Western Journal of Emergency Medicine最新文献

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.

Introduction: The National Clinical Assessment Tool for Emergency Medicine (NCAT-EM) was designed to standardize medical student assessments during emergency medicine clinical rotations. While multiple assessment tools implemented in medical education have been prone to inequities, it remains unknown how student and rater demographics impact NCAT-EM scores. In this study we examined how a student's gender and status as under-represented in medicine (URM) affected NCAT-EM scores.

Methods: This was a retrospective cohort study of all NCAT-EM assessments of clerkship medical students at a single institution in 2022. We performed mixed-effect ordinal logistic regression analyses to determine the association between the seven NCAT-EM domains (history/physical, prioritized differential, formulation of plans, observation/monitoring, emergency management, communication, and global assessment) and student gender, as well as the NCAT-EM domains and students' URM status (specifically in domains of race and ethnicity). We adjusted our analyses for the site of rotation, time, the rater's role (attending or resident), and rater demographics (gender, URM status). We then evaluated the interaction in gender concordance and URM-status concordance on outcomes.

Results: A total of 1,881 NCAT-EM assessment forms were submitted on 142 students completed by 266 raters. There were no significant associations between student gender and NCAT-EM ratings across the seven domains. We found an association between URM students and lower scores in multiple NCAT-EM domains, including global assessment (odds ratio [OR] 0.50, CI 0.25-0.99, P = .01); history/physical (OR 0.38, CI 0.19-0.77, P = .01); and prioritized differential (OR 0.47, CI 0.26-0.88, P = .02). This effect was moderated by a significant positive interaction effect with URM concordance between raters and students in the prioritized differential and observation/monitoring domains.

Conclusion: This is the first study to highlight differences in both gender and status as under-represented in medicine within the nationally implemented NCAT-EM assessment tool. Women students were overall rated similarly across the NCAT-EM domains compared to men, with no association of gender on ratings. However, students' URM status was associated with lower scores in multiple NCAT-EM domains. This finding was mitigated by URM concordance between faculty and resident raters. Our findings support the need for additional studies to understand bias and inequities in the application of the NCAT-EM tool nationally.

Introduction: Demographic inequities in cardiovascular care have been well established, with evidence of effects from sex, age, and body mass index (BMI). For instance, women are less likely to receive guideline-based care for acute myocardial Infarction, bystander cardiopulmonary resuscitation, or recognition of cardiac arrest. We investigated the impact of patient sex, along with other patient demographics such as age and BMI, on the quality of focused cardiac ultrasounds (FOCUS). We hypothesized that females would have lower overall FOCUS quality and more frequently omitted apical four-chamber (A4C) views due to breast tissue. Secondary objectives included evaluating differences in image quality and omission rates by BMI, and by age and sonographer sex and training level.

Methods: In this multicenter, retrospective study we investigated 1,200 total adult patients (100 females and 100 males per site) at six participating sites. The FOCUS quality was determined by two blinded experts per site using a 1-5 ordinal scale per view (parasternal long, parasternal short, A4C, and subxiphoid). The primary outcome, overall quality, was the summed score of the four views, with a maximum score of 20. This scale was then collapsed into three categories for the individual FOCUS views: images inadequate to support diagnosis; images meeting the minimum to support diagnosis; and images supporting the diagnosis well. Secondary outcomes were A4C quality and omission rate. We evaluated associations between sex and FOCUS overall quality using unadjusted mixed-effects models followed by multivariable mixed-effects models adjusted for patient age, BMI, operator sex, and operator experience level.

Results: The A4C images of female patients were of significantly lower quality (P < .001) and had been omitted more frequently (P < .001); male patients had > 60% higher odds of a diagnostic A4C view (95% CI 1.3 - 2.0). Overall FOCUS quality decreased as BMI deviated from normal and as age increased. There was no significant difference in overall FOCUS quality between female and male patients.

Conclusion: We did not find sex-based differences in overall FOCUS quality; however, we did find that females received lower quality apical four-chamber views and had this view omitted more frequently. Additionally, overall quality declined as BMI deviated from normal, and as age advanced. Future research should elucidate the clinical implications of these differences in quality and the explanation behind not obtaining high-quality views in older patients, in individuals whose BMI deviated from normal toward either underweight or overweight, or in female patients.

Introduction: Syncope is a common emergency department (ED) presentation and frequently results in low-yield hospitalizations. The Canadian Syncope Risk Score (CSRS) is a validated risk stratification score that identifies 30-day risk of serious adverse events for patients presenting with syncope. In this retrospective, cross-sectional study we aimed to evaluate syncope admissions with the CSRS to determine potentially unnecessary hospitalizations.

Methods: We identified patient visits for syncope at 11 EDs from February 2019-January 2020. We excluded patients with additional serious diagnoses that would have independently required admission and those who were discharged. We then randomly sampled the remaining charts until finding 200 that met study inclusion criteria on full chart review. We retrospectively calculated CSRS via manual chart review and identified the proportion of patients with low-risk CSRS. We compared demographic characteristics between those with low- vs medium- and high-risk CSRS.

Results: We identified 5,718 adult patients hospitalized for syncope. Of these patient visits 3,999 were initially excluded, 336 were sampled, and 200 included for analysis. Of these, 39% (77/200, 95% CI 32-46%]) were low risk (CSRS < 1). Patients with low-risk CSRSs were younger (61.2 years vs 70.6 years of age; absolute difference [AD] 9.4 years; 95% CI 4.8-13.9), less likely to have heart disease (1.3% vs 61.8%; AD 60.5%, 95% CI -69.4% to -51.5%), and more likely to have substance use disorder (14.3% vs 4.9%; AD 9.4%, 95% CI 0.7-18.1%).

Conclusion: In this sample of patients hospitalized for syncope, 39% had low-risk Canadian Syncope Risk Score. Had the CSRS been used, these patients could have been safely discharged, as their estimated 30-day serious adverse event rate was < 1%. Wider adoption of the CSRS could potentially reduce unnecessary hospitalizations for patients with syncope.

Introduction: Alcohol intoxication is a common patient presentation to urban emergency departments (ED). There is limited data on the healthcare financial impact of caring for alcohol-intoxicated patients in the ED. In this study we examined the facility-based financial billings and collections related to ED visits for alcohol intoxication.

Methods: Using a retrospective cohort analysis of two large, urban EDs, with a combined yearly census of approximately 150,000 patient visits, we included all encounters between June 2018-December 2021 with a discharge diagnosis consistent with acute alcohol intoxication. We reviewed records of patient encounters with a final diagnosis consistent with acute alcohol intoxication who only had minimal or no interventions performed, implying the visit was solely consistent with acute alcohol intoxication. We reviewed the facility charges of these patients, along with insurance status and average payment by status to understand the financial impact.

Results: Of 495,436 patient presentations to the EDs during the study period, 13,454 met study criteria (2.7% of total patients). Patient length of stay in the ED had an average of 254 minutes and median of 240 minutes. In total, this cohort of patients occupied ED beds for 56,505 hours cumulatively, or an average of 43.2 bed hours per day for alcohol intoxication-related visits, representing 3.14% of all ED bed hours across both sites. The majority of patient encounters were billed as a level 3 facility code (76%). Facility charges for the cohort totaled $22,590,000. The estimated reimbursement based on the percentage reimbursed by payor mix was $1.7 million (7.5%), or an average of $126 per patient visit-less than one quarter of the general average visit collection.

Conclusion: Patients with acute alcohol intoxication and no other complaints are a minority of ED patients, yet their care results in substantial charges and ED resources. Based on the known facility collection rates per insurer, the weighted prevalence of insurers among this cohort yields an estimated collection rate of 7.5%. Opportunities to provide proven alcohol-related interventions should consider the unreimbursed costs of these visits when determining cost effectiveness.

Introduction: Patients with respiratory distress are frequently encountered in the emergency department (ED). Efforts to assess, initiate treatments, and stabilize these patients require a systematic and rapid response. Emergency physicians need a comprehensive and efficient approach for evaluating, treating, and managing patients presenting to the ED with moderate respiratory distress.

Methods: The American College of Emergency Physicians convened an expert panel of academic and community emergency physicians, critical care specialists, respiratory therapists, hospitalists, and pharmacists to develop and subsequently disseminate consensus recommendations regarding the diagnosis and treatment of patients with moderate respiratory distress presenting to the ED.

Results: A digital tool using a consensus-based framework was developed to aid emergency clinicians in diagnosing and caring for patients with moderate respiratory distress. The tool can be employed at each step in the diagnostic and treatment process.

Conclusion: The evidence-based tool is a practical and freely available bedside instrument for emergency clinicians to diagnose and treat patients with moderate respiratory distress. Further studies are needed to examine the effectiveness of this approach.