Western Journal of Emergency Medicine最新文献

Introduction: Emergent endotracheal intubation is common in critically ill patients. Underlying pathophysiologic derangements puts these patients at increased risk of peri-intubation major adverse events (MAE) and have been associated with higher morbidity and mortality. Investigating the impact of interventions in the peri-intubation period on the rate of peri-intubation hypoxemia and hypotension can help improve management of emergent airways.

Methods: We searched PubMed, Embase, and Scopus databases from their beginning through April 2024 to identify randomized controlled trials (RCT) evaluating interventions to prevent peri-intubation hypoxemia and hypotension. Random-effects meta-analysis was used for the outcomes of peri-intubation hypoxemia and hypotension. We used the Cochrane risk-of-bias tool and Cochrane Q-statistic and I2 to assess the quality and heterogeneity of the included studies, respectively.

Results: We included 16 RCTs included in our analysis with a total of 7,778 patients. All studies reported incidences of peri-intubation hypoxemia, and 11 studies reported rates of hypotension. One study had some concern of bias; otherwise all others were found to have low risk of bias. The examined interventions were associated with a 25% reduction in rates of hypoxemia (OR 0.748, 95% CI 0.566 - 0.988, P = .04). The subgroup of preoxygenation techniques showed a 63% reduction in rates of hypoxemia (OR 0.37, 95% CI 0.23 - 0.61, P < .001). Interventions to prevent hypotension were not associated with a significant decrease in rates of peri-intubation hypotension (OR 0.848, CI 0.676 - 1.063, P = .15).

Conclusion: Preoxygenation interventions, in the form of noninvasive ventilation, are associated with lower odds of hypoxemia in the peri-intubation period. More research is needed to determine whether interventions can be successful at preventing cardiovascular collapse.

Introduction: Emergency department-based intensive care units (ED-ICU) address the increasing demand for critical care services and represent a transformative approach to the specialty's management of critically ill patients within emergency medicine. However, data on their financial impact and operational effects remain limited.

Methods: We conducted a retrospective, quasi-experimental study at an urban, academic ED with approximately 90,000 annual visits. In July 2019, a nine-bed ED-ICU model, referred to as "Next Pod," was implemented. We analyzed Current Procedural Terminology (CPT) coding data and professional revenue (charges billed and payments received) for 35 weeks before and after the intervention (November 2018-March 2020). The intervention involved repurposing a nine-bed ED area and adjusting physician and nursing staffing models. We compared critical and non-critical care CPT coding proportions and professional revenue using the Student t-test.

Results: During the study period, there were 38,283 ED visits pre-implementation and 36,424 visits post-implementation. Across the entire ED, critical care coding significantly increased following implementation (CPT 99291: 6.2 - 8.8% [total percentage increase of 41.94%]; 99292: 0.5 - 1.0% [total percentage increase of 100%]). Encounters where 99292 was billed multiple times increased by 128.1% (32 vs 73). Non-critical care coding (99282, 99283) decreased 23% (9.1% vs 7.0%, P< .001) / 29.6% (16.2 vs 11.4, P < .001), respectively. There was a non-statistically significant increase in 99284. Higher acuity codes (99285) increased by 10% (31.7% vs. 34.9%, P < .001). Average ED charges per visit increased by $40 (95% CI $37.2 - $45.5) post-implementation..

Conclusion: The implementation of an ED-ICU was associated with significant increases in critical care and high-acuity coding, as well as enhanced professional revenue. These findings suggest that ED-ICU models can improve both fiscal performance and operational efficiency. Further research is needed to explore the contributions of resource allocation, documentation improvements, and care practices to these outcomes.

Introduction: Applying to emergency medicine (EM) residency programs is costly. In the past several years, the EM residency application process has undergone multiple changes in recommendations regarding away rotations and interview format, primarily but not solely driven by COVID-19 restrictions. To date, little is known about the financial impact of these changes on EM applicants. This study assesses recent trends and changes in the costs of the EM residency application.

Methods: We analyzed EM applicant survey data from the Texas STAR (Seeking Transparency in Application to Residency) database from 2019-2024. Application cycles were grouped into three time periods: pre-pandemic (2019-2020), pandemic (2021-2022), and post-pandemic (2023-2024). Applicants' self-reported data for application fees, away rotation costs, interview costs, and total expenses were analyzed. We conducted Kruskal-Wallis testing to evaluate differences in expense-related variables across the three time periods. We performed post-hoc analysis using the Dunn test if significant differences were detected.

Results: This study included 3,495 EM applicants, which represents 8.4% of the total 41,497 Texas STAR survey respondents from 2019-2024. Average per-applicant total costs were $5,412, $2,076, and $3,156 in the pre-, during-, and post-pandemic application cycles. Self-reported total applicant expenses decreased between the pre- and pandemic period and increased from the pandemic and post-pandemic period (P < .01). Applicants had the lowest overall costs in 2021. Away rotation, second look, application costs, interview travel and lodging, and virtual interview costs all reached their lowest levels during the pandemic period (P < .01). In the post-pandemic period, travel and lodging costs were higher than pre- and during pandemic levels, while interview costs remained lower due to the continued use of virtual interviews (P < .01). Applicants from the Western Region of the US saw the highest total costs compared to the Northeast, which saw the lowest.

Conclusion: The total expenses reported by medical students applying to EM residency programs were significantly reduced during the pandemic, compared to other years. Some expenses, notably away rotation and second look and application costs, have risen post-pandemic. To help reduce the financial burden of the EM residency process, the continued use of virtual interviews is an opportunity for cost savings.

Introduction: Recent evidence suggests that survival to hospital discharge in patients with out-of-hospital cardiac arrest (OHCA) is similar among patients receiving a single dose epinephrine protocol compared to a multi-dose epinephrine protocol. However, it is unknown whether survival to hospital rates differ for single dose vs. multi-dose epinephrine within sex and race subgroups. Our objective in this study was to determine whether survival to hospital discharge rates varied for single dose vs. multi-dose epinephine protocols among men, women, White, and non-White patients.

Methods: We conducted a pre-post Single Dose Epinephrine Implementation Study from November 1,2016 - October 29, 2019 at five North Carolina emergency medical services (EMS) systems, involving patients ≥ 18 years old with non-traumatic OHCA. Data on race, sex, and the primary outcome of survival to hospital discharge were determined from the Cardiac Arrest Registry to Enhance Survival and from EMS records. We performed intention-to-treat analysis. We compared survival to hospital discharge rates between single dose vs multi-dose epinephrine protocols within sex and race subgroups using generalized estimating equations with a logit link to account for clustering among EMS agencies and to adjust for age, witnessed arrest, automated external defibrillator availability, EMS response interval, the presence of a shockable rhythm, receiving bystander cardiopulmonary resuscitation, and sex or race. In the model, we evaluated interactions between epinephrine protocol and race and sex.

Results: Of the 1,690 patients included, (899 multi-dose, 791 single dose), 38.7% (657/1,690) were female and 74.7% (1,262/1,690) were White. Survival to hospital discharge occurred in 13.6% (122/899) of patients in the multi-dose group and 15.4% (122/791) in the single dose epinephrine group (OR 1.19, 95%CI 0.89-1.59). Single dose epinephrine was associated with increased survival to hospital discharge rates in White patients (adjusted odds ratio [aOR] 1.17, 95% confidence interval [CI] 1.05-1.30). However, the rates were similar for single dose vs. multi-dose epinephrine among men (aOR 1.03, 95% CI 0.93-1.14), women (aOR 1.23, 95% CI 0.97-1.56), and non-White patients (aOR 1.08, 95% CI 0.78-1.51). Interactions between epinephrine protocol and subgroups were not significant.

Conclusion: Rates of survival to hospital discharge were similar in the single dose and multi-dose epinephrine strategies regardless of sex. Single dose epinephrine was associated with increased survival to hospital discharge among White patients but not in non-White patients, which may be due to unmeasured confounding or inadequate power.

Introduction: Although ultrasound is readily available to emergency physicians and known to be very accurate for diagnosing rotator cuff tears, it is rarely used for this purpose. Our goal in this study was to develop and preliminarily assess the accuracy of a simplified shoulder ultrasound protocol (the "supra-short" protocol), designed to be used by emergency physicians for diagnosis of supraspinatus tears.

Methods: We performed a pilot diagnostic accuracy study in which we assessed the accuracy of the supra-short protocol as performed by minimally trained emergency physicians for identifying supraspinatus tears in volunteers. As a criterion standard, a sports medicine physician also performed a complete shoulder ultrasound on each volunteer. We determined the test characteristics of the supra-short protocol for supraspinatus tears, as well as the median time to complete a scan and the percentage of images deemed adequate by expert review.

Results: Nine emergency physicians performed a total of 40 bilateral supra-short scans on six volunteers (two of whom were known to have shoulder pathology and four of whom had normal shoulders). Of the 80 shoulders scanned, there were 18 cases in which complete ultrasound performed by the sports medicine physician revealed a supraspinatus tear; 12 (66.7%) of those were identified by the novice sonographers using the supra-short protocol. Overall, the sensitivity of the supra-short protocol was 66.7% (95% CI 29.9-92.5%) and the specificity was 87.1% (95% CI 70.2-96.4%). The median time to completion of each shoulder was 133 seconds (interquartile range 88-182). Upon expert image review, 80.0% of the images were deemed adequate.

Conclusion: After minimal training, emergency physicians were able to quickly perform the supra-short US protocol but were only able to identify supraspinatus tears with moderate accuracy, suggesting the need for more extensive training before clinical use.

Introduction: Ambulances are often left to idle, which may contribute to maintenance costs, environmental harm, and resource inefficiencies. Engine idling affects the health of first responders due to the consequences of exhaust. Our study objective was to gain understanding of current emergency medical services (EMS) policies and perspectives on ambulance engine idling.

Methods: We designed an anonymous, 48-question survey that was distributed to all levels of EMS clinicians. There were 684 total survey responses from 11 states. We excluded those that only included demographics, yielding 507 responses. The response rate was 10.8%. The questions surveyed demographics, service characteristics, and current policies and perspectives on idling. We used multiple question types, including some that asked participants to rate their level of concern on a five-point Likert scale. "Strongly disagree" was coded as 1, and "strongly agree" was coded as 5. "Neither agree or disagree" was considered a neutral response and was coded as 3. Additionally, we conducted a thematic analysis on data derived from the free-text responses to identify themes.

Results: Few (12%) respondents reported written policies on idling. The biggest concerns regarding idling involved the following (reported as median (IQR, 25^th and 75^th percentiles): patient comfort (4, IQR 4-5); EMS clinician comfort (4, IQR 4-5), and medication compromise (4, IQR 4-5). There was a neutral level of concern regarding equipment failure (3, IQR 3-4) and response delays (3, IQR 3-5). There was a less than neutral level of concern regarding engine failure (2, IQR 2-4); vehicle theft (2, IQR 2-4), air quality (2, IQR 2-3); increased fuel usage (2, IQR 2-3); and carbon emissions (2, IQR 2-3). Six themes emerged: fear of harming patient; safety; effects on air quality; habits and indifference; cost of idling; and frustration.

Conclusion: Emergency medical services clinicians mainly hesitate to turn off their engines out of concern for patient/personnel harm and potential equipment failure. The theme of frustration, noted in free-text responses, describes EMS clinicians' feelings of suspicion and concern for an ulterior motive behind the study, which highlights the need for a collaborative effort at addressing this collective issue.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic significantly altered emergency department (ED) utilization patterns. This study quantifies the statistics at a Level I trauma center in Southern California from 14 months before to nine months after the start of the pandemic (January 2019-December 2020). We hypothesized that during the COVID-19 pandemic, changes in ED use patterns impacted patient acuity, as measured by admission rate, mortality rate, ED volume, Emergency Severity Index (ESI), and female:male ratio, even when controlling for COVID-19 cases.

Methods: In this study we examined 97,793 ED visits from January 2019-December 2020 at the University of California, Irvine Medical Center in Orange, CA, via an administrative database comprised of anonymized datapoints from the electronic health record. We included all months from January 2019-December 2020 to account for potential secular trends by calendar month. Primary outcome measures were hospital admission rate and all-causes mortality rate among non-COVID-19 patients who presented to the ED. Secondary outcome measures included the mean number of ED visits per month, mean ESI, and female:male ratio among non-COVID-19 patients. Statistical analyses were performed.

Results: We found an increase in the mortality rate per ED visit of 0.8859% before the pandemic to 1.2706% (P < .001) during the pandemic. After excluding COVID-19 cases, the mortality rate per ED visit remained elevated at 1.1746% (P < .001), a relative increase of 32.6%. Hospital admission rate increased from 26.0% before the pandemic to 32.3% during the pandemic (P < .001). The mean number of ED visits per month decreased from 4,271.2 ± 193.1 before the pandemic to 3,558.7 ± 437.1 per month during the pandemic (P < .001), a relative decrease of 16.7% when excluding COVID-19 cases. The mean ESI of non-COVID-19 related cases during the pandemic decreased from 2.85 pre-pandemic to 2.84 during the pandemic (P = .03). The female:male ratio decreased from 1.003 pre-pandemic to 0.885 during the pandemic (P < .001).

Conclusion: This study reveals a decrease in patient volume with an increase in mortality and admission rate, demonstrating an association between shifts in ED utilization patterns and increased patient acuity during the pandemic. Understanding patients' emergency care-seeking behavior during this period is essential for preparing for future large-scale public health crises and optimizing ED resource allocation and mobilization based on lessons learned from COVID-19. Overall, these findings highlight the need for further research into the development of strategies to address changes in care-seeking behavior during access-limiting scenarios.

Introduction: Heatwaves are becoming more frequent and severe globally. Heat is associated with increases in emergency department (ED) volumes and higher morbidity for a range of chronic conditions. We describe how temperature impacts ED arrivals at different acuity levels.

Methods: We obtained time-series records for daily ED arrivals stratified by Emergency Severity Index (ESI) from 2010 - 2019 from hospital records. Wet-bulb temperature was the exposure of interest; analysis was controlled for precipitation, snow, wind speed, day of week, and federal holidays. We fitted a Poisson model for each ESI category and estimated the association between temperature and ED arrival acuity with a distributed lag non-linear model with three days of lag to account for delayed health effects of temperature.

Results: We analyzed data for 3,652 days totaling 556,663 arrivals between 2010 - 2019. At lag 0, lower temperatures were associated with a reduced relative risk of arrival to the ED for ESI 2, ESI 3, and total arrivals. At higher temperatures, ESI 2 and ESI 3 showed an increased relative risk of arrival (wet-bulb exposure of 25°C at 0-day lag: ESI 2 RR = 1.06 [1.02-1.10]; ESI 3 RR = 1.04 [1.01-1.07]). While not statistically significant, ESI 1 exhibited a subtle increase in arrivals at the highest temperatures while ESI 4 & 5 displayed a subtle decrease in relative risk of arrivals under these conditions.

Conclusion: Extremes of temperature, particularly heat, appear to affect ED arrivals differently across different acuity levels. Medium- to higher-acuity presentations appear to be more responsive to heat, with a statistically significant increase in ED presentations on days with the highest heat burden. The highest acuity presentations became numerically but not statistically more frequent on days with the highest heat burden, while the lowest acuity presentations decreased numerically but not statistically in these conditions.

Introduction: Over 20% of the United States population speaks a language other than English, and many use the emergency department (ED) to access healthcare. However, there remains concern that patients preferring languages other than English are under-represented in clinical research. Thus, our goal was to assess the proportion of ED studies that excluded patients for recruitment due to language.

Methods: We conducted a narrative review using seven search engines for 2018-2023. We included studies if they mentioned language of participants and prospectively enrolled patients in an ED or prehospital setting. We excluded studies if they only included patients <18 years and/or were conducted exclusively outside the US. Two independent reviewers reviewed studies. Analyses included descriptive statistics.

Results: Of the 10,513 studies we identified, 281 were eligible for review; 163 (58%) excluded non-English language preferred (NELP) patients. Among the 107 interventional studies, 69% excluded NELP patients. Of the 135 studies focused on health equity/social emergency medicine, 47% excluded NELP patients.

Conclusion: We found 163 (58%) studies conducted in the ED that mention language and excluded NELP patients. Additional work is needed to encourage and support inclusive study designs.