Journal of the American College of Emergency Physicians open最新文献

Objectives: To describe the experience of health care professionals involved in the care of young people with acute severe behavioral disturbance across the acute care setting.

Methods: We used purposive and snowball sampling to recruit paramedics, nurses, doctors, and mental health clinicians caring for young people with acute severe behavioral disturbance in the prehospital and/or emergency department environments. We conducted one-to-one telephone-based semistructured qualitative interviews with each staff member. The audio recordings were transcribed verbatim, and participant pseudonyms were assigned. We iteratively developed a thematic coding structure. Data collection continued until thematic saturation was reached.

Results: We interviewed 31 health care professionals-12 doctors, 5 nurses, 7 mental health clinicians, and 7 paramedics. Participants outlined factors they felt contributed to the young person's behavioral disturbance. They detailed the management strategies used. Participants spoke about their exposure to physical violence while managing these young people and the challenges of balancing patient and staff safety. There was a significant personal impact on participants through providing care to this cohort. Participants acknowledged the workflow, staff resource, and bystander impacts of these presentations.

Conclusion: Based on participant's experiences, health care staff aim to provide high-quality care to young people with behavioral disturbance in circumstances that present risks to their safety. There is variability in the way staff are currently managing these young people likely because of the limited high-quality evidence currently available, highlighting key areas for future research.

Objectives: This study aims to conduct a gap analysis to determine the feasibility of mapping electronic health record data from the Clinical Emergency Data Registry (CEDR) to the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM).

Methods: We employed a structured approach using a custom-built comparison matrix. This matrix facilitated the alignment of CEDR data fields with the corresponding elements in the OMOP-CDM schema. Each field was evaluated for compatibility, with categorization into 3 distinct types: direct matches, fields requiring transformation, and fields with no OMOP-CDM equivalent. The mapping process was informed by consultations with the Observational Health Data Sciences and Informatics community forums and was guided by existing documentation and best practices in data harmonization. We performed descriptive analyses, quantifying the extent of direct matches and identifying the specific transformations needed for each CEDR-CDM field to ensure compliance with the OMOP-CDM model.

Results: Our analysis indicates a high degree of compatibility between CEDR and OMOP, with over 90% (244/269) of CEDR fields being successfully mapped. Specifically, 173 fields had direct matches, whereas 71 required transformations. Challenges identified include addressing fields unique to CEDR with no OMOP-CDM equivalent and managing the transformations required for proper alignment.

Conclusion: The OMOP-CDM presents a promising framework for standardizing emergency medicine data, thereby enhancing future query automation, analytics, and cross-institutional collaboration. Despite the potential challenges in capturing unique CEDR fields and addressing necessary transformations, most emergency department data can be standardized within the OMOP-CDM, fostering broader insights and applications in research and public health.

We present a case of acute carpal tunnel syndrome secondary to tight handcuffs in a detained patient. The severity of the motor and sensory deficits prompted consultation with orthopedic specialists and admission for an observation period with ultimate emergency operative intervention. Handcuff neuropathies are well documented in the literature, mainly involving the superficial branch of the radial nerve, which has strict sensory input into the dorsum of the hand. Less common median nerve neuropathies have also been documented following handcuff injury; however, none have required emergency intervention. We aim to highlight this unusual presentation and the emergency nature of the condition, as well as advocate for increased caution when caring for detained patients in the emergency department.

Objectives: Patients with a history of incarceration experience bias from health care team members, barriers to privacy, and a multitude of health care disparities. We aimed to assess care processes delivered in emergency departments (EDs) for people with histories of incarceration.

Methods: We utilized a fine-tuned large language model to identify patient incarceration status from 480,374 notes from the ED setting. We compared socio-demographic characteristics, comorbidities, and care processes, including disposition, restraint use, and sedation, between individuals with and without a history of incarceration. We then conducted multivariable logistic regression to assess the independent correlation of incarceration history and management in the ED while adjusting for demographic characteristics, health behaviors, presentation, and past medical history.

Results: We found 1734 unique patient encounters with a history of incarceration from a total of 177,987 encounters. Patients with history of incarceration were more likely to be male, Black, Hispanic, or other race/ethnicity, currently unemployed or disabled, and had smoking and substance use histories, compared with those without. This cohort demonstrated higher odds of elopement (OR: 3.59 [95% CI: 2.41-5.12]), leaving against medical advice (OR: 2.39 [95% CI: 1.46-3.67]), and being subjected to sedation (OR: 3.89 [95% CI: 3.19-4.70]) and restraint use (OR: 3.76 [95% CI: 3.06-4.57]). After adjusting for covariates, the association between incarceration and elopement remained significant (adjusted odds ratio: 1.65 [95% CI: 1.08-2.43]), while associations with other dispositions, restraint use, and sedation did not persist.

Conclusion: This study identified differences in patient characteristics and care processes in the ED for patients with histories of incarceration and demonstrated the potential of using natural language processing in measuring care processes in populations that are largely hidden, but highly prevalent and subject to discrimination, in the health care system.

Objectives: Skin and soft tissue infections (SSTIs) constitute a significant portion of emergency department (ED) cases, with some requiring admission into the observation unit (OU) for ongoing care. Identifying factors linked to OU admission is essential for optimizing patient disposition decisions.

Methods: A retrospective cohort study identified patients with the International Classification of Diseases 10th Revision (ICD-10) codes indicating SSTI at an urban, tertiary care ED over 3 years (2017-2019) who were ultimately discharged. Patients admitted at index visit were excluded. Medical charts were reviewed for demographic and clinical data. Simple logistic regression models explored bivariate associations with OU admission, while a multiple logistic regression model adjusted for demographics, clinical characteristics, vital signs, and pre-index visit and in-ED management.

Results: Among 1675 patients (42.9% female; mean age, 45.5 ± 15.4 years; 56.4% identifying as Black), 20.7% (n = 346) were admitted to the OU. Unadjusted analysis showed associations between OU admission and factors, including age, history of intravenous drug use (IVDU), lower extremity SSTI, subjective systemic illness, fever at index visit, ED surgical consultation, and pre-index visit antimicrobial choice. After adjustment, age (odds ratio [OR], 1.16; 95% CI, 1.04-1.30), immunocompromised status (OR, 1.83; 95% CI, 1.07-3.13), extremity cellulitis (lower: OR, 2.51; 95% CI, 1.55-4.14; upper: OR, 2.35; 95% CI, 1.36-4.12), surgical consultation (OR, 2.64; 95% CI, 1.79-3.91), and prehospital methicillin-resistant Staphylococcus aureus (MRSA) antibiotic prescription (OR, 2.76; 95% CI, 1.69-4.54; P = .0001) remained statistically significant.

Conclusion: Identifying factors associated with OU admission provides insights into clinician decision making, potentially identifying patients who might benefit from OU admission through future work, which should focus on predictors of hospital admission, OU failure, and antimicrobial selection to reduce OU failure rates.

Objectives: Limited recent national data exist measuring burnout levels among emergency medical services (EMS) clinicians and the potential impact of burnout on workforce strength and stability. We aimed to measure current EMS burnout and its association with workforce-reducing factors.

Methods: In April 2022, a random sample of nationally certified EMS clinicians was sent a survey that included the Copenhagen Burnout Inventory (CBI) to assess for burnout in 3 dimensions: personal, work-related, and patient-related. Descriptive statistics (count and percentage) and multivariable logistic regression (odds ratio [OR] and 95% CI) were used to identify and measure each domain of burnout and the relationship between these domains and workforce-reducing factors.

Results: From 1838 survey responses (9% response rate), prevalence of EMS burnout was high in the personal (52%), work-related (49%), and patient-related (23%) domains. Burnout was higher for paramedics than for emergency medical technicians across all domains. Higher odds of reporting 10 or more sick days was observed for those with personal (OR, 2.66; 95% CI, 1.70-4.15), work-related (OR, 1.99; 95% CI, 1.31-3.01), or patient-related burnout (OR, 1.85; 95% CI, 1.20-2.86). Higher odds of reporting likelihood to leave the EMS profession was observed for those with personal (OR, 3.06; 95% CI, 2.16-4.33), work-related (OR, 3.34; 95% CI, 2.35-4.74), or patient-related burnout (OR, 3.42; 95% CI, 2.39-4.90).

Conclusion: Nationally certified EMS clinicians demonstrated high burnout in 2022. Combined with increased absenteeism and intent to leave the profession associated with these high levels of burnout, these findings suggest that a renewed and deliberate focus on EMS clinician well-being is needed to ensure job satisfaction and workforce stability.