6,465 calls with albuterol administration of 601,943 (1.1%) calls per week. Therefore, while total EMS calls declined by 6% during the transition period, the proportion of albuterol calls within this decline went down by 1.5% (2.6% to 1.1%), reflecting rapid deimplementation.

Conclusion: Deimplementation of albuterol administration in the beginning of the COVID-19 pandemic was significant in its rate and success in adherence to guidelines when compared to other changes in EMS policies, procedures, and protocols. A better understanding of deimplementation can guide future EMS efforts to phase out ineffective practices while minimizing disruption to care.

Introduction: Transfers between emergency departments (ED) can have an important impact on patient care and experience. We examined interfacility transfers from an academic ED due to insurance status to determine whether they disproportionately affected minority demographics.

Objective: Our objective was to determine whether interfacility transfers for non-contracted insurance status disproportionately affected minority patients in our hospital ED.

Methods: We extracted data from the hospital's electronic health record system. Records for patients who underwent facility transfer were reviewed to determine which transfers were due to insurance contracting status. We compared the number of patients transferred for insurance incompatibility with the number admitted to the same hospital as initially seen in the ED, either to observation or inpatient status, for groups with socioeconomic minority status including Hispanic, Hispanic non-White, Black, Native American, and non-English speaking.

Results: We identified 2,031 total interfacility transfers. Of these, 735 (36.2%) met inclusion criteria, and 49.7 % (366/735) of these transfers were due to insurance incompatibility. The total transfer rate for all patients was .93% (366/39,299). Increased transfer rates due to insurance incompatibility were observed for all minority demographics queried. The most severe disparity in effect size was for non-English speakers (2.06% compared to 0.90% for English-speakers; 2.32 odds ratio [OR], P < .001). Patients with Hispanic ethnicity experience insurance transfer in 1.31% of cases compared to 0.87% for non-Hispanic whites (OR 1.52, P < .001). The insurance transfer rate for all non-White patients was elevated at 1.11%, but this did not rise to the level of statistical significance (OR 1.28, P = .06).

Conclusion: In our single-center ED study, minority patient populations were disproportionately impacted by interfacility transfers for non-contracted insurance status. We found increased transfer rates due to insurance incompatibility for all minority demographics queried. The most severe disparity was found for non-English speakers and patients with Hispanic ethnicity.

Introduction: Timely documentation of a patient encounter is a necessary component for delivering high-quality healthcare as it has direct impacts on continuity of care. The use of voice recognition software has been integrated into the electronic health record (EHR) to increase efficiency of documentation. We aimed to investigate the impact of dictation use on emergency medicine (EM) residents' time to note completion.

Methods: We conducted this study in a three-year EM residency program at an academic emergency department. Notes written in the EHR by EM residents were included for analysis. We split notes into two cohorts based on academic year: 2018-19 academic year (AY18-19); and 2021-22 academic year (AY21-22). We analyzed approximately 37,000 notes per cohort. Dictation was available to all residents in each cohort. The length of the note (measured by character count) and time to note completion (less than or greater than 24 hours) was analyzed.

Results: For both the AY18-19 and AY21-22, the rate of note completion within 24 hours was higher when using dictation compared to typing (odds ratio [OR] 1.3 and OR 2.9, respectively). Aggregated data of both cohorts showed 77.9% of dictated notes were completed within 24 hours compared to 70.9% of typed notes (P < .001). In both cohorts, the average number of characters per note was larger if the note was dictated. For AY18-19, the average was 6,628 characters for dictated notes vs 6,136 for typed notes (P < .05). Similarly, for AY21-22, the average was 6,531 vs 6,347 (P < .05).

Conclusion: The use of dictation by EM residents for note completion resulted in a higher likelihood of the note being completed within 24 hours.

Introduction: Emergency departments (ED) have increasingly engaged in screening and treatment initiation for patients with opioid use disorder (OUD). Patients with OUD, however, may also be impacted by significant social need, including housing insecurity. We sought to consider the incidence of homelessness and housing insecurity in patients engaged in an ED-initiated medication for opioid use disorder (MOUD) program.

Methods: We performed a secondary analysis, with specific consideration of housing status, on data obtained from a prospective, ED-initiated MOUD study conducted at an urban, academic hospital, inclusive of enrollments from July 2019-February 2022. We obtained data from participant interviews conducted at study intake and at three months to include the question: "In the past 30 days, where have you been living most of the time?" We used descriptive statistics and Pearson chi-square analyses to assess the data.

Results: Of 315 participants, most were White (79.4 %), male (64.4 %), and between the ages of 25-44 (74.6%). At intake, 66 (20.9%) reported active homelessness, including 44 (14.0%) unsheltered. An additional 157 (49.8%) met criteria for housing insecurity. Men were more likely to be experiencing homelessness (25.1% men reported homelessness vs 13.4% women, P = .01). In contrast, women trended toward housing insecurity more than their male counterparts (45.8% men with housing insecurity vs 57.1% women, P = .05). At three-month follow-up, 141 were able to be reached, with a predominance of housed individuals (118 housed; 46.8%); in contrast only 34.8% of persons experiencing homelessness) (23 participants) were able to follow up at three months (P = .07). Significant differences between sexes noted at intake resolved. No significant differences were found at intake or three months when considering race or age comparisons.

Conclusion: Patients in the ED who are engaged in care for OUD are disproportionately (70.8%) impacted by homelessness and housing insecurity; further, sex may play an exacerbating role. Emergency department-initiated MOUD treatment may have a positive impact on housing status, suggested by this study; however, the study was limited due to large loss to follow-up, especially among those with housing insecurity.