Academic Emergency Medicine最新文献

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.

Objective: Inequities in pediatric emergency department (ED) care may be influenced by disparities in clinician communication. We sought to examine, from the perspective of parents from marginalized racial and ethnic backgrounds, how clinician-parent communication is characterized during pediatric ED visits.

Methods: We conducted and analyzed in-depth semistructured individual interviews with parents of pediatric ED patients from marginalized racial and ethnic backgrounds. We applied a constant comparative method approach to conduct a thematic analysis informed by grounded theory. To ensure rigor, we collected and analyzed data concurrently. We used the patient-centered communication (PCC) framework and the 10 principles of Public Health Critical Race Praxis as sensitizing constructs during analysis. Two coders followed several analytical steps: (1) open coding for concept discovery, (2) grouping concepts into themes, (3) axial coding to identify thematic properties, and (4) identification of exemplar excerpts for rich description. Thematic saturation was based on repetition, recurrence, and forcefulness.

Results: Nineteen parents participated. Parents described three clinician communicative behaviors that facilitated their sense of inclusion or marginalization: information exchange, empathic communication, and partnership-building. Parents also stressed the importance of their own proactive communication in facilitating their inclusion. Few participants described experiencing racism during their child's ED visit, yet many did during prior health care encounters, which they connected to their current experience. In particular, parents described how their use of proactive communication was motivated by their past experiences of racism in medical encounters.

Conclusions: These narratives demonstrate ways in which experienced racism, both past and present, may inform how parents receive and respond to gaps in PCC. Communication focused interventions that adapt a race-conscious perspective may have a role in promoting health equity.

Objective: Calibration and discrimination indicators alone are insufficient for evaluating the clinical usefulness of prediction models, as they do not account for the cost of misclassification errors. This study aimed to modify the Geriatric Trauma Outcome Score (GTOS) and assess the clinical utility of the modified model using net benefit (NB) and decision curve analysis (DCA) for predicting in-hospital mortality.

Methods: The Trauma Quality Improvement Program (TQIP) 2017 was used to identify geriatric trauma patients (≥ 65 years) treated at Level I trauma centers. The outcome of interest was in-hospital mortality. The GTOS was modified to include additional patient, injury, and treatment characteristics identified through machine learning methods, focusing on early risk stratification. Calibration and discrimination indicators, along with NB and DCA, were utilized for evaluation.

Results: Of the 67,222 admitted geriatric trauma patients, 5.6% died in the hospital. The modified GTOS score included the following variables with associated weights: initial airway intervention (5), Glasgow Coma Scale ≤13 (5), packed red blood cell transfusion within 24 h (3), penetrating injury (2), age ≥ 75 years (2), preexisting comorbidity (1), and torso injury (1), with a total range from 0 to 19. The modified GTOS demonstrated a significantly higher area under the curve (0.92 vs. 0.84, p < 0.0001), lower misclassification error (4.9% vs. 5.2%), and lower Brier score (0.036 vs. 0.042) compared to the original GTOS. DCA showed that using the modified GTOS for predicting in-hospital mortality resulted in higher NB than treating all, treating none, and treating based on the original GTOS across a wide range of clinician preferences.

Conclusions: The modified GTOS model exhibited superior predictive ability and clinical utility compared to the original GTOS. NB and DCA offer valuable complementary methods to calibration and discrimination indicators, comprehensively evaluating the clinical usefulness of prediction models and decision strategies.

Background: The rate of patients who leave without being seen (LWBS) from an emergency department (ED) is a common measurement of quality, operational efficiency, and patient satisfaction. We hypothesized that adding a nonclinical staff role, guest service ambassadors (GSA), to the ED waiting room would decrease LWBS rates and reduce existing differences by race, ethnicity, sex, and primary language for ED patients.

Methods: We conducted an observational cohort study at a quaternary care academic ED in the Midwestern United States with approximately 60,000 annual visits between April and December 2022. GSAs were trained to guide patients and visitors through the check-in process and help manage the waiting room. LWBS rates were compared between pre- and postimplementation periods using logistic regression. Using two-sample proportion tests, subgroup analyses were performed to assess differences according to race, ethnicity, sex, and primary language.

Results: We analyzed 50,507 ED visits including 9798 during periods of GSA coverage. GSA presence was associated with a reduction in LWBS rate from 3.4% to 2.0% (absolute risk reduction [ARR] of 1.4%, χ² = 17.357, p < 0.001) with an adjusted odds ratio (OR) of 0.65 (95% confidence interval [CI] 0.49-0.85). There was a greater reduction in LWBS for Black, Indigenous, and people of color (BIPOC) patients compared to White patients (BIPOC ARR 1.8%, 95% CI 0.39%-3.14%; White ARR 1.2%, 95% CI 0.48%-1.94%). There was a reduction in LBWS rates for both males and females (female ARR 1.7%, 95% CI 0.80%-2.63%; male ARR 1.0%, 95% CI 0.06%-1.90%). The reduction in LWBS for patients speaking a language other than English and requiring interpreter services did not meet statistical significance (ARR 1.4%, 95% CI -1.04% to 3.85%).

Conclusions: Although some disparities remain, our study suggests that GSAs may provide an effective strategy to reduce the overall LWBS rate and reduce disparities across diverse demographic groups including BIPOC and female patients.

Background: The objective was to investigate the predictive ability of traditional clinical, radiological scores, and combined grading systems for 28-day mortality in patients with nontraumatic subarachnoid hemorrhage (SAH).

Methods: This multicenter cohort study enrolled 451 adults who presented to the emergency departments of six major tertiary care hospitals in Istanbul with nontraumatic aneurysmal SAH. Demographic data; clinical characteristics; and traditional clinical grading scores were recorded, including the Glasgow Coma Scale (GCS), Hunt and Hess scale (HHS), World Federation of Neurological Surgeons (WFNS) scale, modified Fisher scale (mFS), and two combined grading systems, the VASOGRADE and Ogilvy-Carter scales. These data were compared between survivors and nonsurvivors.

Results: A total of 451 patients were included, comprising 242 males (53.7%) and 209 females (46.3%), with a mean ± SD age of 54.8 ± 14.1 years. The overall mortality rate was 28.2% (n = 127). Nonsurvivors had significantly lower mean GCS scores and higher HHS, WFNS, mFS, and Ogilvy-Carter scores compared to survivors (all p < 0.001). A significantly higher proportion of nonsurvivors were categorized in the red group based on VASOGRADE (p < 0.001). Multivariable logistic regression analysis identified age, sex, HHS, mFS, WFNS, and VASOGRADE as independent predictors of mortality. The WFNS scale emerged as the most reliable predictor of mortality with an area under the curve of 0.878.

Conclusions: Although the GCS and Ogilvy-Carter scales effectively distinguished survivors from nonsurvivors, they were not independent predictors of mortality. The WFNS scale was identified as the most reliable predictor of mortality in aneurysmal SAH patients, followed by the mFS and HHS.

Following a review of accepted submissions for this special issue of the Society for Academic Emergency Medicine (SAEM)'s collected papers on diagnosis, we offer a commentary on the variety of reports. We use the metaphor of Newton's demonstration that a complex percept like the rainbow can be broken down by prisms, into a collection of different wavelengths of light. Like Feynman, we believe that the beauty of something may be revealed and augmented by reducing it to its constituent parts.