Academic Emergency Medicine最新文献

Investigating error in healthcare has long been a central focus of patient safety efforts, yet this approach oversimplifies the complexities of a deeply interconnected and dynamic system. This paper argues that framing patient harm solely as "error" has failed to yield meaningful improvements, as it overlooks the broader factors contributing to adverse outcomes. Through a case study, we illustrate how an exclusive focus on error investigation missed critical insights and propose that attention should instead be directed towards identifying and managing hazards. Emphasizing the importance of treating healthcare as a sociotechnical system, we argue for the application of sociotechnical system thinking, particularly in addressing diagnostic errors in high-pressure environments like emergency medicine. The traditional methods, such as root cause analysis, error investigation, and the Swiss cheese model, are no longer sufficient. These outdated frameworks fail to address the systemic challenges clinicians face and often misguide safety interventions. The paper calls for a paradigm shift towards re-designing healthcare systems using human factors research to better align with the complexities of clinical work and the hazards that lead to harm.

Objective: The emergency department (ED) is an essential setting for diagnosis of pregnancy, confirmation of pregnancy location, and management of pregnancy loss and other complications. This health care service delivery is especially important for patients with limited or complicated access into reproductive health care elsewhere. We seek to assess emergency physicians' knowledge, training, attitudes, and practices related to pregnancy options counseling, reproductive health referrals, and provision of medical- and procedural-induced abortion.

Methods: We surveyed a sample of emergency physicians in person at a U.S. national medical meeting regarding knowledge, attitudes, and practices related to reproductive health care delivery. Wilcoxon rank sum tests were used to evaluate differences between abortion-restrictive and -permissive states and chi-square tests were used to compare proportions between the two groups and Wilcoxon signed rank was used to compare median scores between questions. Thematic analysis was used to review qualitative responses.

Results: Of the 295 emergency physicians approached, 252 (85.4%) completed study procedures. The majority (n = 218, 86.5%) practiced in abortion-permissive states. Most (n = 178, 70.6%) supported abortion provision in the ED if legally allowed, though only about half (n = 131, 52.0%) reported ever prescribing medication abortion pills. Despite higher proportions reporting training in services, a small minority responded they could still independently provide pregnancy options counseling (25.1%), direct referrals for abortion (34.9%), medical management for early pregnancy loss (15.1%) or induced abortion (10.7%), or uterine aspiration for any pregnancy indication (1.6%). Training and knowledge were similar, though practice patterns and attitudes differed when comparing abortion-restrictive to -permissive states.

Conclusions: This national survey demonstrates that, while most emergency physicians support the provision of abortion care in this setting, they do not routinely provide this care due to a variety of factors including lack of knowledge, lack of training, and legal and institutional restrictions.

Background: Acute intoxication is common in patients evaluated for traumatic brain injury (TBI). However, the effect of elevated blood alcohol levels (BALs) on the diagnostic accuracy of FDA-cleared biomarkers for evaluating traumatic intracranial injury on computed tomography (CT) scan, namely, glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), has not been well studied.

Methods: We investigated the effect of significantly elevated (>300 mg/dL) and modestly elevated BAL (81-300 mg/dL) at emergency department presentation on the diagnostic accuracy of GFAP and UCH-L1 for predicting a positive CT in patients presenting to 18 U.S. Level I trauma centers within 24 h of TBI as part of the prospective, Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Plasma GFAP and UCH-L1 were measured using Abbott i-STAT Alinity and ARCHITECT assays. Discrimination was evaluated using the area under the receiver operating characteristic curve (AUC).

Results: Of 2320 TRACK-TBI participants studied, 54 (2.3%), 332 (14.3%), 1209 (52.1%), and 725 (31.3%) had significantly elevated BAL, modestly elevated BAL, nonelevated BAL (0-80 mg/dL), and no BAL available, respectively; 48.3% of the cohort had a positive brain CT. Those with significantly elevated and modestly elevated BAL were more likely to have positive CT (61.1% and 60.5% vs. 46.9% and 44.0%) and had higher plasma GFAP and UCH-L1 levels than those with nonelevated BAL and no BAL available. The AUC of GFAP and UCH-L1 combined for predicting CT positivity was higher in those with significantly elevated BAL (0.949) than those with modestly elevated BAL (0.858), nonelevated BAL (0.849), and no BAL available (0.883).

Conclusions: Modestly and significantly elevated BAL does not lower the diagnostic accuracy of GFAP and UCH-L1 for predicting traumatic intracranial injury on CT. These biomarkers may be useful in decreasing avoidable brain CT imaging in persons with acute alcohol intoxication.

Background: Despite the importance of effective communication during verbal de-escalation, research regarding patient primary language during management of agitation symptoms is limited. We evaluated associations between patient primary language and use of physical restraints and intramuscular (IM) sedation in the emergency department (ED).

Methods: This was a retrospective cohort analysis evaluating physical restraint and IM sedation characteristics using electronic medical records from 13 EDs affiliated with a large regional health care network located in the northeast United States. Data were collected for ED visits from 2013 to 2023 for all adult patients ages 18 and older. We performed logistic regression models using the presence of physical restraint and IM sedation orders as primary outcomes, adjusting for patient primary language, sex assigned at birth, age, race and ethnicity, and chief complaints.

Results: In our analysis of 3,406,474 visits, 3,086,512 included English speakers, 250,912 included Spanish speakers, 9,057 included Portuguese speakers, 6,616 included Arabic speakers, 6,425 included Italian speakers, 39,303 included other language speakers, and 7,649 included unknown language speakers; 18,546 visits included use of physical restraints and 48,277 visits included use of IM sedation. After demographic and clinical characteristics were adjusted for, visits with Spanish- and Portuguese-speaking patients had a reduced likelihood of physical restraints and IM sedation compared to English speakers, with adjusted odds ratios (95% confidence intervals) of 0.70 (0.65-0.76) and 0.82 (0.79-0.87) for Spanish speakers and 0.39 (0.20-0.68) and 0.84 (0.66-1.05) for Portuguese speakers, respectively.

Conclusions: ED visits with Spanish- and Portuguese-speaking patients were found to have lower odds of physical restraints and IM sedation, while Arabic, Italian, other, and unknown language-speaking patients were found to have higher odds. Factors contributing to linguistic differences in physical restraint and IM sedation use, such as cultural interpretations of behavior, quality of clinical interactions, and patient-clinician communication strategies, merit further investigation.