Western Journal of Emergency Medicine最新文献

Introduction: Most patients with acute coronary syndrome (ACS) die before hospitalization. Early diagnosis and effective interventions can prevent the disease from worsening. In this single-center, retrospective study we aimed to investigate the appropriateness of the pretreatment of patients referred to the emergency department of our hospital, a percutaneous cardiac intervention (PCI) center, with a prediagnosis of ACS under the previously published European Society of Cardiology guidelines (2017 and 2020) and the new guidelines published in 2023.

Methods: Based on the date of publication of the European Society of Cardiology's most recent ACS guidelines (August 25, 2023), we divided patients admitted between August 25, 2022-August 24, 2024, into two groups: patients who were evaluated and received pretreatment under the previous guidelines; and patients who were evaluated and received pretreatment under the new guidelines.

Results: Of 1,675 patients screened for enrollment who were referred to our PCI center with prediagnosis of ACS, after exclusion criteria, we report on 1,450 (86.6%). Pretreatment (before PCI) compliance rate with all aspects of the previous and new guidelines was low, at 9.8%. Study patients were 69.9% (n = 1,013) male with mean age of 63.9 ± 13.0 years. Comparing the compliance rate between the new versus previous guidelines, for individual components, we found better compliance for aspirin administration (72.6 vs. 66.2%) and anticoagulants (40.3 vs. 22.7%), while for P2Y12 inhibitors, we found lower compliance (58.9 vs. 70.0%, all p< .001). For the subset of patients with ST-elevation myocardial infarction, P2Y12 inhibitors were used less appropriately under the new vs. previous guidelines (31.4 vs. 55.0%, p < .001).

Conclusion: The compliance rates with the previous and new guidelines for ACS pretreatment by physicians working in hospitals without PCI centers were low. Pretreatment compliance during the new guideline period was lower than compliance during the prior guideline period.

Introduction: Using simulation-based medical education has proven to be an effective instructional strategy both procedurally and clinically. Emergency medicine (EM) residency programs use simulation in a variety of ways and settings. Given the ongoing development of the field and the recent expansion of EM training programs, our objective was to assess the current state of simulation use in Accreditation Council for Graduate Medical Education (ACGME)-approved EM residency programs in the United States.

Methods: We performed this cross-sectional national survey from July-September 2022. The survey was sent to the residency program directors of all 277 ACGME-accredited EM residency programs in the US. The survey focused on simulation use, technology, types of simulation (procedural vs case-based), barriers to growth, and overall sentiments regarding simulation in EM.

Results: We attempted to contact 277 programs, successfully reaching 244. We received a total of 100 responses (36%). Nearly all responding programs reported access to a dedicated sim center (95.8%), with available high-fidelity manikin simulators (93%) and task trainers (90%). Most programs engage in simulation didactics monthly (50%), followed by more than monthly (22%) and quarterly (19%). Barriers to simulation implementation included funding, simulation lab availability, and equipment. Programs frequently used simulation to perform the majority of rare but required procedures, and about half of the programs responding reported simulation fellowship-trained faculty on staff.

Conclusion: Simulation education is an important aspect of EM residency and training. Most residency programs reported dedication and resources to developing and integrating simulation into their curriculum. There is likely room for its further use in residency program training in the coming years as residency programs continue to expand.

Introduction: Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process.

Methods: We screened the medical records for patients presenting to the ED of an urban public hospital between 2016-2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics.

Results: A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition.

Conclusion: In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

Background: Emergency medicine (EM) physicians commonly use the National Institutes of Health Stroke Scale (NIHSS) to assess acute ischemic strokes in community settings. However, this assessment is often led by neurology residents in academic teaching hospitals. We implemented a quality improvement intervention to improve EM resident comfort with the NIHSS and to assess if EM resident-led NIHSS evaluation prolonged key stroke metrics, such as door-to-CT (DTCT), door-to-needle (DTN), or door-to-groin puncture (DTGP) times, which may affect stroke outcomes.

Methods: This prospective observational comparison analyzed all patients with acute ischemic strokes at the Zuckerberg San Francisco General Hospital, a Level I trauma center from April 2021-October 2022. We implemented the intervention from April 2022 -October 2022 which included NIHSS certification for all residents and attendings. Both EM and neurology residents recorded NIHSS scores separately for each patient and scores were revealed to each resident during patient care once completed. We then compared stroke metrics between pre- and post-intervention periods.

Results: There were 247 and 122 strokes included in our analysis, pre- and post-intervention, respectively. Overall, 58% (n=213) of all patients were female, 33% were Asian (n=123), and Cantonese was the second most common language after English (15%, n=54). Mean overall NIHSS scores were similar between EM and neurology residents, 6.6 (IQR = 2, 10) and 6.7 (IQR = 1, 10), (p < 0.001), respectively, with substantial agreement between groups (84.4%, κ = 0.63). Median DTCT times were 25 and 28 minutes (p=0.2), DTN times were 38 and 35 minutes (p=0.7), and DTGP times were 94 and 110 minutes (p=0.1) for pre- and post-intervention groups, respectively.

Conclusion: The NIHSS is one element of stroke evaluation and management that can impact stroke metrics. Our intervention found that EM resident-led NIHSS assessment did not prolong DTCT, DTN, and DTGP times and met nationally established goals.

Introduction: Frequent users are a small but important group of patients in the emergency department (ED). This group is often the target of interventions that redirect visits to other areas of the healthcare system under the premise that some of these visits could be best managed elsewhere. Most existing interventions do not consider sociodemographic factors when targeting specific populations, while larger scale policy initiatives often do not reach those who would most benefit from alternative points of healthcare access. In this study we use population-level survey data linked to health administrative data to describe frequent ED users and those whose visits are potentially avoidable and could benefit from additional points of healthcare access.

Methods: This was a population-based cohort study of responses from 18-74 year-old Ontario residents to the Canadian Community Health Survey from 2001-2014, which we linked to administrative health data for one-year following survey completion. We categorized participants according to the frequency of their ED use in the year following survey date and whether any of their visits were potentially avoidable. Associations between category of ED use and various sociodemographic, health, and behavioural factors were examined with multinomial logistic regression.

Results: A total of 181,369 eligible respondents were included in this study. Of these, 1,460 (0.8%) were frequent users (four or more visits) with one or more potentially avoidable visits in the year following survey date. Compared to non-ED users, frequent users with avoidable visits were associated with the lowest quintile of household income (aOR: 1.91, 95% CI: 1.37, 2.65), rural-dwelling (aOR: 1.44, 95% CI: 1.18, 1.77), and the highest quintile of material resource deprived neighbourhoods (aOR: 2.23, 95% CI: 1.47, 3.36). They were more likely to have poor self-reported physical (17.2% vs 9.0%) and mental health (4.1% vs 2.7%) compared to total cohort, and more likely to have comorbidities (63.3% vs 48.7%), but less likely to access a usual provider of care for their healthcare needs (33.3% vs 28.2% without a usual provider of care).

Conclusion: This study provides a novel description of frequent ED users for whom some of their visits were potentially avoidable. As efforts are made to redesign access to primary and community care, and with increasing emphasis on virtual care and other initiatives to reduce avoidable ED use, the healthcare system should ensure that these interventions are responsive to the needs of the people at higher likelihood of needing them.

Introduction: Workplace violence (WPV) is a significant occupational hazard in healthcare, with emergency departments (EDs) recognized as high-risk environments. Although globally significant, data from Latin America remain scarce. In this study we aimed to evaluate the prevalence and effects of WPV on healthcare workers in Brazilian EDs.

Methods: We conducted a cross-sectional survey of healthcare workers in Brazilian EDs. Respondents indicated verbal and physical violence experienced within the preceding six months, along with associated psychological and occupational impacts. Univariable models identified significant associated factors, followed by multivariable models to determine independent associated factors of WPV. We reported results as adjusted odds ratios (aOR) with 95% confidence intervals. Statistical analyses were performed in R v4.4.1, and significance was defined as P < .05.

Results: The response rate was 19.1% (1,255/6,570), Of those responses, 61.3% (769/1,255) met the inclusion criteria and were included in the analysis. Of all respondents, 84.0% were physicians. Respondents indicated 79.6% (612/769) occurrence of WPV, including verbal abuse (79.5%) and physical assault (12.1%). Physical assaults against co-workers were witnessed by 40.3% of respondents. Perpetrators included visitors (85.3%), patients (80.7%), and co-workers (35.8%). The absence of institutional preventive measures was associated with increased WPV (aOR, 2.47; 95% CI, 1.71-3.57; P < .001), while the presence of security staff reduced WPV (aOR, 0.61; 95% CI, 0.42-0.89; P = .01). Indicated impact included post-traumatic stress symptoms (88.4%), considering leaving their job (49.5%), impaired workplace performance (75.2%), and time off work (10%), including 11.5% permanently leaving.

Conclusion: Workplace violence is highly prevalent in Brazilian EDs, with substantial psychological and occupational consequences. The absence of protocols or preventive measures may increase WPV risk, emphasizing the urgent need for public policies to protect healthcare workers in emergency settings.

Introduction: Intraosseous (IO) vascular access is commonly used when critically ill patients require rapid indirect venous access for the infusion of fluids and medications. The proximal tibia (PT) IO insertion site has been shown to be associated with the highest first-attempt placement success rates. However, inadequate catheter length continues to contribute to failure of IO line placement. In this study, we compared patient characteristics to the depth of soft tissue at the PT insertion site, to determine whether any specific patient subgroup may be at high risk for excessive pre-tibial soft tissue depth.

Methods: Patients were enrolled retrospectively from the medical records of adult (≥ 18 years old) subjects who had undergone computed tomography (CT) imaging of the lower extremity. We calculated the pre-tibial soft tissue depth according to a predefined method using CT images. Data were abstracted into a standardized data collection form prior to analysis. Variables including side, age, sex, body mass index (BMI) and comorbidities (i.e., hypertension, diabetes mellitus, atherosclerosis, coronary artery disease, osteoarthritis) were collected and analyzed.

Results: A total of 368 patients were included in the final data analysis. Increased BMI, height and weight had a statistically significant increase in pre-tibial soft tissue depth. Analyzing patients within groups based on this tissue depth (>40 mm, 20-40 mm, <20 mm) showed that height was the only quantitative variable to have a significant association with pre-tibial soft tissue depth measurements between the >40 mm and 20-40 mm groups with a negative correlation. While female sex was associated with a statistically significant increase in pre-tibial soft tissue depth, no such effect was seen with any of the recorded comorbidities.

Conclusions: Female sex, short height, and high weight / BMI appear to be correlated with increased soft tissue thickness at the proximal tibial intraosseous insertion site. Longer catheter sizes may be required for proximal tibial intraosseous cannulation in obese patients, and for female patients when compared to male patients with the same BMI.

Introduction: Firearm injuries have become increasingly more common in the pediatric population; however, there is a paucity of literature examining the management of these pediatric firearm-related injuries (FRI) specifically as they affect the upper extremity. This study identifies demographic and environmental risk factors in pediatric upper extremity FRIs and evaluates the severity of injury, concomitant injuries, and rates of surgical intervention in pediatric patients treated at a Level I pediatric trauma center over 20 years.

Methods: We completed a retrospective analysis on 540 patients <18 years of age with FRIs at a single institution from 2001 - 2020. Of these, 72 (13%) had FRIs involving the upper extremity. The patients were stratified into groups based on whether they had received operative intervention or a bedside procedure for their injury and on their year of presentation between two decades (2001 - 2010 vs. 2011 - 2020). We obtained upper extremity injury-specific variables along with hospital demographics. The primary outcomes in this study included hospital length of stay, number of bullet wounds, motor and sensory deficits, and amputation.

Results: In the last 10 years, the rate of upper extremity FRIs observed in the pediatric population has increased by 380% at our institution (15 vs. 57, P < .001). After 2010, cases were more likely to present with an increased number of gunshot wounds per patient (1.14 vs. 1.98, 95% confidence interval [CI] -0.94 - 0.24, P = .03) but were less likely to require admission to the intensive care unit (19% vs. 67%, P < .001). When stratifying by intervention, both the operative intervention and bedside procedure groups had a similar number of gunshot wounds (1.86 vs 1.76, 95% CI -0.52 - 0.43, P = .86). The operative intervention group was more likely to have had a soft tissue injury (68% vs. 35%, P = .005) and motor deficit at follow-up (45% vs.15%, P =.02). Patients in the operative intervention group had longer lengths of stay (9.66 vs. 2.25 days, 95% CI -1.16 - -0.21, P < .01) and more morbid injuries despite similar patient demographics.

Conclusion: In the last decade, an increased frequency of pediatric upper extremity firearm-related injuries was noted despite a stagnant state population. Emphasis should continue to be placed on education and improving firearm safety in settings in which children are present.

Introduction: Urgent care centers (UC) play an important role in addressing non-emergent health concerns, offering a convenient alternative to emergency departments (ED). However, accessibility to UCs can vary based on transportation availability and socioeconomic factors. In this study we evaluated the geospatial accessibility of UCs and EDs in Milwaukee County, Wisconsin, and sought to characterize the relationship between transit options, socioeconomic vulnerability, and access to care.

Methods: We included 13 EDs and 13 UCs in the study. Public and private transit times between census tracts in Milwaukee County and the nearest UC or ED were calculated using an application programming interface that recorded data from Google Maps. We employed socioeconomic vulnerability index (SEVI) scores to define community vulnerability. Statistical analyses, including Mann-Whitney U tests and Pearson correlation coefficients, were used to determine differences in commute times and their relationship with socioeconomic status.

Results: Private transit times were shorter than public transit times when commuting to the nearest ED (7 minutes vs 22 minutes, P <.001) and the nearest UC (9 minutes vs 31 minutes, P < .001). The EDs were generally more accessible than UCs, with shorter transit (22 vs 31 minutes, P < .001) and walk times (11 vs 14 minutes, P <.001). Socioeconomically disadvantaged communities with higher SEVI scores had longer private transit times to UCs (r = 0.17, P = .003) while having shorter public transit times to EDs (r = -.21, P < .001).

Conclusion: Access to urgent care centers and EDs in Milwaukee County is influenced by socioeconomic factors and transportation modes. While EDs are more accessible to socioeconomically vulnerable communities, UCs are less accessible, which may contribute to higher ED utilization for non-emergent needs. These findings highlight the need to address transportation limitations as a social determinant of health that can impact how disadvantaged populations seek care and the implications for non-emergent ED use and ED crowding.