Michael J. Burla DO, Peter C. Michalakes BA, Jeanne S. Wishengrad MSc, Drew R. York BA, Holly A. Stevens BSN-RN,MHRT-CSP, Teresa L. May DO
Objective
There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine.
Methods
This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected.
Results
Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p = 0.012), have run-sheets reported (p = 0.001), and serve rural areas (p = 0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed.
Conclusions
There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.
{"title":"Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting","authors":"Michael J. Burla DO, Peter C. Michalakes BA, Jeanne S. Wishengrad MSc, Drew R. York BA, Holly A. Stevens BSN-RN,MHRT-CSP, Teresa L. May DO","doi":"10.1002/emp2.13330","DOIUrl":"10.1002/emp2.13330","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (<i>p</i> = 0.012), have run-sheets reported (<i>p</i> = 0.001), and serve rural areas (<i>p</i> = 0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11491542/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142482480","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dragan Vasin, Miona Jevtovic MD, Sabina Fiuljanin MD, Katarina Trajković MD, Tarik Plojović MD, Marković Danilo MD, Dušan Micić, Ksenija Mijovic MD, Aleksandar Pavlović MD, Dragan Mašulović
An 81-year-old man with a history of hypertension presented to the emergency department with epigastric pain, vomiting, hiccups, anorexia, and obstipation for 3 days. Physical examination was notable for a painful epigastric tenderness. Laboratory examinations revealed a white blood cell count of 22.1 (3.4–9.7)(10 × 9/L).
Plain abdominal radiography showed pneumobilia and an enlarged gastric bubble (Figure 1), and abdominal ultrasound also demonstrated an enlarged stomach with a large amount of content within a curvilinear focus of increased echogenicity with posterior shadowing in duodenal bulb (Figure 2). Subsequent computed tomography (CT) image is shown in Figure 3.
{"title":"Gastric outlet obstruction in a patient","authors":"Dragan Vasin, Miona Jevtovic MD, Sabina Fiuljanin MD, Katarina Trajković MD, Tarik Plojović MD, Marković Danilo MD, Dušan Micić, Ksenija Mijovic MD, Aleksandar Pavlović MD, Dragan Mašulović","doi":"10.1002/emp2.13285","DOIUrl":"10.1002/emp2.13285","url":null,"abstract":"<p>An 81-year-old man with a history of hypertension presented to the emergency department with epigastric pain, vomiting, hiccups, anorexia, and obstipation for 3 days. Physical examination was notable for a painful epigastric tenderness. Laboratory examinations revealed a white blood cell count of 22.1 (3.4–9.7)(10 × 9/L).</p><p>Plain abdominal radiography showed pneumobilia and an enlarged gastric bubble (Figure 1), and abdominal ultrasound also demonstrated an enlarged stomach with a large amount of content within a curvilinear focus of increased echogenicity with posterior shadowing in duodenal bulb (Figure 2). Subsequent computed tomography (CT) image is shown in Figure 3.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11491546/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142482481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dan Mayer MD, Sangil Lee MD, MS, Malene Plejdrup Hansen MD, PhD, Michael Gottlieb MD, Michael Brown MD, Richard Sinert DO, Joshua Davis MD
<p>Overdiagnosis occurs when people with or without symptoms are diagnosed with a disease that ultimately will not cause them to experience worsening physical symptoms, disability, or early death. Clinicians have been paying more attention to the problem of overdiagnosis as part of the more general problem of “overmedicalization” of society in general. This also includes overtreatment, diagnostic creep, and disease mongering.<span><sup>1</sup></span></p><p>In this issue of <i>JACEP Open</i>, Meltzer et al demonstrated that a point-of-care multiplex polymerase chain reaction (PCR) analyzer identifying the microbiological cause of an infectious disease at an urgent care center (UCC) led to increased patient satisfaction.<span><sup>2</sup></span> Patients presenting to an UCC with respiratory symptoms were randomized to point-of-care multiplex PCR testing identifying viral and bacterial pathogens or a control group that got no testing. They found patients were more cognizant of the need to quarantine and take time off work when they knew the test results. There was no significant effect on antibiotic prescription, although the study was only powered for patients’ satisfaction.</p><p>Superficially, this seems reasonable for UCCs, and some may argue that this technology could be useful in the Emergency Department. However, this begs the question of whether the wider use of these diagnostic tools would increase the potential for overdiagnosis.</p><p>The definition of overdiagnosis was articulated in a 2018 editorial:<span><sup>3</sup></span> “identification of abnormalities that were never going to cause harm, abnormalities that do not progress, that progress too slowly to cause symptoms or harm during a person's remaining lifetime, or that resolve spontaneously.” They focused primarily on the overdiagnosis of cancers, but the concept is also applicable here. Overdiagnosis and over-testing are a complex problem, with many implications. The risk of overdiagnosis increases with the number of tests ordered that identify a disease not destined to meaningfully harm the patient, making the risks of testing outweigh the benefits. While difficult to determine at the individual level, this should be studied in population samples where the chance of an overdiagnosis in a particular situation can be estimated.<span><sup>3</sup></span></p><p>It is understood that overdiagnosis has many harms including the cost of the tests, the need for follow-up testing, treatment for diseases that will not affect health or longevity, and giving patients either a false sense of security or causing unnecessary anxiety. Patients may not understand why testing should be avoided and health care providers must spend more time counselling patients to avoid unnecessary testing.</p><p>Overused medical testing also effects patients’ life by involving them in more frequent medical encounters and potentially serious effects of unnecessary treatment. Another harmful impact is that patients
{"title":"Overdiagnosis and overtreatment of infectious diseases at the intersection of individual disease diagnosis, treatment, and public health","authors":"Dan Mayer MD, Sangil Lee MD, MS, Malene Plejdrup Hansen MD, PhD, Michael Gottlieb MD, Michael Brown MD, Richard Sinert DO, Joshua Davis MD","doi":"10.1002/emp2.13307","DOIUrl":"https://doi.org/10.1002/emp2.13307","url":null,"abstract":"<p>Overdiagnosis occurs when people with or without symptoms are diagnosed with a disease that ultimately will not cause them to experience worsening physical symptoms, disability, or early death. Clinicians have been paying more attention to the problem of overdiagnosis as part of the more general problem of “overmedicalization” of society in general. This also includes overtreatment, diagnostic creep, and disease mongering.<span><sup>1</sup></span></p><p>In this issue of <i>JACEP Open</i>, Meltzer et al demonstrated that a point-of-care multiplex polymerase chain reaction (PCR) analyzer identifying the microbiological cause of an infectious disease at an urgent care center (UCC) led to increased patient satisfaction.<span><sup>2</sup></span> Patients presenting to an UCC with respiratory symptoms were randomized to point-of-care multiplex PCR testing identifying viral and bacterial pathogens or a control group that got no testing. They found patients were more cognizant of the need to quarantine and take time off work when they knew the test results. There was no significant effect on antibiotic prescription, although the study was only powered for patients’ satisfaction.</p><p>Superficially, this seems reasonable for UCCs, and some may argue that this technology could be useful in the Emergency Department. However, this begs the question of whether the wider use of these diagnostic tools would increase the potential for overdiagnosis.</p><p>The definition of overdiagnosis was articulated in a 2018 editorial:<span><sup>3</sup></span> “identification of abnormalities that were never going to cause harm, abnormalities that do not progress, that progress too slowly to cause symptoms or harm during a person's remaining lifetime, or that resolve spontaneously.” They focused primarily on the overdiagnosis of cancers, but the concept is also applicable here. Overdiagnosis and over-testing are a complex problem, with many implications. The risk of overdiagnosis increases with the number of tests ordered that identify a disease not destined to meaningfully harm the patient, making the risks of testing outweigh the benefits. While difficult to determine at the individual level, this should be studied in population samples where the chance of an overdiagnosis in a particular situation can be estimated.<span><sup>3</sup></span></p><p>It is understood that overdiagnosis has many harms including the cost of the tests, the need for follow-up testing, treatment for diseases that will not affect health or longevity, and giving patients either a false sense of security or causing unnecessary anxiety. Patients may not understand why testing should be avoided and health care providers must spend more time counselling patients to avoid unnecessary testing.</p><p>Overused medical testing also effects patients’ life by involving them in more frequent medical encounters and potentially serious effects of unnecessary treatment. Another harmful impact is that patients","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13307","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142448989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sabrina Schalley LCSW, Kristi M. Goldenstein MSW, PLMPH, Trisha Graeve LCSW, Zebulon Timmons MD, Nadia Elshami LCSW, Rinad S. Beidas PhD, Jennifer A. Hoffmann MD, MS
Objective
Caring Contacts are brief caring messages sent to patients with suicidal thoughts or behaviors after an emergency department (ED) visit or hospitalization, which may decrease subsequent suicide attempts. We aimed to retrospectively evaluate the implementation of Caring Contacts in a children's hospital ED.
Methods
We conducted a retrospective observational study to evaluate the implementation of Caring Contacts within routine clinical care at an academic children's hospital ED from May 2020 to April 2023. Patients 5‒18 years old presenting for suicidal thoughts or behaviors were eligible to receive six handwritten cards with individualized caring messages, mailed over 12 months. We assessed enrollment rates (the percentage of patients offered Caring Contacts who agreed to receive them), fidelity to the intended schedule and card writer, return visits for suicidal ideation or behaviors while receiving Caring Contacts, and program costs.
Results
Of 627 encounters eligible for and offered Caring Contacts, 614 (98%) resulted in enrollment. Among instances of enrollment, 587 (96%) had cards sent per the intended schedule and 541 (88%) had cards written by the intended writer. A return ED visit for suicidal ideation or behaviors occurred for 168 (27%) during program participation. Costs per participant were $4.54 in materials and 0.9 h of personnel time.
Conclusion
In a children's hospital ED, Caring Contacts were feasible to implement with low costs and high fidelity to the intended schedule and card writer. Prospective studies are needed to assess Caring Contacts’ effectiveness in reducing suicide risk among adolescents following an ED visit.
{"title":"Retrospective evaluation of implementation of caring contacts for youth suicide prevention in an emergency department","authors":"Sabrina Schalley LCSW, Kristi M. Goldenstein MSW, PLMPH, Trisha Graeve LCSW, Zebulon Timmons MD, Nadia Elshami LCSW, Rinad S. Beidas PhD, Jennifer A. Hoffmann MD, MS","doi":"10.1002/emp2.13322","DOIUrl":"https://doi.org/10.1002/emp2.13322","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Caring Contacts are brief caring messages sent to patients with suicidal thoughts or behaviors after an emergency department (ED) visit or hospitalization, which may decrease subsequent suicide attempts. We aimed to retrospectively evaluate the implementation of Caring Contacts in a children's hospital ED.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a retrospective observational study to evaluate the implementation of Caring Contacts within routine clinical care at an academic children's hospital ED from May 2020 to April 2023. Patients 5‒18 years old presenting for suicidal thoughts or behaviors were eligible to receive six handwritten cards with individualized caring messages, mailed over 12 months. We assessed enrollment rates (the percentage of patients offered Caring Contacts who agreed to receive them), fidelity to the intended schedule and card writer, return visits for suicidal ideation or behaviors while receiving Caring Contacts, and program costs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 627 encounters eligible for and offered Caring Contacts, 614 (98%) resulted in enrollment. Among instances of enrollment, 587 (96%) had cards sent per the intended schedule and 541 (88%) had cards written by the intended writer. A return ED visit for suicidal ideation or behaviors occurred for 168 (27%) during program participation. Costs per participant were $4.54 in materials and 0.9 h of personnel time.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>In a children's hospital ED, Caring Contacts were feasible to implement with low costs and high fidelity to the intended schedule and card writer. Prospective studies are needed to assess Caring Contacts’ effectiveness in reducing suicide risk among adolescents following an ED visit.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13322","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142448988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jake Toy DO, MS, Lauren Friend MD, Kelsey Wilhelm MD, Michael Kim MD, Claire Gahm MD, Ashish R. Panchal MD, PhD, David Dillon MD, PhD, Joelle Donofrio-Odmann DO, Juan Carlos Montroy MD, PhD, Marianne Gausche-Hill MD, Nichole Bosson MD, MPH, Ryan Coute DO, Shira Schlesinger MD, MPH, James Menegazzi PhD, MS
Objectives
Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022.
Methods
We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non-traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually.
Results
We identified 1764 unique publications, 87 RCTs were included after title/abstract and full-text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, p = 1.0). Geographic analysis of study centers found 31 countries represented; Denmark (n = 13, 15%) and the United States (n = 9, 10%) conducted the majority of trials. Nearly all trials included adults (n = 84, 97%) and few included children (n = 9, 10%). The majority of trials focused on out-of-hospital cardiac arrest (n = 62, 71%). Thirty-eight (44%) trials used an intervention characterized as a process improvement; 28 (32%) interventions were characterized as a drug and 20 (23%) as a device. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra-arrest (53%) and post-arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days.
Conclusions
Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in-hospital cardiac arrest and pediatric patients.
{"title":"Evaluating the current breadth of randomized control trials on cardiac arrest: A scoping review","authors":"Jake Toy DO, MS, Lauren Friend MD, Kelsey Wilhelm MD, Michael Kim MD, Claire Gahm MD, Ashish R. Panchal MD, PhD, David Dillon MD, PhD, Joelle Donofrio-Odmann DO, Juan Carlos Montroy MD, PhD, Marianne Gausche-Hill MD, Nichole Bosson MD, MPH, Ryan Coute DO, Shira Schlesinger MD, MPH, James Menegazzi PhD, MS","doi":"10.1002/emp2.13334","DOIUrl":"https://doi.org/10.1002/emp2.13334","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non-traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We identified 1764 unique publications, 87 RCTs were included after title/abstract and full-text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, <i>p</i> = 1.0). Geographic analysis of study centers found 31 countries represented; Denmark (<i>n</i> = 13, 15%) and the United States (<i>n</i> = 9, 10%) conducted the majority of trials. Nearly all trials included adults (<i>n</i> = 84, 97%) and few included children (<i>n</i> = 9, 10%). The majority of trials focused on out-of-hospital cardiac arrest (<i>n</i> = 62, 71%). Thirty-eight (44%) trials used an intervention characterized as a <i>process improvement</i>; 28 (32%) interventions were characterized as a <i>drug</i> and 20 (23%) as a <i>device</i>. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra-arrest (53%) and post-arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in-hospital cardiac arrest and pediatric patients.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13334","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142451259","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ali Ghobadi MD, Michael Hanna MD, Stephanie Tovar MS, Duy H. Do PhD, Lewei Duan PhD, Ming-Sum Lee MD, PhD, Elizabeth A. Samuels MD, MPH, Corey S. Davis JD, MSPH, Adam L. Sharp MD, MSc
Objective
Opioid overdose is a public health epidemic adversely impacting individuals and communities. To combat this, California passed a law mandating that prescribers offer a naloxone prescription in certain circumstances. Our objective was to evaluate associations with California's naloxone prescription mandate and emergency department (ED) overdose visits/hospitalizations, opioid and naloxone prescribing, and 30-day mortality.
Methods
This retrospective cohort study included data from January 1, 2018, to December 31, 2019, and included all Kaiser Permanente Southern California (KPSC) members aged >10 years across 15 KPSC EDs. Exposure was defined as presentation to the ED within the study period. The primary outcome was ED visits for opioid overdose pre- and post-implementation of California's naloxone prescription mandate.
Results
A total of 1.1 million ED visits (534K pre/576K post) were included in the study population. ED opioid overdose visits were 344 (6.4/10,000) pre-policy and 351 (6.1/10,000) post-policy implementation, while non-opioid overdose visits were 309 (5.8/10,000) pre-implementation and 411 (7.1/10,000) post-implementation. The unadjusted rate of visits with opioid prescriptions decreased significantly (14.9% pre to 13.5% post) after implementation. ED naloxone prescriptions increased substantially (104 pre vs. 6031 post). Primary adjusted interrupted time series analysis found no statistical difference between monthly opioid overdose visits pre versus post (odds ratio 1.02, 95% confidence interval [CI] 0.98‒1.07). Difference-in-differences analysis revealed no significant changes in hospitalization (coefficient [CE] = ‒0.05, 95% CI = ‒0.11 to 0.02) or 30-day mortality (CE = ‒0.01, 95% CI = ‒0.03 to 0.01).
Conclusion
This study revealed that the implementation of California's naloxone prescription mandate was associated with significantly increased naloxone prescribing and decreased opioid prescribing, but no significant change in ED opioid overdose visits, hospitalizations, or 30-day mortality. This indicates that increasing naloxone prescribing alone may not be sufficient to lower opioid overdose rates.
{"title":"Impact of California's naloxone co-prescription law on emergency department visits, 30-day mortality, and prescription patterns","authors":"Ali Ghobadi MD, Michael Hanna MD, Stephanie Tovar MS, Duy H. Do PhD, Lewei Duan PhD, Ming-Sum Lee MD, PhD, Elizabeth A. Samuels MD, MPH, Corey S. Davis JD, MSPH, Adam L. Sharp MD, MSc","doi":"10.1002/emp2.13236","DOIUrl":"https://doi.org/10.1002/emp2.13236","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Opioid overdose is a public health epidemic adversely impacting individuals and communities. To combat this, California passed a law mandating that prescribers offer a naloxone prescription in certain circumstances. Our objective was to evaluate associations with California's naloxone prescription mandate and emergency department (ED) overdose visits/hospitalizations, opioid and naloxone prescribing, and 30-day mortality.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This retrospective cohort study included data from January 1, 2018, to December 31, 2019, and included all Kaiser Permanente Southern California (KPSC) members aged >10 years across 15 KPSC EDs. Exposure was defined as presentation to the ED within the study period. The primary outcome was ED visits for opioid overdose pre- and post-implementation of California's naloxone prescription mandate.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 1.1 million ED visits (534K pre/576K post) were included in the study population. ED opioid overdose visits were 344 (6.4/10,000) pre-policy and 351 (6.1/10,000) post-policy implementation, while non-opioid overdose visits were 309 (5.8/10,000) pre-implementation and 411 (7.1/10,000) post-implementation. The unadjusted rate of visits with opioid prescriptions decreased significantly (14.9% pre to 13.5% post) after implementation. ED naloxone prescriptions increased substantially (104 pre vs. 6031 post). Primary adjusted interrupted time series analysis found no statistical difference between monthly opioid overdose visits pre versus post (odds ratio 1.02, 95% confidence interval [CI] 0.98‒1.07). Difference-in-differences analysis revealed no significant changes in hospitalization (coefficient [CE] = ‒0.05, 95% CI = ‒0.11 to 0.02) or 30-day mortality (CE = ‒0.01, 95% CI = ‒0.03 to 0.01).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>This study revealed that the implementation of California's naloxone prescription mandate was associated with significantly increased naloxone prescribing and decreased opioid prescribing, but no significant change in ED opioid overdose visits, hospitalizations, or 30-day mortality. This indicates that increasing naloxone prescribing alone may not be sufficient to lower opioid overdose rates.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13236","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142449051","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Shea L. van den Bergh MPH, Lakeshia T. Logan DMSc, PA-C, Jonathan R. Powell MPA, NRP, Christopher B. Gage MHS, NRP, Kathryn R. Crawford MS, Lisa Collard AS, Michael G. Miller EdD, RN, Ashish R. Panchal MD, PhD
Objective
The COVID-19 pandemic required unprecedented changes to emergency medical services (EMS) educational frameworks in the United States. It is unclear if pandemic-related changes impacted paramedic educational outcomes. We aimed to evaluate curricular and performance changes resulting from the initial COVID-19 pandemic on paramedic educational programs.
Methods
We performed a retrospective cross-sectional evaluation of paramedic educational programs in 2019 and 2020 using the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions annual reports. These reports contain detailed program components and measures of program success. We included programs reporting at least one graduate in the study period. Descriptive statistics (proportions [%], median [interquartile range, IQR]) were calculated for paramedic program characteristics in 2019 and 2020, as well as pandemic specific curriculum changes. Wilcoxon rank-sum and Fisher's exact tests were used to evaluate differences in characteristics by year.
Results
The number of paramedic educational programs in our population decreased from 640 programs in 2019 to 612 in 2020, with a statistically significant decrease in clinical hours (2019: 219 [IQR 168‒272]; 2020: 200.5 [IQR 157‒261]). There was no difference in first or third-attempt certification examination success between years. Temporary shutdown was experienced in 34% of programs (duration: 3 weeks [2‒7]) and 72% of required curricular changes. Curricular changes commonly included decreased in-person education (86%), traditional classroom lectures (78%), number of clinical sites (78%), and increased online didactic education (92%). Only 20% of programs decreased laboratory simulation or total training hours.
Conclusion
During the pandemic, paramedic educational programs changed educational delivery with no observed differences on overall program performance. Identifying key curricular changes and best practices for implementation may be necessary to better optimize future educational delivery.
{"title":"Paramedic educational programs maintain entry level competency throughout the COVID-19 pandemic","authors":"Shea L. van den Bergh MPH, Lakeshia T. Logan DMSc, PA-C, Jonathan R. Powell MPA, NRP, Christopher B. Gage MHS, NRP, Kathryn R. Crawford MS, Lisa Collard AS, Michael G. Miller EdD, RN, Ashish R. Panchal MD, PhD","doi":"10.1002/emp2.13316","DOIUrl":"https://doi.org/10.1002/emp2.13316","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>The COVID-19 pandemic required unprecedented changes to emergency medical services (EMS) educational frameworks in the United States. It is unclear if pandemic-related changes impacted paramedic educational outcomes. We aimed to evaluate curricular and performance changes resulting from the initial COVID-19 pandemic on paramedic educational programs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We performed a retrospective cross-sectional evaluation of paramedic educational programs in 2019 and 2020 using the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions annual reports. These reports contain detailed program components and measures of program success. We included programs reporting at least one graduate in the study period. Descriptive statistics (proportions [%], median [interquartile range, IQR]) were calculated for paramedic program characteristics in 2019 and 2020, as well as pandemic specific curriculum changes. Wilcoxon rank-sum and Fisher's exact tests were used to evaluate differences in characteristics by year.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The number of paramedic educational programs in our population decreased from 640 programs in 2019 to 612 in 2020, with a statistically significant decrease in clinical hours (2019: 219 [IQR 168‒272]; 2020: 200.5 [IQR 157‒261]). There was no difference in first or third-attempt certification examination success between years. Temporary shutdown was experienced in 34% of programs (duration: 3 weeks [2‒7]) and 72% of required curricular changes. Curricular changes commonly included decreased in-person education (86%), traditional classroom lectures (78%), number of clinical sites (78%), and increased online didactic education (92%). Only 20% of programs decreased laboratory simulation or total training hours.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>During the pandemic, paramedic educational programs changed educational delivery with no observed differences on overall program performance. Identifying key curricular changes and best practices for implementation may be necessary to better optimize future educational delivery.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13316","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142449050","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A 48-year-old male with no known past medical history presented to the emergency department with left flank pain of 3 days duration. A urinalysis performed revealed trace blood, which was equivocal for the diagnosis of ureteric colic. A bedside ultrasound performed during assessment revealed a cystic structure within the left renal pelvis (Figure 1A) initially thought to be a renal cyst. Given its unusual location, Doppler ultrasound was utilized with detection of a pulsatile flow (Figure 1B) in the lesion. Computed tomography (CT) urography revealed a ruptured large left renal artery aneurysm (RAA) (Figure 2). The patient subsequently underwent a successful angioembolization of the aneurysm by interventional radiology.
Renal cysts are common incidental findings on imaging. However, they are typically found in the peripheries of the kidney. Parapelvic cysts (PPC) are uncommon, accounting for 1%–2% of all renal cysts.1 This case exemplified the need to consider differential diagnosis such as RAA when encountering PPC, especially when there is pain involved. The additional utilization of doppler ultrasound can help to differentiate these two entities, of which the latter is a common and rather benign diagnosis while the former is a rare but potentially dangerous diagnosis to miss.
RAA is known to also mimic other diagnoses on ultrasound. Case reports have described them mimicking renal cell carcinoma and even nephrolithiasis.2, 3 Once again, the use of doppler may potentially help to differentiate these diagnoses.
{"title":"Man with flank pain","authors":"Da Xian Pang MMed, Wei Feng Lee MMed","doi":"10.1002/emp2.13295","DOIUrl":"https://doi.org/10.1002/emp2.13295","url":null,"abstract":"<p>A 48-year-old male with no known past medical history presented to the emergency department with left flank pain of 3 days duration. A urinalysis performed revealed trace blood, which was equivocal for the diagnosis of ureteric colic. A bedside ultrasound performed during assessment revealed a cystic structure within the left renal pelvis (Figure 1A) initially thought to be a renal cyst. Given its unusual location, Doppler ultrasound was utilized with detection of a pulsatile flow (Figure 1B) in the lesion. Computed tomography (CT) urography revealed a ruptured large left renal artery aneurysm (RAA) (Figure 2). The patient subsequently underwent a successful angioembolization of the aneurysm by interventional radiology.</p><p>Renal cysts are common incidental findings on imaging. However, they are typically found in the peripheries of the kidney. Parapelvic cysts (PPC) are uncommon, accounting for 1%–2% of all renal cysts.<span><sup>1</sup></span> This case exemplified the need to consider differential diagnosis such as RAA when encountering PPC, especially when there is pain involved. The additional utilization of doppler ultrasound can help to differentiate these two entities, of which the latter is a common and rather benign diagnosis while the former is a rare but potentially dangerous diagnosis to miss.</p><p>RAA is known to also mimic other diagnoses on ultrasound. Case reports have described them mimicking renal cell carcinoma and even nephrolithiasis.<span><sup>2, 3</sup></span> Once again, the use of doppler may potentially help to differentiate these diagnoses.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13295","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142449181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Fang-Yu Lin MD, Chan-Han Wu MD, Chi-Wei Chen MD, MS
A 75-year-old woman with a history of coronary artery disease, diabetes mellitus, and a previous stroke was found to have dyspnea and hypotension at a nursing home. She was brought to the emergency department in her baseline comatose state. Her vital signs were as follows: blood pressure 78/61 mmHg, heart rate 53 beats/min, respiratory rate 30 breaths/min, body temperature 36.7°C, and oxygen saturation of 100% while receiving oxygen via a non-rebreather mask.
An initial electrocardiogram (ECG) revealed mild ST-segment elevation in the inferior leads with reciprocal changes, suggestive of an acute ischemic event. However, the rhythm was inconclusive due to atypical T wave morphology (Figure 1). The emergency physician performed point-of-care ultrasonography (POCUS) to assess the relationship between atrial and ventricular contractions (Video 1).
POCUS identified two atrial contractions for every ventricular contraction, indicating a 2:1 second-degree atrioventricular (AV) block. ECG interpretation can be difficult when waveforms are obscured by overlapping or multifocal signals, complicating arrhythmia classification.1 In cases of bradycardia, timely identification of AV blocks is crucial. When ECG findings are inconclusive, POCUS serves as an effective tool to assess AV conduction, enhancing diagnostic accuracy and guiding immediate clinical decisions.2
{"title":"Bradycardia in a woman","authors":"Fang-Yu Lin MD, Chan-Han Wu MD, Chi-Wei Chen MD, MS","doi":"10.1002/emp2.13336","DOIUrl":"https://doi.org/10.1002/emp2.13336","url":null,"abstract":"<p>A 75-year-old woman with a history of coronary artery disease, diabetes mellitus, and a previous stroke was found to have dyspnea and hypotension at a nursing home. She was brought to the emergency department in her baseline comatose state. Her vital signs were as follows: blood pressure 78/61 mmHg, heart rate 53 beats/min, respiratory rate 30 breaths/min, body temperature 36.7°C, and oxygen saturation of 100% while receiving oxygen via a non-rebreather mask.</p><p>An initial electrocardiogram (ECG) revealed mild ST-segment elevation in the inferior leads with reciprocal changes, suggestive of an acute ischemic event. However, the rhythm was inconclusive due to atypical T wave morphology (Figure 1). The emergency physician performed point-of-care ultrasonography (POCUS) to assess the relationship between atrial and ventricular contractions (Video 1).</p><p>POCUS identified two atrial contractions for every ventricular contraction, indicating a 2:1 second-degree atrioventricular (AV) block. ECG interpretation can be difficult when waveforms are obscured by overlapping or multifocal signals, complicating arrhythmia classification.<span><sup>1</sup></span> In cases of bradycardia, timely identification of AV blocks is crucial. When ECG findings are inconclusive, POCUS serves as an effective tool to assess AV conduction, enhancing diagnostic accuracy and guiding immediate clinical decisions.<span><sup>2</sup></span></p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13336","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142449171","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abdullah Khan MD, Abdelmoneem Mohammed Elsheikh MD, Khalid Alansari MD
Objective
Septic arthritis is an orthopedic emergency and if not evaluated and treated appropriately, it can lead to poor clinical outcomes. Previously several studies have been performed to identify the etiology of septic arthritis in the pediatric population in developed countries. The main objective of our study was to identify the etiology of septic arthritis in children in Qatar in previously healthy and fully vaccinated children.
Methods
We performed retrospective chart analysis of children presenting to our emergency department between July 2018 and June 2024, who were diagnosed and treated with septic arthritis. The study was conducted at a level 1 pediatric trauma center and the only children's hospital in the country. We used ICD 9 and ICD 10 codes to identify such cases. After using predefined exclusion criteria, children with positive blood cultures, blood titers for Brucella and/or synovial cultures were included in the analysis. Clinical symptoms and signs, ultrasound findings, and culture results were tabulated using descriptive statistics.
Results
A total of 45 patients were included. The median age of children was 5 years (interquartile range [IQR] 2–10 years). Majority (60%) were male. The most common clinical findings were limping/limitation of joint movement (100%), fever (80%), and swelling of joints (58%). The median C-reactive protein and erythrocyte sedimentation rate were 94 mg/L and 47 mm/h. The knee and hip were the most common joints affected. The most common causative organisms were Staphylococcus aureus (56%), Streptococcus pyogenes (13%), and Brucella (11%). Pre-intervention imaging, such as ultrasound and/or magnetic resonance imaging, was performed in 95% of patients. All patients recovered without any complications. One of the limitations of our study is that cases of Kingella kingae septic arthritis may be underreported as polymerase chain reaction (PCR) analysis of synovial fluid was not performed on all patients.
Conclusion
Gram-positive cocci, especially S. aureus, remains the most common cause of septic arthritis in vaccinated children. We also identified Gram-negative bacilli as causative organisms in our study. We suggest including empiric coverage for both Gram- and Gram-negative bacilli when treating children with suspected septic arthritis till culture results are available.
{"title":"Etiology of septic arthritis in children of Qatar","authors":"Abdullah Khan MD, Abdelmoneem Mohammed Elsheikh MD, Khalid Alansari MD","doi":"10.1002/emp2.13313","DOIUrl":"https://doi.org/10.1002/emp2.13313","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Septic arthritis is an orthopedic emergency and if not evaluated and treated appropriately, it can lead to poor clinical outcomes. Previously several studies have been performed to identify the etiology of septic arthritis in the pediatric population in developed countries. The main objective of our study was to identify the etiology of septic arthritis in children in Qatar in previously healthy and fully vaccinated children.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We performed retrospective chart analysis of children presenting to our emergency department between July 2018 and June 2024, who were diagnosed and treated with septic arthritis. The study was conducted at a level 1 pediatric trauma center and the only children's hospital in the country. We used ICD 9 and ICD 10 codes to identify such cases. After using predefined exclusion criteria, children with positive blood cultures, blood titers for Brucella and/or synovial cultures were included in the analysis. Clinical symptoms and signs, ultrasound findings, and culture results were tabulated using descriptive statistics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 45 patients were included. The median age of children was 5 years (interquartile range [IQR] 2–10 years). Majority (60%) were male. The most common clinical findings were limping/limitation of joint movement (100%), fever (80%), and swelling of joints (58%). The median C-reactive protein and erythrocyte sedimentation rate were 94 mg/L and 47 mm/h. The knee and hip were the most common joints affected. The most common causative organisms were <i>Staphylococcus aureus</i> (56%), <i>Streptococcus pyogenes</i> (13%), and Brucella (11%). Pre-intervention imaging, such as ultrasound and/or magnetic resonance imaging, was performed in 95% of patients. All patients recovered without any complications. One of the limitations of our study is that cases of <i>Kingella kingae</i> septic arthritis may be underreported as polymerase chain reaction (PCR) analysis of synovial fluid was not performed on all patients.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Gram-positive cocci, especially <i>S. aureus</i>, remains the most common cause of septic arthritis in vaccinated children. We also identified Gram-negative bacilli as causative organisms in our study. We suggest including empiric coverage for both Gram- and Gram-negative bacilli when treating children with suspected septic arthritis till culture results are available.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13313","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142449180","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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