Western Journal of Emergency Medicine最新文献

Introduction: The emergency department (ED) serves as an entry point to the healthcare system for many patients, and the increased use of advanced imaging has resulted in identification of masses of unclear significance. We describe patients presenting to an ED who were referred to an undiagnosed mass clinic (UMC).

Methods: We performed a retrospective observational cohort study of patients ≥16 years of age presenting to Mayo Clinic in Jacksonville, Florida, from October 31, 2018-March 31, 2023, who were referred to the UMC.

Results: There were 116 patients referred to the UMC with a median of 3.5 days from ED encounter to clinic date and a median of 14.5 days from ED encounter to biopsy. Using an analytic tool in the electronic health record, we estimated that of 16,872 patients, 116 (0.69%) Mayo Clinic Florida (MCF) ED patients ≥18 years of age who received computed tomography and were discharged from the ED were referred to the UMC. Ultimately, 35 of 65 patients (53.8%) seen in the UMC received a cancer diagnosis.

Conclusion: Our study shows a viable care path from ED encounter to undiagnosed mass clinic. Further research is needed to ensure timely transitions of care for patients who are uninsured or out of network.

Introduction: Geriatric emergency medicine (GEM) has emerged as a subspecialty of emergency medicine (EM) with seven fellowships available throughout North America and opportunities for career development in administration, clinical leadership, education, and research. Our objective in this study was to ascertain the perspectives and understanding of the subspecialty among EM trainees.

Methods: We recruited participants from four geographically diverse institutions. Three institutions were academic and had GEM faculty or divisions, and the fourth institution was a community site without geriatric-specific faculty. We conducted semi-structured interviews, adapted from a prior protocol, via teleconferencing and subsequently transcribed them. Codes were generated by two investigators and categorized into themes derived from the data.

Results: Seventeen trainees with an average age of 32.1 years across four institutions participated in the study. Three themes emerged, demonstrating that trainees' perceptions of GEM were affected by 1) education and exposure; 2) perception of geriatrics; and 3) future career considerations. Trainees with exposure to GEM had greater appreciation for the specialty, but their understanding of career opportunities was mixed. Participants acknowledged broader clinical and social considerations for older adults and in general felt that specialty training would benefit older patients. However, most participants had no personal interest in pursuing GEM, with reasons for disinterest including belief that they would only see older patients, dislike of geriatric complexity, and uncertainty about GEM as a career. Many participants identified educational opportunities for GEM, including noting that curricula include dedicated time for other subspecialties such as pediatrics but not geriatrics. Fellowship decisions were influenced by duration of training, salary, job opportunities, practice settings, and career goals.

Conclusion: Emergency medicine trainees who participated in semi-structured interviews overall viewed geriatrics as an important aspect of EM with perceptions formed from exposure and education at both the institutional and individual level, perceptions of treating older adults, and future career considerations. However, interest in pursuing GEM was overall low, and participants expressed uncertainty about the subspecialty and career options, indicating opportunity for increased awareness, education, and mentorship.

Introduction: Rib fractures are common in patients with blunt thoracic trauma, and their associated pain causes significant morbidity and mortality. Adequate analgesia is crucial to prevent rib fracture-associated pulmonary complications. However, current analgesic modalities have drawbacks, and the optimal analgesia protocol remains elusive. Intravenous (IV) lidocaine infusions have a well-established safety profile and efficacy in other patient populations and may benefit patients with traumatic rib fractures. To better understand current practices and to inform the design of a multi-centre trial, we believe that a study to determine Canadian trauma centres' current analgesic practices is warranted. This study describes the current familiarity and use of IV lidocaine infusions for management of rib fracture pain. Secondary outcomes included the identification of common Canadian analgesic protocols for rib fractures and willingness to participate in a future multi-centre trial of lidocaine for these traumatic injuries.

Methods: We distributed an online survey to 14 Canadian trauma centres. Study questions were designed to address four themes: trauma centre characteristics; pain management strategies; current use of IV lidocaine infusions; and interest in future study participation. The analysis included a frequencies analysis and a thematic analysis of descriptions.

Results: The medical directors of 12 trauma centres (85%) responded. Six of those centres (50%) experience > 450 annual trauma admissions with Injury Severity Scores > 12. Six sites (50% of respondents) have a rib-fracture analgesic protocol. Four centres (33% of respondents) frequently use IV lidocaine for rib fractures, and 10 (83% of respondents) believe further research with IV lidocaine is needed.

Conclusion: Canadian trauma centres' current practices for rib-fracture pain management are variable. Prospective work is needed to evaluate IV lidocaine as an analgesic for traumatic rib fractures.

Introduction: We assessed the prevalence of burnout syndrome among emergency physicians and advanced practice practitioners (APP) in an academic emergency department (ED) to identify demographic and lifestyle factors associated with burnout.

Methods: We administered a cross-sectional survey including the Maslach Burnout Inventory (MBI) with a demographic/lifestyle component to emergency physicians, residents, and APPs at an academic ED. We reported descriptive data and performed chi-square analysis to identify significant variables, followed by logistic regression to quantify their effects. A factor count was performed to assess for additive effects of burnout risk factors.

Results: We collected 55 surveys (60% response rate) yielding an overall burnout prevalence of 52.7%. The following had a significant association with burnout: 0-6 days off per month; fewer than two major hobbies; thoughts of quitting one's job "at least some of the time"; and spending less than four hours outdoors per week. Zero to six days off per month was associated with 4.70 times more burnout compared to ≥7 days off per month (95% confidence interval [CI] 1.24-17.82). Participants who met 3-4 vs 0-2 of the previously mentioned conditions had a 6.87 times increased burnout prevalence (95% CI 2.01-23.52).

Conclusion: This preliminary study highlights four unique factors associated with burnout. It also demonstrates that a specific number of days off may reduce burnout prevalence. Emergency department wellness efforts should consider focusing on strategically scheduling time off each month while encouraging individual habit generation and time spent outdoors to maximize burnout protection. Further research is needed to evaluate the efficacy of the proposed interventions.

Introduction: Climate change has significantly impacted human health worldwide, contributing to the rise of emerging infectious diseases, allergies, pollution, natural disasters, non-communicable diseases, and malnutrition. One crucial but often overlooked area where climate change has had a notable effect is upon interpersonal violence.

Methods: Following PRISMA guidelines, we searched PubMed and Epistemonikos for studies measuring the effect of temperature on violence. Inclusion criteria encompassed peer-reviewed, English-language articles reporting an association between temperature and violence. Data extraction focused on various forms of violence including homicides, assaults, sexual assaults, suicides, intimate partner violence, riots, and civil wars, and we assessed article quality using Joanna Briggs Institute criteria.

Results: We included a total of 37 studies from 11 countries, three subcontinental regions, and two global-level analyses in this review. Of these, 46% originated from the United States. Rising ambient temperatures were significantly associated with increases in homicides (10 studies), assaults (15 studies), sexual assaults (8 studies), firearm violence (5 studies), intimate partner violence (9 studies), and suicides involving violent methods (9 studies). Conversely, no association was found between temperature and non-violent crimes. Civil wars and riots were also linked to temperature increases in all relevant studies. A meta-analysis of eight studies on violence showed that each 1°C increase in ambient temperature results in 1.64% (95% CI 1.23-2.19%) increase in violence (P<.01).

Conclusion: This review demonstrates a significant association between rising temperatures and increased worldwide incidents of violence and self-harm. These findings underscore the urgent need for public health strategies and interventions to mitigate the societal and health impacts of climate change-induced temperature increases.

Introduction: The global incidence and severity of severe heat illness is on the rise. The increasing number of summer heatwaves in Phoenix, Arizona, gave us a distinctive opportunity to better understand the impact on the clinical presentation and management of acute heatstroke. Our primary objective in this study was to describe the prehospital and emergency department (ED) clinical presentation, treatment, and outcomes of patients with acute heatstroke at a single hospital system during the summers of 2021 and 2022 in Phoenix.

Methods: This was a descriptive, retrospective observational study of heatstroke-associated adult ED presentations occurring from June 1 - August 31, 2021 and June 1 - August 31, 2022, to a single hospital system in Maricopa County.

Results: We identified 60 ED heatstroke encounters. The median environmental daily maximum (Tmax) and minimum (Tmin) were 106.0° Fahrenheit (interquartile range [IQR]) 102.0 - 109.0°F) and 84.0°F (IQR 79.0 - 88.0°F), respectively. The patients were commonly male (42, 70.0%, 95% CI 56.8 - 81.2%), White (26, 43.3%, 95% CI 30.6 - 56.8%), middle-aged (mean 52.7 years, 95% CI 48.4 - 56.9), Medicaid-insured (37, 61.7%, 95% CI 48.2 - 73.9%), and presenting via emergency medical services (60, 100%). Patients were commonly of high acuity (median Emergency Severity Index 1, IQR 1.0 - 2.0), and intubated (45, 75.0%, 95% CI 62.1-85.3%). Forty-seven (78.3%, 95% CI 65.8 - 87.9%) patients were found unresponsive outside with associated substance use (methamphetamines 22, 46.8%, 95% CI 32.1 - 61.9%; and fentanyl 14, 29.8%, 95% CI 17.3 - 44.9%). The average patient Tmax at ED presentation was 41.9°C (IQR 41.1 - 42.2). Forty-one patients (68.3%, 95% CI 55.0 - 79.7%) survived to hospital discharge or transfer, of whom 32 (82.1%, 95% CI 66.5 - 92.5%) were neurologically intact.

Conclusion: During the summers of 2021 and 2022, a significant number of heatstroke presentations were treated in a single healthcare system in Maricopa County, Arizona. A substantial number were successfully treated with cold water immersion and discharged neurologically intact. In this urban population, extreme weather exposure and associated substance use appeared to play significant roles.

Improving resident teaching skills is an expectation of training. Despite the recognized importance of resident-as-teacher (RaT) curricula, variability indicates the need for evidence-based guidelines to inform best practices. This paper outlines expert guidelines for the development, implementation, and evaluation of RaT curricula from the members of the Council of Residency Directors in Emergency Medicine Best Practices Subcommittee, based on a critical review of the literature. It is important to perform a needs assessment prior to creating and implementing a RaT curriculum. The RaT curricula should include instruction on adult learning theory, feedback, and classroom and bedside teaching techniques. Outcomes of RaT curricula should be assessed using multiple sources including direct observation and incorporate both knowledge and skill retention, as well as acquisition.

Introduction: Black and Hispanic patients, and patients with a preferred language other than English experience longer emergency department (ED) wait times and delays in treatment. We aimed to evaluate racial, ethnic, and language-based differences in wait times to see a physician and get a disposition, as well as in the rates of objective vs subjective urgent evaluations.

Methods: This was a retrospective study of all ED visits in our tertiary-care, academic medical center from July 2021-June 2023. Using electronic health record data, we compared time-to-physician, physician-to-decision times, and frequency of triggers (urgent evaluations based on objective criteria) and priority assessments (urgent evaluations that can be based on subjective perception of patient acuity) by race, ethnicity, and preferred language. We used logistic regression, controlling for age, Emergency Severity Index, and sex to compare differences in trigger rates.

Results: We included 93,728 patient encounters in this study. Black patients had a median time-to-physician of 31 minutes compared to 24 minutes for White patients (adjusted median difference (aMD) 3.2, 95% CI 2.4-3.9]) and a median physician-to-decision time of 228 minutes compared to 213 for White patients (aMD 15.0, 95% CI 12.0-17.9). Hispanic patients had a median time to physician of 31 (aMD compared to White patients = 3.4, 95% CI 2.4-3.9) and a median physician-to-decision time of 233 minutes (aMD compared to White patients 21.3, 95% CI 17.5-25.2). Patients with a preferred language other than English had a median time-to-physician of 33 minutes compared to 25 in English-preferring patients (aMD 4.6, 95% CI 3.7-5.6) and a median physician-to-decision time of 234 compared to 214 minutes for English-preferring patients (aMD 17.1, 95% CI 13.6-20.7). Black patients were less likely to have a trigger activated relative to White patients (adjusted odds ratio [aOR] 0.88, 95% CI 0.82-0.95). Black patients (aOR 0.72, 95% CI 0.67-0.77), Hispanic/Latino patients (aOR 0.78, 95% CI 0.71-0.86), and non-English-preferring patients (aOR 0.85, 95%CI 0.78-0.92) were less likely to have a priority assessment called compared to White patients.

Conclusion: Black, Hispanic, and patients who prefer non-English language experience delays in time-to-physician and physician-to-decision time. Black patients are less likely to have triggers activated. Black, Hispanic, and patients who prefer non-English language are less likely to have priority assessments activated compared to White patients. These findings underscore the need to develop additional mechanisms for mitigating biases in the triage process.

Introduction: The key role of emergency departments (ED) is to treat severe and life-threatening cases. A rise in ED visits, particularly for low-acuity conditions, places a burden on resources which may hinder efficient care for high-acuity conditions. We investigated the association between previous outpatient healthcare services use and low-acuity visits in EDs in Germany.

Methods: We analyzed data from the Initiative for Emergency Department Evaluation and Data Collection project, with 454,747 ED visits by 353,926 patients collected from 16 EDs in Germany in 2016. We included a subset of 228,753 (64.6%) patients with 299,914 (66.0%) visits from 12 of the participating EDs for which outpatient care data was available. We categorized ED presentations into low- or high-acuity based on transportation to the ED, triage category, hospital admission status, and intrahospital mortality. By merging patient hospital records with outpatient billing information, we assessed outpatient care utilization prior to ED visits. Using a generalized mixed-effects model, we investigated the relationship between acuity level and outpatient care utilization, adjusting for age, sex, and type of residential area.

Results: Low-acuity patients were considerably younger than high-acuity (mean age ± standard deviation: 45 ±19 vs 58 ±21 years) and used outpatient services less often within 10 days prior to their ED visit: 40.6% vs 49.5%. Key associations for low-acuity ED visits included younger age (per 10-year categories: adjusted odds ratios 0.72, 95% confidence interval 0.72-0.73), urban residence (1.17; 1.13-1.22), and timing of the last outpatient contact. Longer durations since the last outpatient contact were associated with a higher likelihood of presenting to the ED with low-acuity symptoms. Compared to patients who visited their primary care physician (PCP) shortly before their ED visit, those with PCP contact 1-6 months (1.22; 1.19-1.25) and over six months prior (1.33; 1.26-1.41) were more likely to present with low-acuity conditions.

Conclusion: While almost half of both low- and high-acuity patient groups utilized outpatient services prior to the ED visit, low-acuity patients were generally younger and had fewer such contacts. The majority had accessed both primary care and the ED, challenging the assumption that low-acuity patients routinely bypass outpatient care before seeking emergency services. This raises the question of what limitations or unaddressed needs in outpatient care drive these patients to seek subsequent care in the ED. More research is needed to explore the structural and systemic factors influencing low-acuity ED visits.

Introduction: Hypertension and diabetes are common cardiovascular disease risk factors among emergency department observation unit (EDOU) patients evaluated for acute coronary syndrome (ACS). Our primary aim was to determine rates of untreated hypertension and diabetes in the EDOU. Our secondary aim was to identify rates of glycemic control assessment among patients with diabetes.

Methods: We conducted a retrospective, observational cohort study of patients ≥ 18 years old evaluated for ACS in a tertiary care center EDOU from March 3, 2019-February 28, 2020. Known diagnoses prior to EDOU encounter and new outpatient diagnoses within one year for hypertension and diabetes were identified by health record data. We defined untreated hypertension and diabetes as no antihypertensive or antihyperglycemic prescriptions or diabetes counseling within one year. We calculated treatment rates with exact 95% confidence intervals (CI). Multivariable logistic regression adjusting for age, sex, and race compared treatment rates among men vs women and White vs non-White patients. Rates of glycemic control assessment were defined by the proportion of patients with known diabetes who received hemoglobin A1c (HbA1c) measurement within one year.

Results: Among 649 EDOU patients, 59.5% (386/649) were female and 43.8% (284/649) were non-White with a mean age of 59 ± 12 years. Of these, 76.9% (499/649) had known hypertension and 31.3% (203/649) had known diabetes. Within one year, 3.1% (20/649) had newly diagnosed hypertension and 3.2% (21/649) had newly diagnosed diabetes. Among those with known or newly diagnosed hypertension, untreated hypertension occurred in 36.4% (189/519; 95% CI 32.3 - 40.7). Hypertension treatment rates were similar in men vs women (aOR [adjusted odds ratio] 0.82, 95% CI 0.57 - 1.19) and White vs non-White patients (aOR 0.95, 95% CI 0.66 - 1.38). Among those with known or newly diagnosed diabetes, untreated diabetes occurred in 25.0% (56/224; 95% CI 18.5 - 31.2). Diabetes treatment rates were similar in men vs women (aOR 1.41, 95% CI 0.72 - 2.74) and White vs. non-White patients (aOR 1.05, 95% CI 0.56 - 1.97). At one year, just 32.0% (65/203) of patients with diabetes had HbA1c testing.

Conclusion: Given that many patients evaluated for acute coronary syndrome in the ED observation unit do not receive treatment for hypertension and diabetes within one year of presentation, clinicians should consider initiating EDOU-based preventive cardiovascular care for these conditions.