Academic Emergency Medicine最新文献

Background: Opioid-related adverse events (AEs) resulting in or following an ED visit are well described. Less is known about AEs due to opioid administration in the ED, whose detection is limited by the high frequency of administration and poorly specific surveillance methods. We studied the use of the ED Trigger Tool (EDTT) for detection of AEs from high-risk opioid administration in the ED.

Methods: This is a secondary analysis of a multicenter retrospective study of the EDTT for two selected triggers: M2- ≥ 3 doses of hydromorphone administered and M18- opioid + benzodiazepine administration. We applied the EDTT to an 18-month extract of data from three sites and reviewed a balanced sample of ~3000 records/site using a two-tiered approach, characterizing opioid-related AEs by occurrence, type, and severity. Analysis is descriptive.

Results: A total of 13,601/450,852 visits (3.0%) across three sites included one of these triggers: M2 (6447; 1.4%); M18 (6201; 1.4%); or both (853; 0.2%). In our sample of 8719 records, 458 (5.3%) included at least one of these triggers (78 with M2, 347 with M18, and 33 with both). Reviewer agreement was high (Kappa = 0.94). We identified 124 opioid-related ED AEs among 120 triggered visits (26.2%): M2 (37/78 visits; 47.4%); M18 (76/347 visits; 21.9%), and both (7/33 visits; 21.2%). There were no site differences in opioid-related ED AE detection. Common AEs included hypotension, hypoxia, allergic reactions, and delirium, mostly resulting in temporary harm but 30% requiring urgent intervention.

Conclusions: In our sample, 5% of visits included high-risk opioid administration, of which 26% included an opioid-related AE. AE rates were similar across sites, with expected variability in type and severity across triggers and sites. The EDTT is a useful approach for AE detection. Triggers focusing on high-risk opioid administration may have a more favorable yield as a surveillance strategy.

Background: Healthcare system distrust-patients' belief that the healthcare system may not act in their best interests-is a recognized social determinant of health and is associated with poor health outcomes, decreased adherence to treatment, and heightened health disparities, especially among marginalized populations. Compassion from clinicians may be a modifiable factor that can foster trust in healthcare systems, but its association with system-level distrust, particularly in emergency department (ED) settings, remains underexplored.

Methods: We conducted a nested cross-sectional study enrolling adult patients treated at two urban academic EDs in the United States between September 2023 to May 2024. We separately measured patient experience of physician and nursing staff compassion using the validated 5-item compassion measure, and patient healthcare system distrust using the Healthcare System Distrust Scale. Multivariable linear regression models, adjusted for demographics and study site, tested associations between perceived compassion and distrust, including subgroup analyses by race, gender, and other sociodemographic factors.

Results: The primary analysis included 779 patients. Both physician (median score 20 [IQR 17-20]) and nursing staff compassion (median score 20 [IQR 17-20]) were highly rated. Higher compassion scores for both physicians (β = -0.62, 95% CI 0.80 to -0.44) and nursing staff (β = -0.24, 95% CI 0.38 to -0.09) were independently associated with lower healthcare system distrust. Compared to non-Hispanic White patients, Black patients reported higher healthcare system distrust, driven by values (i.e., honesty, motives, and equity)-based distrust rather than competency-based distrust, but did not report lower compassion scores. The association between compassion and reduced distrust was consistent across demographic subgroups.

Conclusion: Greater experience of compassion from ED physicians and nursing staff is independently associated with lower healthcare system distrust. Interventions to enhance clinician compassion have the potential to foster trust and may reduce health disparities in emergency care settings.

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: 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.