Academic Emergency Medicine最新文献

Introduction: Emergency medical services (EMS) providers are often first responders to agitated older adults, providing critical clinical care and transport. However, significant knowledge gaps persist in our understanding of agitation management for older adults in the prehospital setting.

Aims: To describe the barriers and facilitators to the management of agitation in older adults and the reduction of restraint use by EMS providers.

Methods: In-depth semi-structured qualitative interviews (n = 30) took place with EMS providers employed in Alberta, Canada. The theoretical domains framework (TDF) served as a guiding structure for the development of the interview guide. Framework analysis was used to analyze the qualitative data: a line-by-line thematic analysis was used to identify codes/themes, which were then mapped onto the TDF, and behavior change wheel.

Results: Six major thematic categories were identified. EMS providers reported inadequate training and support, especially for managing agitation in older adult populations. Restraints are used as a safety measure for patient and provider safety, and as a last resort once other agitation management strategies have been exhausted. EMS providers report a complex decision-making matrix of balancing the risks, benefits, and ethical considerations of restraint use, which is often collaborative and integrates EMS protocols. Common barriers to effective agitation management in EMS, as well as non-restraint agitation management techniques are also discussed.

Conclusion: The present study is the first in-depth exploration of EMS provider experiences regarding the management of agitation and chemical and physical restraints in older adults.

Background: Syncope places a significant burden on emergency departments (EDs), often prompting extensive testing to exclude life-threatening conditions. However, the diagnostic utility of troponin, B-type natriuretic peptide (BNP), transthoracic echocardiography (TTE), and outpatient cardiac monitoring remains unclear.

Methods: This systematic review assessed the diagnostic accuracy of these tests in adults presenting with syncope. The research question was: In ED patients with syncope, does TTE, cardiac biomarkers (troponin, BNP), or outpatient arrhythmia monitoring, compared with no testing, improve outcomes within 30 days? Primary outcomes included adverse events (death, arrhythmias, structural/ischemic heart disease, and select non-cardiac causes such as pulmonary embolism or aortic dissection) for biomarkers and diagnostic yield for TTE and monitoring. Sensitivity, specificity, and likelihood ratios (LR+ and LR-) were calculated for biomarkers, while diagnostic yield with 95% CI was reported for TTE and monitoring. Risk of bias was assessed using JBI and QUADAS-2.

Results: The database searches identified 1759 citations. After applying inclusion and exclusion criteria, 41 studies (21,557 patients) were included. Significant heterogeneity among the included trials (all with I² > 90%) precluded meta-analysis. For BNP, LR+ ranged 1.4-47 and LR- 0.06-0.4; for troponin, LR+ 1.9-11.2 and LR- 0.2-0.9. TTE diagnostic yield was 0%-29% overall and 8%-28% in high-risk groups. Outpatient monitoring yielded 1%-59% overall and 12%-42% in high-risk patients.

Conclusion: In ED patients with syncope, the diagnostic accuracy and yield of cardiac biomarkers, TTE, and outpatient monitoring show substantial variability, largely due to differences in patient populations, outcome measures, and study methodologies. Based on the existing evidence, these modalities in isolation cannot be recommended for routine use in syncope evaluation. Among these tests, the diagnostic yield of TTE and outpatient monitoring is greater in patients with cardiac risk factors and could potentially contribute to a more accurate diagnosis.

Introduction: Emergency departments (EDs) are increasingly required to screen for social risk and social need, but existing tools are long, hindering their utility in clinical settings, and resulting in incomplete surveys. However, strategies for streamlining screening tools remain unclear. This work aimed to guide future development of an ED-based screener by using a health system's ten-item social risk/social need questionnaire to (1) compare differences in patient populations by questionnaire completeness, (2) observe patterns of responses (e.g., what questions cover the same constructs and can potentially be eliminated), and (3) test for variation in social risk/social need measurement by age.

Methods: This cross-sectional study evaluated patients who responded to at least one question in the social risk/social need questionnaire in our regional health system from February 2019 to March 2023. Descriptive analyses examined patients stratified by questionnaire completeness: lower response (< 60%) versus higher response (≥ 60%). Within the higher response group, factor analysis extracted social risk/social need constructs and the strength of the association between each questionnaire item and its corresponding social risk/social need construct.

Results: Among 330,109 individuals, 248,808 (75%) completed the survey. In the lower response group (28,985; 9%), more patients were caregivers of children ≤ 4 years (18,231; 63%) and had commercial insurance (21,009; 72%) compared to the higher response group (23,873; 8% and 149,814; 50%, respectively). Factor analysis revealed a three-factor structure of the social risk/social need framework which we labeled: core resources, housing, and ability to work. From the magnitude of factor loadings, the items with the strongest indication of social risk/social need were paying for utilities, upcoming housing instability, and unemployment.

Conclusion: In this health system, incomplete social risk/social need questionnaires are common. To improve response rates, the social risk/social need framework elucidated by our factor analysis will guide the development of a consolidated questionnaire for the EDs.

Background: The US is experiencing an epidemic of opioid misuse and mortality. Effective treatments are available, including medications for opioid use disorders (MOUD), but they are greatly underused due to a variety of barriers. In response, some US hospitals have established programs to identify emergency department (ED) patients with opioid use disorders (OUD) and begin treatment with MOUD ("ED induction"). For this model to be widely adopted, financial sustainability for hospitals is critical. Little is known about the financial aspects of ED-based treatment models, including insurance billing and reimbursement.

Objectives: Our study addressed the following questions about ED-based induction of OUD treatment: (1) Which components of this model are billable to insurers? (2) How do hospitals fund the components that are not billable? (3) Does ED-based induction generate savings that could help fund that service?

Methods: We conducted a qualitative study, involving semi-structured interviews with officials at selected US hospitals. Potential interviewees were identified using a snowball sampling approach. We conducted 12 interviews across 10 states, mostly with urban teaching hospitals.

Results: Key findings include, (1) medication costs are often billable to insurers, but costs of key para-professional staff like peer navigators are not, requiring the hospital to absorb their salaries. Even some billable costs are reimbursed at low rates which challenge sustainability. (2) To fund non-billable components, hospitals typically rely on time-limited grant funding, including the federal 340B drug rebate program. (3) Several interviewees anticipated cost savings to their hospitals from reduced use of ED services by patients who had no (or low-paying) insurance.

Discussion: These findings indicate that some hospitals are able to sustain ED-based induction of MOUD using time-limited grant funding. However, wider dissemination of this model will likely require more stable funding streams, such as Medicaid reimbursement, paying adequate rates, and coverage of personnel.

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, yet it remains underdiagnosed and undertreated in emergency departments (EDs). Despite evidence-based guidelines recommending bedside diagnostic maneuvers (Dix-Hallpike and supine roll test) and canalith repositioning maneuvers (CRMs), these are infrequently utilized, leading to unnecessary imaging, prolonged symptoms, and increased healthcare utilization.

Objective: This study aimed to implement an educational strategy to improve the diagnosis and treatment of BPPV in the ED by increasing adherence to guideline-based practices.

Methods: We conducted a multicenter interrupted time series study from August 2020 to September 2023. The intervention, developed using the CAN-Implement framework, included online training, quick-reference tools, and a mobile app. Due to the COVID-19 pandemic, in-person training was canceled. The primary clinical outcome was the proportion of patients receiving the appropriate CRM based on positional test results. Implementation outcomes included fidelity, appropriateness, adoption, penetration, and system impact, reported using the Standards for Reporting Implementation Studies (StaRI) guidelines.

Results: We included 1682 patients (1252 pre-intervention, 430 post-intervention). There was no significant change in the primary outcome (appropriate CRM use, OR = 1.08, 95% CI: 0.76-1.40). However, selective CT use improved (OR = 1.29, 95% CI: 1.09-1.49), supine roll testing increased from 14.2% to 23.5%, and neurology consults decreased from 7.1% to 4.0%. Documentation of diagnostic test descriptors improved, while neurological exam documentation declined.

Conclusion: The intervention did not significantly increase appropriate CRM use but led to improvements in selective imaging, neurology consultation, and horizontal canal testing. Provision of educational tools alone was insufficient to overcome identified environmental barriers. To effectively improve BPPV management in the ED, future efforts should combine hands-on training with system-level supports and workflow integration.