Volume 26 Issue 2 by Western Journal of Emergency Medicine

Volume 26, Number 2, March 2025

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Indexed in MEDLINE

Cardiology

180 Critical Time Intervals in Door-to-Balloon Time Linked to One-Year Mortality in ST-Elevation

Myocardial Infarction

Shin-Ho Tsai, Yu-Ting Hsiao, Ya-Ni Yeh, Jih-Chun Lin, Shi-Quan Zhang, Ming-Jen Tsai

191 Unlocking Cardiac Insights: Displacement of Aortic Root for Calculation of Ejection Fraction in Emergency Department in India

Sudhi Manu, Gopinathan Vivek, Asanaru Kunju Sanjan, A. Ajay, S. Nisarg, Mymbilly Balakrishnan Jayaraj, T. R. Aishwarya, Mohammad Khalid, S. Chetana

Clinical Practice

200 Procedural Sedation in the Emergency Department – An Observational Study: Does Nil Per Os Status Matter?

Brendan Peterson, Amy S. Nowacki, Alexander Ulintz, Sharon E. Mace

210 Immune Checkpoint Inhibitor-associated Pneumonitis: A Narrative Review

Chang Li, Saadia A. Faiz, Megan Boysen-Osborn, Ajay Sheshadri, Monica K. Wattana

Critical Care

219 Cardiac Computed Tomography Measurements in Pulmonary Embolism Associated with Clinical Deterioration

Anthony J. Weekes, Angela M. Pikus, Parker L. Hambright, Kelly L. Goonan, Nathaniel O’Connell

Education

233 Monitoring the Evolving Match Environment in Emergency Medicine 2023

Anthony Sielicki, Brian Milman, Andrew Little, Miriam Kulkarni, James Morris, Laura Hopson, Michael Kiemeney

Penn State Health Emergency Medicine

About Us: Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are the only medical facility in Pennsylvania to be accredited as a Level I pediatric trauma center and Level I adult trauma center. The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Health Children’s Hospital and Penn State Cancer Institute based in Hershey, Pa.; Penn State Health Hampden Medical Center in Enola, Pa.; Penn State Health Holy Spirit Medical Center in Camp Hill, Pa.; Penn State Health Lancaster Medical Center in Lancaster, Pa.; Penn State Health St. Joseph Medical Center in Reading, Pa.; Pennsylvania Psychiatric Institute, a specialty provider of inpatient and outpatient behavioral health services, in Harrisburg, Pa.; and 2,450+ physicians and direct care providers at 225 outpatient practices. Additionally, the system jointly operates various healthcare providers, including Penn State Health Rehabilitation Hospital, Hershey Outpatient Surgery Center and Hershey Endoscopy Center.

We foster a collaborative environment rich with diversity, share a passion for patient care, and have a space for those who share our spark of innovative research interests. Our health system is expanding and we have opportunities in both academic hospital as well community hospital settings.

Benefit highlights include:

• Competitive salary with sign-on bonus

• Comprehensive benefits and retirement package

• Relocation assistance & CME allowance

• Attractive neighborhoods in scenic central Pennsylvania

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR CPRP

Penn State Health Lead Physician Recruiter hpeffley@pennstatehealth.psu.edu

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Andrew W. Phillips, MD, Associate Editor DHR Health-Edinburg, Texas

Edward Michelson, MD, Associate Editor Texas Tech University- El Paso, Texas

Dan Mayer, MD, Associate Editor Retired from Albany Medical College- Niskayuna, New York

Wendy Macias-Konstantopoulos, MD, MPH, Associate Editor Massachusetts General Hospital- Boston, Massachusetts

Mark I. Langdorf, MD, MHPE, Editor-in-Chief

University of California, Irvine School of MedicineIrvine, California

Michael Gottlieb, MD, Associate Editor Rush Medical Center-Chicago, Illinois

Niels K. Rathlev, MD, Associate Editor Tufts University School of Medicine-Boston, Massachusetts

Michael Shalaby, MD, Deputy Editor Mount Sinai Medical Center

Susan R. Wilcox, MD, Associate Editor

Massachusetts General Hospital- Boston, Massachusetts

Elizabeth Burner, MD, MPH, Associate Editor

University of Southern California- Los Angeles, California

Patrick Joseph Maher, MD, MS, Associate Editor Ichan School of Medicine at Mount Sinai- New York, New York

Donna Mendez, MD, EdD, Associate Editor

Gayle Galletta, MD, Associate Editor University of Massachusetts Medical SchoolWorcester, Massachusetts s

Yanina Purim-Shem-Tov, MD, MS, Associate Editor Rush University Medical Center-Chicago, Illinois

Section Editors

Behavioral Emergencies

Leslie Zun, MD, MBA

Rosalind Franklin University of Medicine and Science

Marc L. Martel, MD Hennepin County Medical Center

Behavioral Health

Ryan Ley, MD, MBA, MS University of Nevada School of Medicine

Cardiac Care

Anthony Lucero, MD Kaweah Health Medical Center

Mary McLean, MD, FAAEM, FACEP AdventHealth East Orlando Emergency Medicine Residency

Sam S. Torbati, MD

Cedars-Sinai Medical Center

Clinical Practice

Cortlyn W. Brown, MD Carolinas Medical Center

Casey Clements, MD, PhD

Mayo Clinic

Patrick Meloy, MD Emory University

David Thompson, MD University of California, San Francisco

Kenneth S. Whitlow, DO Kaweah Delta Medical Center

Critical Care

Christopher “Kit” Tainter, MD University of California, San Diego

Dell Simmons, MD Geisinger Health

Joseph Shiber, MD University of Florida-College of Medicine

David Page, MD University of Alabama

Erik Melnychuk, MD Geisinger Health

Quincy Tran, MD, PhD University of Maryland

Disaster Medicine

Andrew Milsten, MD, MS UMass Chan Medical School

Scott Goldstein, DO, FACEP, FAEMS, EMT-T/P

Jefferson Einstein

John Broach, MD, MPH, MBA, FACEP

University of Massachusetts Medical School

UMass Memorial Medical Center

Christopher Kang, MD Madigan Army Medical Center

Rick A. McPheeters, DO, Associate Editor

R. Gentry Wilkerson, MD, Associate Editor University of Maryland

Education

Asit Misra, MD, MSMEd, CHSE University of Miami

University of Colorado

ED Administration, Quality, Safety

Tehreem Rehman, MD, MPH, MBA

Mount Sinai Hospital

David C. Lee, MD

Northshore University Hospital

Gary Johnson, MD Upstate Medical University

Brian J. Yun, MD, MBA, MPH Harvard Medical School

Laura Walker, MD Mayo Clinic

León D. Sánchez, MD, MPH

Beth Israel Deaconess Medical Center

William Fernandez, MD, MPH

University of Texas Health-San Antonio

Robert Derlet, MD

Founding Editor, California Journal of Emergency Medicine University of California, Davis

Emergency Medical Services

Daniel Joseph, MD Yale University

Joshua B. Gaither, MD

University of Arizona, Tuscon

Julian Mapp

University of Texas, San Antonio

Shira A. Schlesinger, MD, MPH Harbor-UCLA Medical Center

Geriatrics

Stephen Meldon, MD

Cleveland Clinic

Luna Ragsdale, MD, MPH Duke University Health Equity

Sara Heinert, PhD, MPH

Rutgers Robert Wood Johnson Medical School

Naomi George, MD, MPH University of New Mexico School of Medicine

Sarah Aly, DO

Yale Department of Emergency Medicine

Lauren Walter, MD, MSPH University of Alabama at Birmingham

Victor Cisneros, MD, MPH

Eisenhower Medical Center

Faith Quenzer Temecula Valley Hospital San Ysidro Health Center

University of Texas-Houston/McGovern Medical School- Houston Texa

Danya Khoujah, MBBS, Associate Editor University of Maryland School of Medicine- Baltimore, Maryland

Payal Modi, MD MScPH University of Massachusetts Medical Infectious Disease

Elissa Schechter-Perkins, MD, MPH Boston University School of Medicine

Ioannis Koutroulis, MD, MBA, PhD

George Washington University School of Medicine and Health Sciences

Stephen Liang, MD, MPHS

Washington University School of Medicine

Injury Prevention

Mark Faul, PhD, MA

Centers for Disease Control and Prevention

Wirachin Hoonpongsimanont, MD, MSBATS Eisenhower Medical Center

International Medicine

Heather A.. Brown, MD, MPH

Prisma Health Richland

Taylor Burkholder, MD, MPH

Keck School of Medicine of USC

Christopher Greene, MD, MPH University of Alabama

Chris Mills, MD, MPH

Santa Clara Valley Medical Center

Shada Rouhani, MD

Brigham and Women’s Hospital

Legal Medicine

Indiana University School of Medicine Statistics and Methodology

Monica Gaddis, PhD University of Missouri, Kansas City School of Medicine

Shu B. Chan MD, MS Resurrection Medical Center

Stormy M. Morales Monks, PhD, MPH

Texas Tech Health Science University

Soheil Saadat, MD, MPH, PhD University of California, Irvine

James A. Meltzer, MD, MS

Albert Einstein College of Medicine

Musculoskeletal

Juan F. Acosta DO, MS

Neurosciences

Antonio Siniscalchi, MD

Annunziata Hospital, Cosenza, Italy

Rick Lucarelli, MD

Medical City Dallas Hospital

William D. Whetstone, MD University of California, San Francisco

Pediatric Emergency Medicine

Ronnie Waldrop, MD

University of South Alabama

Jabeen Fayyaz, MD, MCPS, FCPS, MHPE, PhD, IHP

The Hospital for Sick Children

Muhammad Waseem, MD Lincoln Medical & Mental Health Center

Cristina M. Zeretzke-Bien, MD University of Florida

Public Health

John Ashurst, DO Lehigh Valley Health Network

Tony Zitek, MD

Kendall Regional Medical Center

Erik S. Anderson, MD Alameda Health System-Highland Hospital

Technology in Emergency Medicine

Nikhil Goyal, MD

Henry Fo

Chris Baker, MD University of California, San Francisco rd Hospital

Phillips Perera, MD Stanford University Medical Center Trauma

Whitney K. Brown, MD, MPH, Med, CTropMed University of Cincinnati College of Medicine

Robert Flint, MD, FACEP, FAAEM University of Maryland School of Medicine

Lesley Osborn, MD University of Colorado

Kathleen Stephanos, MD University of Maryland School of Medicine

T. Andrew Windsor, MD AEMUS-FPD

University of Maryland School of Medicine

Pierre Borczuk, MD Massachusetts General Hospital/Havard Medical School

Toxicology

Brandon Wills, DO, MS Virginia Commonwealth University

University of California, Irvine Ultrasound J. Matthew Fields, MD

Robert Allen, MD Los Angeles General Medical Center

Shane Summers, MD Brooke Army Medical Center

Robert R. Ehrman

Wayne State University

Ryan C. Gibbons, MD Temple Health

Women’s Health

Marianne Haughey, MD Northwell Health

Journal of the California Chapter of the American College of Emergency Physicians, the America College of Osteopathic Emergency Physicians, and the California Chapter of the American Academy of Emergency Medicine

American Academy of Emergency Medicine

Available in MEDLINE, PubMed, PubMed Central, CINAHL, SCOPUS, Google Scholar, eScholarship, Melvyl, DOAJ, EBSCO, EMBASE, Medscape, HINARI, and MDLinx Emergency Med. Members of OASPA WestJEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA

Western Journal of Emergency :

Western Journal of Emergency Medicine:

Integrating Emergency with Population Health

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Editorial Board

Board

MAAEM

Amin A. Kazzi, MD, MAAEM

Gayle Galleta, MD

The American University of Beirut, Lebanon

Beirut,

The American University of Beirut, Beirut, Lebanon

Brent King, MD, MMM University Texas, Houston

Brent King, MD, MMM University of Texas, Houston

Christopher E. San Miguel, MD

Ohio State University Wexner Medical Center

Christopher E. San Miguel, MD Ohio State University Wexner Medical Center

Christopher E. San Miguel, Ohio State University Wexner Medical Center

Daniel J. Dire, MD

Daniel J. Dire, MD University Texas Health Sciences Center San Antonio

Daniel J. Dire, MD University of Texas Health Sciences Center San Antonio

Douglas Ander, MD Emory University

Douglas Ander, Emory University

Emory University

Edward Michelson, MD Texas Tech University

Edward Michelson, Texas Tech University

Edward Michelson, MD Texas Tech University

Edward Panacek, MD, MPH South

Edward Panacek, MD, MPH University of South Alabama

Edward MD, MPH University South Alabama

Francesco

“Maggiore della Carità,” Novara, Italy

Francesco Della Corte, MD Azienda Ospedaliera Universitaria “Maggiore della Novara, Italy

Francesco Della Corte, MD Azienda Ospedaliera Universitaria “Maggiore della Carità,” Novara, Italy

Elena Lopez-Gusman, JD

California ACEP

Elena Lopez-Gusman, JD California ACEP American College of Emergency

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Gayle Galleta, MD Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog,

Hjalti Björnsson, MD

Niels K. Rathlev, MD Tufts University School of Medicine

Tufts University School of Medicine

Niels K. Rathlev, MD Tufts University School of Medicine

Scott Zeller, MD

Scott Zeller, MD University of California, Riverside

Hjalti MD Icelandic Society of Emergency Medicine

Hjalti Björnsson, MD Icelandic Society of Emergency Medicine

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de Chile, Región Metropolitana, Chile

Steven H. Lim, MD Changi General Hospital, Simei, Singapore

Jaqueline Le, MD Desert Regional Medical Center

Jaqueline Le, MD Desert Medical Center

Regional

Jeffrey Love, MD

Jeffrey Love, MD The George Washington University School of Medicine and Health Sciences

Jeffrey Love, The George Washington University School of Medicine and Health Sciences

Katsuhiro Kanemaru, MD University of Miyazaki Hospital, Miyazaki, Japan

Katsuhiro Kanemaru, MD University of Hospital, Miyazaki, Japan

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de Bell,

Peter A. Bell, DO, MBA Baptist Health Sciences University

Peter Sokolove, MD University of California, San Francisco

Steven H. Lim, MD Changi General Hospital, Simei, Singapore

Singapore

Terry Mulligan, DO, MPH, FIFEM ACEP Ambassador to the Netherlands Society of Emergency Physicians

Terry Mulligan, DO, MPH, FIFEM ACEP Ambassador to the Netherlands

Peter Sokolove, MD University of California, San Francisco

University of California, San Francisco

Wirachin Hoonpongsimanont, MD, MSBATS

Kenneth V. Iserson, MD, MBA University of Arizona, Tucson

The George Washington University School of Medicine and Health Sciences Arizona,

Leslie Zun, MD, MBA Chicago Medical School

Rachel A. Lindor, MD, JD Mayo Clinic

Rachel A. Lindor, MD, JD

Siriraj Hospital, Mahidol University, Bangkok, Thailand

Robert Suter, DO, MHA UT Southwestern Medical Center

Robert Suter, DO, MHA

Robert Suter, DO, MHA UT Southwestern Medical Center

Robert W. Derlet, MD University of California, Davis

University of California, Davis

Robert W. Derlet, MD University of California, Davis

Rosidah Ibrahim, MD Hospital Serdang, Selangor, Malaysia

Linda S. Murphy, MLIS University of California, Irvine School of Medicine Librarian

Linda S. Murphy, MLIS University of California, Irvine School of Medicine

Chicago Medical School Librarian

Advisory Board

American College of Emergency Physicians

Jennifer Kanapicki Comer, MD FAAEM

California Chapter Division of AAEM Stanford University School of Medicine

DeAnna McNett, CAE

Kimberly Ang, MBA UC Irvine Health School of Medicine

American College of Osteopathic Emergency Physicians

Randall J. Young, MD, MMM, FACEP California ACEP

Kimberly Ang, MBA

American College of Emergency Physicians Kaiser Permanente

UC Irvine Health School of Medicine

Randall J. Young, MD, MMM, FACEP California ACEP American College of Emergency Physicians

Kaiser Permanente

J. American College of Emergency Physicians Kaiser Permanente

Scott Rudkin, MD, MBA University of California, Irvine

Scott Rudkin, MD, MBA

Scott Rudkin, MD, MBA University of California, Irvine

Editorial Staff

Staff

Mark I. Langdorf, MD, MHPE, MAAEM, FACEP

Langdorf, MAAEM, FACEP

Isabelle Nepomuceno, BS Executive Editorial Director

Isabelle Kawaguchi, BS Executive Editorial Director

June Casey, BA Copy Editor

Cassandra Saucedo, MS Executive Publishing Director

UC Irvine Health School of Medicine

UC Irvine Health School Medicine

UC Irvine Health School of Medicine

Robert Suter, DO, MHA

Robert Suter, DO, MHA American College of Osteopathic

American College of Osteopathic Emergency Physicians UT Southwestern Medical Center

Robert Suter, DO, MHA American College of Osteopathic Emergency Physicians UT Southwestern Medical Center

Shahram Lotfipour, MD, MPH FAAEM, FACEP

UC Irvine Health School Medicine

Shahram Lotfipour, MD, MPH FAAEM, FACEP UC Irvine Health School of Medicine

Jorge Fernandez, MD, FACEP

Ian Olliffe, BS Associate Editorial Director, WestJEM

Visha Bajaria, BS WestJEM Editorial Director

Emily Kane, MA WestJEM Editorial Director

Stephanie Burmeister, MLIS WestJEM Staff Liaison

Visha Bajaria, BS WestJEM Editorial Director WestJEM

UC San Diego Health School of Medicine

Jorge Fernandez, MD, UC San Diego Health School of Medicine

Cassandra Saucedo, MS Executive Publishing Director

Nicole Valenzi, BA WestJEM Publishing Director

and Publishing Office: JEM/Depatment of

Tran Nguyen, BS Associate Editorial Director, CPC-EM

Nicole Valenzi, BA WestJEM Publishing Director

Cassandra Saucedo, MS WestJEM Publishing Director

Sheya Aquino, BS Associate Editorial Director

June Casey, BA Copy Editor

Nancy Taki, BS Associate Editorial Director

Alyson Tsai, BS Associate Publishing Director

Official Journal of the California Chapter of the American College of Emergency Physicians, the America College of Osteopathic Emergency Physicians, and the California Chapter of the American Academy of Emergency Medicine

Available in MEDLINE, PubMed, PubMed Central, Europe PubMed Central, PubMed Central Canada, CINAHL, SCOPUS, Google Scholar, eScholarship, Melvyl, DOAJ, EBSCO, EMBASE, Medscape, HINARI, and MDLinx Emergency Med. Members of OASPA. Editorial and Publishing Office: WestJEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA Office: 1-714-456-6389; Email: Editor@westjem.org

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

JOURNAL FOCUS

Emergency medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.

241 Personality Traits and Burnout in Emergency Medicine Residents

Brendan Freeman, Lukasz Cygan, Laura Melville, Theodore Gaeta

246 Productivity and Efficiency Growth During Emergency Medicine Residency Training

Matthew T. Singh, David M. Austin, Stephanie C. Mullennix, Joshua C. Reynolds, J. Adam Oostema

254 Harder, Better, Faster, Stronger? Residents Seeing More Patients Per Hour See Lower Complexity

Corlin M. Jewell, Guangyu (Anthony) Bai, Dann J. Hekman, Adam M. Nicholson, Michael R. Lasarev, Roxana Alexandridis, Benjamin H. Schnapp

261 Push and Pull: What Factors Attracted Applicants to Emergency Medicine and What Factors Pushed Them Away Following the 2023 Match

Michael Kiemeney, James Morris, Lauren Lamparter, Moshe Weizberg, Andy Little, Brian Milman

271 Combining Immersive Simulation with a Collaborative Procedural Training on Local Anesthetic Systemic Toxicity and Fascia Iliaca Compartment Block: A Pilot Study

Katherine B. Griesmer, Maxwell Thompson, Briana Miller, Guihua Zhai, Jaron Raper, Andrew Bloom

279 Development of a Reliable, Valid Procedural Checklist for Assessment of Emergency Medicine Resident Performance of Emergency Cricothyrotomy

Dana E. Loke, Andrew M. Rogers, Morgan L. McCarthy, Maren K. Leibowitz, Elizabeth T. Stulpin, David H. Salzman

285 Virtual Interviews Correlate with Home and In-State Match Rates at One Emergency Medicine Program

Christine Motzkus, Casey Frey, Aloysius Humbert

Emergency Department Operations

290 Two-year Results of an Emergency Department Night Shift Buy-out Program

Charlotte W. Croteau, Joshua N. Goldstein, Lauren Nentwich, Ali S. Raja, Michael VanRooyen, Joshua J. Baugh

295 Modeling Hourly Productivity of Advanced Practice Clinicians in the Emergency Department

Bryan A. Stenson, Peter S. Antkowiak, David T. Chiu, Leon D. Sanchez, Joshua W. Joseph

Geriatrics

301 Injuries and Outcomes of Ground-level Falls Among Older Patients: A Retrospective Cohort Study

Vincent Kan, Wilson Huang, Gretta Steigauf-Regan, Jill Anderson, Ivy Dang, Chad Darling

Health Equity

307 Relationship Between Social Risk Factors and Emergency Department Use: National Health Interview Survey 2016–2018

Iraa Guleria, Jennifer A. Campbell, Abigail Thorgerson, Sanjay Bhandari, Leonard E. Egede

Policies for peer review, author instructions, conflicts of interest and human and animal subjects protections can be found online at www.westjem.com.

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Table of Contents continued

315 Associations of Individual and Neighborhood Factors with Disparities in COVID-19 Incidence and Outcomes

Margaret E. Samuels-Kalow, Rebecca E. Cash, Kori S. Zachrison, Auriole Corel Rodney Fassinou, Norman Harris II, Carlos A. Camargo Jr.

326 Food and Housing Insecurity, Resource Allocation, and Follow-up in a Pediatric Emergency Department

Raymen R. Assaf, Chloe Knudsen-Robbins, Theodore Heyming, Kellie Bacon, Shelby K. Shelton, Bharath Chakravarthy, Soheil Saadat, Jason A. Douglas, Victor Cisneros

338 Gender Disparities and Burnout Among Emergency Physicians: A Systematic Review by the World Academic Council of Emergency Medicine–Female Leadership Academy for Medical Excellence

Suman Thakur, Vivek Chauhan, Sagar Galwankar, Fatimah Lateef, Pia Daniel, Zeynep Cakir, Katia M. Lugo, Samjhana Basnet, Busra Bildik, Siham Azahaf, Sevilay Vural, Busra H. Difyeli, Lisa Moreno-Walton

Neurology

347 Use and Outcomes of Sugammadex for Neurological Examination after Neuromuscular Blockade in the Emergency Department

Stephen D. Hallisey, Christiana K. Prucnal, Annette M. Ilg, Raghu R. Seethala, Paul S. Jansson

Research Methods

353 Analysis of the Highest Altmetrics-scored Articles in Emergency Medicine Journals Başak Bayram, Murat Cetin, Önder Limon, Brit Long, Michael Gottlieb

Toxicology

364 Effort During Ethanol Breath Testing Impacts Correlation with Serum Ethanol Concentration

Samuel J. Stellpflug, William H. Menton, Bjorn C. Westgard, Ryan D. Johnsen, Alexander M. Coomes, Robert C. LeFevere, Michael D. Zwank

Trauma

367 Blood Pressure Variability and Outcome Predictors for Traumatic Brain Injury Patients with Diffuse Axonal Injury: A Retrospective Cohort Study

Christine E. Ren, Anastasia Ternovskaia, Fatima Mikdashi, Hassan Syed, Isha Vashee, Vainavi Gambhir, Natalie Chao, Jessica V. Downing, David Dreizin, Quincy K. Tran

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

This open access publication would not be possible without the generous and continual financial support of our society sponsors, department and chapter subscribers.

Professional Society Sponsors

American College of Osteopathic Emergency Physicians

California American College of Emergency Physicians

Academic Department of Emergency Medicine Subscriber Albany Medical College Albany, NY

Allegheny Health Network Pittsburgh, PA

American University of Beirut Beirut, Lebanon

AMITA Health Resurrection Medical Center Chicago, IL

Arrowhead Regional Medical Center Colton, CA

Baylor College of Medicine Houston, TX

Baystate Medical Center Springfield, MA

Bellevue Hospital Center New York, NY

Beth Israel Deaconess Medical Center Boston, MA

Boston Medical Center Boston, MA

Brigham and Women’s Hospital Boston, MA

Brown University Providence, RI

Carl R. Darnall Army Medical Center Fort Hood, TX

Cleveland Clinic Cleveland, OH

Columbia University Vagelos New York, NY

State Chapter Subscriber

Arizona Chapter Division of the American Academy of Emergency Medicine

California Chapter Division of the American Academy of Emergency Medicine

Florida Chapter Division of the American Academy of Emergency Medicine

International Society Partners

Conemaugh Memorial Medical Center Johnstown, PA

Crozer-Chester Medical Center Upland, PA

Desert Regional Medical Center Palm Springs, CA

Detroit Medical Center/ Wayne State University Detroit, MI

Eastern Virginia Medical School Norfolk, VA

Einstein Healthcare Network Philadelphia, PA

Eisenhower Medical Center Rancho Mirage, CA

Emory University Atlanta, GA

Franciscan Health Carmel, IN

Geisinger Medical Center Danville, PA

Grand State Medical Center Allendale, MI

Healthpartners Institute/ Regions Hospital Minneapolis, MN

Hennepin County Medical Center Minneapolis, MN

Henry Ford Medical Center Detroit, MI

Henry Ford Wyandotte Hospital Wyandotte, MI

Emergency Medicine Association of Turkey Lebanese Academy of Emergency Medicine Mediterranean Academy of Emergency Medicine

California Chapter Division of American Academy of Emergency Medicine

INTEGRIS Health Oklahoma City, OK

Kaiser Permenante Medical Center San Diego, CA

Kaweah Delta Health Care District Visalia, CA

Kennedy University Hospitals Turnersville, NJ

Kent Hospital Warwick, RI

Kern Medical Bakersfield, CA

Lakeland HealthCare St. Joseph, MI

Lehigh Valley Hospital and Health Network Allentown, PA

Loma Linda University Medical Center Loma Linda, CA

Louisiana State University Health Sciences Center New Orleans, LA

Louisiana State University Shreveport Shereveport, LA

Madigan Army Medical Center Tacoma, WA

Maimonides Medical Center Brooklyn, NY

Maine Medical Center Portland, ME

Massachusetts General Hospital/Brigham and Women’s Hospital/ Harvard Medical Boston, MA

Great Lakes Chapter Division of the American Academy of Emergency Medicine

Tennessee Chapter Division of the American Academy of Emergency Medicine

Norwegian Society for Emergency Medicine Sociedad Argentina de Emergencias

Mayo Clinic Jacksonville, FL

Mayo Clinic College of Medicine Rochester, MN

Mercy Health - Hackley Campus Muskegon, MI

Merit Health Wesley Hattiesburg, MS

Midwestern University Glendale, AZ

Mount Sinai School of Medicine New York, NY

New York University Langone Health New York, NY

North Shore University Hospital Manhasset, NY

Northwestern Medical Group Chicago, IL

NYC Health and Hospitals/ Jacobi New York, NY

Ohio State University Medical Center Columbus, OH

Ohio Valley Medical Center Wheeling, WV

Oregon Health and Science University Portland, OR

Penn State Milton S. Hershey Medical Center Hershey, PA

Uniformed Services Chapter Division of the American Academy of Emergency Medicine

Virginia Chapter Division of the American Academy of Emergency Medicine

for Emergency Medicine

To become a WestJEM departmental sponsor, waive article processing fee, receive electronic copies for all faculty and residents, and free CME and faculty/fellow position advertisement space, please go to http://westjem.com/subscribe or contact:

Stephanie Burmeister

WestJEM Staff Liaison

Phone: 1-800-884-2236

Email: sales@westjem.org

Sociedad Chileno Medicina Urgencia Thai Association

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

This open access publication would not be possible without the generous and continual financial support of our society sponsors, department and chapter subscribers.

Professional Society Sponsors

American College of Osteopathic Emergency Physicians

California American College of Emergency Physicians

Academic Department of Emergency Medicine Subscriber Prisma Health/ University of South Carolina SOM Greenville Greenville, SC

Regions Hospital Emergency Medicine Residency Program St. Paul, MN

Rhode Island Hospital Providence, RI

Robert Wood Johnson University Hospital New Brunswick, NJ

Rush University Medical Center Chicago, IL

St. Luke’s University Health Network Bethlehem, PA

Spectrum Health Lakeland St. Joseph, MI

Stanford Stanford, CA

SUNY Upstate Medical University Syracuse, NY

Temple University Philadelphia, PA

Texas Tech University Health Sciences Center El Paso, TX

The MetroHealth System/ Case Western Reserve University Cleveland, OH

UMass Chan Medical School Worcester, MA

University at Buffalo Program Buffalo, NY

State Chapter Subscriber

Arizona Chapter Division of the American Academy of Emergency Medicine

California Chapter Division of the American Academy of Emergency Medicine

Florida Chapter Division of the American Academy of Emergency Medicine

International Society Partners

University of Alabama Medical Center Northport, AL

University of Alabama, Birmingham Birmingham, AL

University of Arizona College of Medicine-Tucson Tucson, AZ

University of California, Davis Medical Center Sacramento, CA

University of California, Irvine Orange, CA

University of California, Los Angeles Los Angeles, CA

University of California, San Diego La Jolla, CA

University of California, San Francisco San Francisco, CA

UCSF Fresno Center Fresno, CA

University of Chicago Chicago, IL

University of Cincinnati Medical Center/ College of Medicine Cincinnati, OH

University of Colorado Denver Denver, CO

University of Florida Gainesville, FL

University of Florida, Jacksonville Jacksonville, FL

Emergency Medicine Association of Turkey Lebanese Academy of Emergency Medicine Mediterranean Academy of Emergency Medicine

California Chapter Division of American Academy of Emergency Medicine

University of Illinois at Chicago Chicago, IL

University of Iowa Iowa City, IA

University of Louisville Louisville, KY

University of Maryland Baltimore, MD

University of Massachusetts Amherst, MA

University of Michigan Ann Arbor, MI

University of Missouri, Columbia Columbia, MO

University of North Dakota School of Medicine and Health Sciences Grand Forks, ND

University of Nebraska Medical Center Omaha, NE

University of Nevada, Las Vegas Las Vegas, NV

University of Southern Alabama Mobile, AL

University of Southern California Los Angeles, CA

University of Tennessee, Memphis Memphis, TN

University of Texas, Houston Houston, TX

University of Washington Seattle, WA

Great Lakes Chapter Division of the American Academy of Emergency Medicine

Tennessee Chapter Division of the American Academy of Emergency Medicine

Norwegian Society for Emergency Medicine Sociedad Argentina de Emergencias

University of WashingtonHarborview Medical Center Seattle, WA

University of Wisconsin Hospitals and Clinics Madison, WI

UT Southwestern Dallas, TX

Valleywise Health Medical Center Phoenix, AZ

Virginia Commonwealth University Medical Center Richmond, VA

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CriticalTimeIntervalsinDoor-to-BalloonTimeLinkedto One-YearMortalityinST-ElevationMyocardialInfarction

Shin-HoTsai,MD

Yu-TingHsiao,MD

Ya-NiYeh,MS

Jih-ChunLin,BS

Shi-QuanZhang,MD

Ming-JenTsai,MD,PhD

DitmansonMedicalFoundationChia-YiChristianHospital,DepartmentofEmergency Medicine,ChiayiCity,Taiwan

SectionEditor: CaseyM.Clements,MD,PhD

Submissionhistory:SubmittedApril11,2024;RevisionreceivedNovember5,2024;AcceptedNovember7,2024

ElectronicallypublishedJanuary30,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20779

Background: Timelyactivationofprimarypercutaneouscoronaryintervention(PCI)iscrucialfor patientswithST-segmentelevationmyocardialinfarction(STEMI).Door-to-balloon(DTB)time, representingthedurationfrompatientarrivaltoballooninﬂation,iscriticalforprognosis.However,the speciﬁctimesegmentwithintheDTBthatismostassociatedwithlong-termmortalityremainsunclear. InthisstudyweaimedtoidentifythetargettimesegmentwithintheDTBthatismostassociatedwith one-yearmortalityinSTEMIpatients.

Methods: Weconductedaretrospectivecohortstudyatatertiaryteachinghospital.Allpatients diagnosedwithSTEMIandactivatedforprimaryPCIfromtheemergencydepartmentwereidentiﬁed betweenJanuary2013–December2021.Patientdemographics,medicalhistory,triageinformation, electrocardiogram,troponin-Ilevels,andcoronaryangiographyreportswereobtained.Wedividedthe DTBtimeintodoor-to-electrocardiogram(ECG),ECG-to-cardiaccatheterizationlaboratory(cathlab) activation,activation-to-cathlabarrival,andcathlabarrival-to-balloontime.WeusedKaplan-Meier survivalanalysisandmultivariableCoxproportionalhazardsmodelstodeterminetheindependent effectsofthesetimeintervalsontheriskofone-yearmortality.

Results: Atotalof732STEMIpatientswereincluded.Kaplan-Meieranalysisrevealedthatdelayed door-to-ECGtime(>10min)andcathlabarrival-to-balloontime(>30min)wereassociatedwithahigher riskofone-yearmortality(log-ranktest, P < .001and P = 0.01,respectively).InthemultivariableCox models,door-to-ECGtimewasasignificantpredictorforone-yearmortality,whetheritwasanalyzedasa dichotomized(>10minvs ≤10min)oracontinuousvariable.Thecorrespondingadjustedhazardratios (aHR)were2.81(95%confidenceinterval[CI]1.42–5.55)forthedichotomizedanalysis,and1.03(95% CI1.00–1.06)perminuteincrease,respectively.Cathlabarrival-to-balloontimealsoshowedan independenteffectonone-yearmortalitywhenanalyzedasacontinuousvariable,withanaHRof1.02 (95%CI1.00–1.04)perminuteincrease.However,ECG-to-cathlabactivationandactivation-to-cathlab arrivaltimesdidnotshowasignificantassociationwiththeriskofone-yearmortality.

Conclusion: Withinthedoor-to-ballooninterval,thetimefromdoor-to-ECGcompletionisparticularly crucialforone-yearsurvivalafterSTEMI,whilecathlabarrival-to-ballooninﬂationmayalsoberelevant. [WestJEmergMed.2025;26(2)180–190.]

INTRODUCTION

Primarypercutaneouscoronaryintervention(PCI)stands asthecornerstonetherapyforpatientsexperiencingSTsegmentelevationmyocardialinfarction(STEMI).1–3 The promptactivationofprimaryPCIuponaSTEMIpatient’ s arrivalattheemergencydepartment(ED)iscrucialfor achievingcoronaryarteryreperfusion.1–3 Thedoor-toballoon(DTB)time,representingtheintervalfromthe patient’sEDarrivaltotheinﬂationofaballoonwithinthe occludedcoronaryartery,servesasapivotalmetricinthis process.1,3 ProlongedDTBtimeshaveconsistentlybeen associatedwithanelevatedriskofshort-termmortalityand majoradversecardiacevents.4–6 Consequently,DTBtime servesasaqualityindicatorforassessingtheperformanceof aPCI-capablehospital.1,7

WithintheDTBtime,severaltimesegmentscanbe delineated,includingdoor-to-electrocardiogram(ECG), ECG-to-catheterizationlaboratory(cathlab)activation, activation-to-cathlabarrival,cathlabarrival-to-needle insertion,andneedleinsertion-to-ballooninﬂationtime. Delaysinanyofthesetimesegmentsmayleadtoprolonged DTBtime.7–9

Previousstudieshaveexploredtherelationshipbetween DTBandshort-termmortality,suchasin-hospitaldeathor 30-daymortality.5,6 However,theimpactofDTBtimeon long-termmortalityandwhichspeciﬁctimesegmentwithin theDTBismostlyassociatedwithlong-termoutcome remainunclear.Toaidinthedevelopmentofimprovement strategies,ourgoalinthisstudywastodeterminethetarget periodwithintheDTBthatismostassociatedwithone-year mortalityinSTEMIpatients.

METHODS

StudyDesign,Setting,andParticipants

WeconductedaretrospectivecohortstudyatDitmanson MedicalFoundationChia-YiChristianHospital,a1,000bedtertiaryteachinghospitalinanurbancityofTaiwan. Thehospital’semergencydepartment(ED)handles approximately80,000patientvisitsannually.Designatedas anaccredited,advancedemergency-responsibilityhospitalin Taiwansince2013,itundergoesregularevaluationstoensure compliancewithSTEMIemergencymanagementstandards. Keyobjectivesincludeproviding24/7emergencycardiac catheterizationservices,ensuringthatover80%ofSTEMI patientsreceiveanECGexaminationwithin10minutesof EDarrival,initiatingdualantiplatelettherapyforatleast 80%ofSTEMIpatientsintheEDbeforeprimaryPCI,and achievingDTBtimesofunder90minutesforover75%of STEMIpatients.Consequently,aprotocolformanaging STEMIpatientsintheEDhasbeenimplemented (Supplementary Figure1).

Uponarrival,immediateECGisperformedforpatients withanycardiopulmonary-relatedsymptomsintriageand promptlyreviewedbyanemergencyphysician.IfSTEMIis

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Timelypercutaneouscoronaryinterventionis essentialforpatientswithST-elevation myocardialinfarction(STEMI);reducing door-to-balloon(DTB)timeimproves survivaloutcomes.

Whatwastheresearchquestion?

WhichintervalwithintheDTBtimeismost associatedwith1-yearmortalityin STEMIpatients?

Whatwasthemajor ﬁndingofthestudy?

Thetimefromdoor-to-ECGcompletion withintheDTBintervalisparticularly importantfor1-yearmortalityin STEMIpatients.

Howdoesthisimprovepopulationhealth?

IdentifyingkeyintervalswithinDTBtime associatedwithlong-termmortalityin STEMIpatientssupportsthedevelopmentof targetedimprovementstrategies.

diagnosed,aloadingdoseofdualantiplatelettherapyand anticoagulantsisadministered,andthecardiologistis immediatelyconsulted.Thecardiologistactivatesprimary PCIafterassessment.Oncethecathlabisprepared,the patientistransferredforprimaryPCIasexpeditiously aspossible.

AllpatientsdiagnosedwithSTEMIandactivatedfor primaryPCIfromtheEDareincludedinthehospital-based STEMIregistry,wheredatawasprospectivelygatheredfor qualityimprovement.Weidentifiedpatientshospitalizedfor STEMIbetweenJanuary1,2013–December31,2021,from theSTEMIregistry.FactorspotentiallyinfluencingSTEMI outcomesandDTBtime,suchasdemographicdata(age, sex,bodymassindex).10,11 timeofEDarrival,12 weekend visit,13 visitduringtheCOVID-19pandemic,4,15 modeof transportationtothehospital,16 triagelevel,17 initial troponin-Ilevels,18 comorbidities,11 findingsofECG andcoronaryangiography,10,11 anddurationof hospitalization,werecollectedfromtheregistryand electronichealthrecords.

VarioustimepointsfromEDarrivaltoballooninflation wereidentified,includingthetimeofcompletionofthe first ECG,activationofthecathlab,arrivalinthecathlab,and ballooninflation.Wedefineddoor-to-ECGtimeasthe durationfromEDarrivaltocompletionofthe firstECG,

Figure1. Timesegmentswithinthedoor-to-balloontime. Cathlab,catheterizationlaboratory; ECG,electrocardiogram; ED,emergencydepartment.

ECG-to-activationtimeasthedurationfromECG completiontoactivationofthecathlab,activation-to-cath lab-arrivaltimeasthedurationfromcathlabactivationto thepatient’sarrivalinthecathlab,andcathlab-arrival-toballoontimeasthedurationfromthepatient’sarrivalinthe cathlabtoballooninﬂation(Figure1).1,3,7 Delaysindifferent timeintervalswithintheDTBweredeﬁnedasfollows:doorto-ECGtime >10min;ECG-to-activationtime >20min; activation-to-cathlabarrivaltime >30min;cathlabarrivalto-balloontime >30min;andDTBtime >90min.1,5

OutcomeMeasurement

Theprimaryoutcomeassessedinthisstudywasall-cause mortalitywithinoneyearafteradmissionforSTEMI.All STEMIpatientswerefollowedupforatleastoneyearfrom thedateofadmissiontoassessmortality.Mortalitytiming wasaccuratelydeterminedbycross-referencingstudy patientswiththeNationalCauseofDeathRegistryfrom theTaiwanNationalHealthInsurancedatabase,which documentsthetimeandcauseofdeathforalldeceased individualsinTaiwan.19 Thelastfollow-updatewas December31,2022.SinceTaiwanNationalHealth Insuranceisacompulsory,single-payerhealthcaresystem coveringnearly99.8%ofthepopulation,theoreticallyall enrolledpatientswhopassawayarerecordedintheNational CauseofDeathRegistry.19 Thus,unlessapatientwithdraws fromtheinsurancesystems,allincludedpatientscanbe trackedeitheruntilthelastfollow-updateortheirdateof death.Patientswithout-of-hospitalcardiacarrest(OHCA) andthosewithmissingdatawereexcludedfromtheanalysis.

Thiswasahealthrecordreviewstudyinwhichwe followedthemethodologicalcriteriaforhealthrecordreview studiesproposedbyWosteretal.20 AfteridentifyingSTEMI patientsfromthehospital-basedSTEMIregistry,weuseda pre-designedformwithdeﬁnedvariablestorecordpatients’ data.Fourtrainedemergencyresidentsandnursesreviewed theelectronichealthrecordsandinputdataintotheform. Regularmeetingswereheldtoensurethecorrectnessofdata collection,andasupervisorrandomlyauditedtheaccuracy ofthedatacollected.Thedataabstractorswerenotawareof thestudy’shypothesisandwereinformedonlythattheywere

helpingtoestablishaSTEMIdatabaseforresearchpurposes. ThestudyprotocolreceivedapprovalfromtheInstitutional ReviewBoardofDitmansonMedicalFoundationChia-Yi ChristianHospital(approvalnumber:CYCH-IRB 2024010),withanexemptionfrominformedconsentowing totheretrospectivenatureofthestudy.

StatisticalAnalysis

WecompareddatafromtheincludedSTEMIpatients betweentwogroups:thosewithandwithoutone-year mortality.Continuousvariableswereexpressedasmean ± standarddeviationormedian(interquartilerange)and assessedbetweengroupsusingtheStudent t -testorMannWhitneyUtest,respectively,basedondatadistribution.We presentcategoricalvariablesasnumber(percentage)and assessedthemusingchi-squaretest.Themortalityratewas expressedaseventsper100person-years.Toidentifythe targettimesegmentwithintheDTBmostassociatedwith one-yearmortality,weemployedKaplan-Meiersurvival analysis.Survivalcurveswereplottedforpatientsstratiﬁed intodelayvsnon-delaygroupsacrossdifferenttimeintervals withintheDTB,withdifferencesassessedusinglog-rank tests.WeusedunivariableCoxproportionalhazardsmodels toassesstheassociationbetweeneachvariableandone-year mortality.TimeintervalswithintheDTBweretreatedas eitherdichotomized(delayornon-delaygroups)or continuousvariables.Wefurtheranalyzedvariables demonstratinga P -valueoflessthan0.1intheunivariable analysisinamultivariableCoxmodelemployingforward variableselection(setat P < 0.05foradditiontothemodel) todeterminetheirindependenteffectontheriskofone-year mortality.TheSchoenfeldtestwassubsequentlyusedto verifytheassumptionofproportionalhazards.

SensitivityAnalysis

Weconductedadditionalsensitivityanalysestoexamine theassociationbetweenvarioustimeintervalswithinthe DTBandshort-termmortalityoutcomes,suchasin-hospital and30-daymortality,aswellasone-yearmortality.These analysesusedmultivariablelogisticregressionwithaforward stepwiseWaldtest.Thevariablesincludedintheseanalyses

werethesameasthoseinthemultivariableCoxanalysis.The timeintervalswithintheDTBwereincorporatedintothe modelsseparatelyandweretreatedaseitherdichotomizedor continuousvariables.Furthermore,consideringtheextended recruitmentperiodofthisstudy(nineyears),weconducted anothersensitivityanalysistocontrolforpotential confoundingfactorsacrossdifferenttimeperiods.In additiontoadjustingforassociatedvariables,weperformed amultivariableCoxmodelincludingtheyearofpatient recruitmentasacovariate.Finally,asensitivityanalysis usingamultivariableCoxmodelwasconductedtoevaluate therelationshipbetweenDTBtimeintervalsand cardiovascular-relatedone-yearmortality.Weperformed statisticalanalysesusingStata17.0(StataCorp, CollegeStation,TX),withstatisticalsigniﬁcancesetat two-tailed <0.05.

RESULTS

Duringthestudyperiod,738patientswithSTEMIwere identified.AfterexcludingthosewithOHCAormissing data,732patientswere finallyincluded.Amongthem,59 patientsdiedwithinoneyearafterSTEMI(Figure2),with37 deathsattributedtocardiovascular-relatedcauses.The overallmortalityratewas9.05per100person-years (95%confidenceinterval[CI],7.02–11.69).

Table1 presentsthecharacteristicsofpatientswithand withoutmortalitywithinoneyearafterSTEMI.Patients whodiedwithinoneyearafterSTEMIwereolder(73.2 ± 13.7vs61.0 ± 12.6years, P < .001)andhadahigher proportionoffemales(35.59%vs14.56%, P < .001).They weremorelikelytobetransportedtothehospitalby ambulance(40.68%vs24.37%, P = 0.006)andhadhigher

triageacuity(triagelevel1:32.2%vs.8.92%, P < .001)and initialtroponin-Ilevels(1.72[0.12–8.52]vs0.13[0.02–2.40) nanogramspermilliliter, P < .001].Theywerealsomore likelytohavediabetesmellitus(54.24%vs38.04%, P = 0.02), hypertension(76.27%vs63.30%, P = 0.05),cerebrovascular accident(20.34%vs.6.39%, P < .001),andchronickidney disease(20.34%vs6.69%, P < .001),whilebeinglesslikelyto havehyperlipidemia(27.12%vs63.30%, P < .001).

Additionally,theyhadlongerhospitalizationdurations (6[3–14]vs5[4–6]days, P = 0.02)andlongerdoor-to-ECG (7[5–11]vs4[3–6]min, P < .001], cathlabarrival-to-balloon (25[17–40]vs22[16–28]min, P = 0.02),andDTBtimes (74[56–88]vs64[52–75]min, P < .001].Moreover,ahigher proportionofpatientshadDTBtimelongerthan90min (22.03%vs8.82%, P < .001).

Figure3 showstheKaplan-Meiercurvesformortality afteradmissionforSTEMI.Weanalyzedthemortality probabilitybetweentwogroupsbasedontheDTBtime (Figure3A).Thecumulativemortalityratewassigniﬁcantly higherinthedelayedDTBgroup(DTB > 90min)compared tothenon-delayedgroup(DTB ≤ 90min)duringtheoneyearfollow-upperiod(long-ranktest, P < .001).Next,we separatelyanalyzedforthedifferenttimesegmentswithinthe DTB.Patientswithdelayeddoor-to-ECG(Figure3B) andcathlabarrival-to-balloontimes(Figure3E)hada highermortalityriskthantheirnon-delayedcounterparts (P < .001andP = 0.007,respectively).However,no signiﬁcantdifferencewasobservedbetweenpatientswithand withoutdelaysinECG-to-cathlabactivation(Figure3C) andactivation-to-cathlabarrival(Figure3D).

IntheunivariableCoxanalyses(Table2),anincreasein age,femalesex,ambulance-transportedpatients,higher

Figure2. Flowchartofthepatientsincludedinthestudy. ECG,electrocardiogram; OHCA,out-of-hospitalcardiacarrest; STEMI,ST-segmentelevationmyocardialinfarction.

Table1. Characteristicsofpatientswithandwithoutone-yearmortalityafteradmissionforSTEMI*.

Age(year)

Characteristics1-yearsurvival(N = 673)1-yearmortality(N = 59) P-value

± 12.6

Femalesex98(14.56)21(35.59) <.001

Patientarrivaltime

Dayshift294(43.69)33(55.93)0.19

Eveningshift251(37.30)17(28.81)

Nightshift128(19.02)9(15.25)

Weekendvisit197(29.27)18(30.51)0.84

DuringCOVID-19pandemic(2020–2021)143(21.25)8(13.56)0.16

Ambulance-transportedpatient164(24.37)24(40.68)0.006

Triagelevel

160(8.92)19(32.20) <.001

2553(82.17)38(64.41)

360(8.92)2(3.39)

Laboratorytest

Medicalhistory

Diabetesmellitus256(38.04)32(54.24)0.02

Hypertension426(63.30)45(76.27)0.05

Hyperlipidemia426(63.30)16(27.12) <.001

Cerebrovascularaccident43(6.39)12(20.34) <.001

Chronickidneydisease45(6.69)12(20.34) <.001

Coronaryarterydisease92(13.67)9(15.25)0.74

COPD18(2.68)4(6.78)0.08 PAOD8(1.19)1(1.70)0.53

Smoking410(60.92)29(49.15)0.08

ECGreport

AnteriorSTEMI305(45.32)31(52.54)0.29

InferiorSTEMI340(50.67)25(42.37)0.22

LateralSTEMI23(3.43)2(3.39)1.00

PosteriorSTEMI12(1.79)0(0.00)0.61

Numbersofvesseldisease2(1–3)2(2–3)0.06

Findingsofcoronaryangiography

1vesseldisease206(30.66)14(23.73)0.23

2vesselsdisease244(36.31)18(30.51)

3vesselsdisease220(32.74)27(45.76)

Durationofhospitalization(day)5(4–6)6(3–14)0.02

Timeinterval

Door-to-ECG(min)4(3–6)7(5–11) <.001

ECG-to-activation(min)10(6–15)11(8–19)0.13

Activation-to-cathlabarrival(min)23(16–30)22(16–30)0.94

Cathlabarrival-to-balloon(min)22(16–28)25(17–40)0.02

(Continued onnextpage)

Table1. Continued.

–75)

Dataarepresentedasn(%),mean ± SD, ormedian(interquartilerange).

BMI,bodymassindex; COPD,chronicobstructivepulmonarydisease; ECG,electrocardiography; ng/mL,nanogramspermilliliter; PAOD, peripheralarterialocclusiondisease;*STEMI,ST-segmentelevationmyocardialinfarction.

Figure3. Kaplan-Meiercurvesillustratingcumulativemortalityrateswithinaone-yearfollow-upperiodafterSTEMI*admissionfordelayand non-delaygroupsindoor-to-balloon(A),door-to-ECG(B),ECG-to-activation(C),activation-to-cathlabarrival(D),andcathlabarrival-toballoon(E)times.

*STEMI,ST-elevationmyocardialinfarction.

troponin-Ilevels,amedicalhistoryofdiabetes,hypertension, cerebrovascularaccident,orchronickidneydisease,and eachadditionaldayofhospitalizationwereassociatedwitha higherriskofone-yearmortality.Additionally,patientswith alowertriagelevelandhyperlipidemiahadalowerriskof one-yearmortality.Moreover,door-to-ECGandcathlab arrival-to-balloontimesweresigniﬁcantlyassociatedwitha higherriskofonw-yearmortalityafterSTEMI.

Table3 presentstheresultsofmultivariableCoxanalyses. Inmodel1,weanalyzedthetimeintervalsasdichotomized variables(delayvsnon-delaygroups).Afteradjustingfor associatedfactors,adelayeddoor-to-ECGtime(>10min) remainedanindependentpredictorofone-yearmortality, withanadjustedhazardratio(HR)of2.81(95%CI 1.42–5.55).Inmodel2,thetimeintervalswereanalyzedas continuousvariables.Wefoundthateachminuteincreasein

Table2. UnivariableCoxmodelsforpredictingone-yearmortality afterSTEMI*admission.

Characteristics

Age(year) 1.08(1.05–1.10) <.001

BMI 0.94(0.88–1.01)0.11

Femalesex 2.95(1.73–5.03) <.001

Patientarrivaltime

Dayshift Reference

Eveningshift 0.63(0.35–1.13)0.12

Nightshift 0.63(0.30–1.31)0.21

Weekendvisit 1.06(0.61–1.84)0.85

DuringCOVID-19 pandemic(2020–2021)

0.63(0.30–1.33)0.23

Ambulance-transported patient 2.06(1.23–3.47)0.006

Triagelevel

1 Reference

2 0.24(0.14–0.41) <.001

3 0.11(0.03–0.48)0.003

Laboratorytest

Troponin-I(ng/mL) 1.01(1.01–1.02) <.001

Medicalhistory

Diabetesmellitus 1.85(1.11–3.08)0.02

Hypertension 1.84(1.01–3.35)0.05

Hyperlipidemia 0.23(0.13–0.40) <.001

Cerebrovascularaccident3.35(1.78–6.31) <.001

Chronickidneydisease3.13(1.66–5.91) <.001

Coronaryarterydisease1.17(0.58–2.38)0.66

COPD 2.42(0.88–6.69)0.09

PAOD 1.35(0.19–9.76)0.77

Smoking 0.63(0.38–1.05)0.07

ECGreport

AnteriorSTEMI 1.36(0.81–2.26)0.24

InferiorSTEMI 0.71(0.43–1.20)0.20

LateralSTEMI 0.98(0.24–4.00)0.97

PosteriorSTEMI 4.53E-15(0–∞)1.00

Numbersofvessel disease 1.37(0.99–1.90) 0.06

Durationofhospitalization (day) 1.03(1.02–1.05) <.001

Timeinterval

Door-to-ECG >10min4.82(2.68–8.66) <.001

ECG-to-activation > 20min 1.48(0.80–2.75)0.21

Activation-to-cathlab arrival > 30min 0.87(0.47–1.61)0.65

(Continued onnextcolumn)

Table2. Continued.

Timeinterval Door-to-ECGtime(min)1.02(1.00–1.04)0.03 ECG-to-activation time(min)

Activation-to-cathlab arrivaltime(min)

Cathlabarrival-to-balloon time(min)

–1.05) <.001

BMI, bodymassindex; COPD,chronicobstructivepulmonary disease; CI,conﬁdenceinterval; ECG,electrocardiography; HR,hazardratio; PAOD,peripheralarterialocclusiondisease; *STEMI,ST-segmentelevationmyocardialinfarction.

door-to-ECGtime(adjustedHR,1.03;95%CI1.00–1.06) andcathlabarrival-to-balloontime(adjustedHR,1.02;95% CI1.00–1.04)wereindependentlyassociatedwithone-year mortality.Furthermore,age,triagelevel,initialtroponin-I levels,andahistoryofdiabetesmellitusandhyperlipidemia wereindependentpredictorsofone-yearmortality(Table3). TheSchoenfeldtestyielded P -valuesof0.65and0.43for models1and2,respectively,indicatingnoviolationofthe proportionalhazardsassumptionfortheincludedcovariates.

Supplementary Table1 presentsthesensitivityanalysis conductedusinglogisticregressionfortheoutcomesofinhospital,30-dayandone-yearmortality.Afteradjustingfor associatedfactors,door-to-ECGtimewasconsistently identifiedasanindependentpredictorforin-hospital,30-day, andone-yearmortality,regardlessofwhetheritwasanalyzed asdichotomizedorcontinuousvariables.Moreover,cath lab-arrival-toballoontimewasidentifiedasanindependent predictorfortheone-yearmortalityoutcomewhenitwas analyzedasacontinuousvariable.Supplementary Table2 displaysanothersensitivityanalysisthatincludedtheyearof patientrecruitmentasacovariatetoaddresspotential confoundingfactorsacrossdifferenttimeperiods.Theresults weresimilartothemainanalysis.Supplementary Table3 showstheresultsofasensitivityanalysisfocusedonone-year cardiovascular-relatedmortality,whichwereconsistentwith themain findings.

DISCUSSION

Inthisstudy,weexploredspecifictimesegmentswithinthe DTBintervalassociatedwithone-yearmortalityinpatients withSTEMI.Our findingsrevealedthattheduration fromdoortoECGcompletionisparticularlyassociated withone-yearmortality,whilecathlabarrival-to-balloon inflationmayalsoberelevant.However,theintervals fromECGcompletiontocathlabactivationandfrom

Table3. MultivariableCoxmodelsforpredictingone-yearmortalityafterSTEMI*admission.

Timeinterval

>30min -

**ThevariablesincludedinthemultivariableCoxmodelwithforwardselectionanalysiswereage,sex,ambulance-transportedpatient,triage level, troponinI,diabetesmellitus,hypertension,hyperlipidemia,cerebrovascularaccident,chronickidneydisease,numbersofvessel disease,durationofhospitalization,door-to-ECGtime,andcathlabarrival-to-balloontime.Thecharacteristicspresentedinthetable representthevariablesthatwereultimatelyselectedforinclusionintheCoxmodels.

ECG,electrocardiography; HR,hazardratio; ng/mL,nanogramspermilliliter;*STEMI,ST-segmentelevationmyocardialinfarction.

activation-to-cathlabarrivalwerenotsigniﬁcantly associatedwithone-yearmortality.Additionally,age,triage acuitylevel,initialtroponin-Ilevels,andahistoryofdiabetes mellitusandhyperlipidemiawereidentiﬁedasindependent predictorsforone-yearmortalityinSTEMIpatients.

Weobservedthatadelayindoor-to-ECGtime(>10min) wasassociatedwitha2.81-foldincreasedriskofmortality withinoneyearcomparedtothosewithoutdelay.Each minutedelayinECGacquisitionmayincreasetheriskof mortalityby3%withinoneyearafterSTEMI(Table3).This highlightstheimportanceofearlyECGacquisitionforthe long-termprognosisofSTEMI.Duringthetreatmentcourse forpatientswithSTEMI,therapeuticinterventions, suchasearlyadministrationofdualantiplateletagents, anticoagulants,andvigilantmonitoring,areinitiatedupon STEMIdiagnosis,priortoangiographicassessment (Supplementary Figure1).Currentguidelinesrecommend earlyplateletinhibitionasafundamentalcomponentof pharmacologictreatmentintheearlystagesofSTEMI,with expectedbeneﬁtsincludingenhancedplateletinhibitionafter primaryPCIandalowerincidenceofstentthrombosis.3,21,22 Arecentsystematicreviewandmeta-analysisadditionally alsoshowstheimportanceofusingupstreamanticoagulation beforePCI,whichisassociatedwithalower30-daymortality risk,alowerincidenceofin-hospitalcardiogenicshock,and improvedreperfusionoftheinfarct-relatedartery.23 Early ECGcompletionenablespromptdiagnosisofSTEMIand timelyinitiationofantiplateletagents,anticoagulants,and

intensivecare,whicharecrucialforachievingcoronary arteryreperfusion,preventingthrombosisfollowingprimary PCI,andminimizingmyocardialdamagepostinfarction.22,23 Consequently,asobservedinthisstudy, notonlyisshort-termmortalityimproved,butlong-term mortalityaswell.Our ﬁndingsalsosupporttheimportance ofprehospitalECG,whichhasbeenshowntoreduceDTB timeandimproveshort-termmortality.24,25 Additionally, whencombinedwithprehospitaldualantiplatelettherapy, thesemeasuresmayfurtherimprovelong-termoutcomesin STEMIpatients.26

Ourstudyalsorevealedanassociationbetweencathlab arrival-to-balloontimeandone-yearmortalityfollowing STEMI,indicatingthateachminuteofdelayinthisinterval mayincreasethemortalityriskby2%withinthe firstyear (adjustedHR1.02)(Table3).Althoughtheeffectsizewas small,this findingmaybereasonable.Inadditionto pharmacologictreatmentintheinitialstagesofSTEMI, promptrestorationofblood flowintheoccludedcoronary vesselsiscritical.WhileeffortstoreduceDTBtimehasbeen explored,27 researchfocusedondecreasingthedurationfrom cathlabarrival-to-ballooninflationremainslimited.Itis essentialtoconsidervariousfactorsthatmayinfluencecath labarrival-to-balloontime,includingpatient’svascular condition,theexperienceofthecardiologist,equipment preparationandreadiness,andcathlabstaffavailability.28,29 Ongoingresearchondevelopingnewtechniquesandguiding catheterstoreducethetimefromneedleinsertiontoballoon

inﬂationormortalityisimperative.30 Healthcarefacilities mustassessandoptimizethesefactorstoensuretimelyand effectivedeliveryofcaretopatientsundergoingPCI proceduresforSTEMI.

ApartfromtheDTBtimeintervals,age,triageacuity level,initialtroponin-Ilevels,andahistoryofdiabetes mellitusandhyperlipidemiawereidentiﬁedasindependent predictorsforone-yearmortalityinSTEMIpatientsinour study.Theadverseimpactofageanddiabetesmellituson short-andlong-termmortalityinSTEMIpatientshasbeen extensivelydocumented.11 Notably,weobservedan associationbetweenahistoryofhyperlipidemiaandreduced riskofone-yearmortality(adjustedHR,0.31, P < .001in bothmodels)(Table3).Similar ﬁndingswerealsoreportedin previousresearch.31

Onepossibleexplanationforthisishowamedicalhistory ofhyperlipidemiawasdeﬁned,basedonpatients’ prior medicalrecordsandwhethertheyreceivedlipid-lowering therapy,primarilystatins.31 IntheTaiwanNational Insuranceprogram,theprescriptionofstatinsrequiresa conﬁrmeddiagnosisofhyperlipidemia.Therefore,we speculatethatthereducedmortalityriskobservedinpatients withahistoryofhyperlipidemiamaybebecausethese STEMIpatientswerereceivinglipid-loweringtherapy. PreviousstudieshavefoundthatpatientswithSTEMIwho weretriagedashavingloweracuitylevelswhentheyarrived atanEDexperienceddelaysinECGacquisitionand reperfusiontherapy.17,32 However,afteradjustingforDTB timeintervals,ourstudyfoundthatlowertriageacuitywas actuallyassociatedwithalowerriskofone-yearmortality. Thismaybebecausepatientwithhighertriageacuity(triage level1)oftenpresentwithunstablevitalsigns,whichare associatedwithahigherriskofmortality.

Wanamakeretalinvestigatedtherelationshipbetween troponinlevelsatpresentationandin-hospitalmortalityin STEMIpatientsundergoingPCI.Theydemonstratedthat in-hospitalmortalityincreaseswithelevatedtroponinlevels atpresentation,irrespectiveofbaselineclinicalrisk.18 Our ﬁndingsalsorevealedthatinitialtroponinlevelisan independentpredictorforone-yearmortalityinSTEMI patients.Therefore,troponinlevelsintheearlyphaseof STEMImayoffervaluablelong-termprognostic informationinpatientsundergoingprimaryPCI.

LIMITATIONS

Ourstudyhasseverallimitations.Firstly,itisasinglecenterstudywithasmallsamplesize,potentiallylimitingits generalizabilitytootherpopulations.Secondly,being retrospectiveinnature,thereisapossibilityofunmeasured confoundersandselectionbiasthatcouldhaveaffectedthe results.Thirdly,thestudycoversanine-yearperiod,during whichchangesinhospitalstaff,policies,andguidelinesmay haveintroducedconfoundingfactors.However,our sensitivityanalysis,whichcontrolledfortheyearsofpatient

recruitment,yieldedsimilarresults.Nevertheless,further multicenter,prospectivestudiesarewarrantedtovalidate our ﬁndings.

CONCLUSION

WithintheDTBinterval,thetimefromdoor-to-ECG completioniscrucialforone-yearsurvivalafterSTEMI, whilecathlabarrival-to-ballooninﬂationmayalsobe relevant.Strategiesforimprovinglong-termoutcomesfor STEMIpatientsshouldprioritizereducingthetimefrom door-to-ECGacquisition.Thiscouldbeattributedtothe facilitationofearlyinitiationofpharmacologictreatments, suchasdualantiplateletandanticoagulationtherapy,inthe initialstagesofSTEMIprecedingPCI.

AddressforCorrespondence:Ming-JenTsai,MD,PhD,Ditmanson MedicalFoundationChia-YiChristianHospital,Departmentof EmergencyMedicine,No.539,ZhongxiaoRd.,EastDistrict,Chiayi City600,Taiwan.E-mail: tshi33@gmail.com; 07367@cych.org.tw

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

UnlockingCardiacInsights:DisplacementofAorticRootfor

CalculationofEjectionFractioninEmergency

DepartmentinIndia

SudhiManu,MD*

GopinathanVivek,DNB†

AsanaruKunjuSanjan,MD,DNB†

A.Ajay,MD‡

S.Nisarg,MD*

MymbillyBalakrishnanJayaraj,MD*

T.R.Aishwarya,MD§

MohammadKhalid,MD*

S.Chetana,MD*

SectionEditor: QuincyK.Tran,MD,PhD

*DepartmentofEmergencyMedicine,KasturbaMedicalCollege,Manipal, ManipalAcademyofHigherEducation,Manipal,Karnataka,India-576104 † DepartmentofEmergencyMedicine,KasturbaMedicalCollege,Mangalore, ManipalAcademyofHigherEducation,Karnataka,Manipal,576104,India ‡ DepartmentofTraumaandEmergency,AllIndiaInstituteofMedical Sciences,Nagpur,India

§ DepartmentofHospitalAdministration,KasturbaMedicalCollege,Manipal, ManipalAcademyofHigherEducation,Manipal,Karnataka,India-576104

Submissionhistory:SubmittedFebruary4,2024;RevisionreceivedNovember6,2024;AcceptedNovember8,2024

ElectronicallypublishedFebruary25,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.19394

Introduction: Assessingcardiacfunctioniscrucialformanagingacutedyspnea.Inthisstudyweaimed toevaluatedisplacementoftheaorticroot(DAR)asamethodforcalculatingejectionfraction(EF)in patientswithundifferentiateddyspneapresentingtotheemergencydepartment(ED).Theprimary objectivewastocompareEFvaluesobtainedthroughDARwiththemodiﬁedSimpsonmethod,whichis consideredthecriterionreference,withinanIndianacademicED.

Methods: Weconductedaprospective,cross-sectionalstudyspanningtwoyears(December 2019–December2021).Thestudyenrolled110consecutiveEDpatients ≥18yearsofage,presenting withundifferentiateddyspneaandnormalsinusrhythm.Ultrasound-trainedinvestigatorsmeasuredDAR usingM-modeultrasonography.Experiencedechocardiographers,blindedtoDAR,determinedEF usingthemodiﬁedSimpsonmethod.StatisticalanalysesincludedtheShapiro-Wilktest,McNemartest, andthereceiveroperatingcharacteristiccurve.

Results: ThemeanDARmeasurementwas0.781centimeters,withanaveragecalculatedEFof54.4%. TheEFcalculatedusingDARdidnotdiffersignificantlyfromEFcalculatedusingthemodifiedSimpson method.ComparativeanalysisrevealedDAR’ssuperiorsensitivity(86.21%)comparedtomitralannular planesystolicexcursion(48.28%)andend-pointseptalseparation(45.45%).TheDARmethodexhibited highaccuracy(areaunderthecurve = 0.958)withacut-offvalue0.706(sensitivity88.7%, specificity93.1%).

Conclusion: Evaluatingdisplacementoftheaorticroottocalculateejectionfractioninundifferentiated dyspneademonstratedhighaccuracy,sensitivity,andagreementwiththemodiﬁedSimpsonmethod, whichisconsideredthecriterionreference.Itssimplicityandnon-invasivenessmakesitavaluableinitial screeningtoolinemergencysettings,withthepotentialtoreshapecardiacassessmentapproachesand optimizepatientcarepathwaysintheED.[WestJEmergMed.2025;26(2)191–199.]

INTRODUCTION

Background

Assessingcardiacfunction,particularlyejectionfraction (EF),iscrucialformanagingacutedyspnea.1–3 EchocardiographyisthecurrentstandardforcalculatingEF, butdisplacementoftheaorticroot(DAR)hasemerged asapotentialtoolforEFcalculationinpatientswith undifferentiateddyspnea.2,3 TheDARmethodquantifies alterationsinleftventricular(LV)volumethroughoutthe cardiaccycle,providingasurrogatemeasureforestimating EF.3 End-pointseptalseparation(EPSS)measurementisa relativelystraightforwardskillthatanemergencyphysician canacquirewithminimalexperience,evenwhenconfronted withregionalwallmotionabnormalities.4,5 However, measurementofLVend-systolicandend-diastolicdiameters using2DorM-modeechocardiographycanposechallenges totheemergencyphysicianinclinicalpractice.Tracingthe endocardialborderoftheheartinanechocardiogramduring diastoleandsystoleisoftendifficultandtime-consuming, especiallywherethewallispoorlydefined.6–10 Thisapproach providesclinicianswithmultipleoptionsforassessingLV systolicfunction,cateringtovaryinglevelsofexpertiseand clinicalsettings.

Mitralannularplanesystolicexcursion(MAPSE) assessesverticalmitralvalvemotionusingM-mode echocardiography,measuringannulardisplacementtowards theapex.Unlikeothermethods,MAPSEdoesn’trequire optimalendocardialdeﬁnitionorclearLVapex visualization,enablingbroadapplicability.Diminished systolicmitralvalveexcursion,reﬂectedinMAPSE measurements,reliablyindicatesLVsystolicdysfunction. TheMAPSEdemonstratesstrongcorrelations,particularly innon-criticallyillpatients,offeringeffectiveLVfunction assessmenteveninchallengingimagingscenarios.11–15

EmergencyphysiciansareaccurateatvisualLVEF estimationwithoutquantitativemeasurements,butobjective measurescanbeneﬁtearlylearnersandfacilitate communication.6 However,EFcalculationusingtheDAR methodhasnotbeendoneinanIndianpopulationintheED setting.Thishighlightstheneedforfurtherstudiesto determineDAR’sreliabilityandclinicalapplicabilityinthe contextofanIndiansetting.

Importance

GiventhecurrentlimitedresearchontheutilityofDARin IndianacademicEDsettings,withthisinvestigationwe aimedto ﬁllthegapbyassessingDAR’sreliabilityand clinicalapplicability.Thestudyspeciﬁcallyfocuseson patientswithundifferentiateddyspnea,apopulationwhere EFestimationiscrucialforappropriatemanagement.

GoalofthisInvestigation

OurprimaryobjectivewastocalculatetheEFusingDAR andthencompareitwithEFmeasurementsobtained

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Whilethemodi ﬁ edSimpsonmethodisthe criterionreferencetocalculateejection fraction,simplerandmorerapidtoolsare crucialforassessingleftventricular(LV) functioninemergencies.

Whatwastheresearchquestion?

Candisplacementoftheaorticroot(DAR) accuratelyestimateLVejectionfractionin theED?

Whatwasthemajor ﬁndingofthestudy?

TheDARcutoffof0.706centimetersshowed highaccuracy(AUC0.958,P < 0.001),with 88.7%sensitivityand93.1%speci ﬁ city.

Howdoesthisimprovepopulationhealth?

TheDARmethodoffersarapid,non-invasive EFscreeningtool,enhancingtimelydiagnosis andimprovingcareforpatientswith LVdysfunction.

throughthemodiﬁedSimpsonmethod,deﬁnedasthe criterionreferencebytheAmericanSocietyof Echocardiography(ASE).9,16 Thesecondaryobjectivewas toidentifythecut-offforDAR,whichcouldpredictLV dysfunctionbasedonEFcalculation.Additionally,we soughttocomparetheEFcalculatedfromDARwiththose obtainedthroughEPSSandMAPSE.ByevaluatingDARin comparisontotheestablishedmethods,weaimedtoprovide insightsintoitspotentialasareliabletoolforEFestimation intheIndiansetting.

MATERIALANDMETHODS StudyDesignandSetting

Thisprospective,cross-sectionalstudywasconducted acrossaspanoftwoyears,fromDecember2019–December 2021,withintheEDofateachinghospitalinIndia.The hospitalprovidesabroadspectrumofspecialties,andits adultEDhasapproximately37,200visitsannually.We obtainedinitialinstitutionalresearchboard/institutional ethicscommitteeapproval,withtheregistrationnumber ECR/146/Inst/KA/2013/RR-19,IEC:1057/2019,dated May8,2020,andapprovalforstudymodiﬁcationson September22,2021.Additionally,thestudyisregisteredwith theClinicalTrialsRegistry–IndiaunderthenumberCTRI/ 2020/10/028704,datedOctober28,2020.Weadheredto ethicalstandardsbyobtaininginformedconsentand

ensuringthevoluntaryparticipationandcompliance ofallsubjectsinvolvedinthestudy.WeassessedtheEF of110patientswithundifferentiateddyspneausing differentmethods.

SelectionofParticipantsandMethodsofMeasurements

Weenrolledpatients ≥18yearsofage,presentingwith undifferentiateddyspneaandnormalsinusrhythmbasedon aconveniencesampling.Thefollowingwereexcluded: patientsintubatedoutsideofahospital;pregnantwomen; individualswithelevatedcardiacbiomarkersatpresentation; thosewithatrial ﬁbrillation,knownvalvularpathologyor surgery,primaryormetastaticcarcinomainthethorax; patientsforwhomthetimebetweenechocardiographyto obtainEFusingDARandthemodiﬁedSimpsonmethod

Figure1. Theprobeispositionedintheparasternallong-axis view,withthetransducerplacedperpendiculartothechestwallat thethirdorfourthintercostalspace,justtotheleftofthesternum, andtheprobemarker(blackstar)directedtowardsthepatient’s rightshoulder.

wasmorethan30minutes;andthosewhodidnotprovide consent.Thesefactorscouldhaveinﬂuencedtheaccuracy andreliabilityoftheEFmeasurementsobtainedthrough differentmethods.Demographicvariables,includingage andgender,wereconsideredaspotentialconfoundingfactors inthisstudy.

Afterobtainingwritteninformedconsent,theemergency clinicianconductedthebedsideultrasonographyproctored bytheexpertinpoint-of-careultrasound(POCUS).Usinga 3.6-megahertzmicro-convextransducer,theinvestigator, trainedinPOCUSduringresidencytrainingasperthe curriculum,employedaPhilipsCX50ultrasoundmachine (KoninklijkePhilipsNV,Amsterdam,Netherlands)to computetheEFusingDAR.Initially,2Dechocardiograms oftheparasternallong-axisviewwerecapturedforDAR measurement.Thisviewwasachievedbypositioningthe footprintofthetransducerperpendiculartothechestwallat thethirdorfourthintercostalspace,justtotheleftofthe sternumwiththepointertowardstherightshoulder (Figure1).17 Optimumimagerequiredclearviewofmitral valveleaﬂetsandaorticvalves.Subsequently,M-modewas placedjustabovetheleveloftheaorticvalveandDAR recordingsweretaken.3 ThemaximumanteriorDARfrom thehorizontalaxisatend-systolewasmeasuredusingthe leading-edgetechniqueandrecordedincentimeters(cm) (Figure2A).ThecomputationofEFwasthendone,using theformula20 + 44*DAR(cm).

FollowingtheDARmeasurement,theinvestigator calculatedtheEFusingEPSSdeterminedbyEF = 75.5 –(2.5 × EPSS),andusingMAPSEcalculatedby4.8 × MAPSE (millimeters[mm]) + 5.8formenand4.2 × MAPSE(mm) + 20forwomen.5,14,18–21 Anexperiencedechocardiographer, blindedtothestudyprocedure,evaluatedLVEFusingthe ASErecommendedModiﬁedSimpson’sruleforthis measurement(Figure2B).9,16

Figure2. (A)Weassessedejectionfraction(EF)atthebedsideusingM-modeultrasonography,measuringthedisplacementoftheaorticroot (DAR)intheparasternallong-axisview.TherecordedDARforthispatientwas1.06cm.WecalculatedtheEFusingtheformula(EF = 20 + 44 × 1.06),whichresultedin66.6%.(B)TheechocardiographerscalculatedEFusingthemodiﬁedSimpsonmethod[(EDV ESV)/EDV], where[(90.2 32.7)/90.2] × 100resultedinanEFof63.7%.

Outcomes

Thestudysystematicallycategorizedoutcomesintotwo groups,delineating ‘normal’ EFas50%to70%and ‘lowEF’ <50%.22 Theprimaryoutcomemeasuredsignificant differenceincalculatedEFbetweentheDARandmodified Simpsonsmethods.Thesecondaryoutcomeofthestudywas todeterminecut-offvalueofDARwithhighsensitivityand specificitythroughreceiveroperatingcharacteristic(ROC) curveanalysis.Secondaryoutcomesalsoincluded comparisonofEFcalculatedfromDARwiththatcalculated fromEPSSandMAPSE.

SampleSizeCalculation

Withadesiredmarginoferrorof10%,alphaerrorof5%, andestimatedproportionof0.5,samplesizewascalculated tobe96.Afterconsideringthedropoutrateof15%,the ﬁnal samplesizewas110.

Analysis

WeusedSPSSStatistics,version26.0(IBMCorp, Armonk,NY)toanalysethedata.TheShapiro-Wilktest assessednormalityforcontinuouslydistributeddata,andwe executedgroupcomparisonsinthesubsequentsteps.An exactMcNemartestwasusedtoidentifythestatistically significantchangesinEFcalculatedusingtheDARand modifiedSimpson’smethods.WecalculatedthePearson correlationcoefficienttomeasurestrengthanddirectionof thelinearrelationshipbetweentwotests.TheROCcurve playedapivotalroleindeterminingtheoptimalcut-offvalue forthevaliditymeasureofDAR.

RESULTS

Atotalof135patientsunderwentinitialscreeningfor participationinthestudy.BeforethePOCUSassessment,we excluded25patientsbasedonpredefinedcriteria: fivedueto externalintubation;eightwithelevatedcardiacbiomarkers; threewithabnormalrhythm;fourwithvalvularpathology; and fivewhodeclinedtoparticipate.Followingthat,a POCUSexaminationwasconductedon110patients,with10 excludedduetopoorimagequality(Figure3).The demographicandclinicalcharacteristicsof100patientswho underwentPOCUS,includingage,heartrate,meanarterial pressure,andthemeanDARvaluesinrelationtoage, gender,andcomorbiditiesaredetailedin Table1

InthisstudyweobservedameanDARmeasurementof 0.781cm(SD0.277cm)andanaveragecalculatedEFof 54.4%(SD12.2%).ThePearsoncorrelationcoefﬁcientwas calculatedtomeasurestrengthanddirectionofthelinear relationshipbetweentwotestsandwasfoundtobe0.81, whichsuggestsastrongpositiverelationbetweentheresults. ThestudyconductedanexactMcNemartesttoidentify statisticallysigniﬁcantvariationsinabnormalandnormal EFdistributionbetweentheEFcalculatedusingDAR/ MAPSE/EPSSandtheEFmeasuredbyan

Figure3. Consortpatient ﬂowdiagram. POCUS,point-of-careultrasound.

echocardiographer(criterionreference),asoutlinedin Table2.Thestatisticalanalysisrevealedalackofsigniﬁcant differences(P = 0.39)betweentheEFcalculatedusingDAR andtheEFmeasuredbyechocardiography.

WeconductedROCcurveanalysis,whichdemonstrated DAR’svaliditywithahighaccuracyreflectedinanarea underthecurve(AUC)of0.958(95%confidenceinterval[CI] 0.914–1.000, P < 0.001) forpredictingEF.TheoptimalcutoffpointforDARwasidentifiedas0.706,providinga sensitivityof88.7%,specificityof93.1%,LR+ (likelihood ratio)of12.86,andLR-of0.12.(Figure4).ThePearson correlationcoefficientcalculatedforEFcalculatedby MAPSEandthemodifiedSimpsonmethodwas0.54andthat ofEPSSandthemodifiedSimpsonmethodwas0.76.For calculatedEFwithMAPSE,48.3%ofpatientswere categorizedashavingabnormalEF,exhibitingastatistically significantdifferencecomparedtoEFcalculatedbythe modifiedSimpsonmethod(P = 0.01)(Table2).Similarly, calculatedEFwithEPSSdemonstratedacomparable discordance,with58.6%classifiedasabnormal,significantly differingfromEFcalculatedbythemodifiedSimpson method(P = 0.01)(Table2).

Table3 presentsacomparativeassessmentoftheefﬁcacy ofEFmeasurementsusingMAPSE,EPSS,andDAR againstthecriterionreference.ThesensitivityofDARis notablyhigherthanMAPSEandEPSS,whichsuggests thatitisabetterscreeningtool.CalculatedEFfrom

Table1. Demographicandclinicalcharacteristicswithdisplacementofaorticrootmeanvaluesin100patientsonwhompoint-of-care ultrasoundwasperformed.

PatientcharacteristicsN = 100

Patientageinyears,mean(SD)

53.7(16.4)

Male, n(%) 73(73)

Heartrate,mean(SD) 92(17.8)

Respiratoryrate,min-max(SE) 20–36(0.31)

MAP,mean(SD),mmHg 90.6(16.7)

Symptoms

Fever,n(%) 33(33)

Cough,n(%) 33(33)

Chestpain,n(%) 14(14)

Comorbidities

TypeIIdiabetesmellitus,n(%) 36(36)

Systemichypertension,n(%) 46(46)

IHD,n(%) 16(16)

Cardiomyopathy,n(%) 2(2)

Oxygenrequirement

Nasalprongs(2L–4L),n(%) 26(26)

Facemask(6L–10L),n(%) 59(59)

Non-rebreathingmask(>10L),n(%) 14(14)

min, minimum; max,maximum; SD,standarddeviation; SE,standarderror; MAP,meanarterialpressure; IHD,ischemicheartdisease.

DARobtainedhighestnegativepredictivevalue(NPV), suggestingabetterabilitytocorrectlyidentifypatientswith normalEF.

DISCUSSION

DyspneaisacommonpresentingcomplaintintheED, accountingforapproximately5%ofallEDpresentationsin theAsia-Paciﬁcregion.23,24 Emergencyphysicians frequentlyfacethechallengeofmakingswiftdiagnosesand developingtreatmentplansbasedonlimitedclinical information.25,26 Point-of-careultrasoundhasbecomea standardcomponentofroutineclinicalexaminationsinthe ED,enhancingthemanagementofdyspneabyfacilitating thediagnosisofitsunderlyingcauses.27 Similarly,evaluating LVEFthroughechocardiographyplaysacrucialrolein diagnosingandmanagingawiderangeofpatientsintheED,

Table2. Comparativeanalysisofejectionfraction(EF)measurementsusingDAR,MAPSE,andEPSS*againstactualEFbythemodi ﬁed Simpsonmethod. ActualEFbymodiﬁedSimpsonmethod

EF, ejectionfraction;*DAR,displacementofaorticroot; MAPSE,mitralannularplanesystolicexcursion; EPSS,end-pointseptalseparation.

Figure4. TheROCcurveofthesensitivityofdisplacementofaortic rootforejectionfractionwhenthecut-offvalueis0.70centimeters. AreaundertheROCcurve = 0.958(95%conﬁdenceinterval 0.914–1.000,P < 0.001forpredictingEF). ROC,receiver operatingcharacteristic.

furtheremphasizingtheimportanceofultrasoundin emergencycare. 28 MostresearchintheEDhasemphasized visualassessmentsofLVEFinsteadofrelyingon

calculationsderivedfrommeasuringthedimensionsofthe LVchamberacrossthecardiaccycle.29–31

Thisstudyaddressesacrucialaspectofemergencycareby exploringtheassessmentofLVfunctioninpatientswith undifferentiateddyspnea.WhilethemodiﬁedSimpson methodremainsthecriterionreference,investigatingthe potentialofDARasanalternativemethodopensavenuesfor expeditedandmoreaccessibleevaluationsintime-sensitive environmentsliketheED.Asanon-invasiveandeasily accessibletool,DARhasshownpromiseinaccurately predictingLVEF,makingitvaluableforidentifyingpatients atriskofLVdysfunction.3,32 TheDARmethodshowedan accuracyrateof88%incorrectlyclassifyingLVdysfunction, demonstratingitsclinicalapplicabilityinemergencysettings. ThisratesurpassestheaccuracyofMAPSEandEPSS assessmentsforLVdysfunction,includingthe75%accuracy reportedinastudybySchicketal.33

Thisstudy’srobustmethodologyandcompellingresults substantiallycontributetoestablishingthevalidityand clinicalrelevanceofDAR.TheDARmethodexhibitsgood sensitivity(86.2%)andspecificity(88.7%)andhasapositive correlationwiththevaluesofEFobtainedthroughthe modifiedSimpsonmethod.Thissensitivityandspecificityare consistentwiththe findingsofÜnlüeretal,whoreported 94.4%and94.1%,respectively.3 Theincreasedsensitivityof DARcomparedtoEPSSandMAPSEinourstudymakesita

Table3. ComparativeefﬁcacyofejectionfractionmeasurementsusingMAPSE,EPSS,andDAR*againstthecriterionreferencewith95% conﬁdenceintervals.

EF, ejectionfraction; MAPSE,mitralannularplanesystolicexcursion, EPSS,end-pointseptalseparation;*DAR,displacementofaorticroot; CI,conﬁdenceinterval; PPV,positivepredictivevalue; NPV,negativepredictivevalue.

valuabletoolfortheearlydetectionofLVdysfunctionin emergencysettings.These ﬁndingsindicatethatemergency physicianscanuseDARasavaluablealternatetoolfor assessingtheLVfunctionatthebedside.33 IntheED,where rapiddecision-makingiscrucial,DARcanbeincorporated asaninitialscreeningtooltoidentifypatientswith compromisedLVfunction,guidingfurtherdiagnostic testing,management,interventionsorspecialistreferrals.

WhencomparingDARwithtraditionalmethods, MAPSEshowedasensitivityof48.3%(95%CI39.2–57.4) andspecificityof95.8%(95%CI90.3–98.4),whileEPSS exhibitedasensitivityof45.5%(95%CI36.2–54.8)and specificityof97.0%(95%CI94.4–99.4).Theseresults contrastwithpriorstudies,suchasthatbyMcKaigneyetal, whoobservedsignificantlyhigherEPSSsensitivity(83.3%) butmuchlowerspecificity(50.0%),andSchicketal,who reportedMAPSEsensitivityof42%andspecificityof 89%.18,33 Thehighersensitivity(83.3%)andlowerspecificity (50.0%)ofEPSSreportedbyMcKaigneyetalmaystemfrom theircomparisonofEPSSwithEFcalculatedusingthe Teichholzmethod.FollandetalfoundthatEFcalculated throughthemodifiedSimpsonmethoddemonstratedbetter correlationwithradionuclideventriculographythanthe Teichholzmethod,withcorrelationcoefficients(rvalues)of 0.75and0.46,respectively.Furthermore,theASEnolonger recommendstheTeichholzmethodforcalculatingLV volumes.9,34 ThehigherspecificityofMAPSEandEPSSin ourstudysuggeststhatthesemeasurementsaremore effectiveinconfirmingLVdysfunctionthanindetectingit, underscoringtheutilityofDAR’shighersensitivityfor earlyidentification.

TheDARoffersapracticaladvantageintheEDsetting duetothestraightforwardvisualizationoftheaorticroot comparedtoLVstructures,makingiteasiertomeasure underchallengingconditions.Furthermore,themotionof theaorticrootresemblestheleftatrialvolumecurve, suggestingthatitsmovement,influencedbyitsattachmentto thecardiacskeleton,mayreflectthedynamicsofleftatrial fillingandemptying.35–37 Theobservedcorrelationbetween DARandstrokevolumesuggeststhatDARmeasurements maycalculateLVEFeffectively,providingvaluableinsights intocardiacperformance.LowerDARvalueswere consistentlyassociatedwithconditionslinkedtoreduced strokevolumeandEF,highlightingDAR’srelevancein assessingpatientswithundifferentiateddyspneaand potentiallycompromisedcardiacfunction.

TheDAR’shighNPVenhancesitsreliabilityinexcluding patientswithnormalEF,whichiscrucialfordetermining appropriatenextstepsinEDcare.TheEPSSexhibitedthe highestpositivepredictivevalue,emphasizingitsrolein conﬁrmingreducedEF.However,DAR’scombined sensitivityandNPVmakeitamorecomprehensivetoolfor initialscreening,ensuringthatpatientswithlikelynormal cardiacfunctionareappropriatelytriaged.Despiteits

advantages,DARshouldnotbeseenasareplacementforall echocardiographicassessmentsbutratherasa complementarytool,especiallyintime-limited environments.Itsheightenedsensitivitycomparedto MAPSEandEPSS,combinedwithitsrapidapplication, makesitapromisingoptionforemergencyphysicians. However,furtherresearchandvalidationarerequiredto establishDAR’sbroaderapplicabilityindiversepatient populationsandsettings.

LIMITATIONS

Whiletheresultsarepromising,thisstudyhaslimitations. Itwasconductedwithinasingle-centerenvironment, potentiallylimitingthegeneralizabilityofthe findings. Amulticenterstudyinvolvingdiversepatientpopulations wouldprovidemorerobustvalidation.Additionally,the studydoesn’tdelveintothecausesofdyspnea,whichcan varywidelyandmightinfluencetheapplicabilityofDARin differentscenarios.Weexcluded9%ofpatientsfromthis studyduetoapoorPOCUSwindow.Patientsenrolledin thisstudyexhibitedexclusivelyregularcardiacrhythms. AlthougheachM-moderecordingoftheaorticroot(AR) hadthepotentialtoencompassmultiplecardiaccyclesfor DARcalculation,itiscrucialtoemphasizethattheextentof ARdisplacementconsistentlyremainsnotableacrossall cardiaccyclesinindividualswithregularheartrhythms. Whenpatientsexhibitirregularheartrhythms,apotential adaptationcouldinvolvecalculatingtheaverageDAR measurementoverthreeto fivecardiaccycles.This adjustmentcouldenhancetheaccuracyofmeasurementsin suchcohorts.Futureresearchinitiativescoulddelvedeeper intoinvestigatingandaddressingthisparticularaspect.

CONCLUSION

DARemergesasanefﬁcientandreliablemethodforrapid EFassessment,providingemergencyphysicianswitha valuabletoolforbedsideevaluationofLVfunction, especiallywhentimeandresourcesarelimited.Thispaves thewayforintegratingDARintoemergencyprotocolsand routineemergencyclinicalpractice.Whilethese ﬁndingsare promising,weacknowledgetheneedforprospective validationinadiversepatientpopulation.

AddressforCorrespondence:SanjanAsanaruKunju,MD,DNB, DepartmentofEmergencyMedicine,KasturbaMedicalCollege, Mangalore,ManipalAcademyofHigherEducation,Karnataka, Manipal,576104,India.Email: sanjan.a@manipal.edu, sanjan. asanar@gmail.com

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

ProceduralSedationintheEmergencyDepartment – An

ObservationalStudy:DoesNilPerOsStatusMatter?

BrendanPeterson,PharmD*

AmyS.Nowacki,PhD†‡

AlexanderUlintz,BS/BA,MD§

SharonE.Mace,MD†∥

SectionEditor: KennethScottWhitlow,DO

*OhioStateUniversity,SchoolofPharmacy,Columbus,Ohio † ClevelandClinicLernerCollegeofMedicineofCaseWesternReserveUniversity, Cleveland,Ohio ‡ LernerResearchInstitute,DepartmentofQuantitativeHealthSciences, ClevelandClinic,Cleveland,Ohio

§ OhioStateUniversity,DepartmentofEmergencyMedicine,Columbus,Ohio ∥ ClevelandClinic,DepartmentofEmergencyMedicine,Cleveland,Ohio

Submissionhistory:SubmittedDecember17,2023;RevisionreceivedOctober31,2024;AcceptedNovember1,2024

ElectronicallypublishedJanuary15,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18561

Introduction: Proceduralsedation(PS)iscommonlyperformedintheemergencydepartment(ED).Nil peros(nothingbymouth)(NPO)guidelinesextrapolatedfromstandardsforpatientsundergoingelective proceduresintheoperatingroomhavebeenappliedtoEDPSpatients.Therehasbeennolargestudyof EDPSpatientscomparingdifferencesinadverseeventsandPSsuccessratesbasedonNPOstatus.

Methods: FromacohortofconsecutiveEDPSpatientsofallagesinthe20EDsofonehospital system onequaternaryED,fourtertiaryEDs,sixcommunityhospitalEDs,oneruralED,twopediatric EDs,andsixfreestandingEDsintwostatesintheMidwestandSouth weconductedaretrospective analysisonaprospectivedatabaseover183monthsfromApril2000–June2015.Primaryoutcomewas theincidenceofsideeffectsandcomplications,whichcomprisedtheadverseeffects.Thesideeffects werenausea,vomiting,itching/rash,emergencereaction,myoclonus,paradoxicalreaction,cough,and hiccups.Complicationswereoxygendesaturation <90%,respiratorydepression(respiratoryrate <8), apnea,tachypnea,hypotension,hypertension,bradycardia,andtachycardia.Normalvitalsignswere agedependent.Secondaryoutcomewassuccessfulsedationde ﬁnedascompletionoftheprocedure. WeexaminedtheassociationbetweenadverseeventsandsuccessfulsedationwithNPOstatus.

Results: Of3,274visits,exactNPOstatuswasknownin2,643visits.ComparisonofNPO <8hoursin 1,388patientsvs ≥ 8hoursin1,255patientsrevealedsideeffects5.5%vs4.5%(P = 0.28); complications11.9%vs17.7%(P < 0.001);adverseevents16.3%vs21.5%(P < 0.001),interventions 4.1%vs4.4%(P = 0.73),andproceduralcompletions94.3%vs89.7%(P < 0.001).Afteradjustmentfor age,sex,transferstatus,AmericanSocietyofAnesthesiologyphysicalstatusclassiﬁcation,race, primarysedative,multiplesedatives,sedativeplusanalgesic,andprimaryanalgesic,wefoundno associationbetweenNPOstatusandsideeffects(P = 0.68),complications(P = 0.48),oradverseeffects (P = 0.26);however,proceduralcompletionrateremainedsigniﬁcantlyhigherforNPO < 8hours (P = 0.007).

Conclusion: Anilperosstatus ≥8hoursmayhavesimilarorworseoutcomesthanNPO <8hours, whichiscontrarytomanysuggestedguidelines.StrictadherencetoNPOguidelinesinEDprocedural sedationpatientsmaynotbenecessary.[WestJEmergMed.2025;26(2)200–209.]

INTRODUCTION

Emergencydepartment(ED)patientsfrequentlyundergo proceduralsedation(PS)andanalgesia,whichisdesignedto alleviatetheirpainandanxietyduringdiagnosticand/or therapeuticmedicalprocedures.1 Guidelinesregarding fastingpriortoperformingPS,promulgatedbyvarious organizationsforgeneralanesthesia,areoftenfollowedby cliniciansperformingPSintheED.1–5 Thisconcepthas recentlybeenchallenged.5 Therehasbeensomeevidencein thepediatricpopulationthatadherencetosuchguidelines doesnotresultinfeweradverseeventsduringEDPS,6–13 althoughsomeofthereportsofpediatricPShaveinvolved PSperformedinlocationsotherthantheED6,7 orinvolved onlyonesedativeinsteadofarangeofsedativeagents.8,12 SuchdataislackingforadultEDpatients.Ourgoalinthis studywastoevaluatetheeffectoffastingonPSintheEDin allagesofEDpatients,includingtheelderly.

Importance

StudiesintheliteratureontheeffectoffastingonEDPS havefocusedonthepediatricpopulation,withasurprising lackofstudiesinadults,includingtheelderly.Alarge-scale studyoftheincidenceofadverseeventsandtheneedfor interventionshasnotbeendescribed,thusrepresentinga largegapinknowledgeforacommonpractice.

GoalsofThisInvestigation

Ourgoalinthisstudywastodeterminetheimpactof fastingguidelinesonthesideeffects,complications,andneed forinterventionsduringEDPSinpatientsofallages.

METHODS

StudyDesignandSetting

Thiswasacohortstudyofconsecutivepatientsofallages undergoingPSinthe20EDsofonehospitalsystem consistingofoneurban,academic,quaternaryED,four tertiaryEDs,sixcommunityhospitalEDs,oneruralED,two pediatricEDs,andsixfreestandingEDsintwostateslocated intheMidwestandtheSouth.Weperformedaretrospective analysisonaprospectivelycollecteddatabaseover183 monthsfromApril2000–June2015.Allpatientswho underwentparenteralPSintheED,performedbyattending emergencyphysicians(EP)wereincluded.Weexcluded sedationsdoneoutsidetheEDand/ornotadministered byEPs.

DataCollection

Amandatory,four-page,standardizedsedationform mustbecompletedbytheregisterednurse,respiratory therapist,andattendingphysicianonallpatientsundergoing PSthroughoutthehospitalincludingtheED.Thisform includespre-sedationassessment,post-sedationassessment (includingreadinessfordischarge),anddocumentationof thePSitself.DocumentationofthePSincludesthe

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Proceduralsedation(PS)isacommonED procedure.Applyinganesthesiologynilperos (NPO)guidelinesforelectiveproceduresto EDPSpatientshasbeenquestioned.

Whatwastheresearchquestion?

Whatistheincidenceofadverseeventand proceduralcompletionratesforpatients meetingvsnotmeetingNPOguidelines?

Whatwasthemajor ﬁndingofthestudy?

NPO < 8vs ≥ 8hours:adverseevents16.3%vs 21.5%P < 0.001,proceduralcompletions 94.3%vs89.7%P < 0.001.

Howdoesthisimprovepopulationhealth?

NPO ≥ 8hourshassimilarorworseoutcomes thanNPO < 8hours,contrarytomany suggestedguidelines. Strictadherenceto NPOguidelinesinEDPSpatientsmaynot benecessary.

continuousmonitoringofvitalsigns:heartrate,respiratory rate,bloodpressure;pulseoximetry,cardiacrhythm, respiratorytherapyassessment,includingcapnography;and patientresponses,medicationadministration,andpatient interventions.Allsedationsincludingthesedationformsand electronichealthrecord(EHR)notesarereviewedaspartof thehospitalqualityimprovement(QI)monthlymeetingbya physician-ledcommittee.Themembersofthiscommittee werenotinvolvedinthisstudybutarepartofthehospital’ s QIprocess.

Weperformedthisretrospectivereviewwithadherence tothe12methodologiccriteriaasde fi nedbyWorsteretal.14 Dataresultedfromanelectronicpullofinformationfrom theEHR.Wedidnotuseabstractors.Therefore,criteria1, 4,5,6,7,and8accordingtoWorsteretalwerenot applicable.Theremainingcriteria(2,3,9,10,11,and12) weremet.Forcriterion2,caseselectioncriteriawere de fi nedapriori.Forcriterion3,variableswerede fi nedin themethods.Forcriterion9,thehealthrecorddatabasewas described.Forcriterion10,allpatientvisitsintheEHR meetingcriteriawereincluded.Forcriterion11,dataused waspartofamandatorystandardizedsedationform,and themissingdatawasminimal.Asdiscussedinourstudy fl owdiagram,weconductedacompletecaseanalysis.For criterion12,theinstitutionalreviewboardapproved thestudy.

OutcomeMeasures

Theprimaryoutcomewastheincidenceofsideeffectsand complications,whichcomprisedtheadverseeffects.Side effectswerenausea,vomiting,itching/rash,emergence reaction,myoclonus,paradoxicalreaction,cough,and hiccups.Complicationswereoxygendesaturation <90%, respiratorydepressionwitharespiratoryrate <8,apnea, tachypnea,hypotension,hypertension,bradycardia,and tachycardia.Thenormalrangeofvitalsignswasage dependent.Successfulsedationwascompletionof theprocedure.

StatisticalAnalysis

Descriptivestatisticsofpatientdemographicsand proceduresarepresentedascount(percentage),median (Q1–Q3),orrange.Weexploredbivariableassociationsof patientdemographicsandprocedureswithNPOstatuswith eitheraWilcoxonrank-sumtestorachi-squaretest,as appropriate.TheNPOwasoriginallyrecordedasanumeric valueinpatientchartsand,thus,weexploredNPOstatus threeways:(1)classiﬁedasexactNPOstatusknownor unknown;(2)dichotomizedateighthourstoalignwith clinicalcareguidelines;and(3)originalscaletomaintainfull detail.WeexploredassociationsofNPOstatuswithbinary outcomemeasuresusinggeneralizedestimatingequations models,assumingacompoundsymmetrycorrelation structuretoaccommodatemultipleEDvisitsperpatient. Thiswasperformedbothunadjustedandadjustingforyear ofvisit,patientagegroup,sex,transferstatus,American

SocietyofAnesthesiology(ASA)physicalstatus classification,race,primarysedative,useofmultiple sedatives,useofsedativeplusanalgesic,andprimary analgesic.TheASAisusedtopredictoperativeriskwhere ASA1isanormalhealthypatient;ASA2isapatientwith mildsystemicdisease;andASA3isapatientwithsevere systemicdiseasethatisnotlife-threatening.TheASA4isa patientwithseveresystemicdiseasethatisaconstantthreat tolife;ASA5isamoribundpatientwhoisnotexpectedto survivewithouttheoperation.15 Reportedaretheresulting oddsratios,95%confidenceintervals,andassociated P -values.Similaranalyseswereconductedtoexplorethe associationofNPOstatuswiththeneedformedical intervention.Weusedasignificancelevelof.05.Analyses wereconductedusingSASversion9.4(SASInstitute,Cary, NC)statisticalsoftware.

RESULTS

CharacteristicsofPatients

Therewere3,274PSperformedintheEDon2,570 patientsofallagesbyemergencyphysiciansintheED (Figure1).Byagegrouptherewere1,177PSperformedon pediatricpatients(age ≤21years),and2,097PSperformed onadults(age >22years),ofwhom708weregeriatric (≥65yearsofage)PS.

NPOStatus:KnownvsUnknown

ThepatientswithNPOunknownweresigniﬁcantlyolder, withahigheracuityasdenotedbyhigherASAandby “ more

Figure1. StudyvisitCONSORTdiagram.

*Numberofpatientsdoesnotadduptohigherleveltotalas110patientshadmultiplevisitswithsomevisitsclassiﬁedasNPO <8hoursand ≥8hoursandthusthosepatientsarecountedinbothsubgroups.Numberofvisitsisinboldandinbluecolor.Numberofpatientsisinitalics andparentheses.

ED,emergecydepartment; NPO,nilperos(nothingpermouth); PS,proceduralsedation.

Table1. Patientdemographics,ASAandprocedurecharacteristics.

Ethnicity

Black 786(30%) 210(33%) 431(31%)355(28%)

White 1816(69%) 413(66%) 931(67%)885(71%)

Other 41(2%) 4(1%) 26(2%)15(1%)

ASAcategory

ASA1 952(36%) 121(19%) 589(42%)363(29%)

ASA2 667(25%) 160(25%) 353(25%)314(25%)

ASA3 904(34%) 250(40%) 391(28%)513(41%)

ASA4 115(4%) 78(12%) 54(4%)61(5%)

ASA5 5(0.2%) 22(3%) 1(0.1%)4(0.3%)

Procedure < 0.001

-100(16%)

ASA1isanormalhealthypatient.ASA2isapatientwithmildsystemicdisease.ASA3isapatientwithseveresystemicdiseasethatisnotlife threatening. ASA4isapatientwithseveresystemicdiseasethatisaconstantthreattolife.ASA5isamoribundpatientthatisnotexpectedto survivewithouttheoperation.

ASA,AmericanSocietyofAnesthesiologyphysicalstatus; NPO,nilperos(nothingbymouth); EGD,esophagogastroduodenoscopy.

critical” proceduressuchaslumbarpuncture, ventriculostomy,orcardioversioncomparedtoorthopedic proceduresorsuturing(Table1).Whenweevaluatedthe reasonsforanunlistedNPOstatustheseincludedthatthe patientwascriticalandadmittedtoanintensivecaresetting withdiagnosessuchasshockand/orrespiratorydistressor hadbeenintubatedorwasundergoingemergencysurgery. Asigniﬁcantnumberwereunabletogivereliable informationaboutwhentheyatelastduetomedicalreasons thatincludedalteredmentalstatus,dementia,autism/ developmentaldelay,andneurologicdisorders.Another largegroupofpatientswereunwillingand/orunableto

provideaccurateinformationabouttheirlastoralintakefor psychiatricreasonsincludingacutepsychiatricillnesssuchas acutemanicstateorschizophrenia,orbecausetheywere experiencingsubstanceoralcoholintoxication.Therewere alsoseveralyoungchildrenbroughtinfromdaycareor schoolbyemergencymedicalserviceswhowere unaccompanied,atleastinitially,byanadult,suchastheir daycareproviderorteacheroraparent,whocouldgive information;ortheadultwiththemhadnoinformation regardingtheirlastoralintake.Thus,youngagewithlackof abilitytotelltimewasanothercauseforanunknownNPO status.Additionally,somepatientswereonlyabletoprovide

arangeoftimesuchas “morethansixhoursago.” Intotal, therewere631visits(19.3%)wheretheexactNPOwaseither notobtainable(13.2%)ornotdocumented(6.1%).This emphasizesthefactthatPSmayneedtobedoneinanED withouttheluxuryofknowingthelastoralintakeinabout oneof ﬁvepatientpresentations(Figure1)(Table1).

Adverseeventsandprocedurecompletions

Therewasnosignificantdifferenceforsideeffects, complicationsoradverseeventsbetweenexactNPOstatus knownvsexactNPOstatusunknown(Table2).The incidenceofsideeffects,whichwasprimarilyvomiting,was greaterforNPO <8hoursat5.5%thanforNPO ≥8hoursat 4.5%,butthiswasnotstatisticallysignificant.However, whenNPOwasconsiderednumeric,itwasfoundthatas NPOtimeincreases,theriskofasideeffect,generally vomiting,significantlydecreases.Thecomplicationsand adverseeventsweresignificantlygreaterforNPO ≥8hours thanforNPO <8hoursbothwhenNPOstatuswasbinary andnumericwithcomplicationsat11.9%forNPO <8hours and17.7%forNPO ≥8hoursandadverseeventsat16.3%for

NPO <8hoursand21.5%forNPO ≥ 8hours(Table2) (Figure2).Therateofproceduralcompletionswas signiﬁcantlyhigherwhenNPOstatuswasknown(92.1%vs 86.1%)andwhenNPO <8hours(94.3%vs89.7%)(Table2, Figure 2A).Wedidnot ﬁndanyinstancesofpulmonary aspirationaswerenotedinpreviousstudiesofEDPS.5 We hadoneintubationoutof3,274PS(0.03%).

LengthofNPOcategoriesislower-boundinclusive.Thus, the ﬁrstcategoryconsistsofNPOvaluesfromzerotoless thanfourhours,thesecondcategoryconsistsofNPOvalues fromfourtolessthaneight,etc.

InterventionsbyNPOstatus

Theneedforinterventionwasrelativelylowoverallat approximately4%.Theproportionofvisitsrequiring interventiondidnotsigniﬁcantlydifferwhentheexactNPO statuswasknown(4.2%)vsunknown(4.0%)(P = 0.70)or whenNPO <8hours(4.1%)vs ≥8hours(4.4%)(P = 0.75). Notably,therewasonlyoneintubationof3,274PS(0.03%). Thiswasanelderlyfemalewithahistoryofhypertension undergoingreductionofashoulderdislocationwhoreceived

Table2. Sideeffects,complications,adverseeventsandprocedurecompletionsaccordingtonilperosstatus.

NPO, nilperos(nothingbymouth).

NPOcategorized

Figure2. (A)Sideeffects,complications,adverseevents,and incompleteproceduresbynilperosgroup: <8hoursvs ≥8hours. (B)Sideeffects,complications,adverseevents,andincomplete proceduresbynilperos. NPO,nilperos(nothingbymouth).

propofolandhydromorphone.Sheexperiencedbradypnea. Shewasbaggedandthenintubatedforfewerthan ﬁve minutes.ShewasextubatedintheEDwithoutcomplications anddischargedhome.Atfollow-upintheofﬁceweekslater, shewaswellwithnoproblemsresultingfromtheintubation/ EDvisit(Table3).

Demographicandproceduralvariablesaffecting adverseevents

Accordingtomultivariateanalysis,NPOstatus,yearof visit,sex,whethertransferredornot,race,anduseofmultiple sedativeswerenotsignificantfactorsassociatedwithside effects,complications,oradverseeffects.AhigherASA classificationandolderagegroup(adult/geriatric)were significantlyassociatedwithhigherriskofcomplicationsand, thus,adverseevents(P < 0.0001)butnotsideeffects.The choiceofprimarysedativewassignificantlyassociatedwith theincidenceofsideeffects,complications,andadverse events.Comparedtopropofol,theuseofetomidate,ketamine, midazolam,orothersedativesallshowedanincreasedriskof sideeffects,primarilyvomiting;andtheuseofmethohexitalor etomidateshowedadecreasedriskofcomplications.The choiceofanalgesicwasnotassociatedwiththeincidenceof sideeffectsbutwassignificantlyassociatedwiththe

occurrenceofcomplicationsandadverseevents.Comparedto fentanyl,theuseofhydromorphone,morphine,oroxycodone showedadecreasedriskofcomplications.Usingbotha sedativeandananalgesicwasassociatedwithahigherriskof sideeffectsandadverseevents(Table4).

Sideeffects,complicationsandadverseeventsand interventionsbyfastingtime

OfinterestwastherelationshipbetweenNPOduration andpatientoutcomes,specificallysideeffects,complications, overalladverseevents,anyinterventions,respiratory interventions,andotherinterventions(non-respiratory).We exploredseveralwaysofdefiningNPOduration(Table2). First,wecomparedNPOdurationstatusknownvsunknown andfoundnosignificantdifferenceinanypatientoutcome. Next,wedichotomizedNPOdurationas <8hoursvs ≥8 hoursandfoundasignificantlyhigherrateofcomplications andoveralladverseeventsintheNPO ≥8hoursgroup.When analyzingNPOdurationasanumericvariable,wesawthat eachadditionalhourofNPOwassignificantlyassociated withadecreaseinriskofsideeffectsandanincreaseinriskof complicationsandoveralladverseevents.

Finally,wecategorizedNPOdurationintotwo-hour intervalsandcomparedeachtothereferencegroupof ≥8 hours.Therewerenosignificantdifferencesinsideeffects whencomparingthevariousNPOtimeintervals0to <2,2to <4,4to <6,and6to <8hourstoNPO ≥8hours. ComplicationsatNPO2to <4,4to <6,and6to <8hours were significantlylessthanforNPO ≥8hours.Therewere fewercomplicationsintheNPOtimeinterval0to <2hours comparedtoNPO ≥8hours,althoughthisdidnotachieve statisticalsignificance.However,itshouldbenotedthat the0to <2hoursNPOgroupcontainedonly31visits (Figure3, Table2).

DISCUSSION

StudiesregardingNPOstatusandEDPSinthepediatric populationhavefoundnoassociationbetweenNPOstatus andadverseevents.8–13 Surprisingly,toourknowledge,there havebeennoadultstudiesofNPOstatusandadverseevents inEDpatientsfromtheUnitedStatesandonlytwo internationalstudies.OnesmallAustralianstudyinpediatric andadultEDsubjectswithasomewhatatypicalpatient populationconsistingofpredominatelyASA1and2patients andanoverwhelmingmajority(84%)oforthopedicpatients withpropofolbeingtheonlysedativefounda22.4% incidenceofadverserespiratoryeventsfornot-fastedpatients vs19.5%forfastedpatientsanda33.3%incidenceof respiratoryinterventionsfornot-fastedcomparedwith 24.6%forfastedpatients.16 Ourstudyhadmorethaneight timesthenumberofpatientencountersthaninthisstudyand includedhigheracuitypatientswithhigherASAs,agreater rangeofproceduresperformed,andavarietyofsedatives andamorerobuststatisticalanalysisthatconsideredother

Table3. Interventionsbynilperosstatus.

NPO, nilperos(nothingbymouth); NPA,nasopharyngealairway; IVF,intravenous ﬂuids.

potentialconfoundingfactors.Ourincidenceofadverse eventsof16.3%forNPO <8hoursand21.5%forthosefasted ≥8hoursiscomparabletotheAustralianstudy.16

Ouroverallincidenceofadverseevents(18.4%)compares favorablywithanotherstudy,alsofromAustralia,in pediatricandadultEDpatientsthatlookedprimarilyat adverserespiratoryeventsduringEDPS.Tayloretal reportedahigher20.8%incidenceofjustairwayeventsand foundnoassociationoffastingstatuswithvomiting.17 Our studyisconsistentwithapriorreportofelectivePSin pediatricpatientsperformedbyanelectivesedationservice regardingpredictorsofcomplicationsforpatients undergoingPSandanotherpediatricstudyofnon-emergent sedationsforresearchprocedures,whichbothreporteda higherrateofcomplicationswithhigherASA.7,18

Whencomparingbyagegroup,pediatricpatientshad significantlyfewersedation-relatedcomplicationsand adverseeventsthanadults,especiallygeriatricadults.Side effects,mostcommonlyvomiting,werehigherinpediatric patientsthanadults,whichmayatleastbepartlyexplained bythegreateruseofemetogenicsedatives,specifically ketamine,inthepediatricpatients(Table4).Ketamineasa sedativeincreasestheriskofvomitingascomparedwith othersedatives.10,11 Thespecificagegroup pediatric,nongeriatricadult,andgeriatricadult affectedtheoccurrence ofsideeffects,complications,andadverseevents.Thisage

groupfactorforEDPShasnotbeenevaluatedpreviouslyby robuststatisticalanalysis(Table4).

Wefoundinourunadjustedanalysisthatfasting ≥8hours wasassociatedwithaslightlylowerincidenceofsideeffects, mostlyvomiting,andastatisticallysignificantlygreater occurrenceofcomplicationsandadverseevents(Table2). ThisdiffersfromthepreviouspediatricEDPSstudiesthat didnot findanassociationbetweenadverseeventsandNPO status.8–13 Inonepediatricstudy,therewasanonsignificant increasedincidenceofvomitingwithincreasedfastingtime, butthecomparisonwasofthosefasted <1hourvsthose fasted ≥3hours.12 InanAustralianstudythatincluded adults,therewasnosignificantdifferenceintheincidenceof adverseprocedure-relatedeventsbasedonthetimetheylast ate/drank.17 Onevariablethatmightaccountforthevarious resultscouldbedifferentpatientpopulations:pediatricvs adultpatients,andvaryingacuityofpatients,althoughother factors,suchasmedications(sedatives,analgesics)and procedurebeingdone,couldalsoplayarole.

Ourresearchaddstothedata,primarilyinthepediatric population,indicatingthatcompliancetofastingguidelines similartothoseforelectivesurgerydoesnotsigniﬁcantly decreasetheincidenceofadverseeventsduringprocedural sedation.Ourstudydocumentsthatsuchadherencetothe recommendedfastingguidelinesmayresultinagreater incidenceofadverseeventsduringPS.Recently,graded

Table4. Multivariateanalysisofnilperosgroupandsideeffects,complications,andadverseevents.

Models ﬁt aregeneralizedestimatingequationsassumingcompoundsymmetrycorrelationstructure.ASA1:normalhealthypatient.ASA2: mildsystemicdisease.ASA3:severesystemicdiseasebutnotlife-threatening.ASA4:patientwithseveresystemicdiseasethatisa constantthreattolife.ASA5:moribundpatientwhoisnotexpectedtosurvivewithouttheoperation.

ASA,AmericanSocietyofAnesthesiologyphysicalstatus; NPO,nilperos(nothingbymouth); CI,conﬁdenceinterval.

fastingprecautionsbasedonvariousfactorsincluding patientcharacteristics,comorbidities,theprocedure,andthe sedationtechniquehavebeensuggested.5

Figure3. Fastingtimeandadverseeventsbyfastingduration inhours.

Therecouldbeseveralreasonswhyfastingmayhavea negativeeffect.Hypoglycemiahasbeendescribedinanadult diabeticpatientwhowasfastingpriortoaprocedure.19 PatientsgoingwithoutPOintakemaybecomedehydrated andhypotensive.Futurestudieswouldbehelpfulin collaboratingwhetherthestatisticallysigniﬁcantnegative impactoffastingpriortoEDPSthatwefound,bothon decreasedPSsuccessratesandonanincreasedincidenceof adverseevents,isspeciﬁctoacertainpatientpopulation, suchashigheracuityadultswithmultiplecomorbiditiesand higherASAs.

LIMITATIONS

Thisstudyhasseverallimitations.Theseresultswere basedonthe ﬁndingsfromonehospitalsystem,whichmay limititsgeneralizability.However,20hospitalEDswith

manydiverselocationsinurban,suburbanandruralsettings, andvaryinggeographiclocationsintwodifferentstates,were included.Moreover,weincludedallagesofpatientswith varyingcomorbidities,ASAs,andmultiplediagnoses undergoingPSperformedbymanydifferentphysiciansover 15.25yearsusingvarioussedativesandanalgesicsandhada highnumber(over3,000)ofEDPS.

Althoughthiswasaretrospectivestudy,therecordingof datawasdoneprospectivelyatthetimeoftheEDPS primarilybythenurses,therespiratorytherapists,andthe EDattendingphysicianonastandardizedfour-pageform usedthroughoutthehospitalonwhichstaffhasbeeninservicedmultipletimesonaregularbasisaspartofthe hospital-wideQIprogram.Datasuchasvitalsignsand rhythmstripmonitoringarerecordedcontinuously throughoutallproceduralsedations,andbecausesuch informationisincludedontheformitseemshighlyunlikely thatanyadverseeventsuchashypo-orhypertension, bradypneaorapnea,oralowpulseoxygensaturationwould nothavebeenrecorded.Inaddition,theEDEHRchart completedbytheemergencyphysicianinattendanceduring thesedationandEDvisitwasalsoreviewed.Moreover,all informationwasrecordedprospectively,whichmakesit doubtfulthatanysigniﬁcantdataoroccurrencewasmissed. Hospitalpolicyrequiresthataminimumofthree personnelbepresentthroughouttheEDPS:anED registerednurse;anEDrespiratorytherapist;andanED attendingphysician.Otherssuchasaconsultantorresident areusuallypresentaswell.Thismakesitimprobablethatthis groupofindividualswouldoverlookornotrecordany adverseevent.

Fastingwasnotdocumentedinaboutone-ﬁfthofpatients, whichcouldaffectthevalidityofthisstudy.Theprimary reasonforthiswasthecriticalconditionandhigherASAof someofourpatientsandtheemergentnatureoftheprocedural sedations(Figure1).Otherfactorsthatmayhavecontributed tomissingdataincludethetimeconstraintsfromabusyED withhighpatientvolumesand,perhaps,theimpressionthat thisdatawasnotessentialgiventhedepthofsedation anticipatedandthecontroversyoverNPOstatusforEDPS.

OurincidenceofNPOnotlistediscomparablewithother studies.OnestudyinapediatricEDhadfastingtimesnot documentedin25.4%ofcases,althoughtheyhadyounger, “healthier” patientswithfewercomorbidities,lowerASAs, andfewerdangerousproceduressuchasventriculostomyor cardioversion.13 Anotherstudyfrompediatricsedation servicesthatincludedscheduledsedationsandsedationsin non-EDsettingsreported22.4%ofNPOunknown.6

BecausetheNPOcutofftimeofeighthoursisconsistently mentionedinthevariousguidelinesandtheliterature,we usedthiseight-hourperiod,aswellasthe2-,4-,and6-hour cutofftimes 2,4,7,8,13 (Figures 2A, 3 and Tables2–4).Arecent consensusstatementdidnotmakeadistinctionbetween NPOtimeforsolids(lightmeal)vsliquids(non-humanmilk

orformula)andusedthesamecut-offtimeforallthesePO intaketypesinhealthyinfantsandchildren.5 Moreover,the guidelines/consensusstatementshavevariedwidelyovertime especiallyforliquidPOintake.Forexample,onerecent guidelinerecommendsaNPOoffourhoursforbreastmilk.2 AnotherconsensusstatementgivesnoNPOrestrictionfor breastmilkifnoriskfactors,twohoursifsomeriskfactors, andfourhoursifmoderateriskfactors.5 Anotherguideline alsodidnotdifferentiatebetweensolidsorliquidsandstated “nomilkorsolidsaftermidnight.”4 Becauseofthelackof consistentNPOtimes,2–5 basedondifferentPOintake,age, andriskfactorsovertheyears,particularlyforPOliquid intake,andthelackofdifferentiationbetweensolidsand liquidsinvariousguidelines/consensusstatements,4,5 weused NPOforanyPOintakeinouranalysis.

Observerswerenotblindedtothemedications administeredorfastingtimes,whichcouldhaveledtobias. However,observerswereunawareofthisstudy.Oursedation formhasablankforthetimeoflastPOintakebutdoesnot specifywhetherliquidsorsolidswereconsumed,although thiswasrecordedinsomeinstances.

CONCLUSION

ToourknowledgethisisthelargestEDprocedural sedationcohortthatincludedadults,particularlygeriatric patientsandhigheracuitypatients,analyzedwiththemost robuststatisticalanalysestoevaluatetheassociationamong nilperosstatusandadverseevents.Weidentiﬁedasigniﬁcant increaseincomplicationsandadverseeventsandincomplete proceduresforthoseNPO ≥8hoursvsNPO <8hours.These resultsindicatethatdelayingsedationtomeetestablished fastingguidelinesmayworsenoutcomesforpatientsofall ages,includingadultsintheED,andisnotindicated.

AddressforCorrespondence:SharonE.Mace,MD,Cleveland Clinic,EmergencyServicesInstitute,9500EuclidAve.,E-19, Cleveland,OH44195.Email: maces@ccf.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.GodwinSA,BurtonJH,GerardoCJ,etal.Clinicalpolicy:procedural sedationandanalgesiaintheemergencydepartment. AnnEmergMed. 2014;63(2):247–58.

2.AmericanSocietyofAnesthesiologists.Practiceguidelinesfor preoperativefastingandtheuseofpharmacologicagentstoreducethe riskofpulmonaryaspiration:applicationtohealthypatientsundergoing electiveprocedures. Anesthesiology. 2017;126(3):376–93.

3.CoteCandWilsonS.Guidelinesformonitoringandmanagementof pediatricpatientsbefore,during,andaftersedationfordiagnosticand therapeuticprocedures. Pediatrics. 2019;143(6):e20191000.

4.AmericanAcademyofPediatricsCommitteeonDrugs.Guidelinesfor theelectiveuseofconscioussedation,deepsedation,andgeneral anesthesiainpediatricpatients. Pediatrics. 1985;76(2):317–21.

5.GreenSM,LeroyPL,RobackMG,etal.Aninternational multidisciplinaryconsensusstatementonfastingbefore proceduralsedationinadultsandchildren. Anaesthesia. 2020;75(3):374–85.

6.GhafferS,HaverlandC,RamaciottiC,etal.Sedationforpediatric echocardiography:evaluationofpreprocedurefastingguidelines. JAmerSocEchocardiography. 2002;15(9):980–3.

7.BeachML,CohenDM,GallagherSM,etal.Majoradverseeventsand relationshiptonilperosstatusinpediatricsedation/anesthesiaoutside theoperatingroom. Anesthesiology. 2016;124(1):80–8.

8.BablFE,PuspitadewiA,BarnettP,etal.Preproceduralfasting stateandadverseeventsinchildrenreceivingnitrousoxidefor proceduralsedationandanalgesia. PediatrEmergCare. 2005;21(11):736–43.

9.AgrawalD,ManziSF,GuptaR,etal.Preproceduralfastingstateand adverseeventsinchildrenundergoingproceduralsedationand analgesiainapediatricemergencydepartment. AnnEmergMed. 2002;42(5):636–46.

10.BhattM,JohnsonDW,TaljaarM,etal.Associationofpreprocedural fastingwithoutcomesofemergencydepartmentsedationinchildren. JAMAPediatr. 2018;172(2):678–85.

11.ChumpitaziCE,CampEA,BhanidipatiDR,etal.Shortened preproceduralfastinginthepediatricemergencydepartment. AmJEmergMed. 2018;36(9):1577–80.

12.TrestonG.Prolongedpre-proceduralfastingtimeisunnecessarywhen usingtitratedintravenousketamineforpediatricproceduralsedation. EmergMedAustralas. 2004;16(2):145–50.

13.RobackMG,BajajL,WathenJE,etal.Preproceduralfastingand adverseeventsinproceduralsedationandanalgesiainapediatric emergencydepartment:aretheyrelated? AnnEmergMed. 2004;44(5):454–9.

14.WorsterA,BledsoeRD,CleveP,etal.Reassessingthemethodsof medicalrecordreviewstudiesinemergencymedicineresearch. Ann EmergMed. 2005;45(4):448–51.

15.DoyleDJ,HendrixJM,GarmonEH. AmericanSocietyofAnesthesiologists Classiﬁcation.TreasureIsland,FL:StatPearlsPublishing,2024.

16.BellA,TrestonG,McNabbC,etal.Proﬁlingadverserespiratoryevents andvomitingwhenusingpropofolforemergencydepartmentprocedural sedation. EmergMedAustralas. 2007;19(5):405–10.

17.TaylorDM,BellA,HoldgateA,etal.Riskfactorsforsedation-related eventsduringproceduralsedationintheemergencydepartment. Emerg MedAustralas. 2011;23(4):466–73.

18.KiringodaR,ThurmAE,HirschtrittBA,etal.Risksofpropofolsedation/ anesthesia forimagingstudiesinpediatricresearch. ArchPediatr AdolescMed. 2010;164(6):554–60.

19.WickerhamAL,SchultzEJ,LewineEB.Nilperosordersforimaging:a teachablemoment. JAMAInternalMed. 2017;177(11):1670–1.

ImmuneCheckpointInhibitor-associatedPneumonitis: ANarrativeReview

ChangLi,MD*

SaadiaA.Faiz,MD†

MeganBoysen-Osborn,MD,MHPE‡

AjaySheshadri,MD†

MonicaK.Wattana,MD§

SectionEditor:CaseyM.Clements,MD,PhD

*McGovernMedicalSchoolatUniversityofTexasHealth,Divisionsof Pulmonary,CriticalCareMedicineandSleepMedicine,Houston,Texas

† TheUniversityofTexasMDAndersonCancerCenter,Departmentof PulmonaryMedicine,Houston,Texas

‡ UniversityofCaliforniaIrvineSchoolofMedicine,DepartmentofEmergency Medicine,Irvine,California

§ TheUniversityofTexasMDAndersonCancerCenter,Departmentof EmergencyMedicine,Houston,Texas

Submissionhistory:SubmittedMarch4,2024;RevisionreceivedSeptember12,2024;AcceptedDecember7,2024

ElectronicallypublishedFebruary7,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20305

Immunecheckpointinhibitors(ICI),suchaspembrolizumab,nivolumab,durvalumabandipilimumab,have significantlyenhancedsurvivalratesformultiplecancertypessuchasnon-smallcelllungcancer, melanoma,Hodgkinlymphoma,andbreastcancer,andtheyhaveemergedasanadjunctorprimary therapyformalignantdisease.Approximately40%ofpatientswithcanceronICItherapyexperienceside effectscalledimmune-relatedadverseevents(irAE).Whilenotthemostcommon,pulmonarytoxicitiescan berapidlyprogressive,potentiallyfatal,andposeathree-foldincreasedriskforrequiringintensivecare unit-levelofcare.Pneumonitisisafocalordiffuseinflammationofthelungparenchyma,andclinical manifestationsmaybehighlyvariable.Whiletheonsetisgenerallyobserved6–12weeksaftertheinitiation oftherapy,drugtoxicitycandeveloprapidlywithindaysafterthe firstinfusionormanymonthsintotherapy. Pneumonitissymptomscanbesubtleornon-specific;therefore,athoroughandsystematicevaluation consideringotherpossibleetiologiesiscrucial.Moreover,extrapulmonary findings,suchasskinlesions, colitis,orendocrinopathies,shouldraisesuspicionforirAEasdrugtoxicitycanaffectmultipleorgans simultaneously.DuetothesignificantoverlapofclinicalfeaturesbetweenICI-associatedpneumonitisand respiratoryinfections,itcanbechallengingtodifferentiatethetwoconditionsbasedonclinicalpresentation alone.AmultidisciplinaryapproachtomanagementisrecommendedforthetreatmentofICI-associated pneumonitis,andclassificationofseverityhelpstoguideinterventions.Treatmentoptionsinmoresevere casesincludesystemicimmunosuppression.GiventheincreaseduseofICIsandgreaterprobabilitythat patientswithICI-associatedpneumonitiswillbeseenintheemergencydepartment,weaimedtoprovidea comprehensiveframeworkforthediagnosisandmanagement.Inaddition,identifyingpotentialchallenges indiagnosisand/orothercontributorsofrespiratorysymptomsandradiographicmanifestationsis highlighted.[WestJEmergMed.2025;26(2)210–218.]

INTRODUCTION

Patientswithcancerfrequentlyrequirecareinemergency departments(ED)owingtoacutepresentationsofmalignant disease,cancer-associatedcomplications,therapy-related adverseevents,and/orothercoexistingcomorbidities. Fortunately,mortalityhasimprovedamongmanycancer types.1,2 Inparticular,immunecheckpointinhibitors(ICI) havesigniﬁcantlyimpactedsurvivalrates,usedaloneoras

supportivetherapytoconventionalcancertreatments.3 GiventheefﬁcacyofICIs,itislikelythatemergency physicianswillseeincreasingnumbersofcancerpatientson ICIsintheyearstocome.4

Immunecheckpointinhibitors,suchaspembrolizumab, nivolumab,andipilimumab,workbyblockingcheckpoint protein-binding.Thisinhibitorysignalremovalallows T-cellstoattackcancercells.Approximately,40%ofpatients

onICIsexperiencesideeffectscalledimmune-relatedadverse events(irAEs).5 PatientswithirAEsoftenpresentwithsubtle andnon-speciﬁcsymptomsthatmaymimicotherdiagnoses; therefore,detectionofirAEscanbechallenging. Furthermore,theycaninvolve(almost)everyorgansystem. PatientsdiagnosedwithirAEsintheEDgenerallypresent withhigher-gradetoxicities,and3.5%ofpatientswithgrade 3irAEsrequirehospitalizationandcorticosteroid treatment.6 DelaysinidentiﬁcationofirAEsmayresultin worsenedprognosisandlongerhospitallengthsofstay.6,7 Whiletoxicitiesofthepulmonarysystemarenotthemost commonirAE,theyoccurinupto10%ofpatients.8 When present,pulmonarytoxicitiescanberapidlyprogress;they arepotentiallyfatalandassociatedwithasubstantially increasedriskforrequiringintensivecareunit-ICUlevel care.9,10 Thus,promptrecognitionofICI-related pneumonitisisparamount.Inthisreviewweaimedto provideareviewoftheclinicalpresentation,riskfactors, diagnosticapproach,andmanagementofpulmonaryirAEs intheED.

CLINICALPRESENTATION

Pneumonitisisfocalordiffuseinﬂammationofthelung parenchyma,andclinicalmanifestationsmaybehighly variable.8,11 OnsetofpneumonitisfromICIsisusually6–12 weeksaftertheinitiationoftherapy,butdrugtoxicitycan developrapidlywithindaysofthe ﬁrstinfusionormany monthsintotherapy.8,11–14 ShortertimetoonsetofirAEsis seeninpatientswithlungcancercomparedtoothertypesof malignancy,perhapsduetocomorbidpulmonarydisease, particularlyunderlyinginterstitiallungdisease.15 The severityofsymptomsassociatedwithICIpneumonitiscan rangefromasymptomaticwithonlyradiographicchangesto

life-threatening,fulminantrespiratoryfailure(Figure1). Commonsymptomsmayincludeexertionaldyspnea,cough, fatigue,anddecreasedactivitytolerance;hypoxemiamay presentacutelyorinsidiously.Feverand/orchestpain,when presentwithotherrespiratorysymptoms,shouldprompta searchforotheretiologies,includingpneumonia.

Becausethesymptomsofpneumonitiscanbesubtleor non-speciﬁc,athoroughevaluationiscrucialinreachingthe correctdiagnosis.Competingdiagnoses,suchasrespiratory infections,cardiogenicpulmonaryedema,disease progressionoftheunderlyingmalignancy,andotherdrugrelatedcomplicationsmustbeconsidered.Moreover, extrapulmonary ﬁndings,suchasskinlesions,colitis,or endocrinedisorders,shouldraisethesuspicionofirAEs,as drugtoxicitycanaffectmultipleorganssimultaneously. Additionalinformationfromcomputedtomography(CT)of thechest(Figure2)andbronchoscopyisusually incorporatedtoexcludealternativediagnoses.

Separatefrompneumonitis,infusionreactionsareadverse reactionsunrelatedtothemechanismofactionofICIs. Althoughrelativelyuncommon,theyhavebeenshownin4% ofpatientstreatedwithprogrammedcelldeath1(PD-1)or programdeath-ligand1(PD-L1)antibodiesandin2–6%of patientstreatedwithipilimumab(cytotoxicT-lymphocyte antigenorCTLA-4inhibitor).16,17 Theonsetofsymptoms canoccurwithinanytimeframeduringtheinfusionorupto onehouraftertheinfusion.Symptomsincludechest tightness,wheezing,rigors,rash,pruritus,tongueswelling, dizziness,tachycardia,hypotension/hypertension,or anaphylaxis.Infusionreactionsaretypicallymildto moderateandusuallyresolvewiththecessationofinfusion andsupportivecare.However,severereactionsuchas anaphylaxiscanoccur;therefore,premedicationwith

Figure1. Representativecaseofimmunecheckpointinhibitor-(ICI)associatedpneumonitis.A)Elderlywomanwithmelanomatreatedwith ICIpresentedwithpatchybilateralconsolidativeopacitieswithoutanyrespiratorysymptoms(Grade1).B)Elderlymanwithmelanoma affectingscalpunderwentsurgeryfollowedbyneoadjuvantICIpresentedwithpersistentdrycough.Computedtomographyofthechest (CTchest)revealedmultifocalconsolidativeopacities.Heunderwentbronchoscopywithbiopsyoflymphnodesandbronchoalveolarlavage withoutevidenceofmalignancyorinfection.HewasdiagnosedwithGrade2ICI-associatedpneumonitis,andheimprovedwithoralsteroids. C)Middle-agedwomanwithtriplenegativebreastcanceronICIpresentedwithcoughanddyspneawithexertionnotimprovedonoutpatient oralsteroidtherapy.Onphysicalexamshewasnotedtobetachypneicandhypoxiconroomair.CoronalCTchestrevealedconsolidative opacitiesontherightandleftalongwithground-glassinﬁltratesontheleftupperlobe.ShewasadmittedandtreatedforGrade3ICIassociatedpneumonitiswithintravenousmethylprednisolone(1mg/kg)followedbyinﬂiximab.Sheimprovedandwasdischargedon prolongedsteroidtaper.

glucocorticoidsandantihistamineshouldbeusedwhenthe patienthashadpriorreactions.18

RISKFACTORS

TheclinicalproﬁleofirAEsisdependentontheaffected organandtheICIagentused.Forexample,CTLA-4agents aremorelikelytocausecolitisanddermatitisthan pneumonitisorthyroiditis.19 Whilethepathophysiologyof ICI-relatedpneumonitisisnotfullyunderstood,potential riskfactorshavebeenreportedandcanbecategorizedas treatment-related,patient-related,andtumor-related factors,andthepresenceorabsenceofthemcanmodifyone’ s riskofdevelopingpneumonitisinducedbythetreatment.

Treatment-relatedFactors

Therearedifferentdegreesofpulmonarytoxicity dependingonwhetherICIsareusedasasingleagentvsin combinationwithanotherICIagent,targetedtherapy,or radiation.Ingeneral,pneumonitisoccursmorefrequentlyin patientstreatedwithPD-1inhibitors,ascomparedto patientstreatedwithPD-L1inhibitorsorwithCTLA-4 inhibitors.16,20,21 Further,PD-1andPD-L1inhibitorscause pulmonarytoxicitymoreoftenthanCTLA-4inhibitors.22

Forexample,inpatientswithadvancednon-smallcelllung cancer(NSCLC),acombinationofPD-1andCTLA-4 inhibitors(nivolumab/ipilimumab)resultedinahigher responserateandbetterprogression-freesurvivaltimethan thosereceivingchemotherapyalone.23 However, pneumonitis,particularlyhigh-gradepneumonitis,occurred moreoftenwithcombinationtherapythanICImonotherapy orchemotherapy,suggestingasynergisticeffectininducing lunginﬂammation.11,22,24 Furthermore,theriskof pneumonitismayincreasewhenICIsareusedin combinationwithepidermalgrowthfactorreceptor-tyrosine kinaseinhibitors(EGFR-TKI)NSCLC.Speciﬁcally, patientstreatedwithosimertinib(EGFR-TKI),followedby aPD-1oraPD-L1inhibitor,areatahighrisk ofpneumonitis.25,26

Pneumonitisafterthoracicradiationiswelldocumented, raisingtheconcernofenhancedpulmonarytoxicitywiththe combinationofICIsandradiationtherapy.27,28 Ingeneral, radiationdosescorrelatewiththeriskoflunginjury.An observationalstudyillustratedthatmorepatientsdeveloped ICI-relatedpneumonitisinthegroupthatreceivedcurative intentradiotherapythanthegroupthatreceivedpalliative intentradiotherapy.29 Otherstudieshavenotedthatmean lungdoseisasignificantriskfactorforpneumonitis,withor withoutICI.30,31 Radiation-recallpneumonitisisan inflammatoryreactionthatoccurswithinpreviously irradiated fieldsfollowingexposuretocertainchemotherapy (taxanes,anthracyclines,alkylatingagents,antimetabolites, orpyrimidineanalogs)orothermedications(tamoxifen, simvastatin,levofloxacin,orisoniazid),oftenmonthsto yearsapartfrompreviousradiationexposure.32,33 Radiation-recallpneumonitisinducedbyICIagentshasbeen reportedincasereports.34,35 Incontrasttothecommon radiographicpatternsassociatedwithICIpneumonitis, radiationrecallpneumonitisisgenerallyconfinedtoareaof priorthoracicradiation.

Chemotherapymayalsoenhanceone’sriskforICI pneumonitis.ThePACIFICstudydemonstratedstriking survivalbeneﬁtswithdurvalumab(PD-L1inhibitor)as adjuvanttherapyafterchemoradiation.36 However,ahigher incidenceofpneumonitiswasalsofoundinthedurvalumab group(34%)comparedtotheplacebogroup(25%). Therefore,patientswithadvancedNSCLCtreatedwith concurrentchemoradiationandICIsaremuchmorelikelyto developpneumonitisthanwithconcurrentchemoradiation alone.Ingeneral,higherradiationdosesalsoincreasetherisk oflunginjury.

Patient-relatedRiskFactors

Pre-existinglungconditions,particularlyinterstitiallung disease(ILD),havebeenrecognizedasanindependentrisk factorforlunginjuryafterICItherapy.11,13 Patientswith ILDwerepreviouslyexcludedfromclinicaltrialsdueto

Figure2. Radiographicmanifestationofimmunecheckpointinhibitor-associatedpneumonitis.

concernofpotentialexacerbationwithimmunotherapy. Therefore,theefﬁcacyandsafetyofICIuseinpatientswith underlyinginterstitialabnormalitieshasbeenanactivearea ofinterest.Multipleretrospectivestudieshavedemonstrated thatpatientswithILDwhoreceivedICItherapyweremore likelytodevelopICIpneumonitis.PatientswithNSCLC haveahigherrateofpre-existingILDthanothersolid tumors,owingtothefactthatbothlungcancerandILDare closelyassociatedwithsmokingandotherfactorssuchas advancedage.37 PatientswithNSCLCandpre-existinglung diseasesincludingILDandchronicobstructivelungdisease (COPD),canhaveimpairedsurvivaloncepneumonitis develops.8 Theriskforpneumonitismayalsobehigherin patientswithinterstitiallungabnormalitieswithoutclinical ILD.15 ConsideringtheassociationbetweenILDandlung cancer,ICI-relatedcomplicationsareamajorconcerninthis patientpopulationgiventheshiftingparadigmfavoring ICItherapy.

Additionalpatient-relatedriskfactorstoconsiderinclude autoimmunediseasesandsmoking.Retrospectivestudies showedthatpatientswithautoimmunediseasemayhave higherratesofimmunotoxicity,including ﬂaresoftheirpreexistingautoimmuneconditionsand/orirAEsrelatedtoICI therapy.38,39 Inamulticentercohortstudy,71%ofpatients withautoimmuneconditions,suchasrheumatoidarthritis andpsoriaticarthritis,werenotedtohave ﬂaresorirAEs, whichweremostlymanageablewithglucocorticoids.40 WhethersmokingisdirectlyorindirectlylinkedtoICIrelatedpneumonitisisunclear,especiallywhenconsidering thecloseconnectionbetweensmoking,ILD,andlung malignancy.Inonestudy,patientswithlungcancerand

tobaccoexposuremorethan50yearshadhigherincidenceof all-gradepneumonitis.41

Tumor-relatedRiskFactors

Certaintumortypesandhistologyareathigherriskof ICI-relatedpneumonitis.Onemeta-analysisonclinicaltrials ofICIagents(PD-1,PD-L1,andCTLA-4)from2003–2015 foundthatpneumonitiswasmorelikelytooccurinNSCLC andrenalcellcarcinomaascomparedtomelanoma.42 Anotherstudyreportedhigherratesofpneumonitisin patientswithNSCLCtreatedwithPD-1antibody.24 Additionally,squamouscellcarcinoma,asubtypeof NSCLCthatistypicallyfoundinpatientswithsmoking history,wasshowntobemoreassociatedwithpneumonitis whencomparedtoothersubtypesofNSCLC.43 However, otherstudieshavenotdemonstratedalinkbetweenNSCLC subtypeandpneumonitisrisk.8 Thisdiscrepancymaybe becausesquamouscellcancerismorecommoninpatients whosmoke,andpatientswhosmokehaveahigherrateof pneumonitisthatmaybemediatedbythepresenceof interstitiallungabnormalitiesorclinicalILD.

DIAGNOSTICAPPROACH

Evaluationofthecancerpatientwithrespiratory symptoms,feverand/orhypoxiacanbechallenging,anda broaddifferentialisneeded(Figure3).Therearemanyother conditionsthatmaybedifﬁculttodistinguishfromICIassociatedpneumonitisorwithwhichanirAEmaycoexist. Becausethesymptomsofpneumonitiscanbesubtleornonspeciﬁc,athoroughevaluationiscrucialinreachingthe correctdiagnosis.Competingdiagnoses,suchasrespiratory

Figure3. Differentialdiagnosisforimmunecheckpointinhibitor-associatedpneumonitis. COPD,chronicobstructivepulmonarydisease; irAE,immune-relatedadverseevents.

infections,cardiogenicpulmonaryedema,disease progressionoftheunderlyingmalignancy,andotherirAE mustbeconsidered.Asmentionedpreviously, extrapulmonary ﬁndings,suchasskinlesions,colitis,or endocrinedisorders,shouldraisethesuspicionirAEasdrug toxicitycanaffectmultipleorganssimultaneously.

PneumonitisassociatedwithICIisaclinicaldiagnosis, andbothmalignantandinfectiousetiologiesshouldbe excluded.44 Physicalexam findingscanbenormalormay includerhonchiorralesonauscultation.Unfortunately, therearenopathognomonicsymptomsorradiographic findingsthatconfirmICI-associatedpneumonitis;therefore, asystematicdiagnosticapproachisneededtoexcludeother clinicalpossibilities(Figure4).45,46 Currentguidelines

recommendthoroughevaluationincludingCTchestwith (angiographyifconcernforpulmonaryembolism)or withoutcontrastandbronchoscopytoexcludealternative diagnoses.Laboratorytestsmayshowleukocytosisand/or elevatedinﬂammatorymarkerspotentiallysupportinga diagnosisofirAE,butthesearenon-speciﬁc.Pneumonitisis gradedbasedonradiographicand/orclinicalseverity(Table) andhelpstodirectfurthermanagement.

Duetothesigniﬁcantoverlapofclinicalfeaturesbetween ICI-associatedpneumonitisandrespiratoryinfections,itcan bechallengingtodifferentiatethetwoconditionsbasedon clinicalpresentationalone.PerAmericanSocietyofClinical Oncologyguidelines,athoroughinfectiousworkup, includingnasalswabforrespiratoryviralpathogens,sputum

Figure4. Challengingcasesofpossibleimmunecheckpointinhibitor(ICI)pneumonitis.A-C)Middle-agedwomanwithmetastaticrenalcell carcinomatreatedwithcabozatinibandnivolumabandradiationtotheleftupperlobe.Shepresentedwithcoughanddyspneawithexertion (Grade2)sixmonthsafterradiationtherapywascompleted.Chestradiographrevealsnewinfiltratesintheleftlung(arrows),andcomputed tomographyofchest(CTchest)demonstratesdenseconsolidationintheleftupperlobewithairbronchograms(B,arrows).Herin filtrates correspondedtoradiation field(C).Shewasdiagnosedwithradiation-relatedlunginjuryandimprovedwithoralsteroid;however,ICIassociatedpneumonitiscouldhavealsocontributed.D)Elderlymanwithnon-smallcelllungcancerwhounderwentdefinitivechemoradiation therapytotherightupperlobefollowedbypembrolizumab.Hewashospitalizedafterafall,andhewasnotedtohavelowoxygensaturations. CTchestrevealedpost-treatmentchangesintherightupperlobe(arrowheads)andbilateralground-glassupperlobeinfiltrates(arrow)inthe settingofdiffuseemphysematouschanges.Hewastreatedforchronicobstructivepulmonarydisease(COPD)exacerbationwithempiric antimicrobialtherapyandoralsteroids.Hissteroidswereprolongedgivenlackofclinicalimprovement,soICI-associatedpneumonitiswas alsoaconcern.Bronchoscopywasnotfeasibleduetosignificantoxygenrequirement.E)Middle-agedmanwithpapillarythyroidcancerwho hadundergoneresectionandtreatmentwithcarboplatinandpaclitaxel.Hewassubsequentlytreatedwithpembrolizumabandpresented withcoughanddyspneawithexertion.Healsohadhistoryofvocalcorddysfunctionwithparalyzedleftvocalcordandaspirationrisk.CT chestrevealeddiffuseperipheralandsubpleuralthickening(arrowheads),ground-glassopacities(arrow),andmosaicattenuation (semicircleshowingcontrast).Heunderwentbronchoscopywithlavage,andhewastreatedempiricallyforinfectionandwithIVsteroidsfor possibledrug-relatedpneumonitis.Otherpotentialetiologiesincludedaspirationpneumonia,interstitiallungdisease,andCOPD exacerbation.F)Middle-agedwomanwithHER2-positivebreastcancertreatedwithpembrolizumabhospitalizedforfever,coughand dyspneawithexertion.CoronalCTchestrevealspatchyopacities(arrows)affectingtherightupper,middle,andlowerlobes.Bronchoscopy wasperformed,andnoobviousinfectionwasfound.ShewastreatedwithempiricantimicrobialtherapyandiIVsteroidsforpresumedICIassociatedpneumonitis.Shewasdischargedonoralsteroidstherapywith Pneumocystisjirovecii prophylaxis.

Table. Commonterminologycriteriaforadverseeventsforimmunecheckpointinhibitor-associatedpneumonitis.46

Grading Symptoms

Numberoflobes involved(onCT)

ORPercentageoflungparenchyma involved(onCT)

Grade1 – mild Asymptomatic One <25%

Grade2 – moderate Symptomatic Morethanone 25–50%

Grade3 – severe Severesymptoms Alllobes >50%

Grade4 – life-threateningLife-threateningrespiratoryfailureAlllobes >50% CT, computedtomography.

culture,bloodculture,andurineculture,isrecommendedfor grade2andabovepneumonitis.PatientsreceivingICIagents arenotnecessarilyathigherriskofinfection.Inasinglecenterstudy,patientswithlungcancertreatedwithbothICI andchemotherapyhadasimilarrateofinfection(15%)asthe controlgrouptreatedwithchemotherapyalone(22%).47 However,patientstreatedwithimmunosuppressiveagents forirAEs,suchascorticosteroidsortumornecrosisfactor (TNF)inhibitors,areathigherriskforopportunistic infectionandtuberculosisreactivation.Overall,the incidenceofinfectioninpatientswithlungcancerreceiving ICItherapyrangesbetween15–20%.47,48 Theincidenceof infectionvarieswithdifferenttumortypes.Bacterial pneumoniaisthemostcommontypeofinfectionandrisk factorsincludediabetes,COPD,andneutropenia.Prior colonizationorinfectionwith Pseudomonasaeroginosa or recentexposuretoparenteralantibioticsareindicationsto selectantimicrobialagentstargeting Pseudomonas species.49

MANAGEMENT

Amultidisciplinaryapproachtomanagementis recommendedforthetreatmentofICI-associated pneumonitis,andclassiﬁcationofseverity(Table1)helpsto guideinterventions.50–52 Itisimperativetoinvolve infectious,pulmonary,and/oroncologicconsultantsearlyto determinethemostappropriatetreatment,especiallyfor complexcaseswithmultipleetiologies.Treatmentoptions generallyconsistoftemporaryICIcessationwithregular clinicalreassessment,andinmoresymptomaticcases, systemicimmunosuppressionmayberequired.53 Forgrade1 (asymptomatic)pneumonitis,ICIagentsmaybewithheld whenthereisradiographicevidenceofpneumonitis progression,butinmanycasestheICIagentcanbe continuedwithcloseclinicalandradiologicreassessmentfor developmentofrespiratorysymptoms.Ifthepatientremains asymptomatic,steroidsarenottypicallyadministered.For grade2(mildlytomoderatelysymptomatic)pneumonitis, steroids,suchasprednisoneormethylprednisolone administratedorallyorintravenously,aregivenat1–2 milligramsperkilogramperday(mg/kg/d)following infectiousworkuptoexcludeotherpotentialetiologies.If symptomsdonotimproveafter48–72hours,ahigherdoseof steroidsshouldbeconsidered.Mildgrade2casescanbe

treatedwiththelowerdoseof1mg/kgiftheresponseto treatmentisrapid.Forgrade3orhigher(severely symptomatic),prednisoneormethylprednisolonearegiven at1–2mg/kg/dwithclosemonitoring.50 Ifnoclinical improvementoccurswithin48–72hours,other immunomodulators(discussedinthe SpecialSituations sectionbelow)shouldbeconsideredtopreventfurther respiratorydecompensation.Itisrecommendedtoobtain evaluationfromconsultantsbeforeadministrationof immunosuppressants,suchassteroids,astheseagentscan havelargeimpactontheoverallclinicaloutcome.Ingeneral, casesofpneumonitisgrade3andhigherresultinpermanent ICIdiscontinuation.Dosingandtaperingcourseofsteroids forICIpneumonitisarelargelyextrapolatedfromtreatment guidelinesforhypersensitivitypneumonitisandcryptogenic organizingpneumonia.54,55 Currentguidelinesrecommenda shortcorticosteroidtaperover4–6weeks.However, retrospectivestudieshaveshownthatpneumonitismayrecur afterimprovementofsymptomsorpersistwithout improvementdespitesteroidtreatment.Shortercoursesof therapymayresultinahigherchanceofrecurrence,but optimalsteroidtaperlengthshavenotbeenstudied.

Empiricantibioticsinpatientspresentingwithrespiratory symptomswhilereceivingICItherapyisreasonablewhile furtherinvestigationisunderway.Onecaveatisthatthe humanmicrobiotaplaysanimportantroleintheresponses tocancertherapy.56 Antimicrobialuseisknowntoalterthe gut ﬂoraandhasbeenshownwithassociatednegative outcomesinpatientsreceivingICItherapy.57 Therefore,the appropriateandjudicioususeofantibioticsshouldbe consideredwhileinfectiousworkupiscarriedout.

SPECIALSITUATIONS

SteroidrefractoryICI-associatedpneumonitisis characterizedbyalackofimprovement,typically,after 48hoursofcorticosteroidtreatment.Patientswhodevelop steroidrefractorypneumonitistendtohaveworseclinical outcomesduetoinfectiouscomplicationsorpneumonitis itself.WhencorticosteroidsareineffectiveintreatingICI pneumonitis,furtherimmunomodulationmayberequired. Treatmentguidelinessuggesttreatingwithagentssuchas intravenousimmunoglobulin,anti-TNFagents, mycophenolate,orcyclophosphamide.However,dataonthe

useoftheseagentsislimitedandmostlyderivedfromcase seriesorreports.58 Inthesestudies,althoughsomepatients achievedclinicalimprovementwiththeadditionof immunomodulators,theoveralloutcomewasmostly poor.59,60 Thechoiceofselectingtheseimmunomodulators intreatingsteroidrefractoryICIpneumonitisdependsonthe patient’scomorbiditiesandtheclinician’sorthecenter’ s experience.Ofnote,anegativeinterferon-gammarelease assay,suchasQuantiFERON,isoftenobtainedbefore initiatinganti-TNFagentsduetotheriskoftuberculosis reactivation.However,giventhatanti-TNFagentsare typicallygivenas1or2dosesinsteadoflong-termtherapy, theshort-termbeneﬁtoftreatingseverepneumonitisusually greatlyoutweighsanyriskofreactivatingindolentinfections.

ReintroductionofICITherapyAfterPneumonitis

Ingeneral,patientswhodevelopgrade2pneumonitisand haverecovered(ie,returntograde1pneumonitis),shouldbe consideredaseligibleforreintroductionofICItherapy.Only afewstudieshaveassessedtherateofrecurrentpneumonitis afterICIreintroduction.Inacohortof107patientswho developedpneumonitis,45underwentre-challengeandof these,nine(20%)developedrecurrentpneumonitiswhile11 (24%)developedadifferentirAE.61 Inapharmacovigilance studyincluding452irAEsoccurringwithICIreintroduction inwhichrecurrencestatuswasveriﬁable,pneumonitis, colitis,andhepatitiswereassociatedwithanincreasedriskof recurrentirAEinadjustedanalyses.62 Whilepneumonitis grade3andhighergenerallyprecludesICIreintroduction, successfulre-challengehasbeenreported.63 Ingeneral,these casesarerare,andICIreintroductioninthisscenario requiresthatthebeneﬁtwithICIclearlyoutweighsthehigh riskofrecurrentandpossiblyseverepneumonitis.

Steroid-dependentPneumonitis

Insomecases,pneumonitisdoesnotresolvedespite adequatecorticosteroidtherapy.Inoneform,Naidooand associateshavesuggestedanentityofchronicpneumonitis deﬁnedasa)pneumonitisthatpersistsorworsenswith steroidtapering;andb)requiresmorethan12weeksof immunosuppressionafterICIdiscontinuation.14,64 Two percentofpatientswithNSCLCandmelanomatreatedwith anti-PD-L1agentsdevelopchronicICI-associated pneumonitis.13 Steroid-dependentpneumonitisisasub-type wherepneumonitisrecurswithoutsomeformof immunosuppression.Thereislittletoguidethetreatmentof thisformofpneumonitis,anduncertaintyexistsaboutthe optimalnon-steroidalimmunosuppression,lengthof immunosuppression,cadenceofsteroidtaper,andcancer outcomesinthisscenario.Whilethisformofpneumonitis rarelyoccurs,strategiescanincludetreatmentwithlow-dose steroidtherapyoruseofotherimmunomodulatorssuchas mycophenolatemofetilbeforeeventualattemptingtotaper.

CONCLUSION

Whileimmunecheckpointinhibitor-associated pneumonitisislesscommonthanotheradverseeffectsfrom ICIs,thepotentiallyfatalconsequencesifmissedmakes diagnosisandpromptmanagementbyemergencyphysicians crucial.Associatedriskfactorsarepatient,tumor,and/or treatmentrelated.Maintainingahighindexofsuspicionis importantwhenevaluatingpatientswithahistoryofICI treatmentpresentingwithrespiratorysymptoms.Workupin theEDinvolvesimagingandlabworktoruleoutcompeting diagnosissuchasinfectionandcardiacetiologies.Severityof ICI-pneumonitisisbasedonagradingsystemthatconsiders clinicalandradiographic ﬁndings;oncesuspected,prompt collaborationwithoncologistsandspecialistsisideal,as treatmentinvolvestheinitiationofhigh-dosesteroidsinthe EDandpossiblecessationofICItreatment.Theintegralrole oftheemergencyphysicianinthetimelydiagnosisand managementofICI-associatedpneumonitisisvitalto improvepatientoutcomes.

AddressforCorrespondence:MonicaWattana,MD,TheUniversity ofTexasMDAndersonCancerCenter,DepartmentofEmergency Medicine,Unit1462,P.O.Box301402,Houston,TX77030-1402. Email: mwattana@mdanderson.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisresearchissupportedinpartbythe NationalInstitutesofHealththroughMDAnderson’sCancerCenter SupportGrant(CA016672).Therearenootherconflictsofinterestor sourcesoffundingtodeclare.

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CardiacComputedTomographyMeasurementsinPulmonary

EmbolismAssociatedwithClinicalDeterioration

AnthonyJ.Weekes,MD,MSc*

AngelaM.Pikus,MD*

ParkerL.Hambright,MD*

KellyL.Goonan,MPH*

NathanielO’Connell,PhD†

SectionEditor:QuincyK.Tran,MD,PhD

*AtriumHealth’sCarolinasMedicalCenter,DepartmentofEmergencyMedicine, Charlotte,NorthCarolina

† WakeForestSchoolofMedicine,DepartmentofBiostatisticsandDataScience, Winston-Salem,NorthCarolina

Submissionhistory:SubmittedApril4,2024;RevisionreceivedOctober31,2024;AcceptedNovember1,2024

ElectronicallypublishedJanuary15,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20763

Introduction: Mostpulmonaryembolismresponseteams(PERT)usearadiologist-determinedright ventricletoleftventricleratio(RV:LV)cut-offof1.0torisk-stratifypulmonaryembolism(PE)patients. Continuousmeasurementsfromcomputedtomographypulmonaryangiograms(CTPAs)mayimprove riskstratiﬁcation.WeassessedassociationsofCTPAcardiacmeasurementswithacuteclinical deteriorationanduseofadvancedPEinterventions.

Methods: ThiswasaretrospectivestudyofaPEregistryusedbyeightaffiliatedemergency departments.Weusedanartificialintelligence(AI)algorithmtomeasureRV:LVonanonymizedCTPAs fromregistrypatientsforwhomthePERTwasactivated(2018–2023)byinstitutionalguidelines.Primary outcomewasin-hospitalPE-relatedclinicaldeteriorationdefinedascardiacarrest,vasoactive medicationuseforhypotension,orrescuerespiratoryinterventions.Secondaryoutcomewasadvanced interventionuse.Weusedbivariableandmultivariableanalyses.Forthelatter,weusedleastabsolute shrinkageandselectionoperator(LASSO)andrandomforest(RF)todetermineassociationsofall candidatevariableswiththeprimaryoutcome(clinicaldeterioration),andtheYoudenindextodetermine RV:LVoptimalcut-offsforprimaryoutcome.

Results: Artiﬁcialintelligenceanalyzed1,467CTPAs,with88%agreementonRV:LVcategorization withradiologistreports(kappa0.36,95%conﬁdenceinterval[CI]0.28–0.43).Of1,639patients,190 (11.6%)hadPE-relatedclinicaldeterioration,and314(19.2%)hadadvancedinterventions.MeanRV:LV were1.50(0.39)vs1.30(0.32)forthosewithandwithoutclinicaldeteriorationand1.62(0.33)vs1.35 (0.32)forthosewithandwithoutadvancedinterventionuse.TheRV:LVcut-offof1.0byAIand radiologistshad0.02and0.53 P-valuesforclinicaldeterioration,respectively.WithadjustedLASSO,top clinicaldeteriorationpredictorswerecardiacarrestatpresentation,lowestsystolicbloodpressure,and intensivecareunitadmission.TheRV:LVmeasurementwasatop10predictorofclinicaldeteriorationby RF.Optimalcut-offforRV:LVwas1.54withoddsratioof2.50(1.85,3.45)andareaunderthecurve 0.6(0.66,0.70).

Conclusion: Artiﬁcalintelligence-derivedRV:LVmeasurements ≥1.5oninitialCTPAhadstrong associationswithin-hospitalclinicaldeteriorationandadvancedinterventionsinalargePERTdatabase. ThisstudypointstothepotentialofcapitalizingonimmediatelyavailableCTPARV:LVmeasurementsfor gaugingPEseverityandriskstratiﬁcation.[WestJEmergMed.2025;26(2)219–232.]

INTRODUCTION

Establishedpulmonaryembolism(PE)risk-stratiﬁcation guidelinesemploybinaryassessmentsofhemodynamic stabilityandrightventriculardysfunction(RVD)using imagingmodalitiesandtroponin.1 Themainimaging modalitiesofRVDareechocardiographyandcomputed tomographypulmonaryangiogram(CTPA).

Comprehensiveechocardiographyprovidesmultifaceted RVDassessments;however,itrarelyconﬁrmsdiagnosisof PEandmaynotbeimmediatelyavailable.ACTPA diagnosesPEandidentiﬁeslimitedparametersofRVD, usuallyasrightventricle(RV)dilatation.Radiologists usuallyreportonRVDasabinaryvariableofRVtoleft ventriclediameterratio(RV:LV)usingarangeofcut-offs from0.9to1.5.2–7 RightventriculardysfunctiononCTPA, whenexpressedasacontinuousvariable,maybeabetter predictorthanitsbinaryversion.

ConsistentreportingofRVDmeasurementsmaybelabor intensiveforradiologists.Artificialintelligence(AI) algorithmshavebeendevelopedtoassistradiologists’ workflowbysimultaneouslyinterpretingpresenceof filling defectsandmeasuringcardiacchambersizes.8,9 WhileRVD byCTPAorechocardiographyisanindependentpredictor ofacuteclinicaldeterioration,10 therehavebeeninconsistent resultsregardingitsrelationshipwith30-day mortality.4,6,11–13 Echocardiographystudieshaveshownthat asRVDseverityincreases,bothriskofclinicaldeterioration anduseofadvancedinterventionsincrease.14

WeaimedtocharacterizetheassociationofAI-derived CTPAcardiacmeasurementswithin-hospitalclinical deterioration(primaryoutcome)inaregistryofpatientswith intermediate-tohigh-riskPE.Thesecondaryobjectivewas tocompareretrospectivelyderivedAImeasurementsin patientswithorwithoutuseofadvancedinterventions (secondaryoutcome).Forourexploratoryobjectives,we compared1)radiologistvsAI-derivedCTPAcategorization ofRV:LVand2)AIvsechocardiographymeasurements.If, byretrospectivestudy,weweretoshowthatAI-derived CTPAmeasurementsarestronglyassociatedwithacute clinicaldeterioration,thencapturingimmediatelyavailable CTPAcardiacmeasurementswithinclinicalworkﬂowcould improvePEriskstratiﬁcation.15

METHODS

StudySettingandDesign

Weconductedaretrospectiveanalysisofdatainour ClinicalOutcomesPulmonaryEmbolismResearchRegistry (COPERR).TheCOPERRispopulatedwithadultpatients identiﬁedasintermediate-orhigh-riskPEatpresentationto anyofeightAtriumHealthemergencydepartments(ED)in NorthCarolina.Weextracteddataforregistrypatientswho weretreatedbetweenJune6,2018–August31,2023.In November2023,werequestedaretrospective,remoteAI

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Pulmonaryembolism(PE)responseteams focusonpatientswithrightventricular dysfunctionusingCT ﬁ ndingsofright ventricletoleftventricle(RV:LV)ratioof 1.0orgreater.

Whatwastheresearchquestion?

WhatCTRV:LVmeasurementsare associatedwithacuteclinicaldeterioration?

Whatwasthemajor ﬁndingofthestudy?

Theoptimalcut-offforRV:LVonCTwas 1.54withanoddsratioof2.50(1.85 – 3.45) foracuteclinicaldeterioration.

Howdoesthisimprovepopulationhealth?

ARV:LVthresholdof1.5onCTmayimprove PEriskstrati ﬁ cationandinformuseof inpatientresources.

analysisofCTPAswithconﬁrmedindexPEfromthis populationofregistrypatients.

SelectionofParticipants

UsingtheCOPERRdatabase,weidentifiedadultpatients (≥18years)presentingtoaparticipatingEDwhohad1) acutesymptomaticPEastheprimaryEDdiagnosis(by positiveCTPA)and2)intermediate-orhigh-riskPE classification.ThePEriskwasclassifiedbyemergency cliniciansusingEuropeanSocietyofCardiology(ESC) guidelines1 andourPEresponseteam’s(PERT) “CodePE” pathway(SupplementalFigure1).Thelattershowsthe structure,function,andlogisticsofPERTactivation, triaging,multispecialtynotification,andconsiderationsfor advancedPEinterventionsbasedonPEseverityand bleedingrisk.Fortheexploratoryobjective,weincluded above-mentionedpatientswithcomprehensivetransthoracic echocardiography(TTE)andRV-focusedmeasurements completedwithin24hoursofPEdiagnosis.

Weincludedpatientswithintermediate-orhigh-riskPEat EDpresentationwithCTimagesof1-mmslicethickness availableforAIanalysisfortheprimaryobjectiveandwith anyAIanalysisforthesecondaryobjective.Weexcludedthe following:patientswithPEdiagnosedonlybyhighprobabilityventilation/perfusionnuclearimaging;those whosepoint-of-careTTE ﬁndingswerehighlysuspiciousof PEbutPEwasnotconﬁrmedbyCT;andthosewhoseCTPA

wasnotforindexPE.WealsoexcludedCTPAsthatcould notbeanalyzedbyAIalgorithm.

DataCollectionandProcessing

DataenteredinCOPERRandavailableforanalysis includeddemographics;clinicalpresentationfeatures (includinginitialandworstvitalsignswithinthreehoursof EDpresentation);comorbidities;PEriskfactors;criteria usedforPEriskstratiﬁcation;radiologistreportofRV:LV; TTEmeasurements,dates,andtimes;PERTnotiﬁcation datesandtimes;laboratorymeasurements;PE-related outcomesandinterventions;andadverseevents.14,16,17 Traineddataextractorsretrievedinformationfromthe electronichealthrecordandentereddataintheregistry.

Duringreal-timeclinicalcareofindexPEhospitalization, RV:LVwasmeasuredbyboard-certiﬁedradiologists,and TTEwasperformedbycertiﬁedcardiacsonographersfrom anechocardiographylaboratoryaccreditedbythe IntersocietalCommissionfortheAccreditationof EchocardiographyLaboratories.Giventhiswasa retrospectivestudy,theradiologistsandsonographerswere notawareofthestudyoritsobjectives.Radiologists measuredRV:LVontheminorcardiacaxisonCTPA. Measurementswereatthewidestpointsbetweentheinner freewallofeachventricletotheinnerwalloftheventricular septum.RadiologistsusedRV:LVcut-offof1.0,withless than1.0considerednegativeforRVdilatation.

SonographersusedstandardorRV-focusedapicalviews tomeasureend-diastolicRVinnerdiameteratthebase.The LVbasalend-diastolicmeasurementswereperformedinthe parasternallongaxisview.Imageswereuploadedintoa securelocalserverandportalsystemMergeCardio (MerativeLP,AnnArbor,MI[formerlyIBMWatson Health]).Board-certiﬁedcardiologistsinterpretedimages andmeasurementsandwereblindtostudyandclinical outcomes.Onlyinitialechocardiographymeasurementsfor indexPEhospitalizationwereusedinthisstudy.

Foreachregistrypatientincludedinthestudy,we exportedthefullyanonymizeddigitalimagingand communicationsinmedicine(DICOM) fileforeachCTPA tosharewiththeAIvendorforanalysis.Wetransferred DICOMdatafromourstudycentertotheserverofanAI operatingsystem(Aidoc,TelAviv,Israel)usingencrypted secure filetransferprotocol.Priortotransfer,alldatawere de-identifiedperthesafeharborde-identificationprotocol definedbytheHealthInsurancePortabilityand AccountabilityAct.The de-identi fi edaccessionnumber was extractedfromtheDICOMheaderofsharedstudies.The studycenterusedthekeypairof de-identi fi edaccessions and identi fi edaccessions computedatthedataanonymization steptore-identifydataforthestudy.

TheAidocPEalgorithmisFDAclearedviathe510(k) premarketnotiﬁcationpathwayrequiredofallAIsoftware medicaldevices.Aidoc’suseindetectingPEonCTPAshas

beenpreviouslyreported.8,18 TheprototypeofthePE detectionalgorithmwasdevelopedusinginputfrom anonymized,1-mmseriesofCTPAreconstructionsand basedonadeepconvolutionalneuralnetworkcomprisinga Resnetarchitectureandtrainedandvalidatedonover25,000 CTPAstakenfrommanyinstitutions.Aidocalgorithmshad specificCTPAinclusioncriteria,includingslicethickness, kernel,andcontrastphasetoallowanalysis.Aidochastwo softwarecomponents:oneforsoftwareanalysisofCTPA DICOM files,andanotherforreal-timeanalysisand reportingofinterpretationstocliniciansandradiologists. Onlythe firstcomponentwasusedinthisstudy.TheAI analysesofCTPAsandmeasurementswerenotperformed duringreal-timeclinicalcare.

EachCTPAwasanalyzedbytwoAIalgorithms independently.Forthe firstalgorithm,ifaPEwasdetected, AIdeterminedwhetherthePEwasacentralclotornot. Centralclotwasdefinedbythefollowinglocations: pulmonarytrunk;saddle(bifurcationofthemainpulmonary arterytrunk);rightorleftmainpulmonaryarteriesorlobar pulmonaryarteries.Forthesecondalgorithm,AImeasured eachRVandLVlargestdiameter(betweeninnerwalls)asa numberandcalculatedtheratioofRVtoLV.Thiswas producedinafour-stepprocess,includingventricular detection,ventricularsegmentation,interventricularseptum detection,andcaliperpositioningandmeasurements.TheAI algorithmalsoidentifiedpatientswithlargecentralPEs.Itis importanttonoteasubsegmentalPEdidnotprovidea positiveresult.ThiswasdonetoallowtheAI-augmented clinicalworkflowtoaccuratelyidentifyacutePEswithRV dilatationasnecessaryconditionsforintermediate-andhighriskPEclassification.

TheAI-basedalgorithmvariablesincludedthefollowing categoricalvalues:1)DidtheAidocalgorithmanalyzethe data(yesorno);and2)didtheCTPAcontainaPE(yesor no)?TheAI-basedcontinuousvariableswereRVbasal diameter,LVbasaldiameter,andRV:LV.Alldatafor AI-derivedCTPAvariableswerematchedtopertinentstudy IDsanduploadedintoastandardelectronicformwithin ResearchElectronicDataCapture(REDCap)toolsat ourinstitution.

Outcomes

TheprimaryoutcomewasPE-relatedclinical deterioration,deﬁnedasacompositeofoneormoreofthe followingclinicaldeteriorationeventswithindaysofindex PEhospitalization:death;cardiacarrest;sustained hypotensiontreatedwithvasoactivemedications;orrescue respiratoryintervention(mechanicalorpositivepressure ventilation).14 Thesecondaryoutcomewasuseofadvanced PE-speciﬁcinterventions,includingsystemicthrombolysis, catheter-directedinterventions,extracorporealmembrane oxygenation(ECMO),orsurgicalembolectomy.

StatisticalAnalysis

Samplesizewasdeterminedbythenumberofpatients eligibleforstudyanalysis.TodetermineassociationwithPErelatedclinicaldeterioration(primaryoutcome),weused variousstatisticalmethods.Weusedbivariableanalysiswith theStudent t -testorchisquaretostratifybyprimary outcomegroups.Weconductedmultivariableanalysesfor theprimaryoutcomeintwoways.First,weusedleast absoluteshrinkageandselectionoperator(LASSO) regressiontodeveloptwomodels,onewithAIassessment variablesonlyandonewithallindependentvariables.We reportedmissingnessofeachvariableandusedcompletecase analysis.Weexpressedstrengthofassociationasoddsratios with95%conﬁdenceintervals(CI).Second,weusedrandom forest(RF)tostatisticallyinferthestrengthoftheassociation ofallindependentvariablesinthedatasetandidentifythetop 20predictorsofPE-relatedclinicaldeterioration(primary outcome)inavariableimportanceplot.

Foreachmodel’sprognosticperformanceontheprimary outcome,wereporteddiscriminationasareaunderthecurve (AUC)andcalibrationascalibrationplotswithcalibration statistics,includingBrier,Brierscaled,interceptandslope. PerformanceforRFandLASSOlogisticmodelswasbased onout-of-bagsamplesand10-foldcrossvalidation, respectively.Finally,toaddressthetrade-offoffalse positivesandfalsenegatives,weusedtheYoudenindexto determineoptimalRV:LVcut-offsandotherAI-derived measurementsforprognosisofclinicaldeterioration.Forthe selectedoptimalRV:LVandotherAIcardiacmeasurements, wedeterminedsensitivity,speciﬁcity,likelihoodratios,and AUCwith95%CI.

Todetermineassociationwiththeuseofadvanced interventions(secondaryoutcome),weusedbivariable analysiswiththeStudent t -testorchisquaretostratifyby secondaryoutcomegroups.Tomeasurereliabilitybetween AI-derivedandradiologistCTclassiﬁcationofRV:LV ≥ 1.0 vs < 1.0,weusedtheCohenkappawithits95%CIs.Weused suggestedguidelinesofLandisandKochtodescribethe strengthofagreementforthe κ statistic:lessthan0 = poor;0to 0.20 = slight;0.021to0.40 = fair;0.41to0.60 = moderate; 0.61to0.80 = substantial;and0.81to1.00 = almostperfect.19

Wereportedmeanandstandarddeviationtimeintervals inhoursbetweenPERTnotiﬁcationandTTEforthemiddle 95%.WeusedtwomethodstoassessagreementbetweenAIderivedCTcardiacandTTEmeasurementsforRV,LV,and RV:LV.First,weusedPearsoncorrelationswith95%CIsfor continuousvariablestotestformagnitudeanddirectionof linearrelationships.20 Second,weusedBland-Altmanplots todepicttherelationshipofdifferenceandmeanforeachpair ofCTPAandTTEmeasurements.

Disclosures

Regardingtherelationshipwiththecompanythat developedandmarketstheAI-basedPEalgorithmusedin

thisstudy,wedeclarethatAidochadnoroleinthedesignof thestudy,thecollection,analysis,andinterpretationofdata, orthepreparationofthepublishedmanuscript.Wefurther declarethatwehavenotreceivedandwillnotreceiveany compensation,directorindirect,fromAidocoranyofits afﬁliates.Wedonotownstockinthecompany.

RESULTS StudyFlow

Figure1 showswescreened1,809patientswithCTPAconfirmedacutePEdiagnosedinED.Ofthese,1,664(92.0%) hadCTPAassociatedwithindexPEdiagnosisand anonymizedDICOM filestransferredforAIanalysis. RadiologistsprovidedcategoricalRV:LVclassificationfor 1,467of1,664(88.2%)CTPAs.TheAIvendoranalyzed 1,660ofthe1,664;fourcaseswereexcludedbecauseof inadequateCTPAslicethicknessforAIanalysis.TheAI assessmentforcentralclotwassuccessfulinall(100%) CTPAsand1,267(76.3%)werefoundtohavelargecentral PEbythealgorithm.TheAI-derivedcardiacmeasurements wereobtainedfor1,617/1,660(97.4%).TheAIfailedto analyze43CTPAsbecause1)theydidnotmeetstudy inclusioncriteria(i.e.,slicethickness,kernel,contrastphase), or2)theRV:LValgorithmwasunabletodetectappropriate landmarkstoperformRV:LVanalysis.Of1,664CTPAs,733 (44.1%)hadcomprehensiveTTEmeasurementsduringindex PEhospitalization.MeanandSDfortimeintervalbetween CTPAandTTEforthemiddle95%was13.6(11.3)hours. Wewereabletodetermineprimaryoutcomeresponsesfor 1,639uniquepatients (Table1) andsecondaryoutcomefor 1,643uniquepatients.Ofthe1,639,meanagewas63.0 ± 16years,805(49.1%)weremale,997(60.8%)wereWhite, and190(11.6%)hadoneormorecomponentsoftheprimary outcome.FourpatientshadmorethanoneEDvisitforacute PEduringthe2018–2023studyperiod.WereportedPErelatedclinicaldeterioration(primaryoutcome)for first visitonly.

PatientCharacteristics

Therewerenosignificantdifferencesbetweenthosewith orwithoutclinicaldeteriorationforage,gender,race,or ethnicity.Thereweresignificantdifferencesformeanvalues ofvitalsigns.PatientswhohadPE-relatedclinical deterioration(primaryoutcome)hadlowersystolicblood pressureandoxygensaturationreadingsandhigher respiratoryrateandheartratesthanpatientswithoutclinical deterioration.Therewassignificantlyincreaseduseof systemicthrombolysis,ECMO,andsurgicalembolectomyin theprimaryoutcomegroup.However,therewereno significantdifferencesinuseofcatheter-directed interventionsbetweenoutcomegroups.Forcategorical cardiacCTPAassessments, Table1 showsradiologists’ binarycategorizationofRVDusingtheRV:LVcut-off1.0 wasnotsignificantbetweenprimaryoutcomegroups.In

Not CT from index PE (N = 145 )

CT with confirmed PE from registry patients between June 2018 to August 2023, N = 1,809

Missing RV/LV ratio N = 176

Radiologist assessment of RV/LV ratio, N = 1,467 RV/LV ratio ≥ 1.0? YES (N = 1,287) NO (N = 180)

AI measurement of LV, RV and RV/LV ratio, N = 1,617 Anonymized CT from Index PE, N = 1,664

Did not meet series level criteria N = 4

Each analyses by 2 AI algorithms independently for RV/LV ratio and central clot N = 1,660

AI qualitative assessment: Presence of central clot? N = 1,660

Advanced intervention analysis, N = 1,643

Clinical information available for outcome analyses, N = 1,643

AI failed on, N = 43

Yes, n= 314 No, n= 1,329

More than one PE hospitalization, n= 4

Unique individual patient for clinical deterioration analysis, N = 1,639

(N = 1,472 ) NO (N = 145)

YES (N= 1,267) NO (N = 393 )

Acute Central PE is defined by the the following locations:

• Pulmonary trunk

• Saddle (bifurcation of the main pulmonary artery trunk)

• Right or left main pulmonary arteries

• Lobar pulmonary arteries

Figure1. Study ﬂowdiagram*. AI,arti ﬁcalintelligence; PE,pulmonaryembolism; CTPA,computedtomographypulmonaryangiography, RV,rightventricle; LV,leftventricle.

contrast,AI-derivedRV:LVbinarycategorizationwas signiﬁcant.FormeanAI-derivedCTPAmeasurements, Table1 showssigniﬁcantdifferencesinRV:LV,RV, andLVbasaldiametersbetweenthosewithandwithout clinicaldeterioration.

Forthe733patientswithTTE,TTEmeasurementswere lessthanAI-derivedCTcardiacmeasurements.OnlyLV basaldiameterhadsigniﬁcantdifferencesbetweenthe primaryoutcomegroups.AlthoughmeanRVbasal diameterwasabovenormallimits,thedifferencewasnot statisticallysigniﬁcantforoutcome-negativeand outcome-positivegroups.

PrimaryOutcome

MultivariableanalyseswithunadjustedLASSOforPErelatedclinicaldeterioration(primaryoutcome)showedthe mostsigniﬁcantindependentAI-derivedpredictorswereRV: LV(19.28[3.0–109.4])andcentralclotbyAI(2.4[1.6–3.6]). BoththeadjustedLASSOandRFmodelsvettedall candidatedatabasevariables.BothRFandadjustedLASSO

prognosticmodelshadexcellentdiscriminationand calibrationmetricsforprognosticaccuracy(Supplemental Figure2):Fordiscrimination,adjustedLASSOandRFhad AUCof0.88(0.85,0.90)and0.87(0.84,0.89),respectively. BothmodelswerewellcalibratedwithBrierscoresof0.07. TheRFmodelwasslightlylesscalibratedthantheLASSO modelonothercalibrationmetrics.

Table2 and Figure2 showcardiacarrestatpresentation wasthetoppredictorofin-hospitalclinicaldeteriorationin bothmultivariablemodels(LASSOandRF).Admissionto theintensivecareunit,lowestsystolicbloodpressure,lowest oxygensaturation,andhighestheartandrespiratoryrates werealsotoppredictorsinbothmodels.TheCTPAcardiac measurementswereamongthetop11predictorsselectedby LASSO.Abnormaltroponinwasoneofthetoppredictorsby LASSObuthadalowerinﬂuenceonRFmodelaccuracy thanCTPAassessments.TheCTPAcardiacmeasurements and ﬁndingsofcentralclotlocationwithRV:LV ≥ 1.0were amongthetop10independentpredictorsofclinical deteriorationintheRFmodel.

Table1. Patientandimagingcharacteristicsbypulmonaryembolism-relatedclinicaldeterioration(primaryoutcome).

Race

Bodysurfacearea

PriordiagnosisofPEorDVT?

FamilyhistoryofVTE?

Recenthospitalization(in3weeks)?

Anticoagulationuse?

Currentorrecentpregnancy(ormiscarriage) within6weeks

(Continued onnextpage)

Table1. Continued.

Recentlimbimmobilization(currentorwithin3weeks)

Recenttrauma(intheprior4–6weeks)?

Surgeryrequired(mechanicalventilationorepidural) within6weeks?

Clottingdisorders(proteinC,S,factorVdeﬁciency)?

Hormonereplacementtherapy

Chronicpulmonarydisease

Congestiveheartfailure

TotalCharlsoncomorbidityindex

LowestsystolicBP(within3hours),mmHg

LowestO2 sat(within3hours),%

Mean(SD)93.1(5.52)85.5(16.4)92(8.00) <

Missing2(0.1%)1(0.5%)3(0.2%)

HighestHR(within3hours)

Mean(SD)106(21.2)120(22.2)108(21.8) <0.001

Median[min,max]106[11.0,198]121[62.0,178]108[11.0,198]

HighestRR(within3hours)

Mean(SD)24.4(8.64)31.3(11.1)25(9.22) <0.001

Median[min,max]23.0[14.0,200]30.0[16.0,103]23[14.0,200]

Missing4(0.3%)2(1.1%)6(0.4%) (Continued onnextpage)

Table1. Continued.

Shockindexgreaterthan1.0?

Advanced/escalatedPEintervention?

Typeofadvancedintervention: systemicthrombolysis

Catheter-directedintervention

Rightventricularassistdevice

Inferiorvenacava ﬁlterused

Computedtomography assessmentofCTbyradiologists

< 1.0

RV:LV(AI)

RV:LV ≥ 1

RV:LV < 1

RVbasalwidth,byAI,cm

LVbasalwidth,byAI,cm

RV:LVratio,byAI Mean(SD) 1.3(0.324) 1.5(0.39) 1(0.336) <0.001

26(1.6%) (Continued onnextpage)

Table1. Continued.

EchocardiographyRVbasalwidth(ECHO)

Mean (SD)

Primaryoutcome( ) (n = 1,449)

Primaryoutcome(+) (n = 190)

Total N = 1,639 P-value

4.22(0.811) 4.25(0.814) 4(0.812)0.70

Missing 640(44.2%) 110(57.9%)752(45.9%)

LVbasalwidth(ECHO)

Mean(SD)

4.1(0.811) 3.9(0.846) 4(0.817)0.004

Missing 153(10.6%) 42(22.1%)196(12.0%)

RV:LV(ECHO)

Mean(SD) 1.0(0.272) 1.1(0.332) 1(0.278)0.07

Missing 685(47.3%) 116(61.1%)1(0.278)

RV:LVcut-off = 1.0bycardiologist

RV:LV ≥ 1.0 1,155(79.7%) 147(77.4%)1,302(79.4%)0.72

RV:LV

Initialtroponin,ng/mL

Initialhigh-sensitivitytroponin,mean(SD),ng/mL195(606)

*WeusedtroponinIorhigh-sensitivitytroponinassays(Abbott,AbbottPark,IL)measuredinng/mLassay.NormalvaluesfortroponinIwere less than0.07ng/mL.Normalvaluesforhigh-sensitivitytroponinwerelessthan12forfemalesandlessthan20formales.Abnormal troponinlevelswerehigherthanabove-mentionedcut-offs.

AI,arti ﬁcialintelligencealgorithm; CT,computedtomography; BP,bloodpressure; DVT,deepveinthrombosis; ECHO,echocardiography; ECMO, extracorporealmembraneoxygenation; HR,heartrate; ng/mL,nanogramspermilliliter; O2 sat,oxygensaturation; RR,respiratory rate; LV,leftventricle; RV,rightventricle; RV:LV,rightventricletoleftventriclediameterratio; VTE,venousthromboembolism.

Table3 showsoptimalcut-offsofAI-derivedcardiacCTPA measurementswithpredictionmetricsforPE-relatedclinical deteriorationasRV:LV1.54(OR2.5[1.85–3.45]andAUC 0.6[0.66,0.70]).Thesecut-offvalueshadhighnegative predictivevalues(NPV)butlowpositivepredictive values(PPV).

SecondaryOutcome

Table4 showsbivariableanalysisofcardiacassessments stratiﬁedbyuseofadvancedinterventions(secondary outcome).Regardlessofhowcardiacmeasurementswere derived,thereweresigniﬁcantdifferencesincardiac measurements(whethercontinuousorcategorical)between thosewithandwithoutadvancedinterventions.For example,AI-derivedCTPARV:LVmeanswithSDs were1.62(0.33)vs1.35(0.32)forthosewithandwithout advancedinterventions(secondaryoutcome),respectively. WithTTE,RV:LVmeanswere1.17(0.29)vs 1.02(0.27)forthosewithandwithoutadvanced interventions,respectively.

ExploratoryOutcomes

TherewasagreementbetweenAIandradiologistsonRV: LV ≥ 1.0for1,224casesandonRV:LV <1.0for67cases (88%overallagreement[kappa0.36,95%CI0.28–0.43],data notshown).TheRV:LVmeanswithSDswere1.48(0.31) and0.86(0.11),respectively.Therewasdisagreementfor178 (12.1%)cases.RV:LVmeanswere1.23(0.23)and0.92(0.05) whenAIreportedabnormalRV:LVvsRV:LV < 1.0, respectively.ForcomparisonofAI-derivedCTPAwithTTE measurements,PearsoncorrelationcoefﬁcientsforRV,LV, andRV:LVwere0.47(0.42,0.52),0.58(0.53,0.62),and0.50 (0.45,0.55),respectively.Allkappaswereinterpretedas moderateagreementperLandisandKochguidelines. SupplementalFigure3showsstrongnegativebiaswith lowerTTEmeasurementsthanCTPAmeasurements atpresentation.

DISCUSSION

WefoundAI-derivedRV:LVmeasurementsonCTPA weresigniﬁcantlygreaterinPEpatientsexperiencingclinical

Table2. LASSO*regressionmodels(unadjustedandadjusted)forpulmonaryembolism-relatedclinicaldeterioration(primaryoutcome).

UnadjustedmodelwithAI-derivedCTPAassessmentsonly PE-relatedclinicaldeterioration(primaryoutcome)

PredictorsOddsratiosCon

Adjustedmodelwithallvariablesconsidered

Observations

*LASSO, leastabsoluteshrinkageandselectionoperator; PE,pulmonaryembolism; AI,artiﬁcialintelligence; CTPA,computedtomography pulmonaryangiogram; RV,rightventricle; LV,leftventricle; CPR,cardiopulmonaryresuscitation; ICU,intensivecareunit.

deteriorationorreceivingadvancedinterventionthanthose withouttheseoutcomes.Therewassigniﬁcantlyincreased useofsystemicthrombolysis,ECMO,andsurgical embolectomyintheprimaryoutcomegroup.Inourmodels, whichhadstrongdiscriminationandcalibration,AI-derived RV:LVmeasurementswereindependentpredictorsof clinicaldeterioration,alongwithabnormalvitalsignsand cardiacarrestatpresentationinoneorbothmultivariable models.TheoptimalRV:LVcut-offof1.5hadanoddsratio of2.5andAUCof0.6forPE-relatedclinicaldeterioration (primaryoutcome).TheAI-derivedRV:LVmeasurements performedbetteraspredictorsofprimaryandsecondary outcomesthanradiologists’ orAI-derivedcategorizations usingRV:LVcut-offof1.0.

Otherreportshavefocusedonoutcomessimilartoours. Beigeletal.performedastudyevaluating179intermediateriskPEpatientsforpredictorsofshort-termdeathand advancedinterventions.21 Twenty-sixpatientsrequired advancedintervention,whichwassigniﬁcantlyassociated withechocardiographicevidenceofsevereRVD(42%vs 19%, P < 0.01)orhigherRV:LVmeasurementonCTPA (1.9 ± 0.6vs1.46 ± 0.5, P < 0.001).TheRVdilatationon

TTEwasanindependentpredictorforadvanced interventions.Thisinformationfurthercorroboratesthe importanceofmeasurementstoriskstratifyPEpatients. UnlikeTTEmeasurements,cardiacCTPAmeasurements areimmediatelyavailableatthetimeofPEdiagnosisfor riskstratiﬁcation.22

OtherstudiesthatassessedhowCTPAcardiac measurementsareassociatedwithclinicaloutcomeshad mixedresults.AretrospectivestudybyFoleyetal.involving 101patientswithCT-provenPEsofanyseverityatasingle centershowedstrongagreement(intraclasscorrelation0.83, [0.77–0.88])betweenradiologists’ andAI-derivedCTPA measurementsforRV:LV.15 Inthisstudy,RV:LVranged from0.67–2.43,with65%being ≥ 1.0.TheoptimalRV:LV cut-offfor30-daymortalitywas1.18.TheuseofAIanalysis inourstudyledtoachangeinriskstratificationin45%of patients.However,inalargeprospectivestudyof1,950CTconfirmedPEsbyBeenenetal.,RV:LVmeasurementsby radiologistswerenotsignificantlydifferentbetweenthose withandwithoutshort-termmortality.23 SimilartotheFoley etal.study,wefoundanelevatedRV:LVhadastrong associationwithin-hospitalclinicaldeteriorationinour

Figure2. Randomforestvariableimportanceplotforpredictingclinicaldeterioration. CTPA,computedtomographypulmonaryangiography; LV,leftventricle; RV,rightventricle; ICU,intensivecareunit.

Table3. Optimalcut-offsofartiﬁcialintelligence-derivedcardiacCTPA*measurementswithpredictionmetricsforpulmonaryembolismrelatedclinicaldeterioration(primaryoutcome).

*CTPA, computedtomographypulmonaryangiogram; AI,artiﬁcialintelligence; cm,centimeter; PPV,positivepredictivevalue; NPV,negative predictivevalue; AUC,areaunderthecurve; RV,rightventricle; LV,leftventricle.

intermediate-andhigh-riskPEcohort.OuroptimalRV:LV cut-offof1.5washigherthantheirs.

Apreviousreportshowedfairagreement(kappa0.4)for categoricalassessmentsofRVdysfunctionbetweenCTPA andTTE.22 OurstudyfoundmoderateagreementofRV:LV measurementsbyCTPAandTTE.Webelieveour ﬁndings underscoretheimportanceofusingimmediatelyavailable CTPAmeasurementsofRVDforriskstratiﬁcationand prognosis.However,atmanyinstitutions,RVmeasurements arenotroutinelyperformedorinterpretedonCTPA.One studyinalargeregionalhealthcaresystemwith21sites showedonly18.3%of1,571positiveCTPAinterpretation reportsincludedRVmeasurements.24

TheuseofAItodetectPEandanalyzeCTPAcardiac measurementsattimeofPEpresentationmayimproverisk

stratificationforPERTsandprovidequalityassuranceto enhanceradiologists’ workflow.Thediagnosticaccuracyof AIshouldincludealownumberoffalsepositivestominimize notificationfatigueandpotentialformedication mismanagement.Inaretrospectivemulticenterstudy,Cheik etal.evaluateddiagnosticperformancesoftheAidocPE algorithmonCTPAsandcomparedthemwiththoseof radiologiststodetermineimpactofAIPEdetection.18 Of 1,202patientsincluded,theAIalgorithmdetected219 suspiciousPEs,ofwhich176weretruePEs,including19true PEsmissedbyradiologists.ThehighestsensitivityandNPVs wereobtainedwithAI,whilethehighestspecificityandPPV werefoundwithradiologists.Ourretrospectivestudy focusedonlesssubtlePEdiagnoses;theAIanalysiswas specificallycreatedtofocusonnon-segmentalPE,andAI

Table4. Cardiacassessmentsgroupedbyuseofadvancedintervention(secondaryoutcome). Noadvancedintervention (n = 1,329)

= 314)

CTassessmentbyradiologist

RV:LV ≥ 1.0

RV:LV < 1.0 165(12.4%) 17(5.4%) 182(11.1%)

Missing 133(10%) 23(7.3%) 156(9.5%)

CTassessmentsbyAI

RV:LV > 1(AI)

RV:LV

RV:LV < 1

RVbasalwidth(AI)

Mean(SD)

LVbasalwidth(AI)

RV:LV(AI)

ECHOassessments

Echocardiography

LVdiameter(AI)

RVbasalwidth (ECHO)

LVbasalwidth(ECHO)

RV:LV(ECHO)

AI, arti ﬁcialintelligencealgorithm; CT,computedtomography; ECHO,echocardiography; LV,leftventricle; RV,rightventricle; RV:LV,right ventricletoleftventriclediameterratio.

agreedthatPE findingswerepresentinallCTPAs.Artificial intelligencefurtheranalyzedventriclemeasurementson CTPAanddeterminedcentralvsnon-central fillingdefects. AlthoughourcomparisonofCTPARV:LVcategorization byAIvsradiologistshad88%agreement,thekappa0.34is interpretedasfairagreement.Agreementwasmorelikely

whenRV:LVwaswellaboveorwellbelowthe1.0cut-off;the twosourcesweremorelikelytodisagreewhenRV:LVwas closerto1.0.ItisunknownwhetherAI-derivedCTPA measurementsmight “correct” radiologistassessmentsinreal timeforthoseclosetothe1.0cut-offorwhethersucha “correction” wouldhaveclinicalsigniﬁcanceonpatientcare

andoutcomes.EvenwithanoptimalRV:LVcut-offof1.5,we notethelowPPVforPE-relatedclinicaldeterioration.So,an RV:LVcut-offof1.5isnotsufﬁcienttobethesole determinantofdecision-makingaboutdispositionor advancedinterventions.Similartoanotherreport,ourstudy showedacombinationofCTPAparameters(centralclot locationandRV:LV)hadstrongerassociationswithclinical deteriorationthanRV:LValone(categoricalorcontinuous).22

IncorporationofCTPAcardiacmeasurementsinPErisk stratificationmayimpactlocal/regionalclinicalpracticeor guidelines.Nextstepsmayincludeprospectivestudiesthat includeCTPAmeasurementsaspredictorsofclinical outcomesandPERTriskstratification,andpragmatic comparisonsofAI-assistedworkflowvstraditionalworkflow inwhichCTPAcardiacmeasurements,clinicalmanagement metrics,andpatient-centeredoutcomesareassessed.

LIMITATIONS

Ourstudyhadseverallimitations.First,weconducteda retrospective,remoteAIanalysisofCTPAwithconfirmed intermediate-andhigh-riskPE.Wedidnotstudyreal-time AIanalysesonrecentlycompletedCTPAs.Ourstudydesign andinclusioncriteria,therefore,donotlendtoany interpretationaboutdiagnosticaccuracyoftheAIplatform onCTofpatientswithloweracuityPEorwithoutPE.We cannotreportonfalsepositiveorfalsenegative interpretations,potentialimpactonPERTnotificationsor clinicalmanagement,orcomparetopreviousreportsofAI’ s diagnosticaccuracyforPE.Theoretically,wehaveshown AI-derivedmeasurementswerebetterpredictorsofacute clinicaldeteriorationthancategoricalradiologistassessment ofRV:LVcut-offof1.0.However,toshowtheimpactofAI onpatientcarebyclinicians,therewouldneedtobe pragmatic,randomizedcontrolledtrialscomparingusual carevsAI-assistedclinicalcare.Prospectivestudieswould enablereportingtimelinessofAIanalysisofCTanditseffect onradiologistworkload,physiciannotificationofpositive andsignificant findings,andimpactofmeasurementsonrisk assignment,resourceutilization,advancedinterventions, andclinicaldeterioration.

Otherlimitationsarespeciﬁctotheexploratoryobjectives. Ourstudydidnotverifywhetheragreementsbetween radiologistandAIforRV:LV ≥ 1.0werecorrect;both interpretationscouldbeincorrect.Studydesigncouldbe improvedbyincludingacomparator,suchasareference standard(e.g.,cardiacmagneticresonanceimaging),useof anindependent,blindedradiologistforseparate measurementsortoserveasanadjudicator,orearlier contemporaneousTTEmeasurements.Forthesecond exploratoryobjective,wedidnotdeterminepresenceor absenceofinterventionsintheintervalbetweenCTandTTE. TheTTEandCTPAwereperformedatdifferenttimesand oftenmorethan12hoursapart.Therefore,thedifferences betweenthesemeasuredvariablesmaybeduetoworsening

orimprovingcardiacburdenduringthetimeintervals.Not allpatientsinthecohorthadTTE.HighmissingnessofTTE measurementswasalimitationincomparisonofthemwith theAI-derivedCTPAmeasurements.Thedifferences observedinthesemeanmeasurementsmaybedueto differentimagingmodalityortimeintervalbetweenstudies. ThesubgroupthathadTTElikelyrepresentedthosewith higheracuityatpresentation.

CONCLUSION

Rightventricle:leftventriclemeasurementsof1.5ormore ontheinitialCTpulmonaryangiogramhadstrong associationswithin-hospitalclinicaldeteriorationand advancedinterventionsinalargedatabaseofintermediateandhigh-riskpatientswithpulmonaryembolism.Thisstudy pointstothepotentialofcapitalizingonimmediately availableCTPARV:LVmeasurementsforgaugingPE severityandforriskstratiﬁcation.

AddressforCorrespondence:AnthonyJ.Weekes,MD,MSc,Atrium Health’sCarolinasMedicalCenter,DepartmentofEmergency Medicine,3rdFloorMedicalEducationBuilding,1000BlytheBlvd., Charlotte,NC28203.Email: anthony.weekes@atriumhealth.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

MonitoringtheEvolvingMatchEnvironmentin EmergencyMedicine2023

AnthonySielicki,MD* BrianMilman,MD†

AndrewLittle,DO‡

MiriamKulkarni,MD§

JamesMorris,MD,MPH∥

LauraHopson,MD**

MichaelKiemeney,MD††

* JeffersonEinsteinHospital,DepartmentofEmergencyMedicine, Philadelphia,Pennsylvania

† UTSouthwesternMedicalCenter,DepartmentofEmergencyMedicine,Dallas,Texas ‡ AdventHealth,DepartmentofEmergencyMedicine,Orlando,Florida

§ St.John’sRiversideHospital,DepartmentofEmergencyMedicine,Yonkers,NewYork ∥ TexasTechUniversityHealthSciencesCenter,DepartmentofEmergencyMedicine, Lubbock,Texas

**UniversityofMichigan,DepartmentofEmergencyMedicine,AnnArbor,Michigan †† LomaLindaUniversityMedicalCenter,DepartmentofEmergencyMedicine, LomaLinda,California

SectionEditor:AsitMisra,MD,MSMEd

Submissionhistory:SubmittedNovember9,2023;RevisionreceivedOctober24,2024;AcceptedOctober25,2024

ElectronicallypublishedDecember31,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem

DOI: 10.5811/westjem.18562

Introduction: The2023NationalResidencyMatchingProgram(NRMP)Matchinemergencymedicine (EM)left554spotsand132EMprogramsunﬁlled.TheCouncilofResidencyDirectorsMatchTaskForce soughttocharacterizetheprogramsthatdidanddidnot ﬁll,learnmoreabouttheirSupplementalOffer andAcceptanceProgram(SOAP)applicants,determineresidencyprograms’ needsforfutureNRMP Matches,andinquirewhatactionsprogramleaderswouldliketoseetopromoteahealthyfuturefor traininginEM.

Methods: Weconductedaweb-basedsurveyofEMresidencyprogramleadershipduringMarchand April2023.Wegenerateddescriptivestatisticsfromthesesurveyresults.Thematicanalysiswasused forfree-textresponses.

Results: Of287programs,160(55.7%)respondedtothesurvey,including59of132programs(44.7%) thatdidnot ﬁllintheMatch.Unﬁlledprogramswereoverallcontentwiththequalityofapplicantsinthe SOAP.ProgramsexpressedvaryingopinionsonwhyfewerstudentsarechoosingEM.Whilemost agreedthereareconcernsabouttheworkforce(78.1%),evenmorespreadexistsonwhatactionsshould betakentohelpsupportthefutureofresidencytraininginEM.

Conclusion: Herewepresentdataregardingthe2023MatchenvironmentforEManddescribea residencyprogram-levelneedsassessmentanddesireforaction.AnnualreviewoftheMatchdataand residencyprogramneedsshouldbecontinueduntilweseeimprovementintheMatchenvironment forEM.[WestJEmergMed.2025;26(2)233–240.]

INTRODUCTION

TheNationalResidentMatchingProgram(NRMP) Matchforemergencymedicine(EM)hasevolvedoverthe pastseveralyears.Historically,EMhasbeenacompetitive specialtywithnearly100%programmatchrates.1 The2022 EMMatchrepresentedafundamentalchangecomparedto

thehistoricaldata,withover200EMpositionsandover60 residencyprogramsunﬁlled.2 Thistrendcontinuedinthe 2023match,with554unﬁlledpositionsacross132programs, althoughthistrendimprovedasofthe2024Match.3,4 Table1 displaysseveralyearsofEMmatchdata,which highlightsthegrowthofresidencyprograms,increasing

numberofpostgraduateyear-1positions,andvariable numberofapplicantstoEMresidencyprograms.5,6

Severaltheorieshavebeenproposedtoexplainwhyfewer medicalstudentsareapplyingtoEM.The2030jobsreport leftmanyconcernedthattherewouldnotbeenoughworkfor allemergencyphysicians(EP),7 whileothershavespeculated thatissueswithboarding,drugandnursingshortages, burnout,theCOVID-19pandemic,concernsforfuturenovel infectiousdiseases,andscopeofpracticeofnon-physician medicalpractitionersmaycontribute.Theseissuesare currentlyunderinvestigationbymultiplegroups,including theCouncilofResidencyDirectorsinEM(CORD).8

CORDisanorganizationcomprisedofEMresidency educatorsandprogramleadershipprovidingresourcesand developingbestpracticesforeducationinEM.InMarch 2022,CORDsurveyeditsmemberstounderstandwhatthe organizationcoulddotosupportitsmembersfollowingthe 2022Match.9 Basedonfeedbackfromthatsurvey,the CORDBoardofDirectorsconvenedtheEMMatchTask Force.Theprimaryobjectivesofthistaskforcearetocollect dataandtointervenewithregardtotheincreasednumberof unﬁlledEMresidencypositions.10 Theinitialgoalofthetask forcewastounderstandthefactorsthatledtotheincreased numberofunﬁlledspots,thequalityofapplicantstoEM,as wellasinterviewandrank-listbehaviorsofprogramsinthe 2023Match.Additionalobjectivesincludedexamining residencyleadershipopinionsontheutilityofpreference signaling,readinessofSupplementalOfferandAcceptance Program(SOAP)candidates,anddesiredactionstoimprove theEMMatchenvironment.

Consideringtheseobjectives,theCORDEMMatchTask ForcesoughttoelicittheneedsandperceptionsfromEM residencyprogramleadersasa ﬁrststeptowarddeveloping targetedinterventionstoimprovetheEMMatch environment.Inthispaper,themembersoftheCORDEM MatchTaskForcedescriberesultsofasurveyconducted followingthe2023Match.

METHODS

TheCORDEMMatchTaskForcemembersdevelopeda surveyexpandingupontheworkofthe2022Muranoetal survey.Consensusmethodologybetweentaskforcemembers

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

The2023Matchforemergencymedicineleft 132residencyprogramsun ﬁ lledand554 un ﬁ lledspots.

Whatwastheresearchquestion?

Wesoughttodetermineresidencyprograms ’ needsforfutureMatchesandwhatactions programleadersdesiretopromoteahealthy futurefortraininginEM.

Whatwasthemajor ﬁndingofthestudy?

MostrespondentsagreedthatEMapplication numbersweredownduetoconcernsaboutthe workforce(78%),andtheleadingdesirewas tohaltopeningnewprograms(25%).

Howdoesthisimprovepopulationhealth?

These ﬁ ndingscouldimprovepopulation healthbyensuringahealthyMatchand trainingenvironmentinEM.

wasusedtodevelopandreﬁnethesurvey.Thesurveywas thendistributedtoEMresidencyprogramleadership (programdirectors[PD],assistant/associateprogram directors[APD],clerkshipdirectors[CD],program coordinators[PC],chairs,andgeneralfacultymembers) duringtheCORDAcademicAssemblyinMarch2023inLas Vegas,NV.Surveyparticipationwasvoluntaryandsolicited viaQRcodeduringconferencesessions.Thesurveywasalso distributedontheCORDProgramDirectorListservtoreach programleadershipwhodidnotattendtheconference.The surveywasweb-basedandusedQualtrics(Qualtrics InternationalInc,Provo,UT)fordatacollection.

Thesurveycollectedtherespondents’ residencyprogram, theirrolewithintheprogram,anddemographicinformation abouttheprogram(ie,lengthoftraining,locationof

Table1. EmergencymedicineNationalResidentMatchProgramdata2019–2024.

EM, emergencymedicine; PGY,postgraduateyear.

program,sponsoringinstitutions).Allprogramleaderswere askedaboutthenumberandqualityofapplicantstotheir programaswellasoutcomesintheMatch.Forprograms thatdidnot ﬁllandusedtheSOAP,weaskedquestions regardingthequalityofapplicantsintheSOAPandsought feedbackabouttheSOAPprocess.Additionally,all respondentswereaskedtoidentifywhytheythoughtfewer medicalstudentsareapplyingtoEMandwhatadditional actionstheywouldliketoseetakentoimprovetheMatch environmentinEM.ThisstudywasreviewedbytheLoma LindaUniversityInstitutionalReviewBoardandgiven exemptstatus.

WeanalyzeddatausingMicrosoftExcel365(Microsoft Corp,Redmond,WA)tocalculatedescriptivestatistics.To avoidover-weightingperspectivesfromasingleprogram,we sorteddatatoselectasingleresponseperprogram.Weused thefollowingorderofconsiderationwhenmorethanone responsewasavailableperprogram:residencyPD;PC;chair orvice/associatechair;APD;residencycorefacultymember; generalfacultymember.Free-textresponseswerecoded usingathematicanalysisbetweentwoauthors(BM,MKu) fortheSOAPqualitativedata,andbytwoauthors(BM,JM) fortheinterviewuniformity,decreasingapplicants,and futuredirectionsqualitativedata.Simultaneouscodingwas allowed.Anydisagreementsbetweencodeswereresolvedby twootherauthors(AS,MK),andifnoagreementcouldbe reachedtheresponsewasnotanalyzed.Forallquestions, onlythreeresponseswerediscardedduetonotbeingableto reachanagreement.

RESULTS

FilledandUnﬁlledProgramData

Intotal,245responsestothesurveywererecorded. Twelve(4.9%)wereexcludedduetoincompleteresponses, and74werediscardedduetoeitherduplicateresponsesor multipleresponsesbeingsubmittedfromdifferent representativesfromthesameresidencyprogram.There wereresponsesfrom160ofthe287EMresidencyprograms thatexistnationally,representinga55.7%responserate. Respondentsfromtheprogramsincluded109PDs(67.7%), 33APDs(20.5%),sevenCDs(4.3%),sixfacultymembers (3.7%), ﬁvePCs(3.1%),andonevicechair(0.7%).We compareddemographicinformationofresponding programstoallknownEMprogramsbasedontheAmerican MedicalAssociation(AMA)FellowshipandResidency ElectronicInteractiveDatabaseandtheAmericanBoardof EmergencyMedicinedata,whichispresentedin Table2.11,12 Onaverage,programleadersreportedinterviewing14.9 applicantsperposition(SD4.76)inthe2022–2023 applicationcycle.Comparedtothe2021–2022application cycle,programsreportedinterviewing18.7moreapplicants total(range: 105to +185,SD40.16).Regardingcreationof arankorderlist(ROL),programsindicatedthattheyplaced ameanof13.9applicantsontheirROLperposition(SD

4.39).Comparedtothepriorapplicationcycle,programs placedameanof15.6moreapplicantsontheirROL(SD 28.4).Therewerenostatisticallysignificantdifferences between filledandunfilledprogramsintermsofnumberof applicantsinterviewedperresidencyposition(P = 0.37)or numberofapplicantsontheROLperposition(P = 0.55), usingtwo-tailed t -tests.

Comparedtothe2021–2022recruitmentseason,46/131 respondents(35.1%)indicatedthattheymadenosignificant changesintheconsiderationoftheformationoftheirROL, and47%indicatedthattheyincludedapplicantswithless desirableStandardLettersofEvaluation(SLOE)compared toprioryears.Additionally,39.7%indicatedtheyincluded thosewithmore “red flags ” ontheirapplications,suchas standardizedtestfailures,remediationofclerkships,or professionalismissues.Asimilar39.7%indicatedthatthey rankedapplicantswithalowerclassrankcomparedtoyears prior,while18.3%respondedthattheyrankedmore individualswithlessleadershiporvolunteerism,and12.9% indicatedthattheyrankedmoreofthosewhotheyfeltdidnot alignwiththemissionorvaluesoftheprogram.Five programs(3.8%)statedthattheyconsideredmore osteopathicapplicants,andanother five(3.8%)indicated thattheyconsideredmoreinternationalmedical graduates(IMG).

WhilepreferencesignalingwasnewtoEMthisyear,ithas beenusedbyotherspecialties,suchasotolaryngology,since the2020–2021applicationcycle.13 Emergencymedicine programshadvaryingwaysinwhichtheyusedpreference signalingduringthisapplicationcycle. Table3 provides detailsofhowprogramsinterpretedsignalpreferencing.

Morethanhalfofrespondentsfeltapplicantqualitywas eitheralittleworsethisyear(9.7%)orsubstantiallyworse thisyear(42.5%).Aminority(6.7%)feltapplicantquality hadimprovedthisyear.PerceptionsofMatchresultswere similartoperceptionsofapplicantquality.Morethanhalf felttheirprogram’sMatchresultswerealittleworse(39.4%) orsubstantiallyworse(19.7%)thanthepreviousyear. Notably,11.4%felttheirMatchresultswerebetterthanthe previousyear,and30%indicatedsimilarMatchresult qualitytotheprioryear.Amajorityofprogramsindicated thattheywentlowerdowntheirranklist,with75.2% indicatingthattheyeitherwentalittledeeperorsubstantially deepercomparedtoprioryears.

UnﬁlledProgramandSOAPData

Ofthe132unfilledprograms,59(44.7%)oftheirprogram leadersrespondedtothissurvey.Onaverage,programshad 4.8positionsunfilled(range1–13,SD2.87)outofanaverage cohortsizeof10residentsperclass(range6–16,SD3.42), yieldingameanvacancyrateperunfilledprogramof47.8%. Oftherespondingprogramsthatdidnot fillinthe2023 Match,40.7%didnot fillinthe2021–2022applicationcycle. Programleadersreportedreceivinganaverageof257total

Table2. DemographicinformationcomparingallUSemergencymedicineprogramstothosethatrespondedtotheCouncilofResidency DirectorsMatchTaskForcesurveyregardingthe2023match. AllEMprograms (N=287)

Allrespondingprograms (n=160)

Filledresponding programs(n=101) Unﬁlledresponding programs(n=59)

Region

Hospitalsetting

Other(military,etc)5(1.7%)

Trainingformat

Ageofprogram

EM, emergencymedicine; PGY,postgraduateyear.

Table3. Howresidencyprogramsusedpreferencesignaling.

Morelikelytointerviewapplicants that signaled

32(23.7%)

Minorchangetointerviewselectionprocess24(17.8%)

Nochangetointerviewselectionprocess24(17.8%)

Interviewedmostbutnotallapplicants thatsignaled 13(9.6%)

Interviewedallapplicantsthatsignaled 12(8.9%)

Signalwasusedasatiebreakerbetween similarapplicants 12(8.9%)

Signalwasconsideredwheninvitingapplicants fromthewaitlist 7(5.2%)

Signalwasusedforout-of-regionapplicants6(4.4%)

Didnotoptin 5(3.7%)

SOAPapplications(SD130),or53.6applicationsper unfilledspot.Programsreportedinterviewinganaverageof 16.2applicantsperunfilledpositionintheirprogram(range 5.8–40,SD9.68);83.3%ofprogramsreportedtheywereable to fillallunfilledpositionsintheSOAP. Table4 outlines programperspectivesontheunderlyingreasonswhytheyfelt theirprogramdidnot fillintheMatch.

Table4. Topfactorsthatprogramsbelievedcontributedtonot ﬁlling inthe2023match.

Workforceconcerns 39(76.5%)

Geographic locationofprogram

Virtualinterviewsformat

Sponsoringinstitution(universityvsCMG)7(13.7%)

Programspeciﬁcfactors(wellness,curriculum changes,etc) 6(11.8%)

Socialmediaissues 4(7.8%)

Newleadership 3(5.9%)

Accreditationstatus 2(3.9%)

EM, emergencymedicine; CMG,contractmanagementgroup.

RegardingapplicantsintheSOAPandtheirpreparedness topracticeEM,35leadersofunﬁlledprogramsgave informationabouttheirapplicants.Eighteen(51.4%)stated thatmostapplicantshadcompletedatleastoneEMrotation butnotedthatitwasafterthetimethatERASapplications

weredue,leadingtolateconsiderationofEMastheirdesired medicalspecialty.Fiverespondents(14.3%)reportedmost applicantshadcompletedoneEMrotationbutmentionedno detailsaboutthetimingofthatrotation.Onlytwo respondents(5.7%)reportedthatthetypicalapplicanthadno orminimalexposuretoEM.Interestingly,20%ofprogram leadersmentionedthatmanyapplicantshadexposuretoEM priortostartingmedicalschool,suchasworkingasascribe orparamedic.Programleadersalsoreportedthatroughly 15%ofapplicantshadatleastoneEMSLOEavailablefor themtoreview.

Programleadersreportedtheywererelativelycontent withapplicantsavailabletothemintheSOAP,with78% respondingthattheywereeitherextremelyorsomewhat satisﬁedwiththequalityofapplicants.Inaddition,80% reportedthatSOAPapplicantswereeithersigniﬁcantlyor slightlybettercomparedtothebottomquartileoftheir originalROL.

Programleaderswerealsoaskedwhatworkedwell regardingtheSOAPprocessitself.Free-textresponses underwentthematicanalysisasdescribedabovewith37 recordedresponsesevaluated.Eleven(29.7%)statedthatit wasanopportunityforcollaborationwithintheirprogram leadershipandfacultygroup.Ten(27%)mentionedthatthey thoughttheirpre-planningstrategyandorganizationduring theSOAPworkedwell.Fourrespondents(10.8%)explicitly mentionedthattheNRMPandElectronicResidency ApplicationServicetechnologyworkedwell.Additionally, 8.1%mentionedthestrongqualityofSOAPapplicants availabletothem,5.4%ofrespondentsnotedadequate supportfromCORD,andanother5.4%notedtherewas enoughtimetonavigatetheSOAPandinterviewapplicants.

Conversely,programleaderswerealsoaskedaboutthe challengestheyfacedduringtheSOAP,with49responses includedinthefollowinganalysis.Twelve(34.7%)thought thereweretoomanyapplicantsandnotenoughtimeto reviewtheirapplicationsandinterviewthem.Ten(20.4%) dislikedtheformatofSOAPoffers,notingtheirdesirefor eitheradditionalroundsorthatprogramsshouldbeableto offerspotstomorecandidates.Six(12.2%)noteddifficulties withdisingenuityfromapplicantsorviolatingNRMPSOAP rules.Threeprograms(6.1%)notedalackofqualified applicants,whiletwo(4.1%)notedconcernoverthe applicant’sinterestinacareerinEM.Finally,three programs(6.1%)respondedthattherewereissueswiththe overallnumberofunfilledprogramsandcompetition betweenprogramsforSOAPcandidates.

QualitativeDataAbouttheFutureofEMandNextSteps

Thesurveyaskedopen-endedquestionsabout standardizationoftheinterviewprocess:41.2%of respondentsindicatedtheywouldliketohaveamandated returntoin-personinterviews,while11.8%preferreda requirementforvirtualinterviews.Overall,13.7%wanted

Table5. Reasonswhyprogramleadersbelievefewerstudentsare applyingtoemergencymedicine.

Workforceconcerns

107(78.1%)

Burnout 46(33.6%)

Workenvironment

COVID-19/pandemic

Boarding 36(26.8%)

CorporatizationofEM 21(15.3%)

NegativeEPmodeling 20(14.6%)

Negativepress 18(13.1%)

Advising 14(10.2%)

LackofearlyexposuretoEM 10(7.3%)

Increasedrolesofnon-physicianpractitioners6(4.4%)

Salary 5(3.6%)

EM, emergencymedicine; EP,emergencyphysician.

interviewuniformityamongprograms,and3.9%voiceda desirefor ﬂexibilitytoallowprogramstodowhatworkedfor them.Additionally,9.8%statedtheywouldliketohave uniformcancellationstandardsforapplicants.Whenasked directly,74.3%respondedreportedtheywouldliketoseean interviewcapenforcement.Ofthe94respondentswho supportedaninterviewcapforapplicants,themean suggestedcapwas17.3interviewsperapplicant (range6–50,SD6.7).

Programleaderswerealsoaskedwhytheythoughtfewer medicalstudentswereapplyingtoEM.Themostcommon responsewasthatapplicantswereconcernedaboutthefuture oftheworkforce,which78.1%ofrespondentslistedasatop concern.Furtherresultsforthisquestionarelistedin Table5 Finally,programleaderswerealsoaskedwhatactionsthey wouldliketoseetakentohelpsupportthefutureoftraining inEM.Resultsareshownin Table6.

DISCUSSION

Thisstudybuildsupontheworkthatwasstartedby Muranoetalfollowingthe2022Match.Here,wedescribe factorsthateducationalleadersbelievecontributedtothe decreasingnumberofapplicationstoEMandtothe increasingnumberofbothunfilledprogramsandopen residencypositions.Resultsofthisstudyareconsistentwith previousstudiesidentifyinggeography,specificallylocation intheNortheasternandCentralUnitedStates,asa characteristicofunfilledprograms.14 Infact,58.8%of unfilledprogramleadersinthisstudybelievedgeographic locationwasamajorcontributingfactortotheirprogramnot fillinginthe2023Match.Anotherimportantfactoridentified byunfilledprogramleaderswastheincreasingnumberof EMspots.Therewerenostatisticallysignificantdifferences inthenumberofapplicantsinterviewedperposition,or

Table6. Actionsresidencyprogramleaderswouldliketoseetohelp supportthefutureofemergencymedicine.

HaltopeningofadditionalEMprograms 32(25%)

Increase RRCstandardsforEM 28(21.2%)

Decreasenumberofprograms 24(18.8%)

DecreasenumberoftotalEMspots 24(18.8%)

Positivemessagingcampaign 22(17.2%)

Counterworkforcestudy 16(12.5%)

CloseCMG-sponsoredprograms 8(6.25%)

Mandate4-yearprograms 5(3.9%)

Improveworkenvironment 4(3.1%)

Applicantresourcesfor ﬁndingprogrambest ﬁt2(1.5%)

IncreaseearlyexposuretoEM 2(1.5%)

Producea “ratingsystem” ofEMprograms1(0.8%)

ExpandscopeofEM 1(0.8%)

Combatnon-physicianpractitioner scopeexpansion 1(0.8%)

Increaseresourcesforinternational medicalgraduates 1(0.8%)

EM, emergencymedicine; RRC,ResidencyReviewCommittee; CMG,contractmanagementgroup.

numberofapplicantsplacedontheROL,by ﬁlledcompared tounﬁlledprograms.Therefore,widespreadinterviewing andrankingofmoreapplicantsbyEMprogramswould likelynotbehelpfulinimprovingtheoverallMatchresults becauseofthedecliningapplicantpoolandexcessof trainingspots.

VirtualinterviewformathasbeensupportedbyCORD sincethebeginningoftheCOVID-19pandemic.15 Whilethis mayhelptodecreasecostsassociatedwithresidency interviewsforapplicants,lessenthecarbonfootprint associatedwithtravelforinterviews,andincreasethe amountoftimeavailabletofocusonclinicalexposurein medicalschool,itmayalsoleadtostudentsapplyingtoand interviewingwithmoreprograms.16 Inthe2023Match, studentsapplyingtoEMappliedtoamedianof69programs andinterviewedatamedianof18.5programsaccordingto NRMPChartingOutcomes.17 Comparatively,in2019the averageUSgraduateapplicantappliedto57programs.18 Thisincreasednumberofapplicationsmakesitverydifficult forprogramleaderstoknowwhichapplicantsaretruly interestedintheirprogramvsthosewhoappliedand interviewedduetotheeaseofinterviewingvirtually.This sentimentissupportedbytheresultsofthissurvey,with 45.1%ofunfilledprogramleadersstatingthatvirtual interviewswereakeycontributortowhytheywereunfilled, and41.2%ofrespondentsvoicingadesiretoreturntoinpersononlyinterviews,comparedtoonly11%whowantto continueavirtual-onlyinterviewformat.

Furthermore,amajorityofprogramleaderswereinfavor ofcappinginterviews(73.4%),withameansuggestedcapof 17interviews.However,itisnotcurrentlyknownwhetheran interviewcapispermissibleorenforceablethroughthe NRMP.Neitherisitknownwhetheraninterviewcapwould disproportionatelyharmcertainprograms,suchasmore rural,smaller,ortraditionallylesscompetitiveprograms. Interviewcaps,however,havebeenusedinotherspecialties. InresponsetovirtualinterviewsandtheCOVID-19 pandemic,ophthalmologyhasemployedinterviewcapsfor theirmatchsincethe2020–2021applicationcycleand,in fact,justloweredthecapofinterviewsfrom18to15.19 Obstetricsandgynecologyisalsoconsideringimplementing aninterviewcapand,inasimulatedenvironment,foundthat itincreasedtheoddsthatless-competitiveapplicantswould beofferedinterviews.20

Preferencesignalingwasimplementedforthe ﬁrsttimein 2023forEM,whichwasreportedasalargelydesiredchange intheMuranoetalstudy.Programsusedthesesignalsina varietyofways;however,thepluralityofprogramsstated thatreceivingasignalmadethemmorelikelytoofferan interview.Additionally,17.8%relayedthatitmadeno differenceonthedecisiontointerview,andonly3.7%of respondingprogramleadersdidnotoptintoreceive preferencesignals.Changestopreferencesignalingforthe 2023–2024match,includingtheincreasefrom ﬁvetoseven signalsandtheintroductionofgeographicpreference signalingmayaffecthowapplicantsandprogramsuse signaling.Futureresearchwillbeneededonpreference signalingasitevolvestoincludegeographicregionsignals insteadofsignalstargetedatindividualprogramsalone.

Othergroups,suchastheEmergencyMedicineResident Association,havespeculatedastowhyfewermedical studentsarechoosingEMastheirintendedspecialty,with workforceprojections,concernforincreasingscopegivento non-physicianpractitioners,andburnouttoppingthelist.21 Theresultsofthisstudy,whichcouldbeconsideredas consensusexpertopinion,areinagreementwithseveralof thosespeculations,withover75%ofprogramleadership believingconcernforanoversupplyofEPsistheleading causeofdecliningapplicationnumbers.Othertop contributorsfromthissurveyincludeburnout,which accordingtothemostrecentAMAsurvey,placesEMasthe specialtywiththehighestrateofburnout,with62%ofEPs reportingburnout.22 Thisdegreeofburnoutandconcern overtheworkforcelikelycontributestowhyother respondentsbelievednegativeEPmodeling(14.6%)and advisingfromEPsandmedicalschooldeans(10.2%) contributestofewerstudentschoosingEM.Itisalso importanttonotethatadifﬁcultworkenvironment(lackof neededresources,nursinganddrugshortages,difﬁcult interactionswithadmittingteamsandconsultants),inpatientboardingintheED,andthelong-lastingstressthat COVID-19andconcernforfuturenovelinfectiousdiseases

arealsotopreasonswhyeducationleadersbelievefewer studentsarechoosingEM.

Frequently,thesituationofEMtodayiscomparedtothe expansionofresidencypositionsinanesthesiologyinthe 1980sand1990s.Duringthattime,residencyspotsnearly quadrupled,untilconcernaboutoversupplyof anesthesiologistscauseddecreasedapplicationstothe specialtyandeventualcontractionofthenumberof spots.23,24 Similarly,decreasingthenumberofEMtrainee spotswasakeythemeforrespondentswhenquestioned aboutwhatactionstheybelievedshouldbetakentoaddress theincreasingnumberofunﬁlledEMpositions:25% suggestednotallowinganynewprogramstoopen;and 37.6%wantedtodecreaseeitherthenumberofoverall programsorthenumberofresidencypositions.Many (21.2%)expressedthebeliefthatincreasingtheAccreditation CouncilforGraduateMedicalEducationResidencyReview CommitteestandardsforEMisawaytoaccomplishthis.

InadditiontohaltinggrowthofEMresidencyprograms anddecreasingtheoverallnumberofEMtrainees, respondentsalsovoicedadesiretobeginapositivemessaging campaignaboutEManditsfuture,whichCORDhas alreadybegunonsocialmedia.25 Anothersuggestedaction wastocountertheAmericanCollegeofEmergency Physicians2030workforcestudy(12.5%),whichseveral othershavealreadydone,mainlycitingalowattritionratein theoriginalstudy.26 Lastly,itisimportanttonotethatthe 2024MatchresultsforEMyieldedfeweropenspotsand fewerunﬁlledprogramscomparedto2023.TheCORDEM MatchTaskForcehasongoingworktodeterminehow programschangedtheirrecruitmentstrategiesandhowthis couldhaveaffectedtheMatchresults,orwhetherthistruly representsanimprovementintheMatchenvironment forEM.

LIMITATIONS

Thiswasavoluntarysurveysubjecttoselectionbias,as thosewithstrongneedsandopinionsweremorelikelyto completethesurvey.Inaddition,becausethissurveywas distributedbothattheCORDAcademicAssemblyand throughtheCORDPDListserv,samplingwaslimitedto thoseprogramsinvolvedwithinthisorganization.However, a55.7%responseratefromallEMprogramssuggeststhat thisdatasetrepresentsabroadarrayofprogramsandideas. DatacollectionbeganinMarch2023intheweeks immediatelyfollowingtheNRMPMatchandSOAP.While thishelpedtoincreasetheresponserateandaddedtodata validity,itmayhavemademanyofthefree-textresponses regardingactionsthatshouldbetakenmore emotionallycharged.

Finally,thispaperpresentstheopinionsandvoicesof educationalleadersinEMandmaynotrepresentthereality oftheapplicantpooltoEMresidencyorthefutureof

traininginEM.Resultsreportedhereshouldnotbetakenas advicefromCORDorfromtheEMMatchTaskForce.

CONCLUSION

Herewepresentdataregardingthe2023Match environmentforEManddescribearesidencyprogram-level needsassessmentanddesireforaction.Mostprogram leadersbelievedthatthedecreasingnumberofEM applicantswasduetoconcernovertheEMworkforce, burnoutinEM,anddifﬁcultieswiththeworkenvironment. Amajoritywereinfavorofinterviewcaps.Programleaders alsovoicedadesireforoverallfewertrainingspotsinEM, amongseveralotherideas.AnnualreviewoftheMatchdata andresidencyprogramneedsshouldbecontinueduntil improvementoccursintheMatchenvironmentforEM.

AddressforCorrespondence:AnthonySielicki,MD,Jefferson EinsteinHospital,5501OldYorkRd.,KormanResearchBuilding Suite#B-9,Philadelphia,PA19141.Email: anthony.sielicki@ jefferson.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.NationalResidentMatchingProgram.NationalResidentMatching Program,resultsanddata:2021mainresidencymatch.2021.Available at: https://www.nrmp.org/wp-content/uploads/2021/08/MRMResults_and-Data_2021.pdf.AccessedMarch26,2023.

2.NationalResidentMatchingProgram.NationalResidentMatching Program,resultanddata:2022NRMPmainresidencymatch.2022. Availableat: https://www.nrmp.org/wp-content/uploads/2022/05/2022Main-Match-Results-and-Data_Final.pdf. AccessedMarch26,2023.

3.NationalResidentMatchingProgram.NationalResidentMatching Program,advancedatatables:2023mainresidencymatch.2023. Availableat: https://www.nrmp.org/wp-content/uploads/2023/03/2023Advance-Data-Tables-FINAL.pdf.AccessedMarch26,2023.

4.NationalResidentMatchingProgram.NationalResidentMatching Program,advancedatatables:2024mainresidencymatch.2024. https://www.nrmp.org/wp-content/uploads/2024/03/Advance-DataTables-2024.pdf4. AccessedJune10,2024.

5.NationalResidentMatchingProgram.NationalResidentMatching Program,advancedatatables:2019mainresidencymatch.2019. Availableat: https://www.nrmp.org/wp-content/uploads/2021/07/

NRMP-Results-and-Data-2019_04112019_ﬁnal.pdf AccessedJune10,2024.

6.NationalResidentMatchingProgram.Advancedatatables:2020 match.2020.Availableat: https://www.nrmp.org/wp-content/uploads/ 2021/12/MM_Results_and-Data_2020-1.pdf.AccessedJune10,2024.

7.MarcoCA,CourtneyDM,LingLJ,etal.Theemergencymedicine physicianworkforce:projectionsfor2030. AnnEmergMed. 2021;78(6):726–37.

8.AmericanCollegeofEmergencyPhysicians.Jointstatementonthe emergencymedicine2023matchresults.2023.Availableat: https:// www.acep.org/news/acep-newsroom-articles/joint-statement-match2023.AccessedMarch26,2023.

9.MurranoT,WeizbergM,BoydB,etal.Decipheringachangingmatch environmentinemergencymedicineandidentifyingresidencyprogram needs. WestJEmergMed. 2023;24(1):1–7.

10.CouncilofResidencyDirectorsinEmergencyMedicine.EMMatchTask Force.Availableat: https://www.cordem.org/involved/task-forces/emmatch-task-force.AccessedMarch26,2023.

11.AmericanMedicalAssociation.Fellowshipandresidencyelectronic interactivedatabase(FREIDA™).Availableat: https://freida.ama-assn. org/search/list?spec=42701.AccessedMarch26,2023.

12.EmergencyMedicineResidentsAssociation.EMRAmatch.Available at: https://webapps.emra.org/utils/spa/match#/search/map AccessedMarch26,2023.

13.SocietyofUniversityOtolaryngologists.Otolaryngologypreference signaling:updates.2022.Availableat: https://opdo-hns.org/mpage/ signaling-updates.AccessedMarch26,2023.

14.PreiksaitisC,KrzyzaniakS,BowersK,etal.Characteristicsof emergencymedicineresidencyprogramswithunﬁlledpositionsinthe 2023match. AnnEmergMed. 2023;82(5):598–607.

15.CouncilofResidencyDirectorsinEmergencyMedicine.2023CORD statementonresidencyinterviews.Availableat: https://www.cordem. org/siteassets/ﬁles/board/adv.–position-statements/2023-cordstatement-on-residency-interviews.pdf.AccessedMarch26,2023.

16.MurphyB.4reasonsvirtualresidencyinterviewsmightbeheretostay. 2023.Availableat: https://www.ama-assn.org/medical-students/

preparing-residency/4-reasons-virtual-residency-interviews-might-behere-stay.AccessedMarch26,2023.

17.NationalResidentMatchingProgram.Chartingoutcomes:applicant surveyresultsmainresidencyMatch2023.Availableat: https://www. nrmp.org/wp-content/uploads/2023/09/NRMP-2023-Applicant-Survey. pdf.AccessedOctober16,2023.

18.RamsayN.EMMatch2020bythenumbers.Availableat: https://www. emra.org/students/newsletter-articles/em-match-2020-by-thenumbers.AccessedMarch26,2023.

19.AmericanAcademyofOphthalmology.2022adviceforthe ophthalmologyresidencymatch.2022.Availableat: https://aupo.org/ sites/default/ﬁles/2022-06/2022%20Advice%20for%20the% 20Ophthalmology%20Residency%20Match%20Season%20Slides. pdf.AccessedOctober1,2023.

20.MorganHK,WinkelAF,StandifordT,etal.Thecaseforcapping residencyinterviews. JSurgEduc. 2021;78(3):755–62.

21.MurphyJA.EMresidencyapplicationsaredown.Whatdoesthismean forourfuture?EMResident.2023.Availableat: https://www.emra.org/ emresident/article/presidents-message-january-february-march-2023 AccessedOctober1,2023.

22.BergS.These6physicianspecialtieshavethemostburnout.2023. Availableat: https://www.ama-assn.org/practice-management/ physician-health/these-6-physician-specialties-have-most-burnout AccessedOctober1,2023.

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ORIGINAL RESEARCH

PersonalityTraitsandBurnoutinEmergencyMedicineResidents

BrendanFreeman,DO*

LukaszCygan,DO†

LauraMelville,MD,MS†

TheodoreGaeta,DO,MPH†

SectionEditor:JeffreyDruck,MD

*StatenIslandUniversityHospital|NorthwellHealth,DepartmentofEmergency Medicine,StatenIsland,NewYork † NewYork-PresbyterianBrooklynMethodistHospital,DepartmentofEmergency Medicine,Brooklyn,NewYork

Submissionhistory:SubmittedJune14,2024;RevisionreceivedNovember8,2024;AcceptedDecember16,2024

ElectronicallypublishedJanuary30,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.21139

Background: Burnoutisprevalentinmedicaltraining,andsomedataindicatescertainpersonalitytypes aremoresusceptible.ThecriterionreferenceformeasurementofburnoutistheMaslachBurnout Inventory(MBI),whichscoresthreefactors:emotionalexhaustion(EE);depersonalization(DP);and personalaccomplishment(PA).Emotionalexhaustionmostcloselycorrelateswithburnout.Studies haveyettoevaluatealinkbetweenburnoutmarkersandcertainpersonalitytraitsinemergencymedicine (EM)residents.Thepersonalitytraitsofopenness,agreeableness,extraversion,conscientiousness, andneuroticismcanbemeasuredwitha50-itemInternationalPersonalityItemPool(IPIP)Big5survey. Ourgoalinthisstudywastobethe ﬁrsttoexaminetherelationshipbetweenpersonalitytraitsand burnoutamongEMresidentsandguidefutureresearchonpotentialpredictorsofburnoutandtargeted interventionsforresidentwell-being.

Methods: Thiswasanobservational,cross-sectionalstudyconductedinMarchandAprilof2023inan urban,LevelIItraumacenter,involvingallEMresidentsatathree-yearresidencyprogram.Twosurveys, theIPIPandMBI-HumanServicesSurvey,weredistributedtoallresidents,andtheirresponseswere anonymous.Wecalculatedraw/meanscoresandstandarddeviationsforeachpersonalitytrait/burnout measureandcomparedthembythePearsoncorrelationcoefﬁcient.

Results: All38residentscompletedthesurveys.Atotalof31%ofthecohortreportedhighexhaustion, 13%reportedhighDP,and42%reportedlowPA.Twoof38(5%)residentsreportedthecombinationof highEE,highDP,andlowPA.Therewasastatisticallysigniﬁcantnegativecorrelationbetween conscientiousnessandEE(n = 38;Pearson r = 0.40, P < 0.001)andapositivecorrelationbetween conscientiousnessandPA(n = 38;Pearson r = 0.36, P = 0.03).

Conclusion: Inoursample,residentswhoweremoreconscientiousreportedexperiencinglowerlevels ofemotionalexhaustionandagreatersenseofpersonalaccomplishment.Programsmaycautiously explorethepotentialofassessingresidentpersonalitytraitsaspartofbroadereffortstoidentify predictorsofburnout,butfurtherresearchwithlarger,multicenter,longitudinalsamplesisneededto corroboratetheseresults.Thesmallsamplesizeandsingle-centerdesignmaylimitgeneralizabilityof these ﬁndings,andtheuseofself-reportedmeasuresintroducestheriskofresponsebias.[WestJ EmergMed.2025;26(2)241–245.]

INTRODUCTION

Burnouthasemergedasafocalpointformanyresidency programs,givenitspervasivenessandseveritythroughoutall phasesofmedicaltraining.1–3 Duetoprolongedexposureto elevatedstresslevels,burnoutmanifeststhroughsymptoms suchasirritability,fatigue,cynicism,anddetachment.This phenomenonholdsparticularrelevancewithintherealmof emergencymedicine(EM),a ﬁeldknowntoreportelevated levelsofburnout.TheetiologyofthisproblemwithinEMis multifacetedandrelatedtofactorssuchasworking

environment(eg,physicallayoutandconditions, administrativetasks),shiftwork,violenceintheworkplace, exposuretoinfectiousdisease,patientvolume,clinical variability,stafﬁng,andthelife-and-deathdecision-making inherenttothespecialty.

ThepracticeofEMhingessignificantlyupon interpersonalinteractions,addinganadditionallayerof complexitytothephenomenonofburnoutintheemergency physician.BecauseofthenatureofEM,personalitytraits mayplayamoresignificantroleinpredictingburnoutthanin othersettings.Existinginvestigationsintothisassociation aresmall-scalestudiesconductedwithnon-emergency physiciansandhaveidentifiedcorrelationsofvarious measuresofpersonalitytraitswithburnoutmarkers.4–9 In general,highneuroticism,lowagreeableness,low conscientiousness,lowopenness,andlowextraversionare associatedwithburnout.10 Whilecertainpersonalitytraits mayconferresilienceorsusceptibilitytothechallenges inherentinEM,theprecisenatureofthisrelationship remainsunderexploredwithintheEMliterature.

Thegoldstandardforburnoutmeasurementisthe MaslachBurnoutInventory(MBI),whichmeasures emotionalexhaustion(EE),depersonalization(DP),and personalaccomplishment(PA).11 Amongthese,EEhas emergedasbeingmostcloselycorrelatedwiththepresenceof burnout.12,13 Variousadaptationsofthisinventoryhave beendevisedandvalidated,ofwhich,theHumanServices Survey(HSS)isthemostapplicabletohealthcareworkers.

Personalityassessmentwithinacademicstudiesoften reliesontheframeworkofthe “BigFive” traits,delineatedby Goldberg(1992).14 Thesetraitsencompassopenness, agreeableness,extraversion,conscientiousness,and neuroticism.Opennesscanbeunderstoodonascaleof inventive/curioustoconsistent/cautious.Conscientiousness rangesfromefficient/organizedtoextravagant/careless. Agreeablenessrangesfromfriendly/compassionateto critical/rational.Extraversionisdefinedasoutgoing/ energeticvssolitary/reserved.Lastly,neuroticismranges fromsensitive/nervoustoresilient/confident.Measurements ofthesetraitshavebeenadaptedandvalidatedfor numerousresearchstudies.15–19 Oneformofthisisthe 50-itemInternationalPersonalityItemPool(IPIP) representationoftheGoldbergmarkersfortheBig-Five factorstructure.20

Whilethesepersonalitytraitsexhibitrelativestabilityand maturationbytheageof30,theirpotentialprotectiveor predictiverolesinmitigatingburnoutamongresident physiciansremainunderexplored,particularlywithinthe contextofEM.21 Thescarcityofstudiesdirectlyinvestigating thisrelationshipinemergencyphysiciansunderscoresthe imperativefordedicatedresearchinitiativesaimedat elucidatingtheinterplaybetweenpersonalitytraitsand burnoutwithinthehigh-stressenvironmentcharacteristicof EM.Consequently,ourgoalwastobethe ﬁrsttoexaminethe

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Innon-emergencymedicinesettings,high neuroticism,lowagreeableness,low conscientiousness,lowopenness,andlow extraversionareassociatedwithburnout.

Whatwastheresearchquestion?

Inemergencymedicineresidents,howdothe “ BigFive ” personalitytraitscorrelatewith burnoutmarkers?

Whatwasthemajor ﬁndingofthestudy?

Conscientiousnessisnegativelycorrelated withemotionalexhaustion(Pearson r = 0.40,P < 0.001,whilepositively correlatedwithpersonalachievement (r=0.36,P=0.03,N=38).

Howdoesthisimprovepopulationhealth?

Identifyingburnout-predictivetraitscould helptargetinterventionsandsupportresident well-beingandbetterpatientcare.

relationshipbetweenpersonalitytraitsandburnoutamong EMresidentsandguidefutureresearchonpotential predictorsofburnoutandtargetedinterventionsfor residentwell-being.

METHODS

Thiswasanobservational,cross-sectionalstudy conductedinMarchandApril2023thatinvolvedallEM residentsinathree-yearresidencyprogramatanurban, LevelIItraumacenter.Allresidentswereofferedinclusionin thestudyviaasinglesurveyemailedtotheirworkemails.A totalof ﬁveemailsweresentduringthestudymonthsfor recruitment.Nootherrecruitmentmethodswereused. Subjectswereconsentedandcompletedtwosequentialonline surveysadministeredinasinglesession:the50-itemIPIP representationoftheGoldbergmarkersfortheBig-Five factorstructureandtheMBI-HSS.Theprincipal investigator(BF)selectedtheorderofthesurveysand administeredthepersonalityassessment ﬁrsttoavoidany potentialprimingeffectsfromtheburnoutinventory. Additionally,theIPIPismoretimeintensivethantheMBI and,thus,mayrequiremoreattention.Answersweresecured andanonymous.

Wecalculatedraw/meanscoresandstandarddeviations foreachpersonalitytrait/burnoutmeasureandcompared thembyPearsoncorrelationcoefﬁcient.Resultswere

analyzedbyBFusingMicrosoftExcel(Microsoft Corporation.Redmond,WA)andPython(PythonSoftware Foundation,Wilmington,DE).Thisstudyreceived institutionalreviewboardapproval.

RESULTS

All38residentscompletedbothsurveys.Themean,SD, correlationcoefficientsandconfidenceintervalsarereported inthe Table. Thirty-onepercentofthecohortreportedhigh exhaustion,13%reportedhighdepersonalization,and42% reportedalowsenseofpersonalaccomplishment.Twoof38 (5%)residentsreportedthecombinationofhighEE,high DP,andlowPA.Whiletherewerenostatisticallysignificant differencesinEE,DP,orPAacrosspostgraduateyear(PGY) levels,PGY-1residentshadhigheroverallmeanscoresofEE comparedtoPGY-2residentsandhighermeanDPscores comparedtobothPGY-2andPGY-3residents.AllPGY levelsconsistentlyreportedhighlevelsofPA.

Therewasastatisticallysigniﬁcantnegativecorrelation betweenconscientiousnessandEE(Figure1, n = 38; Pearson’ s r = 0.40, P < 0.001),whichpersistedacrossall PGYlevels.Additionally,anear-signiﬁcantpositive

correlationwasobservedbetweenconscientiousnessandPA (Figure2, n = 38;Pearson’ s r = 0.36, P 0.03),whichalso persistedacrossallPGYlevels.Nootherstatistically signiﬁcantcorrelationswerefoundbetweenpersonalitytraits andburnoutmeasures,regardlessofPGYlevel.Forall correlations,weconsideredBonferroniadjustment (alpha < 0.003).

DISCUSSION

Thenegativecorrelationbetweenconscientiousnessand EEsuggeststhatcertainpersonalitycharacteristicsmayserve asprotectivefactorsagainstburnoutinEMresidents.This findingisconsistentwithpreviousresearchconductedin variousoccupationalsettings.21 Conscientiousindividuals tendtobediligent,organized,andachievementoriented, traitsthatmaybufferagainsttheemotionaltollof demandingworkenvironments.InthecontextofEMwhere residentsarefrequentlyexposedtohigh-stresssituationsand longhours,theabilitytomaintainorderandefficiencyin theirworkmaycontributetolowerlevelsofEE. Furthermore,eventhoughitwasnotbelowtheBonferroni adjustedalpha,therewasanear-significantpositive

Table. Correlationcoefficientmatrixwithconfidenceintervalscomparingtheburnoutfactorsofemotionalexhaustion,depersonalization,and personalaccomplishmentwith fivekeypersonalitytraits.

Valuesinsquarebracketsindicatethe95%conﬁdence intervalforeachcorrelation.* = P < 0.05. EE,emotionalexhaustion; DP,depersonalization; PA,personalaccomplishment.

Figure1. Negativecorrelationbetweenconscientiousnessandemotionalexhaustioninemergencymedicineresidents(n = 38;Pearson’s r = 0.40, P < 0.001).

Figure2. Positivecorrelationbetweenconscientiousnessandsense ofpersonalaccomplishmentinemergencymedicineresidents (n = 38;Pearson’s r = 0.36, P = 0.03).

correlationbetweenconscientiousnessandsenseofPA, whichseemstosuggestthatcultivatingthesetraitsin residentsmayevenbeprotectiveofburnoutandcontributeto personalandprofessionalsatisfactionandcareerlongevity.

Takentogether,theseresultsofferactionableinsightsthat residencyleadershipcanleveragetosupportthewell-being andresilienceofEMresidents.Specifically,theidentification ofconscientiousnessasaprotectivefactoragainstEE suggeststhatinterventionsaimedatfosteringconscientious behaviorsamongresidentsmayhelpmitigatetheriskof burnout.Conscientiousnesshasbeenidentifiedasatraitthat canbeenhancedwithinterventionssuchasmindfulnessand life-skillstraining.22,23 Moreresearchisneededtodetermine whichinterventionsaremosteffectiveanddurable,but residencyprogramscouldconsiderincorporatingtargeted trainingsessionsorworkshopsfocusingonorganizational skills,time-managementstrategies,andstress-management techniquestocultivateconscientioustraitsamongresidents. Additionally,whileweusedanonymousdatainthisstudy, residencyleadershipmayconsiderimplementingpersonality traitassessmentsaspartofconfidentialresidentevaluations oronboardingprocesses.Occultburnoutmaypresentwith poorperformanceorevenunprofessionalbehavior.Thus, personalitytraitassessmentcouldbeusedtoinitiate conversationsaboutburnout.

Whilepersonalitytraitsmayplayaroleinshaping individuals’ susceptibilitytoburnout,organizationalfactors, workload,supportsystems,andcopingmechanismsalso exertsigniﬁcantinﬂuences.Futureresearchshouldaimto explorethesemultifacetedinteractionscomprehensively, incorporatinglongitudinalstudiestotrackthetrajectoriesof burnoutandpersonalitydevelopmentovertimeastheyrelate toEMresidents.Additionally,qualitativeresearchmethods couldprovidevaluableinsightsintothesubjective experiencesofresidentsandthecontextualfactorsthat contributetoburnoutinEMtrainingprograms.

Whilethisstudyprovidesvaluableinsightsintothe relationshipbetweenpersonalitytraitsandburnoutamong EMresidents,itrepresentsjustonefactoramongmany. Addressingburnoutinthispopulationrequiresa multifacetedapproachthatconsidersbothindividual characteristicsandsystemicfactorswithintheresidency educationenvironment.Bygainingadeeperunderstanding ofthesedynamics,wecandevelopmoreeffective interventionstosupportthewell-beingandresilience ofEMresidents.

LIMITATIONS

Thesmallsamplesizeandsingle-centerdesignlimitthe generalizabilityofthe findingstoresidentsinothersettings, suchasruralorcommunityhospitals.Selectionbiasisalsoan importantconsiderationasresidentsmayhavechosenthis specificprogrambasedonindividualpreferences,suchas geographiclocation,whichcouldintroducevariability unrelatedtoclinicalexperienceorprogramtype.Thetiming ofthestudywaschosentoalignwitharelativelylowerperiod ofstressinourresidencyprogramacrossallPGYlevels,but theresultsmaydifferbetweentheperiodsofthesame academicyear,calendaryear,orclinicalrotations. Additionally,responsebiasisafactor,asthemeasures evaluatedhereareself-reportedandparticipants’ responses maynotaccuratelyreflecttheirtruecharacteristics.More longitudinaldatawillbeneededtofullyunderstandthe natureofthecorrelationsbetweenburnoutscoresand personalitytraitsobservedinthiscross-sectionalstudy.

CONCLUSION

Inoursample,residentswhoweremoreconscientioushad lowerlevelsofemotionalexhaustionandagreatersenseof personalaccomplishment.Programsmaycautiouslyexplore thepotentialofassessingresidentpersonalitytraitsaspartof broadereffortstoidentifypredictorsofburnout,butfurther researchwithlarger,multicenter,longitudinalsamplesis neededtocorroboratetheseresults.

AddressforCorrespondence:BrendanFreeman,DO,StatenIsland UniversityHospital|NorthwellHealth,DepartmentofEmergency Medicine,475SeaviewAvenue,StatenIsland,NY,10305.Email: bfreeman@northwell.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.GopalR,GlasheenJJ,MiyoshiTJ,etal.Burnoutandinternalmedicine residentwork-hourrestrictions. ArchInternMed. 2005;165(22):2595.

2.IsHakWW,LedererS,MandiliC,etal.Burnoutduringresidency training:aliteraturereview. JGradMedEduc. 2009;1(2):236–42.

3.OgundipeOA,OlagunjuAT,LasebikanVO,etal.Burnoutamong doctorsinresidencytraininginatertiaryhospital. AsianJPsychiatry. 2014;10:27–32.

4.AlarconG,EschlemanKJ,BowlingNA.Relationshipsbetween personalityvariablesandburnout:ameta-analysis. WorkStress. 2009;23(3):244–63.

5.BabazadehM,MolavynejadS,BereihiF,etal.Relationshipbetween personalitytraitsandburnoutinoncologynurses. JFamMedPrimCare. 2019;8(9):2898.

6.McManusIC,KeelingA,StressPaiceE.Burnoutanddoctors’ attitudes toworkaredeterminedbypersonalityandlearningstyle:atwelveyear longitudinalstudyofUKmedicalgraduates. BMCMed. 2004;2(1):29.

7.MorganBanddeBruinK.Therelationshipbetweenthebig ﬁve personalitytraitsandburnoutinSouthAfricanuniversitystudents. SAfr JPsychol. 2010;40(2):182–91.

8.RippJ,BabyatskyM,FallarR,etal.Theincidenceandpredictorsofjob burnoutin ﬁrst-yearinternalmedicineresidents:a ﬁve-institutionstudy. AcadMed. 2011;86(10):1304–10.

9.LindemanB,PetrusaE,McKinleyS,etal.Associationofburnoutwith emotionalintelligenceandpersonalityinsurgicalresidents:canwe predictwhoismostatrisk? JSurgEduc. 2017;74(6):e22–30.

10.AngeliniG.BigFivemodelpersonalitytraitsandjobburnout:a systematicliteraturereview. BMCPsychol. 2023;11(1):49.

11.MaslachCandJacksonSE.Themeasurementofexperiencedburnout. JOrganBehav. 1981;2(2):99–113.

12.MaslachCandLeiterMP.Earlypredictorsofjobburnoutand engagement. JApplPsychol. 2008;93(3):498–512.

13.GarzaJA,SchneiderKM,etal.Burnoutinresidency:astatewidestudy. SouthMedJ. 2004;97(12):1171–3.

14.GoldbergLR.Thedevelopmentofmarkersforthebig-ﬁvefactor structure. PsycholAssess. 1992;4(1):26–42.

15.GoldbergL.Internationalpersonalityitempool.2019.Availableat: https://ipip.ori.org/.AccessedJanuary10,2024.

16.EhrhartKH,RoeschSC,EhrhartMG,etal.Atestofthefactorstructure equivalenceofthe50-itemIPIP ﬁve-factormodelmeasureacross genderandethnicgroups. JPersAssess. 2008;90(5):507–16.

17.McCraeRRandJohnOP.Anintroductiontothe ﬁve-factormodelandits applications. J Pers. 1992;60(2):175–215.

18.JudgeTA,HellerD,MountMK.Five-factormodelofpersonalityandjob satisfaction:ameta-analysis. JApplPsychol. 2002;87(3):530–41.

19.KimHJ,ShinKH,SwangerN.Burnoutandengagement:acomparative analysisusingtheBigFivepersonalitydimensions. IntJHospManag. 2009;28(1):96–104.

20.AdministeringIPIPmeasures,witha50-itemsamplequestionnaire. Availableat: https://ipip.ori.org/New_IPIP-50-item-scale. htm#SampleQuestionnaire.AccessedJanuary10,2024.

21.TerraccianoA,McCraeRR,CostaPT.Intra-individualchangein personalitystabilityandage. JResPers. 2010;44(1):31–7.

22.KrasnerMS,EpsteinRM,BeckmanH,etal.Associationofan educationalprograminmindfulcommunicationwithburnout,empathy, andattitudesamongprimarycarephysicians. JAMA. 2009;302(12):1284–93.

23.RobertsBW,LuoJ,BrileyDA,etal.Asystematicreviewofpersonality traitchangethroughintervention. PsycholBull. 2017;143(2):117–41.

ORIGINAL RESEARCH

ProductivityandEfﬁciencyGrowthDuringEmergencyMedicine ResidencyTraining

MatthewT.Singh,MD*†

DavidM.Austin,PhD‡

StephanieC.Mullennix,MSN†

JoshuaC.Reynolds,MD*†

J.AdamOostema,MD*†

SectionEditor:JeffreyDruck,MD

*CorewellHealth/MichiganStateUniversityCollegeofHumanMedicine, GrandRapids,Michigan

† EmergencyCareSpecialists,GrandRapids,Michigan ‡ GrandValleyStateUniversity,GrandRapids,Michigan

Submissionhistory:SubmittedMay21,2024;RevisionreceivedNovember20,2024;AcceptedNovember22,2024

ElectronicallypublishedFebruary5,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem

DOI: 10.5811/westjem.21227

Introduction: Throughouttraining,anemergencymedicine(EM)residentisrequiredtoincrease efficiencyandproductivitytoensuresafepracticeaftergraduation.Multitaskingisoneofthe22 AccreditationCouncilforGraduateMedicalEducation(ACGME)EMmilestonesandisoftenmeasured throughevaluationsandobservation.Providingquantitativedatatobothresidentsandresidency administrationonpatientsseenperhour(PPH)andefficiencycouldimprovearesidentexperienceand traininginmanyways.Ourstudywasdesignedtoanalyzevariousthroughputmetricsandproductivity trendsusingappliedmathematicsandarobustdataset.Ourgoalsweretodefinethecurveofresident PPHovertime,adjustforrelevantconfounders,andanalyzeadditionalefficiencymetricsrelatedto throughputsuchasdoor-to-decisiontime(DTDT).

Methods: Weusedaretrospective,observationaldesigninasingle,tertiary-carecenteremergency department(ED)thatseesapproximately110,000adultpatientsperyear;ourstudyspannedtheperiod July1,2019–December31,2021.Atotalof42residentsfromanACGME-accreditedthree-year residencywereincludedintheanalysis.Weexcludedpatients <18yearsofage.Datawascollected usingasecuredatavendor,andwecreatedanexponentialregressionmodeltoassessresidentPPH data.Additionalmodelswerecreatedaccountingforpatientcovariates.

Results: Weanalyzedatotalof79,232patientsover30months.Usinganexponentialequationand adjustingforpatientcovariates,medianPPHstartedat0.898andendedat1.425PPH.ThemedianPPH bypostgraduate(PGY)yearwere1.13forPGY1;1.38forPGY2;and1.38forPGY3.MedianDTDTin minuteswasasfollows:185minutesforPGY1;171forPGY2;and166forPGY3.

Conclusion: ProductivityandefﬁciencymetricssuchasPPHandDTDTdataareanessentialpartof workinginanED.Ourstudyshowsthatresidentsimprovewithnumberofpatientsseenperhourover threeyearsbuttendtoplateauintheirsecondyear.Door-to-decisiontimecontinuedtoimprove throughouttheirthreeyearsoftraining.[WestJEmergMed.2025;26(2)246–253.]

INTRODUCTION

Asaspecialtydedicatedtoacute,unscheduledcare,the practiceofemergencymedicine(EM)demandsthat cliniciansnotonlypracticeexceptionalmedicineaddressing awidevarietyofcomplaintsbutdosoquicklyandefﬁciently. Theseskillsareimportantinthesettingofincreasingpatient

volumesandillnessseverity1 aswellasthedownward pressuresonEMreimbursement.2 Initspositionstatement onemergencydepartment(ED)staffingmodels,the AmericanCollegeofEmergencyPhysiciansemphasizedthat determiningappropriateandsafestaffingmodelsrequiresan understandingofemergencyclinicianefficiency.3 Efficiency

metricsareusednotonlytoensureadequatestaffingbutalso foremergencyphysicianreimbursement.4 Despitethecentral importanceofphysicianefficiencyinclinicalpractice,EM residencyprovideslittlestructurededucationregarding efficiency,andmanyresidentbehaviorsmayaffect efficiency.5 Moreover,despitetheuseofrobusttoolstoassess EMresidentmedicalknowledge,clinicalreasoning,and interpersonalcommunication,residentefficiency assessmentsarelargelybasedonsubjectiveevaluationsfrom supervisingphysicians.6

Althoughefficiencyisanimportantaspectofpracticing EM,currentliteraturesuggeststhatthereiswidevariability inthemeasuresusedtoassessclinicianefficiency.Inarecent scopingreviewbyAnjumetal,patientvolumeand processingtimeweretwoofthemostcommonlyreported metricstoassessproductivityandefficiency,respectively.7 Providingquantitativeresidentproductivityandefficiency datamayhelpwiththeclinicalgrowthofresidentsandhelp residencyadministrationstructurestaffingandcurriculato betterprepareresidentsfortheirfuturepractice.Objective measurementsofproductivitymayallowforimplementation ofinterventionsandsupportforresidentswhoare performingbelowtheirpeersandprovidebettercustomized learningexperiencesforhigherperformingresidents.8 It couldalsohelpresidencyclinicalcompetencycommittees (CCC)toassessresidentmilestoneachievementandensure graduatingresidentsarereadyforindependentpractice.9 Finally,understandingtherangeandnormaltrajectoryof residentefficiencymetricsmaybeusefultoinformstaffing modelchangesintheEDormeasuretheimpactofefficiencyfocusedcurricula.10

Previousstudieshaveexaminedresidentefficiencywith regardtonumberofpatientsseenperhour(PPH)and relativevalueunits;however,manyofthestudieswere performedoveradecadeagobeforetheadventofaccurate electronichealthrecord(EHR)data.11,12 Thereisalackof dataregardingtheshapeofresidentproductivityand efficiencygrowthoverthecourseoftrainingandtheeffectof patientmixonefficiency.Toaddressthisknowledgegap,we usedalargeadministrativedatasettoestimateresident productivityandefficiencyoverthecourseoftrainingwith thegoalofdefiningacurveofresidentproductivityaswellas estimatingvariabilitybetweenresidentsoverthecourseof theirtraining.

METHODS

StudyDesign

InthisretrospectiveobservationalstudyweestimatedEM residentproductivityandefﬁciencyinacohortofconsecutive adultEDpatientsoverthecourseof30monthsfrom July1,2019–December31,2021.TheSpectrumHealth InstitutionalReviewBoardexemptedthisstudyasaquality improvementproject.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencymedicine(EM)residentsare expectedtogrowinbothef ﬁ ciencyand productivityduringtraining.

Whatwastheresearchquestion?

CanapredictivemodelofEMresident productivityandef ﬁ ciencygrowthbede ﬁ ned?

Whatwasthemajor ﬁndingofthestudy?

Patientsseenperhourplateaued:PGY1, 1.13;PGY2,1.38,andPGY3,1.38.Decision times(inminutes)continuedtoimprove: PGY1,185;PGY2,171;andPGY3,166.

Howdoesthisimprovepopulationhealth?

EnsuringthatEMresidentsaretrainedin bothef ﬁ cientandproductivepatientcareis essentialtoprovidesafeandeffectivecare.

StudySetting

Thisstudywasconductedinasingle,regional,tertiarycarecenterED,whichisaLevelItraumacenterand comprehensivestrokecenter.Ithasanannualvolumeof approximately110,000adultpatientsperyearandregional populationofoveronemillion.Patients <18yearsofageare nottreatedinthisED;theyaretransportedtotheadjacent children’shospitalunlesstheyrequireemergentstabilization. Weexcludedfromouranalysisanypatient <18yearsofage inthedataset.ApproximatelyhalfoftheEDfootprintis staffedbyEMresidents,whopreferentiallyseehigheracuity, morecomplexcaseswithanaverageadmissionrateof42%. Theresidencyprogramisathree-yeartrainingprogram accreditedbytheAccreditationCouncilofGraduate MedicalEducation.TheEMresidentsworkanaverageof15 eight-hourshiftspermonthatthisfacility.Onshift,residents areresponsiblefordirectpatientcarewithattending oversight.Seniorresidentsdonotdirectlysupervisemore juniorresidents.Asresidentsprogressintopostgraduateyear (PGY)2andPGY3,theyareexpectedtoseehigheracuity patientsandmorecomplexity.Non-EMresidentsworkon thistrainingsitebutaccountforlessthan20%ofthetotal residentsandwerenotincludedinthisanalysis.

DataSourceandStudyPopulation

WeusedanadministrativedatasetthatincludesallED visitsatthestudyhospital.Thisiselectronicallyextracted fromthehospitalEHRandcontainspatient-level

demographics,limitedclinicaldata,throughputmetrics, testingdetails,disposition,andtreatingclinicians.We includedalladultpatientstreatedbyatleastoneEMresident duringanEDvisit.WeexcludedpatientencountersfornonEMresidentsorpatientswhohadnoresidentcontact.

ExposuresandOutcomes

Eachpatientinthedatasetwasassignedtothe first residentwhoprovidedtheirclinicalcare.Theprimary exposureofinterestwasresidentexperienceasmeasuredby elapsedmonthoftraining(1–36).Residentexperiencewas codedatthecaselevelforeachencounterbycalculatingthe differencebetweenthecalendarmonthofthevisitandthe calendarmonththeresidentstartedresidency.Covariates includedpatientage,sex,EmergencySeverityIndex(ESI) triageacuity,attendingofrecord,and finaldisposition (admissionvsdischarge).Theprimaryproductivityoutcome wasnumberofpatientsseenperhour(PPH).Becausethe administrativedatasetdidnotcontainresidentshiftlengths, wedefinedshiftsbygroupingconsecutivecasesseenbyeach residentuntiltherewasafour-hourgapbetweenregistration times.WecalculatedPPHbydividingthisnumberofcases bytheaverageshiftlengthforresidents(eighthours).The primaryefficiencyoutcomewasdoor-to-decisiontime (DTDT),definedasthetimeinminutesbetweenEDarrival todispositiondecision(placementofanadmissionor dischargeorder)astime-stampedintheEHR.

StatisticalMethods

Weexaminedassociationsbetweenresidentmonthof trainingandthetwoprimaryoutcomesusingmixed-effects regressionmodelstoaccountfordifferencesincasemixand toquantifythevariationinPPHthatmaybeattributableto theindividualresidentsorattendings.Inthesemodels, residentexperience(inmonths),patientage,sex,ESItriage acuity,andadmissionstatusweretreatedaspatient-level ﬁxedeffectswhiletheresidentandattendingcaringforthe patientweretreatedascrossedrandomeffects.This approachwasusedbecauseresidentsworkwithvarious attendingsandviceversa.Thesemodelsallowforestimation ofassociationsbetweenpatient-levelcharacteristicsand residentproductivityaswellasquantifyingthecontribution ofresident-andattending-levelvariabilityusingthe intraclasscorrelationcoefﬁcient(ICC).Thisstatisticmaybe understoodastheproportionofvariationineachoutcome thatisexplainedbyapatientbeingcaredforbyanindividual residentorsupervisedbyanindividualattending.This analysiswasthenrepeatedforeachpostgraduateyearof trainingtoexaminewhethertheresident-levelvariability differedoverthecourseoftraining.Additionally,togain someunderstandingintovariabilityovertime,modelswere repeatedinsampleslimitedtoeachpostgraduateyear.

Next,usingexponentialregressionwedeveloped ﬁgures demonstratingthetrajectoryofresidentproductivity(PPH)

andefﬁciency(DTDT)overthecourseoftraining.Wethen developedmodelsusingresidentexperiencelevelasalone predictorvariableaswellasmodelsaccountingforpatientlevelcovariates(patientage,ESItriageacuity,andadmit status).WedevelopedexponentialmodelsusingPython’ s scriptlibrary(PythonSoftwareFoundation,Wilmington, DE)andmixed-effectsregressionmodelsusingStataversion 15(StataCorp,CollegeStation,TX).

RESULTS

Atotalof79,232patientsencountersthatinvolveda residentwereidentiﬁedover30monthsfromJuly1, 2019–December31,2021.Thesamplecontained42distinct residentswhoworkedanestimated8,378shiftsand accountedfor806resident-monthsoftraining. Characteristicsofthepatientpopulationandtheanalyzed residentsarepresentedin Table1 and Table2,respectively.

ResidentProductivityOverTime

Thebivariateassociationsbetweentheexposuresand residentproductivityaswellastheresultsofmultivariable mixed-effectsregressionmodelsarepresentedin Table3 Patient-levelfactorsassociatedwithreducedPPHincluded older age,ESIacuitylevels2and3(comparedtoacuitylevel 1),andhospitaladmission.Patientfemalesexdemonstrated nostatisticallysigniﬁcantassociationwithhigherPPHin eitherunadjustedoradjustedmodels.Residentexperience waspositivelyassociatedwithPPHsuchthateachonemonth ofincreasedexperiencewasassociatedwith0.016additional patientsseenperhour(P < 0.001).Furthermore,while presenceofasupervisingattendingexplainedverylittleofthe

Table1. Characteristicsofthepatientpopulation.

PatientcharacteristicsPatientencountersN = 79,232(%)

ESItriageacuity

Level4 2,887(3.7)

Level5 270(0.3)

EDdisposition

Admit 29,734(38.9)

Discharge

ED, emergencydepartment; ESI,EmergencySeverityIndex.

Table2. Characteristicsofresidentpopulation.

–1.6)

–1.4)

–1.6) PGY-3

–1.8)

MedianresidentDTDT(minutes) 174(113–247)

PGY-1 185(123–254)

PGY-2 171(119–245)

PGY-3

–240)

PGY, postgraduateyear; PPH,patientsperhour; DTDT,door-todecisiontime.

Resultsofthebest-ﬁtexponentialmodelofresident productivityovertimearepresentedin Figure1.Resident productivityincreasesmostrapidlyduringthe ﬁrst12 monthsofresidencywithlittlemeaningfulchangebeyondthe beginningofPGY-2year.Thisrelationshipwasconsistent evenafteraccountingforpatient-levelcovariates(age,sex, ESItriageacuity).

ResidentEfﬁciencyOverTime

Bivariateassociationsbetweentheexposurevariablesand DTDTandtheresultsofmultivariablemixed-effects regressionmodelsarepresentedin Table4.Aswithmodelsof residentproductivity,age >60yearsofagewasassociated withreducedefﬁciency(longerDTDT),aswasESItriage acuity2–4andhospitaladmission.FemalepatientshadasixminutelongerDTDTcomparedtomales(P < 0.001).When examininggroup-levelcontributionstovariabilityin DTDT,neitherattending(ICC = 0.008)norresident (ICC = 0.012)accountedforameaningfulproportionof observedvariability.

variabilityinthenumberofPPH(ICC = 0.036),residentof recordaccountedforover14%ofPPHvariability (ICC = 0.145).Resident-levelICCstatisticschangedlittle acrossmodelslimitedtoeachpostgraduateyear(ICC0.19, 0.23,and0.15forPGY1,2,and3).Whiledirectstatistical comparisonsoftheseICCswerenotpossible,PGY-2 residentsdemonstratedthenumericallygreatestbetweenresidentvariability.

Resultsforexponentialmodelsofresidentefﬁciency overtimearepresentedin Figure2.Therateofchange observedinDTDTwaslessthanandmoregradual thanthenumberofPPHoverthecourseofresidency

Table3. Mixed-effectsregressionmodelsdemonstratingassociationsbetweenpatientcharacteristicsandresidentproductivityasmeasured bypatientsseenperhour.

Residencyproductivitymeasuredbypatientsseenperhouroverthecourseoftraining.

training,withimprovementlevellingoffduringthe PGY-3year.

DISCUSSION

Throughouttraining,EMresidentsmustdevelopskillsin managingthecomplexneedsofmultiplepatientssuchthat theybecomebothproductiveandefﬁcient.Theseskillsare undoubtedlyimportantandarelogicalelementstoevaluate overthecourseofresidencytraining.Nevertheless,few existingcompetenciesaddresstheseaspectsofpractice directly,andtheirassessmentisprimarilydependentupon

subjectiveevaluationbyattendingphysicians.Inthisanalysis wesoughttoquantifyresidentproductivityandefﬁciencyin ourinstitutionoverthecourseofresidencytrainingthrough examiningthenumberofPPHandDTDT.

Weobservedthatresidentproductivityincreases dramaticallyduringthe ﬁrstyearofresidencybutlevelsoff earlyinthePGY-2year,similartoplateausdescribedin previousstudies.12–14 Patient-levelfactorssuchasolder-age patientsrequiringhospitaladmissionwereassociatedwith lowerPPH,whilepatientstriagedaslowerESIacuity (especiallylevels4and5)wereassociatedwithhigherPPH

Table4. Mixed-effectsregressionmodelsdemonstratingassociationsbetweenpatientcharacteristicsandresidentefﬁciencyasmeasured bydoor-to-decisiontime.

ESI, EmergencySeverityIndex; ICC,intra-classcorrelationcoefﬁcient.

Figure1.

Residencyproductivitymeasuredbydoor-to-decisiontimeoverthecourseoftraining.

similartoattending-basedstudiesofPPHbyJosephetal.15 Afteraccountingfortheserelationships,theindependent associationbetweenexperienceandproductivitywas actuallystronger,suggestingthatresidentsbecomemore efﬁcientoverthecourseoftrainingwhilealsoseeingamore difﬁcultcasemix.

Wealsoobservedsignificantbetween-residentvariability. Overall,individualresidentsaccountedforover14%of observedvariationinPPHafteraccountingforpatient-level factors,whileattendingphysicianscontributedverylittle (3.6%).Furthermore,thedegreeofvariabilityattributableto individualresidentsafteraccountingforcasemixwashighest forPGY-2residents,butloweramongPGY-1andPGY-3 residents.Thismaysuggestthatresidentsbeginandendtheir trainingatsimilarlevelsofproductivitybutmayreachtheir plateauatdifferentpointsduringPGY2.These findings suggestthatproductivityisinpartanattributeofindividual residentsratherthancasemixorattendingstaffingpractices. Thus,theremaybearolefordesigningeducation interventionsforresidentswhodemonstratelower productivitybytheendofPGY1.Whileproductivity appearstobeanattributeofresidentsthemselves,the improvementinICCmaysuggestthatresidencytraining doeshelptoreduceperformancevariabilitytosomedegree.

Toexamineresidentefficiency,wechosetoevaluate DTDTratherthanotherthroughputmakerssuchasED lengthofstay,sinceDTDTismorelikelytoreflectresident behaviorratherthansystemfactorssuchasstaffingandED boarding.IncontrasttoPPH,thismetricdidnotplateau earlyinresidencybutrathercontinuedtoimproveoverthe courseofaresident’straining.AswithPPH,patient-level factorsweresignificantlyassociatedwithlongerDTDT, includingolderage,ESItriageacuity2and3,andadmission status.Relativetootherpatient-levelfactors,resident experiencelevelhadamoremodestrelationshipwithDTDT suchthataresident’sexperiencealoneaccountedforan

approximate15-minutereductionoverthe36monthsof training.Furthermore,incontrasttoPPH,only1%ofthe unexplainedvariationinDTDTwasattributabletothe residentprovidingcare(ICC = 0.012),andalmostnoneofit wasattributabletothesupervisingattending(ICC = 0.008). ThismaybepartiallyexplainedbythefactthatPPHisa metricthatisinherentlytiedtoresidents,resultingingreater between-residentvariation.Nevertheless,itisalsolikelytrue thatstructurallimitations(eg,timetolabresults, timetoconsultantphonecallreturn)resultingreater homogenyincompletingEDworkupsthatmayexplainthis lowerlevelofbetween-residentvariabilitywithregard toDTDT.

Usingthisdatafromthisanalysisraisesnumerous opportunitiesforresidencyadministrationandassisting residentsinmaximizingtheirperformanceandgrowth. RecognizingthatthereisaplateauinthenumberofPPH duringtrainingcouldhelpwithstaffingmodelstoensure appropriateresidentcoverageandmanageexpectations.One potentialopportunitytoleveragedatamightbeforresidency programstomonitortheirproductivitydataseveraltimes duringanacademicyeartoensurethattheirresidentsare progressingappropriatelyalongthedescribedcurve. Residentswhoarenotshowingappropriategrowthbythe endofPGY1maybenefitfromtailoredinterventionsor individualizedlearningplans.Anotherconsideration relevanttobothproductivityandefficiencymaybeto provideresidentswiththeirownperformanceonthese metricsinrelationtotheirpeers.Inourinstitution,ourCCC reviewsresidentproductivitydatasuchasPPHandDTDT twiceperyearforeachresidencyclass.Thisinformationis deidentifiedanddistributedtoeachresidenttoreviewwith theirfacultyadvisorandprogramdirector.Thisinformation isfrequentlyusedtodevelopindividualizedlearningplansto helpwiththeirpatientefficiencyandoftenusedtoadvance theirACGMEpatientcare-relatedmilestones.

Figure2.

LIMITATIONS

Giventhatthiswasanobservationalanalysis,itis importanttoacknowledgethatthesemodelsdonotprovea causalrelationshipbetweenanyofthepotentialpredictorsof PPHorDTDTandtheirrespectiveoutcomes.WhilePPH andDTDTarerecognizedbenchmarksinmanyEDs,itis alsoimportanttorememberthatthereareotherwaysto defineproductivityandefficiency,andseveralpotential confoundersmayexistinthisdataset.16 Moreadvanced residentsmayusetheirtimeinotherwayssuchaspeer-topeerteaching,managingalargervolumeof “signed-out” patients,moreefficiencywithon-shiftdocumentation,and lesstimespentcontinuingpatientcareaftertheirshifthas ended.Thesepossibilitiesmaynottiedirectlytopatient productivitybutmayprovidevalueforboththeresidency andtheindividualizedlearner.Itiscertainlypossiblethatthe typesofpatientscaredforbyseniorresidentstendedtobe morecomplexevenafteraccountingforESItriageacuity, resultinginresidualconfounding.Furtherstudiescould evaluatesomeofthesevariablestoaccountforwhyresident efficiencytendstoplateauwithnumberofPPHintheir secondyearofresidency.

Additionally,whileourmethodofreconstructingshifts basedonpatientregistrationtimeslikelyresultsina reasonablyaccuratesummary,itremainspossiblethatsome patientswereincorrectlyassignedtoashiftresultingin under-oroverestimationofresidentproductivity.Finally, ourinstitutiondivertsloweracuitypatientstoa “fast-track” areathatisnotstaffedbyresidents.Thislikelyaccountsfor thedistributionofESItriageacuityandadmissionrates, whicharehigherthanageneralEDpopulation.Thus,the absoluteproductivitynumbersshouldbeinterpretedwith caution,anditisdifﬁculttoknowhowtheseresultsmay compareacrossinstitutions.

Anotherimportantconfounderthatmayreducethe generalizabilityofthisanalysisistheimpactoftheCovid-19 pandemic.Giventhatourdatasetincludesperiodsimpacted byCOVID-19,itispossiblethatthismayhaveinfluenced residentproductivityandefficiency.17 Therearemitigating factorsthatsuggestouranalysiswasnotadverselyaffected bythepandemic.First,sinceouranalysisisdefinedbymonth ofexperienceratherthancalendartime,theimpactof COVID-19wasspreadequallyamongtrainingmonths. Second,duetothemodulestructureofourdepartment,the teachingmoduleispreservedforhigher-acuitycomplaints andislessimpactedbylowEDvolumesorboardingpatients thanotherlocationsintheED.Weexaminedoverallresident patientsandPPHoverthecalendardurationofthestudy periodandfoundnomeaningfulrelationshipbetween COVID-19andnon-COVID-19periods(supplemental figure).Finally,residentswerenotrestrictedfrommanaging patientsundertheinvestigationofCOVID-19.

Lastly,itmustbeemphasizedthatproductivityand efﬁciency,whileimportantskillstotheemergencyclinician,

shouldnotsupplantorovershadowthemanyothercritical skillsthatrequireattentioninresidencysuchasacquisitionof medicalknowledge,effectivecommunication,andthe deliveryofcompassionate,empathetic,andequitable patientcare.

CONCLUSION

Thisanalysisconfirmsthatresidentproductivityand efficiencyimproveoverthecourseofresidencytraining. Similartothe findingsofpreviousresearch,productivityas measuredbynumberofpatientsseenperhourappearsto advancemorequicklyandreachaplateaubythePGY2year.However,efficiencyasmeasuredbydoor-to-decision timeimprovesoverthecourseoftraining.These relationshipspersistfollowingadjustmentforpotential patient-levelconfoundersand,inthecaseofPPH,are associatedwithindividualresidents.Interestingly,attending variabilityhaslittleeffectonPPH.These findingssuggest thatassessmentofthesemetricsperiodicallyduringresidency maybehelpfulintailoringeducationalinterventionstoassist residentsindevelopingtheseskills.Furtherstudyisneededto verifythese findingsanddeterminetheimpactof interventionsdesignedtomodifyresidentproductivityand efficiencyduringtraining.

AddressforCorrespondence:MatthewT.Singh,MD,Corewell Health/MichiganStateUniversity,CollegeofHumanMedicine,4100 EmbassyDrSE,Suite400,GrandRapids,MI49546.Email: matthew.singh@corewellhealth.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.MohrNM,WessmanBT,BassinB,etal.Boardingofcriticallyill patientsintheemergencydepartment. CritCareMed. 2020;48(8):1180–7.

2.WelchS.StrategiestohelpyourEDadapttovariablevolumesand patientneeds.2024.Availableat: https://www.acepnow.com/article/ strategies-to-help-your-ed-adapt-to-variable-volumes-and-patientneeds/

3.Stafﬁngmodelsandtheroleoftheemergencydepartmentmedical director.2024.Availableat: https://www.acep.org/patient-care/policystatements/stafﬁng-models-and-the-role-of-the-emergencydepartment-medical-director/

4.ACEPrespondstomajorannualMedicareproposedregulation impactingphysicianpayments.2024.Availableat: https://www.acep. org/federal-advocacy/federal-advocacy-overview/regs–eggs/regs–eggs-articles/regs–eggs september-8-2022/

5.EganHM,SwansonMB,IlkoSA,etal.High-efﬁciencypracticesof residentsinanacademicemergencydepartment:amixed-methods study. AEMEducTrain. 2020;5(3):e10517.

6.AmericanCollegeofEmergencyPhysicians.Emergencymedicine providerproductivity:aninformationpaper.2024.Availableat: https:// www.acep.org/siteassets/uploads/uploaded-ﬁles/acep/clinical-andpractice-management/resources/administration/ep_provider_ prod_ip_ﬁnal_0909.pdf

7.AnjumO,YadavK,ChhabraS,etal.Deﬁnitionsandfactorsassociated withemergencyphysicianproductivity:ascopingreview. CJEM. 2023;25(4):314–25.

8.BeesonMS,CarterWA,ChristopherTA,etal.Thedevelopmentofthe emergencymedicinemilestones. AcadEmergMed. 2013;20(7):724–9.

9.CooneyRR,MuranoT,RingH,etal.Theemergencymedicine milestones2.0:settingthestagefor2025andbeyond. AEMEducTrain. 2021;5(3):e10640.

10.ShiberJandFontaneE.Progressionofemergencymedicineresident productivity. AcadEmergMed. 2008;15(1):107.

11.FredetteJ,KimT,McHughD,etal.Adescriptiveanalysisofemergency medicineresidentproductivityoverthecourseoftraining. AEMEduc Train. 2021;5(Suppl1):S44–8.

12.BrennanDF,SilvestriS,SunJY,etal.Progressionof emergencymedicineresidentproductivity. AcadEmergMed. 2007;14(9):790–4.

13.Turner-LawrenceDandToddBR.Monthlyprogression ofemergencymedicineresidentefﬁciency:whatcanwe expectofourresidentsthroughouttraining? JEmergMed. 2019;57(1):77–81.

14.JosephJW,HenningDJ,StrouseCS,etal.Modelinghourly residentproductivityintheemergencydepartment. AnnEmergMed. 2017;70(2):185–90.e6.

15.JosephJW,DavisS,WilkerEH,etal.Modellingattendingphysician productivityintheemergencydepartment:amulticentrestudy. Emerg MedJ. 2018;35(5):317–22.

16.DentonCA,SoniHC,KannampallilTG,etal.Emergencyphysicians’ perceivedinﬂuenceofEHRuseonclinicalworkﬂowandperformance metrics. ApplClinInform. 2018;9(3):725–33.

17.BoserupB,McKenneyM,ElkbuliA.TheimpactoftheCOVID-19 pandemiconemergencydepartmentvisitsandpatientsafetyinthe UnitedStates. Am JEmergMed. 2020;38(9):1732–6.

EDUCATION SPECIAL ISSUE -ORIGINAL RESEARCH

Harder,Better,Faster,Stronger?ResidentsSeeingMorePatients PerHourSeeLowerComplexity

CorlinM.Jewell,MD* Guangyu(Anthony)Bai,MD†

DannJ.Hekman,MS*

AdamM.Nicholson,MD*

MichaelR.Lasarev,MS‡ RoxanaAlexandridis,PhD‡ BenjaminH.Schnapp,MD,MEd*

*UniversityofWisconsinSchoolofMedicineandPublicHealth,BerbeeWalsh DepartmentofEmergencyMedicine,Madison,Wisconsin † IndianaUniversitySchoolofMedicine-Northwest,Gary,Indiana ‡ UniversityofWisconsinSchoolofMedicineandPublicHealth,Departmentof BiostatisticsandMedicalInformatics,Madison,Wisconsin

SectionEditors:EdUllman,MD,ChristineStehman,MD,andDougFranzen,MD

Submissionhistory:SubmittedFebruary25,2024;RevisionreceivedNovember20,2024;AcceptedNovember22,2024

ElectronicallypublishedJanuary31,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20282

Introduction: Patientsseenperhour(PPH)isapopularmetricforemergencymedicine(EM)resident efficiency,althoughitislikelyinsufficientforencapsulatingoverallefficiency.Inthisstudyweexplored therelationshipbetweenhigherpatientcomplexity,acuityonshift,andmarkersofclinicalef ficiency.

Methods: Weperformedaretrospectiveanalysisusingelectronichealthrecorddataofthepatientsseen byEMresidentsduringtheir ﬁnalyearoftrainingwhograduatedbetween2017–2020atasingle,urban, academichospital.WecomparedthenumberofPPHseenduringthethird(ﬁnal)yeartopatientacuity (EmergencySeverityIndex),complexity(CurrentProceduralTerminologycodes[CPT]),propensityfor admissions,andgeneratedrelativevalueunits(RVU).

Results: Atotalof46residentswereincludedintheanalysis,representing178,037totalcases.The numberofPPHincreasedfrom ﬁrsttosecondyearofresidencyandfellslightlyduringthethirdyearof residency.Overall,foreach50%increaseintheoddsoftreatingapatientrequiringhigh-levelevaluation andmanagement(CPTcode99215),therewasa7.4%decreaseinmeanPPH.Each50%increasein oddsoftreatingacaserequiringhospitaladmissionwasassociatedwitha6.7%reduction(95% conﬁdenceinterval[CI]0.73–12%;P = 0.03)inmeanPPH.Each0.1-pointincreaseinPPHwas associatedwitha262(95%CI157–367;P < 0.001)unitincreaseinaverageRVUsgenerated.

Conclusion: Seeingagreaternumberofpatientsperhourwasassociatedwithalower volumeofcomplexpatientsandpatientsrequiringadmissionamongEMresidents.

[WestJEmergMed.2025;26(2)254–260.]

INTRODUCTION

The2019AmericanBoardofEmergencyMedicineModel ofClinicalPracticerecognizestask-switchingandmultiple patientcareascorephysiciantasks,1 andtheAccreditation CouncilforGraduateMedicalEducation(ACGME)lists multitaskingasEmergencyMedicinePatientCareMilestone 7.2 Emergencyphysicians(EP)mustefﬁcientlyevaluateand treatahighvolumeofpatientstoeffectivelymanagecarein theemergencydepartment(ED).Variousmetricshavebeen

usedtoevaluateefficiencyandqualityofcareprovidedinthe EDbytheEDstaffaswellasindividualEPs(patientlength ofstay,EDadmissionrate,etc).3,4 Ametriccommonlyused byprogramstomeasureefficiencyinresidentsisthenumber ofpatientsseenperhour(PPH).Thismetricisenticing becauseitisbasedondatathatiseasilyretrievableand widelyapplicableacrossclinicalsites.5,6 However,itis currentlyunclearwhetherthenumberofPPHcanadequately encapsulateefficiencyinphysiciantrainees.Itisalso

uncertainhowresidencyprogramsshouldconsiderthis metricwhenassessingtheirtrainees,especiallyifnot consideredalongsideothermetrics.

Aphysician-in-trainingwhoseesmorePPHcould potentiallybeseenasmorecapableofindependently managingthehighernumberofpatientsrequiredfor independentpractice.Thismeasurementisalready commonlyusedwhenevaluatingEMresidentsandisalso frequentlyusedtoevaluateattendingEPs.5,6 However,itis unclearwhethertherearetradeoffsforresidentsthatcome withseeingahigherpatientvolume.Itislikelythatmedical traineesareonlyabletohandlea ﬁnitenumberofcognitive tasksbeforetheirperformanceisimpairedandtheyare unabletotakeonadditionaltasks.

Onemethodtoconceptualizetherelationshipbetween howpatientcomplexityandacuityimpactsotheraspectsof patientcareisthroughcognitiveloadtheory.7 Ingeneral, whencognitiveloadistoohigh,suchasincreasedextraneous loadfrommanagingmultiplepatientsorincreasedintrinsic loadfrommanagingverycomplexpatients,overallcognitive performancemaybeimpaired.Thiscoulddecreasecognitive bandwidthfornewpatient-caretasksaswellaslimitgermane loadtoallowforlearningandillness-schemecreation.7 Conversely,simple,straightforwardpatientpresentations maynotimposesuchasignificantcognitiveload,allowing cognitiveresourcestobedeployedtoseeahighervolumeof patients.8,9 Priorstudieshaveassessedresidentefficiencyin theEDintermsnumberofPPHastrainingprogresses.10 Thesestudieshavedemonstratedthatseniorresidentscansee highernumbersofpatientsperhourcomparedto postgraduateyear(PGY)-1residents,whichplateausinthe finalyearoftraining.11

Comparedtoadvancedpracticepractitioners(APP) (physicianassistants[PA]ornursepractitioners),residents seefewerPPHbutgenerateahigheramountofrelativevalue units(RVU).Thissuggestsresidentsmayseehigheracuity patientsordocumentmorethoroughly.10 TheRVUsarean objectivemeansofmeasuringtheresourcesneededto providemedicalcareasasinglemetric.12 Anothermeansof estimatingtheresourcesneededtoprovidecareareED evaluationandmanagement(E/M)CurrentProcedural Terminology(CPT)codes.Theseallowcoderstouse complexityindocumentationasasurrogatemarkerof complexityofcareprovided.WhileRVUsandCPTcodes aremeasuresassignedfollowingapatient’sED encounter,theEmergencySeverityIndex(ESI)isameansof estimatingtheacuityofthepatientintermsof priorityandresourcesallocationbasedontheir initialpresentation.

Itiscurrentlyunknownhowpatientcomplexityandacuity mayimpactmarkersofclinicalefﬁciencyforEDresidents. Ouraiminthisstudywastobetterevaluatethisrelationship usingmultiplemetricstoallowresidencyleaderstobetter contextualizegreaterresidentefﬁciencyintheED.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Patientsseenperhour(PPH)iscommonly usedbyprogramstomeasureef ﬁ ciencyin residents.Itisunclearwhetherthisadequately encapsulatesef ﬁ ciency.

Whatwastheresearchquestion?

Cantheuseofmultipleclinicalmetricsallow programstobettercontextualizethemeaning ofresidentef ﬁ ciencyintheED?

Whatwasthemajor ﬁndingofthestudy?

Foreach50%increaseintheoddsoftreatinga high-complexcase,therewasa7.4% (0.79 – 13.6%;P = 0.03)decreasein meanPPH.

Howdoesthisimprovepopulationhealth?

ResidentswhoseemorePPHmaynottreatas manycomplexpatients,whichcouldhave implicationsfortheirreadinessfor independentpractice.

METHODS StudySetting

Thestudywasconductedatasinglethree-yearEM residencyprogramassociatedwithanurban,academicED locatedintheMidwesternUS.ThehospitalinwhichtheED issituatedisaLevelIadultandpediatrictrauma,burn, stroke,andSTEMIcenter.TheEDhas43adultbedsand seesapproximately60,000patientvisitsperyear.Duringthe studyperiod,theresidencyhad12PGY-1positions eachyear.

TheadultEDisdividedintothreeseparatetreatment areaswithtwoprimarytreatmentteams.Eachtreatment teamconsistsofasingleattendingphysiciansaswellas2–3 PAsorresidentphysicians.Shiftsareninehoursinduration. Throughoutmostofthestudyperiod,patientsweretreated bytheteamofphysiciansdesignatedtothattreatmentarea. In2019,theEDshiftedtoamodelinwhicheithertreatment teamcouldcareforanypatientineithertreatmentarea.Each treatmentteamisstaffedbyresidentsofanyPGYlevelwith atleastoneseniorresident(PGY-2orPGY-3).Allresidents wereencouragedtoassignthemselvestopatientsofany acuitylevel.Duringthestudy,PAswereemployedintheED andcouldtaketheplaceofaresidentonshift(especially duringweeklyresidentdidactics).TheAPPshadno additionalrestrictionsorprivilegescomparedtoresidentsin assigningthemselvestopatients.

Asstafﬁngisvariable,therearenospeciﬁcnumberof patientsthateachresidentisrequiredtoseepershift.All residentsstaffdirectlywiththeattending;noresidents superviseotherresidents.Duringexpectedpeaktimes(of patientarrival),atriageteamconsistingofasingleattending physicianandaPAisalsopresentandgenerallyseesthe lowestacuitypatients;allresidentsareassigned approximatelythesamenumberofshiftsbutmayfreely tradeshiftsamongthemselves.Whileattendingphysicians canassignthemselvestopatientsprimarily(ie,noresidentor APPassigned),thisisarareoccurrenceandtypicallyoccurs onlyduringtimesofexcessivepatientvolumeoracuity.

StudyDesignandPopulation

Wedesignedthisstudyasaretrospectiveobservational studyusingaggregated,residentcasedataextractedfromthe electronichealthrecord(EHR)(EpicSystems,Verona,WI). DataforPGY1–3residentswereextractedforfour consecutiveclassesofresidentswhograduatedbetween 2017–2020.Toremovesignificantoutliersweexcluded residentsiftheydidnotgraduatefromtheprogramwithin threeconsecutiveyears.Wecollecteddataonthe characteristicsofthepatientsseenaswellasmarkersof residencyefficiencyforallavailablepatientencounters duringthestudyperiod(Table1).Multiplemetricswereused toprovideamoreaccuratemeasureofpatientcomplexity ratherthanasinglemetricinisolation.Theresearchteam wascomposedofaseniorresident(TB)andadepartmental dataanalyst(DH),aswellasfacultyeducators(CJ,AN,BS). Wechosetheselectedmarkersastheyhavebeenusedas markersofresidentclinicalefficiencyinotherstudies.6,10

Patientcarewasattributedtothe ﬁrstassignedresident,as thisresidentistypicallythemostcognitivelyandpractically involvedinthepatient’scare.Patientswhoaresignedoutto anoncomingEDteamaresharedequallyamongall oncomingresidents.Weexcludedpediatricpatient

encounters(ie,patients <18yearsofage)aspediatriccases havesubstantialdifferencesintermsoftheresourcesand cognitiveloadrequiredtoprovideadequatecare.Therefore, itwasdeterminedthatthechosenefﬁciencymetricscouldnot bemeaningfullycomparedtoadultpatientencounters.13 For example,theaveragelengthofstaybetweenpediatricand adultencountersduringthestudyperiodwas219vs362 minutes.Overthecourseoftheirtraining,residentscomplete adedicatedblockofpediatricEDshiftsduringtheir ﬁrstand secondyearsandcompleteanadditional1–3pediatricED shiftsduringeachadultEDrotation.Wecalculatedthe percentageofpatientencounterscomparedtooverall patientencounters.

Giventheaggregatednatureofthedatathatdidnot containanypatientprotectedhealthinformationor identifyingresidentdata,noinformedconsentwascollected. ThedatawasextractedfromtheEHRbythedepartmental dataanalystandwasstoredonapassword-protected departmentalserveravailableonlytomembersofthestudy team.Noadditionalchartreviewwasconductedonthe includedencounters.Thisstudywasdeterminedtobequality improvementandexemptfromformalreviewbyour institutionalreviewboard.

StatisticalAnalysis

WecalculatedthePPHforeachPGY-3residentbyusing thetotalnumberofadultpatientencountersforwhichthey werethe ﬁrstresidentassigned,dividedbythetotalnumber ofhoursworkedintheadultsectionoftheED.Residents weregroupedbasedontheyearofgraduation.Atwo-sided signiﬁcancelevelof P < 0.05wasusedforallstatisticaltests. WeperformedallstatisticalanalysesandgraphicsusingR version4.1.1(RCoreTeam,RFoundationforStatistical Computing,Vienna,Austria).Weusednegativebinomial regressiontoassesstherelationshipbetweenPPHandthe oddsoftreatingapatientwhorequiredadmission,adjusted

Table1. Emergencymedicineresidentmetricsofefﬁciencyandthecharacteristicsofpatientsseen.

MetricDescription

Patientcharacteristics

Emergency SeverityIndex(ESI)

Evaluationandmanagement(E/M)Current ProceduralTerminology(CPT)codes

Hospitaladmission

Efﬁciencymetrics

Relativevalueunits(RVU)

Patientsseenperhour

ED, emergencydepartment; PGY,postgraduateyear.

FrequencyofpatientencountersmatchingeachESIscore(1–5).Thisisameans ofestimatingtimeandresourceallocationforapatientbasedontheir initialpresentation.

FrequencyofpatientencountersreceivingeachE/MCPTcode(99281–99285). Theserepresentameansofdeterminingpatientcomplexitybasedonmeeting certaindocumentationcriteria.

Numberofpatientencountersinwhichaninpatientadmissionoccurred

TotalnumberofworkRVUsgenerated

TotalnumberofpatientsseendividedbytotalnumberofhoursworkedintheED duringPGY-3

forhoursworkedandpatientcomplexity.Allanalyseswere performedattheresidentlevel.

TodeterminetherelationshipbetweenESIandPPH,we firstdichotomizedESIintohighandlowseverity.High severityincludedencountersfromthethirdyearofresidency thatwerelabeledESI1and2andlowseverityincluded encountersthatwerelabeledESI3,4,and5.TheESI1 encounterswerenotseparatelyanalyzedastheseare relativelyrarecomparedtotheoverallnumberofpatient encounters.Wethencalculatedtheoddsoftreatingapatient withahigh-severityESI.TherelationshipbetweenCPT codesandPPHwassimilarlycalculatedbydichotomizing CPTintomoreandlesscomplex.Morecomplexincludedthe highestcomplexityCPTcode(99285),andlesscomplex includedtheremainingfourcodes(99281–99284).Wedid notconsiderCPTcode99291asonlyattendingscanbillfor criticalcare,andthereissignificantvariationwithinour attendinggroupintheuseofcriticalcarebilling.Therefore, webelievedthatthiswaslesslikelytobearesident-sensitive metric.Wesimilarlycalculatedtheoddsoftreatingapatient withamorecomplexCPT.Toassesssignificantdifferences amongPGYthatcouldintroducebias,weusedthe Kruskal-WallistestandtheNemenyiprocedurefor post-hoccomparisons.14

WeusedRVUsasaproxyforshiftcomplexityand regressedthatastheresponseinamultivariableregression modelusingPPH,PGY,andtheinteractionbetweenPPH andPGYasexplanatoryvariables.

RESULTS

Atotalof46residentsmetinclusioncriteria.Oneresident wasexcludedwhohadanon-consecutivetrainingperiod, andanotherresidentlefttheprogrampriortograduationat theendoftheirPGY-1year.Overall,1.6%ofthetotalpatient encounterswereassigned99291/99292CPTcodesandwere excludedfromthatanalysis.Anadditional17.6%oftotal patientencounters,consistingofpediatriccases,werealso excluded,leavingatotalof178,037patientencounters. AveragePPHdataforthefourincludedPGYscanbeseenin Table2.TheaverageESIduringthestudyperiodwas2.8.

CurrentProceduralTerminology

Adjustedforclassyear,a50%increaseintheoddsof treatingacomplexcasewasassociatedwiththemeanPPH decreasing7.42%(95%conﬁdenceinterval[CI]0.79–13.6% reductioninmeanPPH; P = 0.03).Therelationshipbetween PPHandoddsoftreatingahigh-complexitycasecanbeseen in Figure1

HospitalAdmission

Each50%increaseinoddsoftreatingacaserequiring hospitalorintensivecareunit[ICU]/intermediatecareunit admissionwasassociatedwitha6.7%(95%CI0.73–12%; P = 0.03)reductioninmeanPPH.Therelationshipbetween

Table2. Patientsseenperhourdataforclassyears2017–2020. ClassyearAcademicyearMeanPPH(95%CI) 2017 2014–2015 PGY-11.20(1.13–1.28)

2015–2016PGY-21.51(1.42–1.61)

2016–2017PGY-31.52(1.43–1.62) 2018 2015–2016PGY-11.11(1.05–1.16)

2016–2017PGY-21.50(1.43–1.58)

–2018PGY-31.45(1.39–1.52)

2017PGY-11.08(1.03–1.13)

–2018PGY-21.37(1.31–1.44) 2018–2019PGY-31.26(1.21–1.32)

–2018PGY-11.01(0.96–1.05) 2018–2019PGY-21.33(1.28–1.39) 2019–2020*PGY-31.09(1.04–1.14)

*MayhavebeenimpactedbytheCOVID-19pandemic. CI, conﬁdence interval; PPH,patientsseenperhour; PGY, postgraduateyear.

Figure1. Relationshipbetweenoddsoftreatingahigh-complex caseandmeanpatientsseenperhourduringpostgraduateyear-3, groupedbygraduationyear.Shadedregionsrepresent95% conﬁdenceintervals. CPT,CurrentProceduralTerminology.

PPHandoddsoftreatingacaserequiringadmissioncanbe seenin Figure2.

EmergencySeverityIndex

AftercontrollingforPGY,therewasnosigniﬁcant relationshipobservedbetweenPPHandtheoddsoftreating ahighacuitycase(P = 0.30).

RelativeValueUnits

Themodelssuggestedthateach0.1pointincreaseinPPH isassociatedwitha262unitincrease(95%CI157–367; P < 0.001)inaverageworkRVUsgenerated,withtheassociation betweenaveragetotalRVUandPPHstableacrossthefour years.See Figure3 fortherelationshipbetweenRVUs generatedandPPH.

Figure2. Relationshipbetweenoddsofacaseresultingin admissionandmeanpatientsseenperhourduringpostgraduate year3,groupedbygraduationyear.Shadedregionsrepresent95% conﬁdenceintervals.

IMC,intermediatecareunit; ICU,intensivecareunit.

Figure3. Therelationshipbetweenrelativevalueunitsgenerated andpatientsseenperhourduringpostgraduateyear3, groupedbygraduationyear.Shadedregionsrepresent95% conﬁdenceintervals.

RVU,relativevalueunits.

DISCUSSION

Residentsseeinghighernumbersofpatientssawfewer complexpatientsandfewerpatientsrequiringaninpatient admission.Webelievethisstudyisthe firsttoexaminethe associationofpatientcomplexityandacuityontheclinical efficiencywithwhichEMresidentsoperate.Assuggestedby cognitiveloadtheory,wefoundthatresidents’ capacityto pickupcomplexpatientsinthisstudywas finite.More complexpatientsandpatientsrequiringadmissionmay imposemoreofataskload(eg,phonecallstoconsultantsor admittingphysicians,reviewofrecords,orlongerhistorytaking)thanpatientswithloweracuity.Thisgreater cognitiveloadcouldresultinadecreaseinPPHas complexitygoesup.Thiseffectmaybemitigatedsomewhat byavarietyofeffectiveclinicalpractices,suchaspartnering withnursesorassistancefromtheirsupervisingattending. However,moreresearchisneededtodeterminewhether otherfactors,suchastheincorporationofevidence-based efficiencypracticesoraddingscribesfordocumentation,may affectresidentefficiency.

OurdatashowsthatPPHrisessharplybetweenPGY-1 and-2yearsandthenplateausbetweenthePGY-2and3years.This findingisinlinewithpreviousliterature.11 Whiletheunderlyingcauseofthis findingisultimately unknown,itmaybesecondarytochangesinfocusthatoccur betweenthelatteryearsintraining.Forexample,anyfurther increasesintheabilityofPGY-3residentstoseeadditional patientsoveraPGY-2residentmaybeoffsetbyafocuson departmental flow,instructionofjuniorlearners,orsimply succumbingto “senioritis.” Itisalsopossiblethatthemost seniorresidentspreferentiallyselectedthemostcriticallyill patientsintheEDandtheincreasedcomplexityofthese patientswerethereasonfortheplateau.

WefoundnosigniﬁcantrelationshipbetweenPPHand ESI.However,therewasanegativerelationshipwhen evaluatingPPHandCPTcodesaswellasthelikelihoodof caringforapatientwhowouldneedtobeadmitted.Thismay bebecauseESIisassignedatthebeginningofthepatient’ s treatmentcourse,whereasCPTdesignationandadmission decisionsaremadelaterinthepatient’scourse(orafterthe conclusionoftheencounterinthecaseofCPT).TheESIwas alsotreatedasabinaryvariableforanalysis,withESI3 treatedasalow-acuitypatient.However,manyofthese patientsmayhaveahigheracuityillness;itispossiblethat thisdichotomizationeliminatedatrueeffectthatwould otherwisehavebeenseen.Therefore,itcouldreﬂectthatESI couldnotbeusedtoaccuratelyestimatetheamountof resourcesandcognitiveeffortrequiredtocarefor thesepatients.15

Whilewedidnotanalyzetherelationshipbetweenpatient complexityandoverallgenerationofRVUs,itremainsan interestingavenueforfutureresearch.Whileitmakes intuitivesensethatthecareofasingle,morecomplexpatient wouldgeneratemoreRVUsthanasingle,lesscomplex patient,itisunknownwhetherRVUgenerationisbalanced bytheincreasedamountoftimeandcognitiveloadthese patientsoftenrequire.Thiswasnotdoneinthecurrentstudy asthiswouldalsohavedependedonhospitalcrowding, whichisaconfoundingvariablewechosenottoinclude.

Overall,ourresultssuggestthattheuseofPPHasa surrogatemeasureofpatientefficiencymaypaintan incompletepictureofresidentperformance.Whilethe currentstudydiddemonstrateastatisticallysignificant relationshipbetweenpatientcomplexityandPPH,the clinicalsignificanceisunclear.Therequirednumberof patientsseenduringtrainingrepresentsacritically unexploredareaofresidencytraining.Experientiallearning theorywouldsuggestthatseeingagreaternumberofpatients wouldresultinahigherlevelofcompetence,butthismaybe mediatedbycomplexityorotherfactors.Residency leadershipteamswhoplantoevaluatetheirresidentsontheir abilitytotaskswitchbetweenmultiplepatients(ACGME MilestonePC7)maywishtoexploretheuseofothermarkers thatmaycorrelatewithPPH.Thesemaybettercapturethe

complexityofthecareprovided,althoughfurtherstudyis requiredbeforethiscanbeconsideredbestpractice.

LIMITATIONS

Animportantlimitationofthisstudyisitssingle-center design.Theresultsseenmaybeduetouniquefactorsofthe studysiteand,therefore,maynotbegeneralizabletoother sites.Forexample,thestudysitechangedfromapod-based modelin2019,whichmayhaverestrictedtheefficiencyof someresidents,toa “free-for-all” modelwhereresidents couldassignthemselvestonewpatientsassoonastheywere ready.Additionally,theremayhavebeensubtlechangesto thepatientpopulationseenbytheresidentsovertheyears,or changestotheresidency,thatwerenotassessedinthecurrent study.Forexample,the finalyearofthestudydataincludeda fewmonthsthatwereaffectedbytheCOVID-19pandemic. Thiswouldonlyhaveimpactedasmallportionofthe final yearoftrainingfortheClassof2020.However,itmayhave ledtothediscrepancyseeninPPHbetweentheClassof2020 andtheotherincludedclassesasseenin Figure3.Itis interestingthatthisdidnotresultinasubstantialchangein RVUsgenerated.Nospecificdocumentationinterventions wereimplementedduringthistimeandmaysimplyrepresent generalchangesindocumentationpractices.

Wedidnotfactorinhowpatientswhoweretakeninsignoutwouldaffecttheutilizedmetrics.Itislikelythatresidents whoweresignedoutpatientsrequiringmultipleadditional actions(suchasconsultationcalls,procedures,etc)would negativelyimpacttheirabilitytotakeonnewpatients.These caseswereexcludedbecauseitwouldhavebeenunfeasibleto accountforhowmuchadditionalworkwasrequiredfor thesepatients.Forexample,somepatients,eventhosewho werecriticallyill,maybesignedoutwhenallmajor diagnosticandtherapeuticinterventionshavealreadybeen completed,andthepatientissimplyawaitingtransfertothe hospital ﬂoor.

Wedidnotconsiderpatientswhowerespecifically admittedtoourstep-downICUunits,orthosewhowent directlytotheoperatingroom.Whiletherateofadmissionto theselocationscouldcertainlyimplyalevelofcomplexity, thewaythisisdeterminedvariesgreatlybetweeninstitutions andwouldhaveaddedasignificantlayerofcomplexitytothe currentstudy.Atourinstitution,wehavetwoaffiliated hospitalsthatwecanadmitpatientsto,eachwithdifferent levelsofcapabilitiesanddifferentcriteriaforICU/stepdown unitstatus.Thisrepresentsaninterestingavenueof futurestudy.

WealsoexcludedpatientsassignedCPTcodes99291and 99292(whichdenotecriticalcare)fromouranalysisofthe relationshipbetweenPPHandCPTcodes.Thiswasdoneas criticalcarebillingcanonlybedonebytheattending physician,anddocumentationpracticesforthisarevariable withinourattendinggroup.Theoverallpercentageof patientswhoreceived99291or99292CPTcodeswasonly

6%.However,thesepatientswerenotexcludedentirelyand wouldhavebeenincludedintheanalysisofothermetrics apartfromCPT.Asstatedearlier,theuseofmultiplemetrics inthisstudywasdesignedtoovercomelimitationsin individualmetricsalone.

Itispossiblethatthepresenceoftriagephysicianduring peakhoursofpatientarrivalmayhaveimpactedthemetrics usedinthisstudy.Whilethiswasnotspeciﬁcallycontrolled for,thetriagephysicianteamprimarilyseesonlythelowest acuitypatients(eg,simplelacerationrepairs,anklesprains, needlestickinjuries)andwasfelttonothaveabigimpacton ourchosenmetrics.Wedidnotwishtoexcludeshiftsin whichthetriagephysicianwaspresentasthistimeframe representsthehighestpatientcensusinourED.Ifanimpact occurred,thiswouldbeexpectedtodecreasethemagnitude oftherelationshipbetweenPPHandthechosen variables.Despitethis,asigniﬁcanteffectwas stilldemonstrated.

Finally,thisnumericaldatadoesnotcompletely encapsulateotherfactorsthatwouldinﬂuencearesident’ s overallefﬁciency. Thesefactorscouldincludetheirclinical abilitiesandmedicalknowledge.Becauseofthis,wecaution residencyprogramsfromlookingatthevariables investigatedinthisstudyinisolationwhenassessingtheir owntrainees.

CONCLUSION

Residentscaringforhighernumbersofpatientsperhour wereassociatedwithfewercomplexpatientsandpatients whorequiredinpatientadmission.

AddressforCorrespondence:CorlinM.Jewell,MD,Universityof WisconsinSchoolofMedicineandPublicHealth,BerbeeWalsh DepartmentofEmergencyMedicine,800UniversityBayDr., Madison,WI53705.Email: cmjewell@medicine.wisc.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.BeesonMS,AnkelF,BhatR,etal.The2019Modelofthe ClinicalPracticeofEmergencyMedicine. JEmergMed. 2020;59(1):96–120.

2.AccreditationCouncilforGraduateMedicalEducation.ACGME CommonProgramRequirements(residency).2022.Availableat:

https://www.acgme.org/globalassets/pfassets/programrequirements/ cprresidency_2023.pdf.AccessedFebruary25,2024.

3.SørupCM,JacobsenP,ForbergJL.Evaluationofemergency departmentperformance – asystematicreviewonrecommended performanceandquality-in-caremeasures. ScandJTraumaResusc EmergMed. 2013;21:62.

4.WilerJL,WelchS,PinesJ,etal.Emergencydepartmentperformance measuresupdates:Proceedingsofthe2014EmergencyDepartment BenchmarkingAllianceConsensusSummit. AcadEmergMed. 2015;22(5):542–53.

5.JosephJW,DavisS,WilkerEH,etal.Modellingattendingphysician productivityintheemergencydepartment:amulticentrestudy. Emerg MedJ. 2018;35(5):317–22.

6.KirbyR,RobinsonRD,DibS,etal.Emergencymedicineresident efﬁciencyandemergencydepartmentcrowding. AEMEducTrain. 2019;3(3):209–17.

7.YoungJQ,VanMerrienboerJ,DurningS,etal.Cognitiveloadtheory: implicationsformedicaleducation:AMEEGuideNo.86. MedTeach. 2014;36(5):371–84.

8.GraberML,KissamS,PayneVL,etal.Cognitiveinterventionsto reducediagnosticerror:anarrativereview. BMJQualSaf. 2012;21(7):535–57.

9.RothschildJ,LandriganC,CroninJW,etal.Thecriticalcare safetystudy:theincidenceandnatureofadverseevents andseriousmedicalerrorsinintensivecare. CritCareMed. 2005;33(8):1694–700.

10.HamdenK,JeanmonodD,GualtieriD,etal.Comparison ofresidentandmid-levelproviderproductivityinahigh-acuity emergencydepartmentsetting. EmergMedJ. 2014;31(3):216–9.

11.DouglassA,YipK,LumanauwD,etal.Residentclinicalexperiencein theemergencydepartment:patientencountersbypostgraduateyear. AEMEducandTrain. 2019;3(3):243–50.

12.AMACPTInternational.RelativeValueUnits.Availableat: https://cpt-international.ama-assn.org/relative-value-units AccessedOctober25,2024.

13.HeatonHA,NestlerDM,JonesDD,etal.Impactofscribesonpatient throughputinadultandpediatricacademicEDs. AmJEmergMed. 2016;34(10):1982–5.

14.NemenyiP. Distribution-freeMultipleComparisons.Princeton,NJ: PrincetonUniversity,1963.

15.SaxDR,WartonEM,MarkDG,etal.Evaluationofversion4ofthe EmergencySeverityIndexinUSemergencydepartmentsfortherateof mistriage. JAMANetwOpen. 2023;6(3):e233404.

EDUCATION SPECIAL ISSUE -ORIGINAL RESEARCH

MichaelKiemeney,MD*

JamesMorris,MD,MPH†

LaurenLamparter,MD‡

MosheWeizberg,MD§

AndyLittle,DO∥

BrianMilman,MD¶

*LomaLindaUniversitySchoolofMedicine,LomaLinda,California

† TexasTechUniversityHealthSciencesCenter,Lubbock,Texas

‡ UniversityofIllinoisChicago,Chicago,Illinois

§ StatenIslandUniversity,StatenIsland,NewYork

∥ AdventHealthEastOrlando,Orlando,Florida

¶ UniversityofTexasSouthwesternMedicalCenter,Dallas,Texas

SectionEditors:MatthewTews,MD,AndrewKetterer,MD,andAndrewGolden,MD

Submissionhistory:SubmittedMay24,2024;RevisionreceivedNovember8,2024;AcceptedNovember25,2024

ElectronicallypublishedFebruary14,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.21249

Introduction: Emergencymedicine(EM)historicallyenjoyedanearly100%matchrate.Arapidchange saw46%ofEMprogramswithoneormoreunﬁlledpositionsafterthe2023Match.Muchhasbeen discussedaboutpotentialcauses,andcharacteristicsofunﬁlledprogramshavebeeninvestigated.We surveyedrecentapplicantstoEMtofurtherunderstandwhatcontinuestodrawthemtoEMandwhat concernsdeterthemfromchoosingacareerinEM.

Methods: Across-sectional,mixedmethodssurveywasdistributedinthesummerof2023toa conveniencesampleofrespondentsviathelistservsofnationalEMresidentandstudentorganizations aswellasclerkshipdirectorsinEM.Wedidnotcalculateresponserateduetolistservconvenience sampling.Atotalof213responseswerereceived,representing7.7%ofthetotalnumberofEM applicants(2,765)in2023.Applicantswereaskedtorankfrom1to5theirexperienceswithEMandthe characteristicsofthespecialtythatwereimportantintheircareerdecision.Wecalculatedmeansand 95%conﬁdenceintervalsforquantitativeresults.Weperformedqualitativeanalysisoffree-text responsestoidentifythemes.

Results: PositivefactorsforapplicantswereinteractionswithEMfaculty(4.29on1–5scale)and residents(4.42)aswellasclinicalexperiencesinthird-year(4.53)andfourth-yearclerkships(4.62). ApplicantscontinuetobedrawntoEMbythevarietyofpathologyencountered(4.66), flexiblelifestyle (4.63),andhigh-acuitypatientcare(4.43).Mostapplicants(68.5%)experiencedadvisementawayfrom EM.Ofthosewhoreceivednegativeadvisement,non-emergencyphysicianswerethemostcommon source(73.3%).FactorsnegativelyinfluencingacareerchoiceinEMwerecorporateinfluence(2.51), EDcrowding(2.52),burnout(2.59),presenceofadvancedpracticepractitioners(APP)inEM(2.63),and workforceconcerns(2.85).Jobconcernsstemmingfromthe2021EMworkforcereportwereidentifiedby respondentsastheprimaryreasonforrecentMatchresults.

Conclusion: Applicantsnotedclinicalexperiencesintheemergencydepartmentandinteractionswith EMattendingsandresidentsaspositiveexperiences.High-acuitypatientcare,varietyofpathology,and flexiblelifestylecontinuetoattractapplicants.ApplicantsidentifiedEMworkforceconcernsasthe primarycontributortorecentEMMatchresults.Corporateinfluence,EDcrowding,burnout,and presenceofAPPsintheEDwerealsosignificantissues.[WestJEmergMed.2025;26(2)261–270.]

INTRODUCTION

Emergencymedicine(EM)hashistoricallyenjoyedavery competitiveoutcomeintheNationalResidencyMatching Program(NRMP,or “theMatch”)with >95%ofprograms fillingtheirspots.1 Beginningin2022,however,adramatic declineoccurredleavingmanyprogramsunfilled.2 This declinecontinuedin2023,with46%ofEMprograms remainingunfilled.3 Although79.1%ofthoseprograms filled intheSupplementalOfferandAcceptanceProgram(SOAP),4 thisrepresentsatremendouschangefrompreviousyears.

Thecauseofthischangeislikelymultifactorial,with majorcontributingfactorsbeingtheexpansionofthe numberofresidencypositions,studentperceptionsofthe futurejobmarketwithinEM,andthevirtualinterview format.5,6 Otherproposedetiologiesofthedeclineinclude thecorporatepracticeofEM(whichoccurswhenanonphysicianorcorporationexertscontroloverthemedical decision-makingorcollectsreimbursementforthemedical servicesofphysicians),7 theexpandeduseofadvanced practicepractitioners(APP)suchasphysicianassistantsand nursepractitionersintheemergencydepartment(ED),and increasedburnoutfollowingaglobalpandemic.6 Concerns regardingthejobmarketandexpandeduseofAPPsare likelyrelatedtothe2021EMworkforcereportbyMarco etal,whichproposedarangeofpotentialoutlooksbasedon variousfactorswiththemostpublicizedresultbeinga projectedoversupplyofemergencyphysiciansby2030.8

Severalfactorsaffectedwhichprogramsweremorelikely togounfilledintheMatch.Getteletalfoundthatprograms accreditedwithintheprevious fiveyears,aswellasprograms thatwereunderfor-profitownershipweremorelikelytogo unfilled.9 Anotherstudyfoundthatpredictorsofnot filling werehavingunfilledpositionsinthepreviousMatch,a smallerprogramsize,locationintheMid-AtlanticorEast NorthCentralarea,priorAmericanOsteopathicAssociation accreditation,andcorporateownershipstructure.10 Overall, programsfelttheirmatchoutcomeswereworsethanin previousyears,buttheyperceivedthequalityofapplicantsas similartopreviousyears.5

Manyfactorsinfluenceastudent’sdecisiononwhich specialtytopursueincludingrolemodels, financialincentives, gender,degreeofpatientcontact,proceduralskills,prestige, andlifestyle.11–14 Thefactorsmostassociatedwithachoiceto specializeinEMincludelifestyle,diversityofpatient presentations, flexibilityinchoosingapracticelocation,worklifebalance,andperceivedjobsatisfaction.15–19 Factors associatedwithearlierselectionofEMincludeearlyexposure tothe field,presenceofanEMresidencyprogramata student’smedicalschool,prioremploymentintheED, previousexperienceasaprehospitalpractitioner,and completionofathird-yearEMclerkship.16

InthisstudywesurveyedEMapplicantsfrom2022and 2023toidentifyfactorsdeterringorattractingthemtothe

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Applicantandspecialtycharacteristics attractingapplicantstoEMhavebeen previouslydocumented.

Whatwastheresearchquestion?

Whatfactorsdeterredandattracted applicantstoEMduringthe2023Match?

Whatwasthemajor ﬁndingofthestudy?

The4th-yearclerkshipwasthemajor attractingfactor(mean4.62,95%CI 4.50 – 4.74),whilecorporatein ﬂ uence(mean 2.51,95%CI2.33 – 2.69)wasthestrongest deterringfactor.

Howdoesthisimprovepopulationhealth?

These ﬁ ndingsoffernewinsightsinto applicantperspectivesofEMandspecialtychoiceconsiderationsfollowingthe 2023Match.

specialtyaswellasmodiﬁableinﬂuencesimpactingtheir careerdecisions.TorestorethecompetitivenatureofEMin theMatch,itisimportanttoknowwhatmotivatesmedical studentstoselectEMasaspecialtyinthecurrent environment.Itisadditionallyimportanttofurther understandthefactorscontributingtodecreasedinterestin EM,sothatwecancontinuetoaddresstheseasaspecialty.

METHODS

TheprojectwasconceivedbytheCouncilofResidency DirectorsinEmergencyMedicine(CORD)MatchTask Force,whichincludesrepresentativesfromtheAmerican AcademyofEmergencyMedicine(AAEM),American AcademyofEmergencyMedicineResidentandStudent Association(AAEM/RSA),AmericanCollegeof EmergencyPhysicians(ACEP),AmericanCollegeof OsteopathicEmergencyPhysicians(ACOEP),ACOEP ResidentandStudentOrganization(ACOEPRSO), AssociationofAcademicChairsinEmergencyMedicine (AACEM),CORD,EmergencyMedicineResidents’ Association(EMRA),theSocietyforAcademicEmergency Medicine(SAEM),andSAEMResidentsandMedical Students(SAEMRAMS).Taskforcememberscollaborated todesignthesurveyinstrument.Theconclusionsinthispaper representtheviewsandopinionsoftheindividualauthors anddonotrepresenttheviewsoftheorganizations.The

studywasapprovedbytheLomaLindaUniversityHealth InstitutionalReviewBoard.

WeperformedaliteraturereviewusingPubMedtocollect studiesinvestigatingfactorsimpactingresidencyapplicants’ specialtychoice.Questionswereadaptedfromprior publishedstudies.16,20 Currentfactorsnotpreviously investigated,suchasCOVID-19orEMworkforce projections,wereaddedfollowinganiterativeprocessof consensusdevelopmentwithintheresearchgroup.The surveywasreviewedbytheCORDMatchTaskForce membersandedited.Thesurveywasthenpilot-testedby currentmedicalstudentsandresidents.Weanalyzedthe responses,andthesurveywasrevisedforclarityandbrevity followingthebetarespondents’ feedback.

Medicalstudentswereaskedmultiple-choicequestions regardingtheirresidencyapplicationstrategyincluding whethertheyhadappliedtomorethanonespecialtyand,if so,whichspecialtiestheyappliedto.Thesurveyparticipants wereaskedtorankspecialtycharacteristicsinfluencingtheir choiceofEMasacareerona five-pointLikertscalefrom stronglypositivetostronglynegative.Theywerealsoasked toranktheimpactofpriorexperiencesontheirspecialty choiceona five-pointLikertscalefromverypositivetovery negative.Weinvestigatedtheimpactofcareeradvisement usingmultiple-choicequestionswiththeoptiontoselectup tothreeresponses.Finally,free-textresponsequestionswere askedtoassessapplicants’ opinionsaboutthecausative factorsleadingtothe2023EMMatchresults.Comment inthisspacewasoptionalandnotmeanttoreach saturationofthemes;rather,itwasmeanttoprovide participantstheopportunitytogiveadditionaldetails abouttheirexperiences.

WeusedaconveniencesampleofEM-boundmedical studentswhoappliedinboththe2022and2023Matchand thosewhoconsideredorareconsideringapplyingtoEMin upcomingMatchcycles.Surveyrespondentsweresenta web-basedsurveyviaQualtrics(QualtricsInternational,Inc, Seattle,WA)inthesummerof2023.Remindermessages weredistributedmonthlyduringthedatacollectionperiod. Thesurveywasdistributedthroughthelistservsofcurrent medicalstudentsinterestedinEMasidentiﬁedbytheir membershipinanEMnationalorganizationincluding AAEM/RSA,ACOEPRSO,EMRA,andSAEMRAMS. SurveyswerealsodistributedthroughtheSAEMClerkship DirectorsinEmergencyMedicine(CDEM)listservtobesent totheirrecentlymatchedapplicantswhomatchedintoEM orhadconsideredbutultimatelydecidednottopursueEM. Conveniencesamplingvialistservdistributiondidnotallow forsurveydistributionquantiﬁcationorresponse-rate calculation.Comparingthenumberofsurveyresponses (213)tothenumberofapplicantstoEMinthe2023Match (2,765)showsoursurveyresponseswereequalto7.7%ofthe totalnumberofEMapplicantsin2023.Theintendedsurvey participantsincludedmedicalstudentswho1)consideredbut

ultimatelydidnotapplytoEMresidency;2)appliedtoEM astheironlyspecialtychoice;3)dualappliedtoEMandan alternatespecialtychoice;or4)enteredEMthrough theSOAP.

A ﬁnancialincentiveofa$10electronicgiftcardwasgiven tothe ﬁrst160participants.Financialsupportforthestudy wasprovidedbyAAEM,AAEM/RSA,ACEP,ACOEP, AACEM,CORD,andSAEM.

WeanalyzeddatausingMicrosoftExcel365(Microsoft Corporation,Redmond,WA)tocalculatemeansand percentages.Wecalculated95%conﬁdenceintervals(CI) usinganonlinetool.21 Aphenomenologicalapproachto qualitativeanalysiswasusedandfree-textresponseswere codedbytwoauthorswithexperienceinqualitativeanalysis (JM,BM)afterestablishingacodebookthroughaniterative processtogenerateanunderstandingofthephenomenonof theEMmatchprocessinconcertwiththequantitative questions.Anydisagreementsbetweencodeswereresolved byathirdauthor(MK).

RESULTS

Wereceivedresponsesfrom213individuals. Demographicsareshownin Table1.Mostrespondents (92.8%)hadappliedtoresidencyalready.Ofthose,87.2% appliedtoEMintheMatch.RespondentssecuredanEM residencypositioninthe2023Match(69.5%),2022Match (9.6%),2023SOAP(12.3%),2022SOAP(0.5%),andby othermeans(5.3%).Asmallproportionofrespondents (2.7%)werenotenteringEMresidency.

Incomparisontoapplicantssecuringapositioninthe 2023Match,oursamplewasfairlysimilarwithregardto genderbreakdown(57.2%male,39.9%femaleinoursample vs54.8%male,45.2%femaleintheMatch)butoversampled osteopathicseniors(42.7%inourstudyvs24.3%inthe Match).Regardingapplicationstrategy,70.1%appliedto onlyEMresidencies.Someindividualsappliedtomorethan onespecialtywithEMpreferred(12.3%).Themostcommon secondaryspecialtieswereinternalmedicineandfamily medicine.ApplyingtoEMasthesecondaryspecialty occurredin2.1%ofindividualswithprimaryspecialties beinganesthesiology,interventionalradiology,orthopedic surgery,andphysicalmedicineandrehabilitation. RespondentswhochosenottoapplytoEMatallmadeup 13.4%ofresponses.Thisgroupofindividualsmost commonlychosetoapplytoanesthesiology(39.1%), orthopedicsurgery(17.4%),generalsurgery(17.4%),family medicine(13.0%),internalmedicine,pathology,and preliminaryyear(each8.7%).(Responseoptionwas “Select allthatapply,” responsesum >100%).

ApplicantsmostcommonlychosetoapplytoEMinthe thirdyearofmedicalschool(33.5%)orbeforemedicalschool (33.0%).Theremainingresponseswereevenlysplitamong thepre-clinicalyearsofmedicalschool(6.8%),thefourth yearofmedicalschool(8.9%),aftermedicalschool(6.8%),

Table1. Demographicdataofsurveyrespondents.

Characteristics

Age(years)(n = 173) N(%)

25–29

35–39 13(7.5%)

40–44 2(1.2%) >44 2(1.2%)

Genderidentity(n = 173)

Male 99(57.2%)

Female 69(39.9%)

Non-binary/thirdgender 1(0.6%)

Prefernottosay 4(2.3%)

Race(n = 177)

AmericanIndian/AlaskaNative 1(0.6%)

Asian 20(11.3%)

Black/AfricanAmerican 10(5.6%)

Hawaiian/PaciﬁcIslander 0

Other 8(4.5%)

Prefernottosay 6(3.4%)

Ethnicity(n = 173)

Hispanic/Latino 18(10.4%)

NotHispanic/Latino

Prefernottosay 8(4.6%)

Medicalschoolbackground(n = 211)

MDinUS 85(40.3%)

DOinUS 90(42.7%)

UScitizenIMG 28(13.3%)

Non-UScitizenIMG 8(3.8%)

Medicalschooltype(n = 171)

Private

Public

Other 1(0.6%)

Medicalschoolgeographicregion(n = 171)

Central(IA,IL,IN,KS,MI,MN, MO,MT,ND,NE,OH,SD,WI) 43(25.1%)

Northeast(CT,DC,DE,MA, MD,ME,NH,NJ,PA,RI,VT)

29(17.0%)

South(AL,AR,FL,GA,KY,LA, OK,MS,NC,SC,TN,TX,VA,WV) 70(40.9%)

West(AK,AZ,CA,CO,HI,ID, NM,NV,OR,UT,WA,WY)

andduringSOAP(8.4%).ParticipantswereexposedtoEM intheirmedicalschoolviarequiredEMclerkshipsinthe fourthyear(42.1%),requiredclerkshipsinthethirdyear (24.0%),EMelectivesinthefourthyear(17.0%),andEM electivesinthethirdyear(11.1%). Table2 showsthedegree ofinfluenceeachfactorheldintheapplicants’ choiceofEM asacareer.Themostfrequentlycitedpositiveinfluenceswere EMresidentsonshift(4.42ona1–5scale),EMattendingson shift(4.29),thefourth-yearEMclerkship(4.62),andthirdyearEMclerkship/elective(4.53).PriorexperienceintheED inanon-physicianrole(4.43),inemergencymedicalservices (EMS)(4.52)orasascribe(4.55),wereidentifiedless frequentlybutasverypositivefactors.

Jobconcerns/workforcereport(65.8%),burnout(56.7%), increaseduseofadvancedpracticepractitioners(APP) (50.8%),andcorporateinfluenceinEM(42.5%)werethe most-citedreasonsforadvisingapplicantsawayfromEM. Emergencydepartmentcrowding(12.5%)andEM experienceduringtheCOVID-19pandemic(5.8%)wereless commonlycitedconcerns.Participantswereaskedabout advisementanditsinfluenceontheirspecialtychoice:68.5% reportedbeingadvisedagainstchoosingEMresidency training.Themostcommonsourcesofadvisementaway fromEMwereattendings/residentsinnon-EMspecialties (73.3%),peers(50.0%),socialmedia/messageboards (47.5%),andEMattendings(37.5%).Medicalschool representativesintheDean’sofficeaccountedforasmall proportionofadvisementawayfromEM(15.8%).Most participantsinoursurvey(81.8%)reportedthatadvising againstenteringEMdidnotchangetheirapplication strategy.Ofthosewhoinitiallypursuedadifferentspecialty 5.7%ultimatelyenteredEMintheSOAP,5.0%appliedto anotherspecialtyasabackuptoEM,and3.3%appliedto EMasabackupspecialty.Ofthoseapplicantswhodidnot changeapplicationstrategydespitenegativeadviceabout EM,themostcommonlycitedreasonswereperceived fitwith EM(73.7%), flexiblelifestyleofEM(64.6%),lackofinterest inotherspecialties(49.5%),anddoubtinaccuracyof workforcereport(49.5%).

Veryfewparticipantssaidtheywouldnotadviseafriend toapplytoEMforthe2024Match(2.3%).Most(75%) wouldadviseafriendtochooseEM.Mostofthosewho indicatedtheywouldadviseafriendagainstapplyingtoEM woulddosobecauseofconcernsabout ﬁtforthespecialty (42.9%)andthejobmarket(22.9%),withcorporatizationof medicine,APPexpansion,andburnoutalsomentioned.

29(17.0%)

IMG, internationalmedicalgraduate; MD,DoctorofMedicine; DO,DoctororOsteopathicMedicine.

Mostsomewhatagreedorstronglyagreedthattheirpeers wouldbemoreinterestedinEMasacareeriftheywere exposedtoEMduringarotationinthethirdyearorearlier (82.7%).Participantswereaskedwhattheythoughtwould makeEMmoreappealingtopeerswhowereundecided

Table2. Factorsinﬂuencingselectionofcareerinemergencymedicine.

CI, conﬁdenceinterval;

aboutaspecialtybutwereconsideringEM.Themost commonresponsesincludedearlyexposuretoEM(31.5%) andalleviatingconcernsaboutjobsecurityraisedbytheEM workforcereport(30.2%).Othersuggestionsincluded addressingtheexpandeduseofAPPsintheED(10.1%), improvingtheperceptionofEMamongmedicalstudents andphysicians(9.4%),andimprovingwork-lifebalanceand compensation(8.7%and8.1%,respectively).

Table3 showshowapplicantsrankeddifferentfactors whenchoosingEMasacareer.Themostimportantpositive factorswerevarietyofpatientpathology(4.66ona1–5 scale),lifestyle/flexibility(4.63),high-acuitypatientcare (4.43),lengthofresidencytraining(4.37),andfamily considerations(4.36).Participantswereaskedspecificallyif theybelievedthatEMisa “lifestylespecialty,” and60.1% respondedyes;9.0%didnotconsiderEMalifestylespecialty, while28.1%wereneutral,and2.8%wereunsure.Thefactors negativelyinfluencingacareerchoiceinEM,definedas95% CIlessthan3.0,werecorporateinfluenceinEM(2.51, 2.33–2.69),EDcrowding(2.52,2.37–2.67),burnout(2.59, 2.44–2.74),anduseofAPPsinEM(2.63,2.47–2.79).

AverageratingofconcernsaboutEMexperienceduringthe COVID-19pandemic(2.95)andworkforcereport/job securitywasnegative(2.85);however,upperlimitof95%CI waspositive,3.12and3.03,respectively.

Applicantswereaskedtoidentifythemostimportant reasoncontributingtoalarger-than-normalnumberof unﬁlledpositionsintheEMMatch.Theyidentiﬁedconcerns aboutjobsecurityandthefutureEMworkforceasthe primaryconcern(Table4).Qualitativeresponsestothe

increaseinunﬁlledspotsintheEMMatchpredominantly reﬂectedconcernsregardingtheEMworkforcereportand jobsecurity.Themesandrepresentativequotationsare includedin Table5.

DISCUSSION

ApplicantsinoursurveyweredrawntoEMbyclinical experiencesintheEDduringthethirdandfourthyearandby interactionswithEDresidentsandattendingphysiciansduring thoseexperiences.Unfortunately,onlyasmallproportionof applicantsinoursurveyhadrequiredEMclinicalexperience duringthethirdyearoftraining.Developingbestpractice recommendationsforearlyexposuretoEMduringmedical schoolmaybeanareatotargettoincreaseinterestinfuture applicants.Additionally,employmentinanEM-related ﬁeld (ie,EMS,scribe)priortomedicalschoolwasalsoapositive experience.Earlyidentiﬁcationofthosestudentswithprior EM-relatedemploymentmaybeanareaformentorship effortsbyEMadvisors.

Applicantscontinuetobedrawntothehigh-acuitypatient care,diversepatientpathology,andthe flexiblelifestyleEM offers.These findingsareinlinewithpriorstudiesofEM applicantattitudesandthecornerstoneofEM’ s appeal.12–19,23 Additionalfactorsthatappealtoapplicants arethevarietyoffellowshipoptionsavailableafterEM residency,thelengthofresidencytraining,compensation, andavailabilityofjobsintheirdesiredlocation.Family considerationsareimportanttoapplicantsand,coupledwith thedesirefora flexiblelifestyle,signaladesireforwork-life balance.ShiftworkintheEDhasdownsidessuchassleep

Table3. Importanceofvariousaspectsofemergencymedicinetoapplicantsinthe2023Match. Howimportantwerethefollowing factorsinyourdecisiontoapply toEMresidency

APPs, advancedpracticepractitioners; CI,conﬁdenceinterval; EM,emergencymedicine; ED,emergencydepartment.

transitionsassociatedwithnightshiftsandworking weekendsandholidays.However,applicantsweresignaling thoseissuesarestillfavorabletobeingoncallorworkingina

Table4. Singlemostimportantreasonforunﬁlledemergency medicine(EM)residencypositionsin2022and2023Match, perEMapplicants. ResponseN% Workforce/jobsecurity

Numberofresidencies

Burnout

Programs’ failuretoadapttochanging applicantpool 2(1.3%)

Note:Totalsexceed100%,asrespondentscouldindicatemorethan one item;%indicatesthepercentoftotalrespondentsendorsing achoice.

APP,advancedpracticepractitioner; EM,emergencymedicine.

clinic ﬁvedaysaweek.Highlightingthefactorsthatresonate withapplicantsisagoodstartingpointwhenpromoting thespecialty.

WithregardtofactorspushingapplicantsawayfromEM, mostapplicantsexperiencedbadmouthingofEMand advisingawayfromthespecialty.Inpriorstudies,overthreequartersofrespondentsreportedexperiencewith badmouthingofanotherspecialtyandone-quarterchanged theirspecialtychoicebecauseofit.24–26 Whenuncertain applicantsarenarrowingtheirspecialtychoicesbetweena fewseriousoptions,contendingwithnegativityaboutyour careerchoice,bothnowandinthefuture,fromfriendsor mentorsinotherspecialtiesmaybeenoughtoswaysomeone awayfromEM.

ThemostcommonsourceofadviceagainstEMin2023 wasnotfrompeers,formalmentors,orDean’sofﬁcesbut fromattendingsandresidentsinnon-EMspecialties. Experiencingnegativeadvisementfromatrustedmentor aboutone’sdesiredspecialtyislikelyimpactful.Inaddition, applicantsreportedreceivingnegativepressurefromtheir peersandsocialmedia.MostpeopleinvolvedinEMmedical educationsuspectedapplicantswerebeingadvisedaway fromEM.Thiswassuggestedbyourdata.Mostassumed advisorsfromtheDean’sofﬁcewereadvisingstudentsaway fromEMtowardmoreprestigiousspecialtiesorthosewith safermatchrates.Butthatwasnotthecaseinoursurvey,as

Table5. Qualitativeanalysisthemesandrepresentativequotationsregardingthe2022and2023EMmatch.

ThemeCodeGuidelineforuse

Employment opportunities

Workforce/jobsecurity

Thiscodeisusedwhenparticipantsdiscusstheworkforcereport, jobsecurity,employmentopportunities,ordifﬁculty ﬁndingjobs

• There isamythgoingaroundthattherearenotenoughjobsforEMphysiciansafterresidency.Iknowalotofpeoplethatmadethis commentuponsayingIwasapplyingtoEM

• Covid,andthatdamnmemo.Yallshotyourselvesinthedamnfootwiththatboneheadmove

• Workforcereporthysteria

• Theinfamousreportpredictingacominglaborsurplus.Thetiminglinesupandittrackswithwhatfriendsinmedschoolweresaying NumberofresidenciesThiscodeisusedwhenparticipantsdiscussresidencyexpansion

• Increased amountofresidencyprogramspotscreatedbyCMGhospitals

• Toomanyresidencyprograms

• Surplusof “pop-up” programsleveragingresidentlaborwithnointentionofrealtraining

APPexpansion

• Midlevel creep

• increasingnumberofNPs/PAs ﬁllinginpositions

• PA/NPtakeover

This codeisusedwhenparticipantsdiscusscompetitionwith APPsforemploymentorincreaseduseofAPPsinEM

• IncreasedNP/PAreplacingjobsandthenMDlicenseonlineforanythingtheydo.Includingsigningtheircharts Practice environment Burnout

• Concern overburnout

• Fearofburnout

• Emergencydoctorsburntout

• Treatment duringCOVID-19

COVID-19

Thiscodeisusedwhenparticipantsdiscussburnout

This codeisusedwhenparticipantsdiscuss theimpactofCOVID-19

• COVID-19experiences,lackofpatientcareopportunitiesduringCOVID-19

• Highstress,especiallyduringCOVID-19

• COVID-19showedEM’struecolors

• COVID-19experiencesandfearsoffuturehealthrisks

Corporatization

• Corporate takeover,thusphysicianslosepowereveryday

• Corporatepracticeofmedicine

• HCAprograms!!!!!Thereareatonofnew,sketchyprograms.

This codeisusedwhenparticipantsdiscusscorporatizationof emergencymedicineorprivateequityinﬂuence

• Increaseinfor-proﬁthospitalslotsavailableinTexas,Cali,andFlorida Qualityoflife,changeinpractice environment (boarding,volume,etc.)

Thiscodeisusedwhenparticipantsdiscuss negativepracticefactors

• Lack ofperceivedqualityoflife

• BadjobprospectsandEDculturehasbecometoxic

• Seeingpatientsinwaitingrooms/bedholds

• CultureofwhatEMhasbecome.Noonewantstochoosetoworkinthisoverrunenvironmentespeciallywhenthejobmarketis uncertainwhentherearespecialtieslikedermatologyandsub-specialtieswhereyoudon’thavetodealwiththechaosandpatient volumeswearenowseeingintheED.ERmedicineisatanall-timelowandneverusedtobethisoverwhelmingpre-pandemic.

Applicantor match factors Programs’ failuretoadapttochanging applicantpool

Thiscodeisusedwhenparticipantsdiscussresidencyprograms’ failuretoassesscompetitivenessorselectapplicantsefﬁciently

• Mismatch betweenprograms’ opinionofthemselves/howtheyareperceivedvsactualapplicantperceptionsofprograms.

• Programsbeingoverlyselectiveandnothonestlyintrospectingregardinghowapplicantsperceivetheirprogram

(Continuedonnextpage)

Table5. Continued.

ThemeCodeGuidelineforuse

Perceptionofemergencymedicine

This codeisusedwhenparticipantsdiscussnegativeperceptions ofemergencymedicineamongstudentsorthroughsocialmedia ormentors

• Lack ofrespecttoemergencyphysiciansandthoughtthatwearenotthatsmart

• PerceptionfromattendingsofbothEMandnon-EM

• Socialmediainﬂuenceandimmaturityonbehalfofapplicants

• Decreasedperceivedcompetitivenessleadingtolackofinterest

• Badreputationamongconsultantspecialties

• Jackofalltrades/EMincompetencystigma

APP,advancedpracticepractitioner; CMG,contractmanagementgroup; EM,emergencymedicine; ED,emergencydepartment; HCA,HospitalCorporationofAmerica; NP,nursepractitioner; PA,physicianassistant.

advisorsintheDean’sofﬁcerankedasthesixthmost frequentsourceofadvisementawayfromEM.

AdditionalfactorspushingapplicantsawayfromEM werecorporateinfluenceinEM,EDcrowding,burnout,the useofAPPsinEM,theexperienceofemergencyphysicians duringCOVID-19,andconcernsregardingjobsecurity stemmingfromthe2021EMworkforcereport.Applicants arewaryofenteringaspecialtydominatedbycorporations thatplaceprofitsoverpatientcare.Residenciesatfor-profit clinicalsiteshad1.3timesgreaterriskofnot fillingin2023.9 Applicantsareshowinganaversiontotrainingatthesesites. However,spotscontinueto fillduringthetime-limitedSOAP asunmatchedapplicantsarelikelyexcitedabouttheability tosecureanytrainingposition.Furtherunderstanding applicantconcernsandtheexperiencesofresidentsin for-profitprogramsisimportantandrequiresadditional study.Likewise,understandingtheexperienceofEM residentswhoentertrainingviatheSOAPisvaluablefor futureinvestigation.

Emergencydepartmentcrowdingnotonlynegatively impactsqualityofpatientcare;italsodetersfuture emergencyphysiciansfromenteringthe ﬁeld.Studentson EDrotationsseethechallengesof ﬁndingspacetoreevaluatepatients,delaysinworkup,andprolongedcareof patientsboardingintheEDwhoareawaitinginpatientbeds. Effortstoaddressboardingaswellastheimplementationof surgecapacityplansmayresultinimprovingthisfactoras studentsconsiderspecialtychoice.

Furthermore,burnoutgeneratedthelargestnumberof moderateorstronglynegativeresponses.Emergency medicineiswidelycitedasthespecialtywiththehighest ratesofburnout. 27 , 28 Requirementstopromotewell-being andcounterburnoutexistinbothundergraduate (LiaisonCommitteeonMedicalEducationstandard 12.3) 29 andgraduatemedicaleducation(Accreditation CouncilforGraduateMedicalEducationCommon ProgramRequirementsforresidencyVI.C). 30 Prior

qualitativeresearchsugg estsfacultymodelingmay in ﬂ uenceresidents ’ careerperspectives,indicating targetingfacultyforeducationonwell-beingandburnout mayyieldsubstantialbene ﬁ tsforbothcurrentand prospectiveresidents. 31

Applicants,additionally,haveconcernsabouttheuseof APPsintheED.Manyfree-textresponsescited “ scope creep ” ofAPPsaswellasthenegativeimpactonphysician jobavailabilityasnegativefactors.Applicantssignaledthat theyarepayingattentiontothetopicofAPPusageintheED anditisanimportantissuetothem.NationalleadersinEM areactivelyworkingtoprotectthescopeofallpractitioners intheEDandcontinuetoemphasizetheimportanceof physician-ledpatientcareteams.Furtherdisseminationof theseadvocacyeffortsandtheeffectsonourspecialtywould bebeneﬁcialforapplicants.

Lastly,theworkforcereporthasbeenfrequently hypothesizedasamajorcontributingfactortotherapid declineinEMresidencyapplicationsoverthelasttwoyears.8 ApplicantstoEMinoursurveyconfirmedthishypothesis, citingprojectionsstemmingfromthereportasthemost importantfactorleadingtothesignificantriseinunfilledEM residencypositionsinthe2022and2023Matches. Subsequentstudieshaveaddressedworkforceconsiderations suchasphysicianattritionandgeographicdistribution.32,33 FurtherinvestigationandclarityintothefutureEM workforcewouldaidapplicantsastheyweightheir careerdecisions.

ReinforcingthepositiveaspectsofEMwhileaddressing thenegativefactorsabovewillgoalongwaytoward bolsteringtheEMapplicantpoolandfutureworkforce.The 2023EMMatchwasunprecedentedwith554unmatched positions.However,EMstillmatched2,456applicants,the fourthlargestnumberinthe2023Match.3 Oursurveyyields insightsintothepositiveaspectsofEMthatdrawapplicants tothespecialtyandidentiﬁesnegativefactorsfollowingthe 2023EMMatch.

LIMITATIONS

Oursurveymaybeimpactedbyselectionbiasasour distributionmethoddidnotguaranteethateveryresidency applicantwhoconsideredapplyingtoEMresidencywas included.Forthisreason,surveyresponseratewasnot calculated,anditisunknowntowhatextentourresultsare representativeofallEMresidencyapplicantsinthe2022and 2023Matchcycles.Additionally,recallbiasmayalso contributeasresponsesfromapplicantswhomatchedtoEM in2022wereincluded.Aspotentialsurveyparticipantswere identifiedthroughtheirmembershipinnationalEMresident andstudentorganizations,thisstudymaynotbe representativeofindividualswhoconsideredEMearlyin theirmedicalschoolcareerandultimatelydidnotpursue EM.Theexactnumberofindividualswhoreceivedthe surveysolicitationisnotknown,makingitimpossibleto calculatearesponserate.Oursurveyresponsesrepresent 7.7%ofthetotalnumberofapplicantstoEMin2023, althoughitisunlikelythesurveyreachedallapplicantsinthe pool.Futurestudiesmaybenefitfromalongitudinal approachsolicitingEMinterest-groupparticipantsinthe firsttwoyearsofmedicalschoolandfollowing themthroughtheirrespectiveMatchyearsto improveresponserate.

CONCLUSION

Thespecialtyofemergencymedicineexperiencedasharp increaseinun fi lledpositionsinthe2022and2023matches. MostapplicantsreceivedadvisementawayfromEMwith themostcommonsourcebeingphysiciansinnon-EM specialties.Applicantsperceivecorporatein fl uenceinEM, EDcrowding,burnout,in fl uenceofadvancedpractice practitionersinEM,andworkforceconcernsasdriving forcesbehindtheEMMatchresults.Applicantscited clinicalexperiencesintheEDandinteractionswith EMattendingsandresidentsaspositivefactors.Highacuitypatientcare,diversepatientpathology,and fl exible lifestylewereseenaspositivecharacteristicsofacareer inEM.

ACKNOWLEDGMENTS

Theauthorswouldliketothanktheboardsofdirectorsof AAEM,AAEM/RSA,ACEP,ACOEP,AACEM,CORD, andSAEMforprovidingfundsforparticipantincentives. TheauthorswouldalsoliketothankAAEM/RSA,ACOEP/ RSO,CDEM,EMRA,andSAEMRAMSforassistance withdistributingthesurveyviatheirrespectivelist-servsand tothankthemembersoftheCORDMatchTaskForcefor assistanceindevelopingthesurveytool.

AddressforCorrespondence:MichaelKiemeney,MD,LomaLinda UniversitySchoolofMedicine,11234AndersonSt,MC-A208,Loma Linda,CA92354.Email: mkiemeney@llu.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Surveyincentivesupportwasprovided byrespectiveBoardsofDirectorsforAAEM,AAEM/RSA,ACEP, ACOEP,AACEM,CORD,andSAEM.Themanuscriptrepresents theindividualauthor’sopinionsanddoesnotrepresenttheopinions oftheorganizationsproviding financialsupport.Therearenoother conflictsofinterestorsourcesoffundingtodeclare.

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EDUCATIONAL ADVANCES

CombiningImmersiveSimulationwithaCollaborativeProcedural TrainingonLocalAnestheticSystemicToxicityandFasciaIliaca CompartmentBlock:APilotStudy

KatherineB.Griesmer,MD,MPH*

MaxwellThompson,MD*

BrianaMiller,MD*

GuihuaZhai,PhD†

JaronRaper,MD*

AndrewBloom,MD*

SectionEditor: MuhammadWaseem,MD

*UniversityofAlabamaatBirminghamHeersinkSchoolofMedicine, DepartmentofEmergencyMedicine,Birmingham,Alabama † UniversityofAlabamaatBirmingham,CCTSBiostatistics,Epidemiology& ResearchDesign(BERD),Birmingham,Alabama

Submissionhistory:SubmittedJuly2,2024;RevisionreceivedOctober31,2024;AcceptedNovember1,2024

ElectronicallypublishedJanuary15,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.25020

Introduction: Readinesstoperformawidevarietyofproceduresormanagenearlyanypatient presentationremainsanessentialaspectofemergencymedicinetrainingandpractice.Often,simulation isneededtosupplementreal-lifeexposuretoprovidecomfortandknowledge,particularlywithrarer pathologyandprocedures.Asthescopeofpracticecontinuestogrow,newerprocedures,suchas ultrasound(US)-guidednerveblocks(UGNB),arebecomingintegratedintoresidenttraining,buildingon previouslyestablishedskills.Thefasciailiacacompartmentblock(FICB)isperformedonpatientswith speciﬁcfemoralfracturesandisanowacomponentofstandardmultimodalpainregimens,withUSguidancelimitingadverseevents.Giventheneedforhighvolumesoflocalanesthetictoperformthe blockitisimperativeforclinicianstounderstanddosingaswellasrecognizeandtreatlocalanesthetic systemictoxicity(LAST).Withsparseliteratureonsequentialimmersiveandproceduralsimulation involvingintertwinedtopics,thispresentsauniqueopportunityforlearners.

Methods: TostudytheperceivedknowledgeandcomfortwithFICBandLAST,apilotstudywas developedwithtwoseparatebutconcurrentone-hoursimulationscompletedencompassingoneofeach topicoveroneday.Wesurveyed19learners,consistingofresidentsrangingfrompostgraduateyears 1–3,priortoandimmediatelyfollowingcompletion,regardingtheirperceptions.WeusedtheStuartMaxwelltesttocomparesurveydata.

Results: Morethanhalfofparticipants(56%)hadnotreceivedpriorformaltrainingonFICB.Therewasa positivetrendinperceivedconﬁdenceandknowledgewithvisualizingrelevantanatomy(4.0[2.0–6.0]vs 9.0[7.5–10.0], P = 0.10),performingFICB(4.0[1.0–5.0]vs9.0[7.0–10.0, P = 0.08]),andperceived abilitytoteachtheirpeers(3.0[1.0–5.0]vs8.5[7.0–10.0], P = 0.20).Perceivedabilityindiagnosingand managingLASTalsoincreasedfollowingthesimulation(5.0[3.0–6.0]vs6.0[6.0–7.0], P = 0.12and 3.0[2.0–6.0]vs6.0[6.0–7.0], P = 0.08,respectively).

Conclusion: Learners’ perceptionsofthissimulationexperienceechothe ﬁndingsofpreviousstudiesin whichsimulationcanbeusedtoteachproceduresandpathology;ofnote,however,wepresenteda novelexperiencewithacombinationofimmersiveandproceduralsimulation.[WestJEmergMed. 2025;26(2)271–278.]

INTRODUCTION

Toenhancepreparednesstocareforuncommonpatient presentationsandprocedures,simulationhasoftenbeenused ingraduatemedicaleducation(GME)tolaythefoundation aswellasto finetuneskills,includingresuscitations.1 Simulationhasalsobeenattheforefrontofproceduralskill acquisitionandincreasinglearner’ sconfidenceatboththe GMEandundergraduatemedicaleducationlevels,witha focusonbothhigh-acuityandlow-occurrenceprocedures.2–4 Bothinsimulationandclinicalpractice,moreproceduresare beingperformedunderultrasound(US)guidancewithtrends towardincreasedsafetyandefficacy,mostnotablyincluding placementofcentralvenouslines.5,6 Withthisincreasing incorporationofUStraininginemergencymedicine(EM) residencyprograms,thevarietyofproceduresperformedin anemergencydepartment(ED)settinghavealsoexpanded.

Regionalnerveblockswerepreviouslycompletedvia landmarkonly;however,therehasbeenprogressiontoward US-guidanceduetoreducedadverseeventsandgreater ﬁrstattemptsuccessrates.7,8 Regionalnerveblockshave increasinglyfallenunderthescopeofEMpractice, particularlywithregardtoUS-guidednerveblocks(UGNB). Manypatientsarepoorcandidatesforfrequentorhighdoses ofopioidsasaprimarypainmanagementstrategyinthe ED.9 Onestudyfoundalmost25%ofelderlypatients sufferedfromdeliriumwhilehospitalized,withthemajority ofthosereceivingpolypharmacy.10 However,UGNBisa valuabletoolformanagingpaininhipfractures,regardless ofpatientabilitytotolerateopioidandnon-opioid analgesics.Nerveblocksarenowrecommendedbythe AmericanCollegeofSurgeonsandtheAmericanAcademy ofOrthopaedicSurgeonsasastandardcomponentofa multimodalapproachtopainmanagement.11,12 The AmericanCollegeofEmergencyPhysicians(ACEP)recently statedthatUGNBsmakeupacoreskillforemergency physicians,voicingbroadsupportforitsuseandcitingits versatilityforavarietyofprocedures,fromcomplex lacerationrepairstoorthopedicreductions/splinting.7

Thefasciailiacacompartmentblock(FICB)canprovide significantanalgesia,particularlyinpopulationsthatmay havecontraindicationsorcomorbiditiesthatpreclude standardsystemicintravenousand/ororalpainregimens includingopioids,ketorolac,andotheranalgesicagents.The block,withitsdiscoveryin1989andeventualintroductionin theEMliteraturein2007,hasbeenslowtobeadopted despiteitssafetyprofileandefficacy.13,14 TheFICBcanbe usedforfemoralneckfracturesinthepre-,peri-,and postoperativestagesgiventheblockadeoffemoralnerve, localfemoralcutaneousnerve,andvariablecoverageofthe obturatornerve.8,15 ByincorporatingUSguidance,the compartmentblockisdonelateraltothefemoraltriangle (femoralnerve,artery,andvein),thusminimizingthechance ofintravascularinjection.13 Ameta-analysisofFICBhas alsobeenshowntoreducemorphinedosingrequirementand

mayevennegatetheneedforadditionalmedicationsbeyond theblock.16 Inanotherstudy,90%ofpatientshadblockade withasigniﬁcantreductioninthevisualanaloguescalefrom 7.5to2.94atthe20-minutemark.17 Withsuchcompelling dataregardingitsefﬁcacyandthewidespreadavailabilityof USinEDs,theFICBrepresentsapowerfultoolinpain controlintheEDsettingthatiswellwithinthescopeofthe emergencyphysician.Withinourcurrentpractice,thiscould resultinincreasedpatientsatisfactionandpossiblyfreeup moreresources,includingnursing,particularlyifnot requiringconsistenttreatmentforbreakthroughpain.

Localanestheticsarecommonplacewithinthemedical ﬁeldandespeciallywithintheEDwheretheyarearoutine componentofanyclinician’smedicalpractice.18 However, complicationsexist,particularlywhenlargequantitiesof anestheticareused,orinadvertentintravascularinjection occur,whichmaycauselocalanestheticsystemictoxicity (LAST).Elderlypatientsorthosewithorgandysfunctionare ataparticularlyhighrisk.19,20 Furthercomplicatingthe syndrome,LASThasconsiderablevariabilityinonsetand symptomatology.19 Itcanbedetrimentalthroughitseffects onboththecentralnervoussystem(CNS)and cardiovascularsystems,resultinginarrhythmias,seizures, cardiovascularcollapse,andriskofcardiacarrest.Each anestheticagenthasitsownmaximum,weight-baseddosing thatmaybeaugmentedifformulatedincombination withepinephrine.19

Previously,itwasbelievedtheagentswouldbehaveina predictable,stepwisemannerwithprecedentCNSsymptoms appearingpriortocardiacdysrhythmias;however,themore potentagentshavebeenfoundtohaveprecedingand possiblyconcomitantcardiacandCNStoxicity.20 The incidenceofLASTisvariablewithonestudyreporting occurrenceinupto25per10,000blockadesandanother specifyingoccurrencein79of10,000brachialplexus blockades.20 Regardlessofthetrueincidence,LAST occurrencehasbeenshowntobereducedwithUS-guided regionalanesthesiabyupto65%,althoughriskstillexists.21 Thus,trainingonrecognitionofthesignsandsymptoms,as wellastreatment,isimperativeforemergencyphysicians. Simulationofthisprocedureanditsmostdangerous complicationallowslearnersanopportunitytogain experiencewiththeconditionwithouteffectsonpatient outcomes.FollowingrecognitionofLAST,injectionmustbe ﬁrstdiscontinuedandinseverecasesmayrequire administrationofintralipidemulsiontherapy(ILE).The AmericanHeartAssociationalsoincludesILEinits guidelinesforcardiacarrestsecondarytoLAST.22

FollowingACEPguidelinesandexpandingonbasicsof well-knownprocedures,FICBmaybeabeneﬁcialprocedure foremergencyphysicianstomasteralongwiththe considerationoftherisksofLASTanditsmanagement. Simulationhasbeendocumentedasbeinganeffective teachingmodality,offeringasafeenvironmentfor

learners.23,24 Ultrasound-basedtraininghasbeenpreviously showntobebeneficialwithanimprovementinconfidence andproceduralskills.23 Theliteratureissparseona combinationofsequentialimmersiveandprocedural simulationtechniquesinmedicaleducation.Whiletaking intoconsiderationthevariablepresentationsandseverityof complicationsrelatedtoLAST,aswellastherising importanceofregionalnerveblocksinEM,apaired simulationexperiencecanimproveidentificationand treatmentofthesyndrome,aswellasallowlearnersto enhancetheirskillset.HerewepresentapilotstudyonEM residents’ perceptionsandconfidencewithdiagnosingand managingLASTaswellasproceduralskillswithFICB.

OBJECTIVES

Ourobjectiveinthisstudywastocreateanimmersive simulationthatteachesEMresidentstorecognizeclinical signsandsymptomsofLAST,developanappropriate treatmentalgorithm,andmanagepotentialoutcomes includingcardiacarrest.Secondaryobjectivesincluded successfulperformanceofUS-guidedFICB,troubleshooting complications,anddeterminingproperlocalanesthetic dosingtopreventLAST.Ultimately,thegoalwastodevelop asimulation-basedcurriculumtoincreaseresidentcomfort andknowledgewiththeFICBwhilerecognizingand managingitsrareandmoredangerouscomplications.

METHODS

Weconductedaprospectivepilotstudy,deemedexempt bytheinstitutionalreviewboard,forbothanimmersivecase andproceduralsimulationinthefallof2023.Apresimulationquestionnairewasadministeredamonthprior withafocusonresidents’ perceivedcomfortlevelswith variousUS-guidedprocedures,alongwithuncommon causesofcardiacarrestandtheirmanagement.Anotherprequestionnairewasadministeredjustpriortotheprocedural FICBsimulationregardingcomfortandknowledgewiththe speciﬁcprocedure.

ParticipantswereEMresidentsrangingfrom postgraduateyears(PGY)1–3ataLevelItraumacenter universityhospitalsystem.Aconveniencesampleof19 residentswhowerepresentfortheconferenceday participated.Allparticipantsvoluntarilyagreedto participateintheactivitieswithinformedconsentprovided. Aspartoftheresidencycurriculum,residentsmustcomplete afour-weekrotationfocusingonUSskillsandinterpretation asPGY-1saswellasfulﬁlltheAccreditationCouncilfor GraduateMedicalEducation-requirednumberof resuscitations,ultrasounds,andprocedures.Anadditional fourweeksofthePGY-1yearisdevotedtotoxicologywith focusonawarenessandmanagementoftoxicologic emergencies.However,asthesessionwascompletedinthe ﬁrsthalfoftheyear,notallPGY-1shadcompleteda toxicologyand/orUSrotation.Priortothesimulations,

hands-onpracticehadonlyoccurredontheindividuallevel inthedepartmentclinicallywithnumbersascertainedprior tothesimulation.Apre-surveyhadbeen ﬁlledoutonemonth priortothesimulations.

TheLASTimmersivesimulationwasperformed firstfor eachparticipanttoavoidparticipantbiasandanchoring.For thesimulation,participantswererandomlydividedinto groupsofapproximatelythreeresidentsfora30-minute novelimmersivecasesimulationwithsubsequentstructured debriefandpost-survey.Thesimulationwasdevelopedin conjunctionwithEMsimulationfellowship-trainedfaculty. Thiscaseinvolvedascertainingahistoryandphysical,which includedarecentFICBforatraumatichipfracture.Thecase progressedwiththepatientshowingclinicalsignsand symptomsofLAST,includingseizureandsubsequent cardiacarrest.Participantsweretestedonandexpectedto developadifferentialdiagnosisforthepatient’spresentation, identifyLAST,andtreatthepatientwithintralipidtherapy aswellassupportivecare.Theteamwasinterdisciplinary withEMnursesandpharmacyresidentsalsoparticipating. Followingthesimulationduringadebriefingsession, diagnosticcriteriaandmanagementofLASTwerediscussed usinginformationprovidedbyaboard-certifiedtoxicologist. Participantsthen filledoutapost-surveyevaluatingtheir knowledgeandcomfortlevelregardingtheirrecognitionand managementofLAST.

Following completionoftheLASTimmersivesimulation, participantsweretransitionedtotheFICBprocedural simulationinaseparatelocationtoavoidcommunication withincomingparticipants.Eachgroupconsistedof approximatelysixresidentstoallowforadequatehands-on time.Apre-surveywasadministeredwithspecificquestions directedtowardresidents’ perceivedcomfortandknowledge withtheFICBprocedure.Abriefdidacticlecturefollowed withfocusonclinicalindicationsfortheprocedure,US anatomy,proceduralsetup,andlocalanesthetic specificationsanddosing.AreiterationofsignsofLASTas wellasmanagementwasincludedinthelectureaswell.A standardizedproceduralchecklistdevelopedinconjunction withboard-certifiedUSfacultywasusedbyallfacilitators (Figure1).Anotherhandoutforpracticingcalculating maximumdoseswasprovidedasacognitiveaid.

Astandardsetupofnerveblocksupplieswasused (Figure2).Theproceduralsimulationusedafasciailiaca manikin(ValkyrieSimulators,JohnsonMills,WV)for practicevisualizinganatomywithUS,andaporcine-tissue modelwasusedtopracticehydrodissectingakinto performingtheprocedureinclinicalpractice(Figure3).No manipulationsweremadetotheporcine-tissuemodel includingadditionofmocknervestructures.Following completionoftheproceduralsimulation,apost-surveywas administeredtotheresidentparticipantswithspeciﬁc questionspertainingtoconﬁdenceandknowledgeof proceduralindications,relevantanatomy,andperceived

Planning for procedure

Confirm patient identity using two-patient identifiers

Obtain informed consent

Perform hand hygiene and don exam gloves

Document physical exam prior to procedure including neurovascular exam

Preparing for procedure

Gatherappropriateequipment

Place patient in neutral position

Calculatemaximumdosingofanesthetic

Procedural Steps

Analyze anatomy with US including location of femoral artery

Disinfect site

Don PPE and drape field

Draw up local anesthetic and normal saline if desired in syringe

Connect spinal needle or PIV needle to connector tubing and syringe

Cover linear array with sterile probe cover

Insert with needle in-plane

Hydrodissect fascia iliaca with partner pushing syringe

Inject entire solution ensuring not to exceed maximum dose

Remove needle

Performing appropriate aftercare

Dispose of all other non-sharp materials

Remove PPE and perform hand hygiene

Clean hands usingalcohol-basedhand sanitizer or soap and water

Figure1. Learnerchecklistforfasciailiacacompartmentblock(FICB)procedure. PPE,personalprotectiveequipment; PIV,peripheralintravenous; US,ultrasound.

Figure2. Suppliesforfasciailiacacompartmentblockprocedure. G,gauge; cc,cubiccentimeter.

comfortinperformingtheprocedurefollowinghands-on teachingandguidance.Board-certiﬁedUSfacultydirected allhands-onteachingandinstruction.

Wecomparedpre-andpost-trainingsurveyresponses usingageneralizedStuart-Maxwelltesttoevaluatethe impactofthetrainingonresidents’ knowledgeandattitudes

Figure3. Simulationofhydrodissectingonporcine-tissuemodel (arrowindicatingneedletip).

towardtheprocedureandLASTtoxicity.Questionnaires includedscaleof1–10forFICBsurveysand1–7forLAST surveys,with1correspondingtostronglydisagreeandthe upperlimitsof7and10representingstronglyagree, respectively.Analphalevelof0.05wassetforallstatistical tests.WeperformedallanalysesinSAS9.4.(SASInstitute Inc,Cary,NC).25

Priortoimplementationofbothsimulations,we performedwalk-throughsessionstoanticipateandidentify anylogisticalorsystemsissues.Nursing,pharmacy,and

Table1. Groupcharacteristics.

Pre-simulationgroup characteristicsLAST(n = 19)FICB(n = 16)

PGYlevel

PGY-1

4(21.1%)3(18.8%)

PGY-2 7(36.8%)5(31.3%)

PGY-3 8(42.1%)8(50%)

Priortoworkshop:numberof previouslyperformedFICB Ihaveneverheardofit

PGY, postgraduateyear; LQ,lowerquartile; UQ,upperquartile; FICB,fasciailiacacompartmentblock; LAST,localanesthetic systemictoxicity.

simulationstaffwerealsoconsultedforinputregardingthe sessionaswellasimplementationinthedepartment.A board-certiﬁedtoxicologistalsoprovidedinputtoensure managementwasconsistentwiththestandardofcare.

RESULTS

Atotalof19EMresidentsrangingfromPGY1–3 participatedintheLASTsimulation,and16residents participatedintheFICBproceduralsimulation.The distributionamongtraininglevelsisdescribedin Table1 with askewtowardmorePGY-3s(42.1%and50%,respectively). Overall,16participants,ormorethanhalf(56%),hadnot receivedpriorformaltrainingonFICB.Halfofthe participantshadpreviouslyperformedaFICB,withthe majority(31.3%)onlyperforming1–3FICBpriortothe session(Table1).Followingsimulation,learnersreportedan improvementinconfidenceandknowledgewithperforming aFICB,withthepre-simulationimprovingfrom4.0 (1.0–5.0)to9.0(7.0–10.0)post-simulationusingthescale previouslymentionedwith10representing “stronglyagree.” Therewasalsoanincreaseintheperceptionoftheutilityof FICBintheED.LearnersfeltmoreconfidentinusingUSto visualizetherelevantanatomy(4.0[2.0–6.0]vs9.0[7.5–10.0]) andgeneralknowledgeofUGNB(5.0[2.0–7.0]vs10.0 [8.0–10.0]).Residentsfeltmoreconfidentintheirabilityto teachtheirpeerstheprocedure(3.0[1.0–5.0]vs8.5 [7.0–10.0]).Ageneralpositivetrendincomfortand knowledgewasnotedintheFICBfollowingsimulation, althoughnoresultswerestatisticallysignificant(Table2). Learnersratedsimilarperceptionincomfortwith diagnosingandmanaginguncommonconditionsbothprior toandfollowingtheLASTsimulation.Therewasanincrease incomfortinbothdiagnosingandmanagingLAST.

RecognitionofLASTincreasedfrom5.0(3.0–6.0)to6.0 (6.0–7.0)frompre-topost-simulation,respectively,with 7.0representingstrongagreementwithastatement. Perceptionregardingmanagementfollowedasimilartrend with3.0(2.0–6.0)pre-simulationto6.0(6.0–7.0)postsimulation(Table2),althoughneitherwasfoundtobe statisticallysigniﬁcant.

DISCUSSION

SimulationisakeycomponentofGME,forboth immersivecasesaswellaspracticingandmastering procedures,butthereislimitedresearchoncombiningboth approachestobettermimicreal-lifepracticeandtiein connectedtopics.SimulationoftheFICB,anditsmost seriousadverseeffect,LAST,offersauniqueopportunityfor residentsimulation.Withminimalresourcesandsetup,itis possibleforlearnerstoexperiencethemultitudeof pathologicpresentationsandneededresuscitativemeasures ofLAST.Althoughthemaingoalofbothsimulationswasto assessperceptionsinknowledgeandconfidence,theresidents werealsoabletopracticemanagementofseizures,airway, andcardiacarrestwhilealso fine-tuning US-guidanceskills. Whileourstudywaslimitedbyunderpowering,asis commoninsimulation-focusedGMEstudiesduetolimited learnernumbers,wefoundevidenceofseveralimportant trendsalthoughtheylackedstatisticalsignificance. 26 Inthe timingimmediatelyfollowingsimulation,residentsreported anincreasingtrendinconfidenceandself-perceived knowledge,withthetrendbeingmoreprofoundfortheFICB proceduralsimulation.These findingsareinlinewithprior proceduralsimulation-basedresearch,demonstratingatrend towardimprovedlearnerconfidenceandknowledge followingtheprocedure.27,28 Residentsalsonotedincreasing comfortwithteachingpeerstheprocedure.Asresident perceptionsweresurveyedimmediatelyfollowingthe simulationevents,itisunclearwhetherthosetrendspersisted beyondthedayofsimulationorwereappliedtosubsequent clinicalpractice.Futureinvestigationswouldbenefitfrom follow-upatascheduledintervalandclinicallyfocused outcomemeasures,suchasproceduralproficiencyorthe absenceofadverseevents.

Regardingtheimmersivesimulation,nosigniﬁcant impactwasseenindiagnosingandmanaginguncommon conditionsorworkinginaninterdisciplinaryteam,although therewasapositivetrendwithresidents’ abilitytodiagnose andmanageLAST.Previousstudieshavefocusedonthe impactofinterprofessionalteamsforimmersivesimulation andhavenotedapositivecorrelationwithappreciationand generalknowledgeofotherhealthcareprofessions.29 Despite resuscitationbeingamajorcomponentofEMtraining,this studymaydemonstrateaneedformoredetailedinstruction regardingrarercausesofarrest.

Overall,perceptionsofthesimulationexperiencewere alsopositivewithlearnersindicatingsupportoffuture

Table2. Pre-andpost-simulationreportedexperiences.

Meanreportedpre-andpost-simulationperceptions(FICB)(n = 16)MedianLQUQ

Perceivedknowledgeofultrasound-guidednerveblocks

PerceivedcomfortlevelwithperformingFICB

Perceivedcomfortvisualizingfasciailiacaanatomy onUS

PerceptionofFICButilityintheED

Perceivedcomfortteachingproceduretopeers

Meanreportedpre-andpost-simulationperceptions(LAST)(N = 19)

Perceivedconﬁdence indiagnosinguncommonconditions

Perceivedconﬁdenceinworkinginamulti-disciplinaryteam

PerceivedconﬁdenceinrecognitionofLAST

PerceivedconﬁdenceinmanagementofLAST

PGY, postgraduateyear; LQ,lowerquartile; UQ,upperquartile; FICB,fasciailiacacompartmentblock; LAST,localanestheticsystemic toxicity; US,ultrasound.

sessionsforotherEMresidentsandclinicians.Althoughnot statisticallysigniﬁcantandlargelysimilarpre-andpostsimulation,thecombinationofcaseswaswellreceivedby residentsinsurveycomments.Combinationcasesmay provideachanceforadeepergraspofintegratedtopicsas wellasauniqueopportunityforresidentstopracticeinan immersivesimulationenvironment.Thelimitedtime availableforresidenteducationmakesthisapproach valuable,asbothsimulationscovermultipleaspectsof medicalcare.

LIMITATIONS

Limitationstothestudyincludeparticipants’ self-reported conﬁdenceandknowledgeafterasingleencounterand,thus, mayhavebeensubjecttobiasgivenitssubjectivenature. Whiletherewasageneraltrendtowardimprovementin perceptionsofknowledgeandskillsfollowingthesimulation, thisisalsoinreferencetoshort-termrecallwithfurther studiesneededtoascertainlong-termretentionofknowledge andproceduralskills.Furtherstudieswouldalsoberequired toelucidatetheeffectsofcombinationsimulationasa

Table3. Learnerperceptionsregardingsimulationexperience. Post-simulationlearnerexperiencesurveyMedianLQUQ

Thegoalsofthesimulationwereclearlyoutlinedpriortoparticipation

Felt hadenoughsupervisionduringsimulation

Feltcomfortableaskingquestionsorforhelpduringthesimulation

Feltwasgivenadequatefeedbackduringsimulation

Simulationcomplimentedlearningstyle

ThisworkshopwouldbeusefulforfutureEDresidentsandclinicians

ED, emergencydepartment; LQ,lowerquartile; UQ,upperquartile.

learningopportunity.Neitherwereweabletomeasure translationtoreal-worldpractice,withunclearintegrationof FICBintotheparticipants’ futureclinicalpractice.An expansionofthestudywithanextendedtimelinemayshowa declineintheknowledgeandskillsacquiredinthis simulationovertime,aswellaspracticechanges. Participationwasanotherkeylimitationwitha predominanceofupper-levelresidents;andlossof participantsmaybeattributedtoschedulingdifﬁculties particularlywithoff-servicerotations.

Furtherlimitationsmayexistifattemptingtoreproduce thisexperienceatothersites;thissimulationisbasedon faculty’sownperceivedskillsandconfidenceinperforming, andteaching,FICB,whichmaynotbeasstrongatother sites.Thissimulationmaynotbeworthwhileatothersitesif FICBprocedurescannotbeimplementedgivenaccessibility tointralipidemulsiontherapyincaseofpossibleLAST. Althoughresearchhasalreadyshownthebenefitofusing FICBinEDsbothintheUnitedStatesandresource-limited areas,furtherstudiesshouldbeperformedonteaching modalities,particularlyforthosewithhistoricallymore limitedultrasoundteaching.13 Thehomogenousresponsesin Table3 mayreflectfurtherlimitationstothestudy,which couldreflectunderlyingbias.

CONCLUSION

Overall,thisstudycontinuestodemonstratethepositive effectregardingtheuseofsimulationinmedicaleducation, bothwithimmersiveandproceduralsimulations.Increasing exposure,evenatanintroductorylevel,ofrarerpathology, includingLAST,mayaidindiagnosisandmanagement. Residents’ perceptionoftheproceduralsimulationinthis study,whilelimitedtofasciailiacacompartmentblock procedure,alsohadapositivetrendtowardcomprehension andskillset.Althoughlimitedinthenumberofparticipants, thisstudydemonstratesthattheuseofcombination immersiveandproceduralsimulationmayprovidean excitingandworthwhileexperienceforlearners,particularly withinterconnectedtopics.

AddressforCorrespondence:KatherineB.Griesmer,MD/MPH, UniversityofAlabamaatBirminghamHeersinkSchoolofMedicine, DepartmentofEmergencyMedicine,52119thSt.,S,General ServicesBuilding,RM240,Birmingham,AL35294.

Email: kbaldwin@uabmc.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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EDUCATION SPECIAL ISSUE -EDUCATIONAL ADVANCES

DevelopmentofaReliable,ValidProceduralChecklistfor AssessmentofEmergencyMedicineResidentPerformance ofEmergencyCricothyrotomy

DanaE.Loke,MD,MS*

AndrewM.Rogers,MD,MBA†

MorganL.McCarthy,MD‡§

MarenK.Leibowitz,MD¶

ElizabethT.Stulpin,MD#

DavidH.Salzman,MD,Med‡∥

* UniversityofWisconsinSchoolofMedicineandPublicHealth,BerbeeWalsh DepartmentofEmergencyMedicine,Madison,Wisconsin

† NorthShoreUniversityHealthSystem,DivisionofEmergencyMedicine, Evanston,Illinois

‡ NorthwesternUniversity,FeinbergSchoolofMedicine,DepartmentofEmergency Medicine,Chicago,Illinois

§ StLuke’sHospital,DepartmentofEmergencyMedicine, NewBedford,Massachusetts

¶ IcahnSchoolofMedicineatMountSinai,InstituteofCriticalCareMedicine, NewYork,NewYork

# EmoryUniversityHospital,DepartmentofEmergencyMedicine,Atlanta,Georgia

∥ NorthwesternUniversity,FeinbergSchoolofMedicine,DepartmentofMedical Education,Chicago,Illinois

SectionEditors: MatthewTews,MDandChristineStehman,MD

Submissionhistory:SubmittedJune15,2024;RevisionreceivedNovember8,2024;AcceptedNovember12,2024

ElectronicallypublishedJanuary30,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20365

Introduction: Emergencycricothyrotomyisararebutpotentiallylife-savingprocedureperformedby emergencyphysicians.Acomprehensive,dichotomousproceduralchecklistforemergency cricothyrotomyforemergencymedicine(EM)residenteducationdoesnotexist.

Objectives: Weaimedtodevelopachecklistcontainingthecriticalstepsforperforminganopen emergencycricothyrotomy,toassessperformanceofEMresidentsperforminganopenemergency cricothyrotomyusingthechecklistonasimulator,andtoevaluatethereliabilityandvalidityofthe checklistforperformingtheprocedure.

CurricularDesign: Wedevelopedapreliminarychecklistbasedonliteraturereviewandsentitto expertsinEMandtraumasurgery.AmodifiedDelphiapproachwasusedtorevisethechecklistand reachconsensusona finalversionofthechecklist.Toassessusabilityofthechecklist,weassessedEM residentsusingacricothyrotomytasktrainer.Scoresweredeterminedbythenumberofcorrectly performeditems.Wecalculatedinter-raterreliabilityusingtheCohenkappacoefficient.Validitywas assessedusingtheWelch t-testtocomparetheperformanceofresidentswhohadandhadnot performedanopenemergencycricothyrotomy,andweusedanalysisofvariancetocompare performanceofpostgraduateyear(PGY)cohorts.

Impact/Effectiveness: The final27-itemchecklistwasdevelopedafterthreeroundsofrevisions.Interraterreliabilitywasstrongoverall(κ = 0.812)withindividualchecklistitemsrangingfromslighttonearly perfectagreement.Atotalof56residentsparticipated,withanaveragescoreof14.3(52.9%). PerformancevariedsignificantlyamongPGYgroups(P < 0.001).Residentswhohadperformedan emergencycricothyrotomypreviouslyperformedsignificantlybetterthanthosewhohadnot (P = 0.005). Thedevelopedchecklist,whichcanbeusedinproceduraltrainingforopenemergencycricothyrotomy, suggeststhatimprovedtrainingapproachestoteachingandassessingemergencycricothyrotomyare neededgiventheoverallpoorperformanceofthiscohort.[WestJEmergMed.2025;26(2)279–284.]

BACKGROUND

Emergencycricothyrotomyisararebutpotentiallylifesavingprocedurethatemergencyphysicians(EP)mustbe abletocompetentlyperform.ItisperformedwhentheEPis unabletooxygenateandventilateapatientafterrapid sequenceintubationisinitiatedand,therefore,mustpursue cricothyrotomyinatime-sensitivemanner.Thus,itis essentialforEPstobeabletoperformtheprocedure correctly.Furthermore,theAccreditationCouncilfor GraduateMedicalEducationincludescricothyrotomyasa “keyprocedure” forwhichresidents “mustdemonstrate competence.”1 However,therearefewopportunitiestolearn thisprocedureintheclinicalenvironment,withonestudy demonstratingthatonly22%ofgraduatingemergency medicine(EM)residentshadtheopportunitytoperform cricothyrotomyonalivingpatient.2 Anotherstudyindicated thatevenexperiencedEPsfeltthattheylackedtrainingin performingcricothyrotomyandthatthisprocedural inexperiencecoulddirectlyaffectthesurvivalofapatientand leadtohighemotionalpressure.3 Lastly,thecritically importantnatureoftheproceduremakeslearningonshifta patientsafetyissue.

Thecombinationofcompetency-basedapproachesusing checklist-basedassessmentsandthesimulationenvironment hasdemonstratedalongtrackrecordofimprovingresident performanceonspeciﬁcproceduralskills.4–8 Whilevarious instructionalvideosandchecklistsmeantfordifferent specialtiesareavailable,astandardized,reliable,valid, comprehensive,anddichotomousproceduralchecklistfor assessmentofperformingemergencycricothyrotomyforEM residenteducationislacking.9–11 Historically,thestudysite program ’smethodforteachingtheopenemergency cricothyrotomyoccurredduringtheannual “ rare procedures” simulationlab.Thesesessionsinvolvednonstandardizedpracticewithatasktrainerorsheeplarynxthat didnotfollowacompetency-basedtrainingmodel.

OBJECTIVES

RecognizingthisunmetneedinEMproceduraltraining forourlearners,wesetseveralobjectivesinthisstudy.The primaryobjectivewastodevelopachecklistcontaining thecriticalstepsforperforminganopenemergency cricothyrotomybasedoninputfromamultidisciplinary teamofexperts.Thesecondobjectivewastoevaluatethe reliabilityandvalidityofthechecklistforperformingopen emergencycricothyrotomy.Finally,thethirdobjectivewas tousethechecklisttoassessagroupofEMresidentsontheir abilitytoperformtheprocedureonasimulatorandcompare performancebytrainingyear.

CURRICULARDESIGN

ChecklistDevelopment

WeperformedaliteraturereviewinMEDLINEandthe MedEdPortaltoassesspublishedliteratureforemergency

cricothyrotomyprocedurechecklistsandcurriculums.Key phrasesforliteraturesearchesincluded “ emergency cricothyrotomycurriculum,”“emergencycricothyrotomy checklist,”“emergencycricothyrotomyprocedure,” “emergencycricothyrotomysimulation,”“ emergency cricothyrotomyresident,”“emergencycricothyrotomy residency,”“emergencycricothyrotomyeducation,” and variationsandcombinationsofthekeywords/phrases. Searchesincludedallarticlespublisheduntilthesearchdate ofNovember1,2020.AnEMproceduralskillstextbookand asurgicaltechniquetextbookwerereviewedaswell.12,13 We alsoevaluatedrelevantarticlesfromthebibliographiesofthe textbooksandincludedstudiesforinclusion.

WeusedtheStufflebeamframeworkforchecklist developmentaftertheliteraturereviewwascompleted.14 A preliminarydichotomous(“done” vs “incorrect/notdone”) checklistwasdevelopedbasedonthisliteraturereview.The initialchecklistwassenttoapanelof13expertscomprisedof emergencyphysiciansandtraumasurgeonsofvarying practicetype(academic,community,military),geographic practicelocation(withintheUnitedStates),andgender. Practicetypeincluded10academic,twocommunity,andone militaryhospital;practicelocationincluded fiveinternaland eightexternal;andbreakdownbysexwas fivefemaleand eightmale.Expertswereblindedtoeachother’sidentities andcomments.Weinformedtheexpertpanelofthe curriculum’sintendedaudienceofEMresidentswith anticipateduseforacompetency-basedcurriculum.Weused amodifiedDelphiapproachtoseriallyrefinethechecklist andreachconsensusona finalchecklist.15,16 Wethenpilottestedthechecklisttoensuretheitems,wording,and formattingwereideallyoperationalized.Finally,theexpert panelrevieweditfor finalapproval.

StudyPopulation

Thestudywasperformedatasingleurbanacademic centerwithafour-yearEMresidencytrainingprogram.Four residentswereexcludedfromthestudyduetotheir participationinthechecklistdesignandassessmentprocess. AllotherEMresidentswereincludedintheeducationaspart oftheannualsimulationcurriculum;however,participation inthestudywasvoluntary.Thestudywasreviewedbythe institutionalreviewboard(IRB)atNorthwesternUniversity, FeinbergSchoolofMedicineanddeterminedtobeexempt. Writteninformedconsentwasobtainedfromparticipants usingaconsentformapprovedbytheIRB.

Assessment

Assessmentsoccurredinthesimulationcenterusinga simulationmanikin(TraumaMan,Simlab,Seattle,WA) fromAugust31–September28,2021.Performance assessmentsweredocumentedusinganelectronicversionof thechecklistinQualtrics(Qualtrics,Seattle,WA),including adichotomous “Yes” or “No” forcompletionofeachstep.

Onein-personrater(DL)wassituatedadjacenttothe simulationmanikinwiththeabilitytomoveaboutthe simulationroomtoensureidealvisualization.Audiovisual recordingoftheassessmentincludedonecameraoverhead providingadirectoverheadviewandasecondcamera situatedtoprovideaviewfromtheside.Eachparticipant assessmentwasrecordedfromstarttocompletionofthe checklist.Thedualvideofeedswithaudioweresavedasa singleside-by-sidevideorecording.Theserecordedvideos werereviewedbyasecondrateratalatertime.Weusedan onlinerandomnumberpicker(https://www.random.org/ lists/)toselect30%oftheparticipantsforscoringbythe secondrater.17 Thesecondrater(AR)scoredtherandomly selectedsampleofvideorecordingsusingthesameelectronic assessmentinstrumentinQualtrics.

DataAnalysis

Thechecklistwasanalyzedforinter-raterreliabilityand validityamongacohortofEMresidentsrangingfrom PGY1-4.Inter-raterreliabilitywascalculatedoverallandfor eachcheckliststepusingtheCohenkappacoefﬁcient.We determinedvalidityusingtheWelch t -testtocomparethe performanceofparticipantswhohadandhadnotperformed anemergencycricothyrotomyinclinicalpracticeor simulationandalsobetweenconsecutivePGYgroups. Analysisofvariancewasusedtocompareperformance amongPGYcohorts.

IMPACT/EFFECTIVENESS

Results

Theliteraturesearchproducedatotalof394articles.After review,13articlesweredeemedsuitabletoinformchecklist development.Anadditionaltwoarticleswereidentifiedand includeduponreviewingreferencesoftheincludedarticles andthetwotextbooks.Wedevelopedapreliminary33-item dichotomouschecklistbasedonthisliteraturereview. Consensuswasachievedafterthreeroundsofrevisions, resultinginthefourthversionofthechecklistbeingthe final version.Wethentestedthe final27-itemchecklistamong ourselvesforusability.Onlyminorwordingandformatting changesweremadetoensureidealoperationalizationofthe checklist.The finalchecklistwasapprovedbytheexpert panelafterusabilitytesting,andnoadditionalrevisions weresuggested.

The table includespercentagecorrectofchecklistitems, inter-rateragreement,andCohenkappacoefﬁcientsforeach checklistitem.Overall,inter-raterreliabilitywasstrong (κ = 0.812)withindividualchecklistitemsrangingfromfair tonearlyperfectagreement,withoneitemhavingslight agreement.Atotalof56residentsparticipated,including15 PGY-1,14PGY-2,13PGY-3,and14PGY-4residents. Whileonlyoneresidenthadperformedanemergency cricothyrotomyonalivepatient,69.6%hadpreviously performedanemergencycricothyrotomyinsimulation.The

averagechecklistscorefortheoverallresidentcohortwas 14.3(52.9%).Emergencymedicineresidentchecklist performancevariedbyPGYclass(Figure).Performance variedsignificantlyamongstPGYgroups(P < 0.001).The PGY-4sperformedbestwithanaveragescoreof16.7 (61.9%)ofchecklistitemscompletedcorrectly.They performedbetterthanPGY-3s,butnotsignificantly(61.9% vs59.5%, P = 0.21).ThePGY-3sperformedsignificantly betterthanPGY-2s(59.5%vs48.9%, P = 0.01).ThePGY-2 performancewasbetterbutnotsignificantlydifferent comparedtoPGY-1performance(48.9%vs.42.7%, P = 0.13).Theresidentswhohadpreviouslyperformedan emergencycricothyrotomyonalivepatientorinsimulation performedsignificantlybetterthanthosewhohadnot (56.8%vs.44.2%, P = 0.005).

Discussion

Althoughweidentiﬁed proceduralnarrativesand checklistswithvaryingdegreesofspeciﬁcityforourlearner groupatthetimeofourliteraturereview,oursearch demonstratedalackofastandardized,validated,reliable, anddichotomousproceduralchecklistforemergency cricothyrotomyforEMresidents.Thischecklistaddsto morerecentlypublishedarticlestargetingattendings, students,and “novice” learners.Thisnewlydeveloped proceduralchecklistforemergencycricothyrotomy addressesthisunmetneedforEMresident proceduraltraining.

Theexpertpanelprovidedcriticalinsightduringthe checklistdevelopment.Ourinitialchecklistfocusedonthe classic “hookanddilator,” scalpel-basedapproachto emergencycricothyrotomy.However,weultimatelyrevised thechecklistbasedonexpertfeedbacktoincludethe additionalacceptedapproachesof “scalpelonly” and “bougie-assisted” emergencycricothyrotomy.Theinclusion ofallthreeacceptedapproachesallowedforamoreversatile checklistthatismoregeneralizabletoallresourcesettings andbetterreﬂectsthevariablereal-worldenvironmentand urgencyoftheprocedure.Theinclusionofmultiple techniquesalsosuggestsgeneralizabilitytootherclinical environments,suchassurgeryandotolaryngology;however, thiswasnottheintendedaudienceatthetimethechecklist wasdeveloped.Whilethereareseveralpotentialoptionsfor performinganemergencycricothyrotomy,includinga needle/wireSeldingertechnique,thischecklistreﬂectsthe developmentwiththeprimaryconstructofusingascalpelbasedapproach.

Thisstudy’sstrongoverallinter-raterreliabilityusingthis checklistandonein-personraterandoneremote-videorater reinforcespreviousstudiesusingasimilartechnique.18,19 Additionally,inter-raterreliabilityusingthismethodwas strongoverall,whichisconsistentwithpriorchecklist developmentstudieswithsimilarmethods.18,19 Most individualitemshadmoderatetonear-perfectinter-rater

Table. Percentcorrect,inter-rateragreement,andreliabilityforindividualchecklist-itemscoring. Checklistitem

1.Gatherssterilesupplies

2. Gathersprimarycricothyrotomyproceduresupplies

3.Gatherssecondary/supplementalcricothyrotomyproceduresupplies

4.Gatherssupplementalintubationsupplies 0%100%n/a*

5.Washeshands

6.Sterilizestheneck

7.Donspersonalprotectiveequipment

8.Proceduralistpositionsonthepatient’srightside

9.Identi ﬁescricothyroidmembrane(CTM)

10.Usesthumbandmiddle ﬁngerofnon-dominanthandtostabilizeairway

11.Confirmsincisionsitewithpalpationbyindex fingerontheCTMusingnon-dominant handwhilemaintainingstabilizationusingthumbandmiddle fingerofnon-dominanthand

12.Usesscalpeltomakeverticalskinincision~2–4cminlengthovertheCTMusing dominanthand

13.DissectsdowntoCTM

14.Re-identiﬁesCTMbypalpationorvisualization

15.Makes~1–2cm(widthofscalpelblade)horizontalincisionthroughCTMwithdominant handandmaintainsscalpelbladeintrachea

16.Maintainspatencyoftract

17.Removesscalpel,onlyaftertrachealhook,Trousseaudilator,bougie,orsecondary scalpelhandleisinplace,maintainingpatencyofCTM

18.ProceduralistdilatesCTM

19.Insertsendotrachealtubeortrach

20.Insertsendotrachealtubeortrachtocorrectdepth

21.Inﬂatesthecuffwitha10-ccsyringe

22.Connectsbag-valve-masktoendotrachealtube/trachandbeginsassistedventilation92.9%94.1%0.638

23.Usescapnographytoconﬁrmtubelocation

24.Listensforbilateralbreathsounds

25.Securesendotrachealtube/trach

26.Orderschestradiograph

27.Documentsprocedure

*Unabletocalculatekappacoefﬁcient duetooneorbothratersgivingthesamescoretoallscoredparticipants.

reliability,overalldemonstratingreliabilityofthechecklist.20 Theitemswiththelowestkappascoresincluded “gathers sterilesupplies” (item1), “identiﬁescricothyroidmembrane” (item9),and “usesscalpeltomakeverticalskinincision ~2–4cminlengthoverthecricothyroidmembraneusing dominanthand” (item12).Wesuspectthatthislikelyreﬂects theremotenatureofthesecondrater,asmishearingarequest forasinglepieceofequipmentorinabilitytoaccurately visualizethemembraneorexactlengthofincisionona recordedvideowouldleadraterstoscoredifferently.This couldhavebeenimprovedwithgreaterverbalizationofall stepsbythelearnerandprimaryraterorhavingasecondinpersonraterwhenable.

Theresidentswhohadperformedanemergency cricothyrotomypreviouslyperformedsignificantlybetter thanthosewhohadnot,demonstratingcriterionvalidityfor thischecklistastherewascorrelationwiththisgroup’sprior experience.Severalstudieswithsimilarmethodshavealso demonstratedcongruent findingsonchecklistvalidity.18,19 Whilenotsignificant,moreseniorPGYresidentsperformed betteraswell.Thismayhavebeenduetoincreasedclinical exposurewithseeinganemergentcricothyrotomyperformed orimprovedproceduralexperiencewithpracticeinthe simulationenvironment.However,despitethesepotential exposuresandpreviousexperiences,thiscohortonly correctlycompletedjustoverhalfofthechecklistitems.

Figure. Emergencycricothyrotomychecklistperformancebyemergencymedicineresidentpostgraduateyear.Boxlimitsrepresentthe25th and75thpercentileswiththemedianchecklistscorerepresentedbythebar. PGY,postgraduateyear.

Additionally,certainitemshadparticularlylow completionrate,including “Gatherssupplemental intubationsupplies” (item4)(0%); “Proceduralistdilates cricothyroidmembrane ” (item18)(3.6%);and “Documents procedure” (item27)(8.9%).Whilesomeofthese completionratesmaybeattributabletothesimulation environment,itisimportanttohighlightthatmerely planningforanintubationwouldnotnecessarilyensure thatallequipmentnecessaryforacricothyrotomywasalso available.Theoverallperformanceofthisresidentgroup, withresidentsonlycompletingroughly50%ofthechecklist items,suggeststhatthecurrent,non-standardized techniqueforteachingemergencycricothyrotomyinthis cohortislackingandthatacompetency-basedapproach usingawell-developedproceduralchecklistmay improveperformance.

LIMITATIONS

Thisstudyhasseverallimitations.First,thesingle-site natureofthestudymaynotreﬂectresidentperformanceat otherinstitutions.Studyingthechecklist’suseatother residencysiteswouldhelptounderstanditsgeneralizability tootherenvironmentswithdifferentapproachestoteaching opencricothyrotomy.Second,whilewerecruitedanexpert panelincludingEMandtraumasurgeryrepresentativeswith diversityinpracticetype,practicelocation,andgender,most oftheexpertspracticedinanacademicenvironment.Despite this,thestepstoperformingtheprocedureshouldnotvaryby practiceenvironmentand,therefore,wedonotbelievethat thislimitsvalidityorgeneralizabilityofthechecklist.Expert panelreviewincludingadditionalcommunityandhybrid expertswouldhelptestthishypothesis.

Third,thechecklistandtestingwereperformedusinga bloodlesssimulationtasktrainer,whichmaynotideally representanactualpatientencounter.However,the infrequentnatureoftheprocedure,asevidencedbyonlyone residenthavingperformedanemergencycricothyrotomy duringtheirtraining,necessitatesanon-clinicalenvironment trainingsimulation.Whileemergencycricothyrotomy simulationexperiencehasbeendocumentedusingsheep larynxand3D-printedmodels,ourstudywasnotperformed usingthesemodelsandinsteadusedacommerciallyavailable trainingdevice.Therefore,wedonotknowtheinﬂuenceof differentsimulationmethodsonthestudyandchecklist performance,andthisremainsanareaforfuturestudy.

CONCLUSION

Wedesignedareliable,valid,dichotomousprocedural checklisttoassessEMresidents’ abilitytoperform emergencycricothyrotomy.Theoverallperformanceofthe residentstestedinthisstudysuggeststhatthecurrentmethod ofteachingemergencycricothyrotomyforthisgroupis insufﬁcient.Giventheneedtodevelopprocedural competencyforthisrarebutpotentiallylife-saving procedure,acurriculumsuchassimulation-basedmastery learningshouldbedevelopedtoensuremasteryofthis procedureforEMresidents.Thechecklistdevelopedinthis studycouldserveasafoundationforsuchacurriculum.

AddressforCorrespondence:DanaE.Loke,MD,MS,Universityof WisconsinSchoolofMedicineandPublicHealth,BerbeeWalsh DepartmentofEmergencyMedicine,800UniversityBayDr.,Suite 310,Madison,WI,53705.Email: dloke@medicine.wisc.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.AccreditationCouncilforGraduateMedicalEducation.ACGME programrequirementsforgraduatemedicaleducationinemergency medicine.2023.Availableat: https://www.acgme.org/specialties/ emergency-medicine/program-requirements-and-faqs-andapplications/.AccessedSeptember11,2023.

2.MakowskiAL.Asurveyofgraduatingemergencymedicineresidents’ experiencewithcricothyrotomy. WestJEmergMed. 2013;14(6):654–61.

3.ZinkW,BernhardM,KeulW,etal.Invasivetechniquesinemergency medicine.I.Practice-orientedtrainingconcepttoensureadequately qualiﬁedemergencyphysicians. Anaesthesist. 2004;53(11):1086–92.

4.BarsukJH,CohenER,CaprioT,etal.Simulation-basededucationwith masterylearningimprovesresidents’ lumbarpunctureskills. Neurology. 2012;79(2):132–7.

5.BarsukJH,McGaghieWC,CohenER,etal.Useofsimulation-based masterylearningtoimprovethequalityofcentralvenouscatheter placementinamedicalintensivecareunit. JHospMed. 2009;4(7):397–403.

6.MillerDT,ZaidiHQ,SistaP,etal.Creationandimplementationofa masterylearningcurriculumforemergencydepartmentthoracotomy. WestJEmergMed. 2020;21(5):1258–65.

7.KleinMR,SchmitzZP,AdlerMD,etal.Simulation-basedmasterylearning improvesemergencymedicineresidents’ abilitytoperformtemporary transvenouscardiacpacing. WestJEmergMed. 2022;24(1):43–9.

8.KleinMR,LokeDE,BarsukJH,etal.Twelvetipsfordeveloping simulation-basedmasterylearningclinicalskillschecklists. MedTeach. 2024.Inpress.

9.MelchiorsJ,TodsenT,NilssonP,etal.Preparingforemergency:avalid, reliableassessmenttoolforemergencycricothyroidotomyskills. OtolaryngolHeadNeckSurg. 2015;152(2):260–5.

10.HockSM,MartinJJ,StanﬁeldSC,etal.Novelcricothyrotomy assessmenttoolforattendingphysicians:amulticenterstudyofanerror avoidancechecklist. AEMEducTrain. 2021;5(4):e10687.

11.IssaN,LiddyWE,SamantS,etal.Emergencycricothyrotomyduringthe COVID-19pandemic:howtosuppressaerosolization. TraumaSurg AcuteCareOpen. 2020;5(1):e000542.

12.RobertsJR,CustalowCB,ThomsenTW.Cricothyrotomyand percutaneoustranslaryngealventilation.In: ClinicalProcedures inEmergencyMedicineandAcuteCare.Philadelphia,PA: Elsevier,2020:127–141.e3.

13.Ciofﬁ WG,AsensioJA,AdamsCA,etal.Chapter3.Surgicalairways: tracheostomyandcricothyroidotomy.In:TownsendCMandEversBM (Eds), AtlasofTrauma/EmergencySurgicalTechniques.Philadelphia, PA:Elsevier,2014:23–34.

14.StufﬂebeamDL.Guidelinesfordevelopingevaluationchecklists:the checklistsdevelopmentchecklist(CDC).2000.Availableat: https:// wmich.edu/sites/default/ﬁles/attachments/u350/2014/guidelines_cdc. pdf.AccessedSeptember11,2023.

15.WaggonerJ,CarlineJD,DurningSJ.Isthereaconsensuson consensusmethodology?Descriptionsandrecommendationsforfuture consensus research. AcadMed. 2016;91(5):663–8.

16.HassonF,KeeneyS,McKennaH.ResearchguidelinesfortheDelphi surveytechnique. JAdvNurs. 2000;32(4):1008–15.

17.WalterSD,EliasziwM,DonnerA.Samplesizeandoptimaldesignsfor reliabilitystudies. StatMed. 1998;17(1):101–10.

18.KleinMR,SchmitzZP,AdlerMD,etal.Developmentofarigorously designedproceduralchecklistforassessmentofemergencymedicine residentperformanceoftemporarytransvenouscardiacpacing. AEMEducTrain. 2021;5(3):e10566.

19.ZaidiHQ,DhakeSS,MillerDT,etal.Emergencydepartment thoracotomy:developmentofareliable,validatedchecklistfor proceduraltraining. AEMEducTrain. 2019;4(2):139–46.

20.McHughML.Interraterreliability:thekappastatistic. BiochemMed (Zagreb). 2012;22(3):276–82.

EDUCATION SPECIAL ISSUE -BRIEF RESEARCH

ChristineMotzkus,MD,PhD* CaseyFrey,MD†

AloysiusHumbert,MD*

*IndianaUniversitySchoolofMedicine,DepartmentofEmergencyMedicine, Indianapolis,Indiana † BooneCountyEmergencyMedicine,Indianapolis,Indiana

SectionEditors:JulesJung,MDandAndrewGolden,MD

Submissionhistory:SubmittedJune2,2024;RevisionreceivedNovember22,2024;AcceptedNovember26,2024

ElectronicallypublishedFebruary5,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.21292

Introduction: Incorporatingvirtualinterviewsintoresidencyrecruitmentmayhelpdiversifyaccessto residencyprogramswhilereducingthecostinvolvedwithtravelandlodging.Programsmaybemore likelytorankstudentstheyhavemetinpersonataninterviewwhencomparedtounknownvirtual applicants.Ourobjectivewastocharacterizehomeinstitution,in-state,andin-regionmatchratesto emergencymedicine(EM)residencyprogramsforfourth-yearmedicalstudents.

Methods: WeusedNationalResidencyMatchingProgramdataavailabletotheprogramdirectorto identifymedicalschoolandmatchlocationoffourth-yearmedicalstudentswhointerviewedatalargeEM residencyprogramintheMidwestfrom2018–2023.Students’ medicalschoolsandultimatelymatched programsweremappedtoElectronicResidencyApplicationServicegeographicregions;subgroup analysesevaluatedallopathicandosteopathicmedicalstudentsseparately.Weusedchi-squareteststo compareproportionsofstudentsmatchingtohome,in-state,orin-regionprogramsacrossyears.

Results: Therewere1,401applicantswithmatchinformationavailable.Thepercentageofstudents matchingtoahomeinstitutionremainedstableoverthecourseofthestudy.Thepercentageofstudents matchingtoanin-stateinstitutionincreasedoverthe firsttwoyearsofvirtualinterviewsrisingfrom23.2% inthe2020matchto30.8%in-statematchesforthe2022match.Chi-squaretestsdidnotrevealany significantdifferencesamonggroupsforallapplicants.Allopathicmedicalstudentsdemonstrateda significantincreaseinmatchestohomeinstitutions.In-regionmatchesstayedrelativelystableoverthe studytimeframeregardlessofsubgroup.

Conclusion: Virtualinterviewschangedthelandscapeofresidencyinterviews.Homeinstitutionandinstatematchesmaybemorelikelyforapplicantsfromallopathicschoolswhoparticipatedinavirtual interviewasbothprogramsandapplicantsaremorefamiliarwitheachother;however,ourstudydidnot ﬁndconvincingevidenceofthispossibilityamongallapplicants.Additionalstudyisneededtodetermine ongoingeffectsofthetransitiontovirtualinterviews.[WestJEmergMed.2025;26(2)285–289.]

INTRODUCTION

Interviewsareacriticalelementoftheresidencymatch processforbothresidencyprogramsandmedicalstudentsto ensureselectionofhigh-qualityapplicantsandtraining programs.UntiltheCOVID-19pandemicstruckinearly 2020,nearlyallinterviewswereconductedinperson requiringmedicalstudentstoarrangetraveltodifferent programlocations,aprocessknowntobeexpensiveand

time-consuming.1 Withtravelrestrictionsandsocial distancingconcerns,the2021Matchcyclemarkedthe ﬁrst useofvirtualinterviewsforemergencymedicine(EM) residencyspots.

Thetransitiontovirtualinterviewswasmarkedwith uncertaintyfrombothstudentsandprograms.Studentswere uncertainastohowtheywouldbeabletoassessprograms whileprogramsfeltsimilarlyabouttheabilitytoassess

students,particularlythosewhohadnotcompleteda rotationattheirprogram.Programdirectorshavealsobeen notedtoreportdifficultyassessingthe fitofapplicantsdespite theincreasedconvenienceofvirtualinterviews.2 However, virtualinterviewsofferincreasedopportunitiesforstudents tocompleteadditionalinterviewsatlowercost,whichhas beennotedinsurgicalspecialtieswithatransitiontovirtual interviews.3 Programdirectorsalsoexpressedconcernsthat programswouldmatchmorestudentsfromtheirhome programs,reducingopportunitiesforprogramstobenefit fromstudentswithnon-homogenousmedicalstudent training.2 Forfellowshipapplicants,similarconcernshave beenexpressed;however,therewasnotfoundtobea significantincreaseininterviewscompletedbypediatricEM fellowshipapplicationsorachangeinfellowshipapplicants matchingwithintheirpreferredstate.4

Weevaluatedwhetherthetransitiontovirtualinterviews atonelarge,MidwesternEMprogramcorrelatedwith increasednumbersofstudentsmatchingtotheirhome programs.Additionally,weevaluatedwhetherthe transitiontovirtualinterviewscorrelatedwithincreased numbersofstudentsmatchingtoin-stateor in-regionprogram.

METHODS

StudyPopulation

WeobtaineddatafromtheNationalResidentMatching Program(NRMP)forrankedmedicalstudentsfromone MidwesternEMresidencyprogramfortheyears2018–2023.

DataCollectionandAnalysis

Allmedicalstudentswhointerviewedatonemidwestern universityfrom2018–2023hadtheirhomeandmatched programsrecordedaspartofroutineNRMPrecordkeeping. Alldatawasstoredonasecureserver.Thisdatawas deidentifiedbytheprogramdirectorandcodedtodetermine whethertheintervieweematchedwithaprogramfromanyof thefollowing:1)thesameinstitutionastheirmedicalschool; 2)thesamestateastheirmedicalschool;and3)thesame regionastheirmedicalschool.Regionsweredefined accordingtoElectronicResidencyApplicationService (ERAS)geographicpreferenceregions;theseregionswere designatedbeginningin2022.Intervieweeswereableto signalageographicpreferenceaccordingtotheseregions. Areasofdisagreementregardingprogramaffiliationwere discussedbetweenauthorsandresolved.AuthorAH performedtheinitialcoding,andafterreviewbyauthorCM anydiscrepancieswereresolvedbetweenaffiliationsusing resourcesincludingtheAccreditationCouncilforGraduate MedicalEducationandprogramwebsitestoverify affiliations.Weusedchi-squaredteststoassessdifferences betweengroups.5 Weconductedsubgroupanalysesto evaluatedifferencesbetweenapplicantsfromallopathic (MD)andosteopathicschools(DO).

Outcome

Theprimaryoutcomeofthisstudywaspercentageof studentswhomatchedtoprogramswithintheirhome institution,state,orregion.

EthicsStatement

Thisstudywasreviewedandapprovedbytheinstitutional reviewboard.Nofundingwasobtainedforthisstudy.

RESULTS

Overthesixinterviewcyclesincludedinthestudyperiod, 1,401studentscontributeddatatotheNRMPandwere subsequentlycodedtohavingmatchedattheirhome programortoprogramswithinthesamestateorregion. Therewasanincreaseinthenumberofinterviewscompleted bytheprogramoverthesix-yearperiodwithanaverageof 201interviewscompletedinanin-personformatpriortoand duringthe2020pre-pandemicinterviewseason.Afterthe globalCOVID-19pandemic,beginninginthe2021 recruitmentseason,therewasaninitialincreaseinthe numberofinterviewsofferedastheformatswitchedto virtual.Virtualinterviewscontinuedthroughoutthe2022 and2023interviewseasons,butoverallnumbersof interviewsdecreasedduringthistimeframe(Table1).

Anincreasingpercentageofstudentsmatchedtotheir homeinstitutionfrom2020–2023,withthelargestincrease beingobservedoverthe2020–2021seasoncorresponding withthetransitiontovirtualinterviews;however,thistrend wasnotstatisticallysignificant.Notably,proportionsof studentsmatchingtohomeinstitutionsweresimilarin2018 and2023.Anincreasingnumberofstudentsmatchedtoinstateinstitutionsfrom2020to2021;furtherincreasesinthe percentageofin-statematcheswereobservedfrom2021to 2022beforestabilizingatapproximately30%ofin-state matchesinthe finalincludedyear,closeto2018levels.Inregionmatchesremainedroughlystableacrossthestudy periodwithslightlylessthanhalfofstudentsmatchingtoan institutionintheirhomeERASgeographicregion(Table1). Chi-squaretestsdidnotrevealanysignificantdifferences betweengroups.

Whenevaluatingthesubgroupofapplicantsfrom allopathicschools,itappearedthatanoverallincreased proportionoftheseapplicantsmatchedtotheirhome institutionsoverthecourseofthesixyearsofthestudy(P < 0.01).Thisincreasewasmostnotablein2023when31.8%of theseapplicantsmatchedtotheirhomeinstitutions,nearly doublethatofanyprioryear.Therewasalsoanincreasein MDapplicantsmatchingtoinstitutionswithinthesamestate astheirmedicalschooloverthestudyperiod(P = 0.01). Regionalinstitutionmatchesforallopathicapplicants remainedstableoverthestudyperiod.Osteopathic applicantsdidshowanincreaseinproportionofthem matchingtoin-stateorin-regioninstitutions;however,these trendswerenotstatisticallysigniﬁcant(Table2).

Applicationyear

DISCUSSION

Wefoundnostatisticallysignificantdifferenceofmatch locationamongallapplicantsapplyingtooneMidwestern EMresidencyprogramaftertheimplementationofvirtual interviews.Similarnumbersofapplicantsmatchedtothe sameERASregionastheirmedicalschoolregardlessofinpersonorvirtual-interviewformat.Applicantsfrom allopathicschoolsdidshowanincreasedproportion matchingattheirhomeorstateinstitutionsafterthe implementationofvirtualinterviews,andthis findingwas statisticallysignificant.Anincreasingnumberofosteopathic applicantsmatchedtoin-stateinstitutionsafterthe implementationofvirtualinterviews.Thistrenddidnot reachstatisticalsignificancebutdidapproachsignificance. Virtualinterviewsreducecosttoapplicantsandmayallow applicantstocompleteinterviewsatadditionalprograms. Correspondingly,thenumberofinterviewsconductedbythe programincreasedinthe firstyearofvirtualinterviewsprior tostabilizingatasomewhathighernumberthaninthe previoustimeframewithin-personinterviews.Increased numbersofinterviewsofferedmeantincreasedtimedemands fromfacultyparticipatinginthoseinterviewsandmayhave contributedtointerviewfatigue.Notably,oneobstetrics/ gynecologyprogramdidnot findanincreaseinnumbersof interviewsofferedtoorcompletedbyapplicants.6 Conversely,applicantshavingtheabilitytocompletemore interviewsmayallowforfewer financialdisparitiesto perpetuateamongstudents,assomestudentsmayhave previouslylimitedinterviewsduetocostconcerns.An AssociationofAmericanMedicalCollegessurveyshowed thatpreviousmonetarycostsforresidencyinterviewsranged from$1,000to$11,580(median$4,000).7 Usingavirtual processmayalsobenefit financiallychallengedstudentsby eliminatingthecostof flightsandhotels,andothertravel expensespreviouslynecessarytocompletetheinterview season.Thetransitiontovirtualinterviewsmayhave downstreameffectsonthediversityoftheEMworkforceif applicantsarelesslikelytomatchoutsidetheirhomeorinstateprograms.8

Table2. Allopathicandosteopathicapplicantmatchlocationbyyear.

Higherpercentagesofallopathicstudentsmatchingtoinhomeandin-stateprogramsmayindicatethatprogramsand applicantsalikepreferentiallyrankeachotherdueto familiarity,althoughgiventheuncertaintiesofthe COVID-19pandemicandrestrictionsonawayrotations from2021onward,itisdifﬁculttoattributethisincreaseto onefactor.Itiswellknownthatmoststudentshaveastrong geographicpreferencetomatchneartheirhomeandthat locationisasigniﬁcantdriverofresidencyprogramchoice.9

Applicationyear

DOapplicants

MD, DoctorofMedicine; DO,DoctorofOsteopathicMedicine.

Table1. Applicantmatchlocationbyyear.

Thistrendhasalsobeenseeninorthopedicsurgeryprograms withtheirtransitiontoavirtualinterviewprocess10; however,thisdidnotholdtrueforneurologyandgeneral surgeryprograms.11,12 Students’ geographicpreferencesin EMseemtohavebeenamplifiedbythetransitiontovirtual interviews,particularlyamongallopathicapplicants.While virtualinterviewsarenottheonlychangethatoccurredinthe residentrecruitmentprocessduringthe2021andsubsequent interviewseasons,itisplausiblethatinterviewformatisone ofmanyfactorsinfluencingstudentinterviewbehavior, althoughwedidnot findevidenceofthisbehavioramongall applicantsinourstudy.

Itwasnotpossibletodeterminewhateffectotherfactors includingtravelrestrictions,societalunrest,andother changeshadonapplicantbehaviorandtheirprocessof selectingapplicationlocations,interviews,andultimately matchlocation.Further,itisdifficulttounderstandwhat effecttheadventofprogramsignalinghadonboth intervieweeandinterviewerbehaviorafteritsintroductionin 2022,andthisremainsanactiveareaofstudy. Understandingthestabilityofthein-regionmatchratesis difficulttointerpretbutsuggeststhatsimilarnumbersof studentsarelookingtoleavetheirmedicalschoolregionover time.TheERASregionswerealsodefinedduringthistime frame,whichmayhavealteredstudents’ perceptionsof region.Thesegeographicpreferencesareanareaforongoing studyasprogramsevaluateresidencymatchestoservetheir communitiesandensuremutuallybeneficialmatches betweenprogramsandapplicants.

LIMITATIONS

Thisstudyhasmultiplelimitations.First,onlyonelarge, MidwesternEMresidencyprogramisrepresented.Thereare multipleotherfactorsincludingthenumeroussocialand societalchangesthattookplaceduringtheCOVID-19 pandemic,aswellastheintroductionofpreferencesignaling certainlyimpactedapplicants’ matchpreferencesand interviewbehaviorsinadditiontothetransitiontoavirtual interviewmodel.Wewereunabletocontrolforthesefactors orotherchangestoapplicantbehaviorsuchasthepotential desiretoremainclosertohomewhentravelwasmore constrainedduringtheglobalpandemicorasaresultof ongoingsocietalunrest.Ofnote,overallapplicantbehavior alsochangedacrossmatchyearswithadecreasein applicationsbeginningin2022andincreasedproportionsof osteopathicandinternationalmedicalgraduates.13 Additionally,EMapplicantscontinuetobeadvisedto completenomorethanoneawayrotationperinterview cycle,whichlimitsprogramandapplicantexposuretoeach other.Further,whileERASregionswereused,thisdoesnot accountforapplicantswhomayhavematchedjustacrossthe bordertoanotherregion,creatingafalseinﬂationof geographicdistance.

CONCLUSION

Virtualinterviewsarenowa fixtureoftheresidency applicationprocesswithEMprogramsrequiringthisprocess toparticipateinthematch.14 Wedidnot findstatistically significantdifferencesinhomeinstitutionorin-statematch ratesforallapplicants;however,allopathicapplicantsdid haveanincreaseinproportionofstudentsmatchingtotheir homeinstitution.Whileourdatadoesnotsuggestanoverall impactofvirtualinterviewsinmatchdecisionsmadeby applicantsorprograms,thesetrendswarrantadditional monitoringforongoingimpact,particularlyamong allopathicapplicantswhereanincreaseinhomeandin-state matcheswasstatisticallysignificant.Furtherlargerstudies wouldbehelpfultounderstandhowtransitioningtothis modelaffectsapplicantmatchbehavior.Additionalstudies wouldbebeneficialtohelpprogramsfurtherunderstandkey areasoffocusandensuresuccessfulinterviewplanningfor EMprograms.

AddressforCorrespondence:ChristineA.Motzkus,MD,PhD, IndianaUniversitySchoolofMedicine,DepartmentofEmergency Medicine,2651EDiscoveryPkwy.,RoomC3018,Bloomington, IN47408.Email: cmotzkus@iuhealth.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.JoshiA,BloomD,SpencerA,etal.Videointerviewing:areviewand recommendationsforimplementationintheeraofCOVID-19and beyond. AcadRadiol. 2020;27(9):1316–22.

2.PonterioJM,LevyL,LakhiNA.Evaluationofthevirtualinterview formatforresidentrecruitmentasaresultofCOVID-19 restrictions:residencyprogramdirectors’ perspectives. AcadMed. 2022;97(9):1360–7.

3.NewsomeK,SelvakumarS,McKennyM,etal.Shifting thesurgicalresidencymatchtoa100%virtualinterview formatduringtheCOVID-19pandemic:howhasitaffected placementintosurgicaltrainingprograms? AmerSurg. 2023;89(4):935–41.

4.BaghdassarianA,BaileyJA,CaglerD,etal.Virtualinterviewsandthe pediatricemergencymedicinematchgeography:anationalsurvey. WestJEmergMed. 2024;25(2):186–90.

5.PreacherK.J.2001.Calculationforthechi-squaretest:aninteractive calculationtoolforchi-squaretestsofgoodnessof ﬁtandindependence [computersoftware].Availableat: http://quantpsy.org AccessedJanuary20,2024.

6.Santos-ParkerKS,HammoudMM,WinkelAF,etal.Distributionsof residencyinterviewswiththeimplementationofvirtualinterviews andstandardizationofinterviewofferdates. JSurgEduc. 2022;79(5):1105–12.

7.AssociationofAmericanMedicalColleges.2024.Thecostof interviewingforresidency.Availableat: https://students-residents. aamc.org/ﬁnancial-aid-resources/cost-interviewing-residency AccessedMarch30,2024.

8.CapersQ,JohnsonA,BerlacherK,etal.Theurgentand ongoingneedfordiversity,equity,andinclusioninthe cardiologyworkforceintheUnitedStates. JAmHeartAssoc. 2021;10(6):e018893.

9.HasnieUA,HasnieAA,Preda-NaumescuA,etal.Exploringmatch space:howmedicalschoolandspecialtycharacteristicsaffect residencymatchgeographyintheUnitedStates. AcadMed. 2022;97(9):1368–73.

10.NestlerAJ,FeibelBM,BeasonAM,etal.Thestudentyouknow: orthopedicsurgeryhomeprogrammatchratesandgeographic relationshipsbeforeandafterCOVID-19. JSurgEduc. 2022;80(3):476–82.

11.BeinhoffP,AttlassyN,CarlsonC.Nogeographicdistributionchange amongresidencyapplicantsintheneurologymatchduringCOVID-19. Cureus. 2023;15(2):e34898.

12.BeesleyH,PernarL,KettoolaY,etal.Theassociationbetween virtualinterviewingandgeographicaldistributionofmatched residencyprogramsforgeneralsurgeryapplicants. JSurgEduc. 2022;80(2):194–9.

13.NationalResidencyMatchingProgram.2023.Resultsanddata:2023 mainresidencymatch.Availableat: https://www.nrmp.org/match-data/ 2023/06/results-and-data-2023-main-residency-match/ AccessedNovember6,2024.

14.AssociationofAmericanMedicalColleges.2024.AAMCinterview guidanceforthe2022–2023residencycycle.Availableat: https://www. aamc.org/about-us/mission-areas/medical-education/interviews-gmewhere-do-we-go-here.AccessedNovember6,2024.

ORIGINAL RESEARCH

Two-yearResultsofanEmergencyDepartmentNightShift Buy-outProgram

CharlotteW.Croteau,MD

JoshuaN.Goldstein,MD,PhD

LaurenNentwich,MD

AliS.Raja,MD,DBA,MPH

MichaelVanRooyen,MD,MPH

JoshuaJ.Baugh,MD,MPP,MHCM

SectionEditor:LauraWalker,MD

HarvardMedicalSchool,MassachusettsGeneralHospital,Departmentof EmergencyMedicine,Boston,Massachusetts

Submissionhistory:SubmittedMarch4,2024;RevisionreceivedOctober23,2024;AcceptedOctober31,2024

ElectronicallypublishedDecember31,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20303

Introduction: Emergencyphysicianshavethehighestratesofburnoutamongourphysicianpeers,with priorliteraturesuggestingclinicianschedulescanplayasigniﬁcantroleinburnout.Weassessedour transitionfromatenure-andage-basedparadigmtoanegalitarian,nightshiftbuy-outprogramthat allowsschedule ﬂexibilityforphysiciansatallstagesoftheircareers.

Methods: Thenightshiftbuy-outprogramwasimplementedintheemergencydepartment(ED)ofan academic,quaternary-carecenterthattreatsapproximately100,000adultpatientsannuallywith56 facultyemergencyphysicians.Wesoughttocreateacost-neutralprogram,carefullybalancing incentivesbetweennocturnistsandthosewantingtoreduceallottednightshifts.Ultimately,theprogram wasdesignedtoallowallfacultytobuyoutofanynumberofnightsfor$500pernightshift,withthefunds generatedusedtoincreasenocturnistsalaries.Weanalyzedtwoyearsoftheprogram(July2022–June 2024)toassesstrendsinnightshiftbuy-outs,theprimaryoutcome.Wealsoconductedanall-faculty surveyaftertheprogram’s ﬁrstyeartogaugesentimentsabouttheprogram.

Results: Overtwoyears,22faculty(42%)fullyboughtoutofnights;anadditional10(15%)boughtoutof somenights.Byyeartwo,theprogramcouldgrantallfacultytheirpreferrednight-shiftallotment.Faculty whoboughtoutfullyhadworkedlongerinEMonaverage,workedfewerclinicalhoursperyear,were morelikelytobeassociate/fullprofessors,andwerelesslikelytobewomen.Nocturnistshadthehighest meanclinicalhoursofthefourgroups,hadthelowestaveragetenure,andwereleastlikelytobe associate/fullprofessors.Atotalof86%offacultyrespondedtothesurvey,towhichmorethan80%of thosebuyingoutreportedthatreducingthenight-shiftburdenwaseither “veryimportant” or “criticalfor continuinginthisjob.”

Conclusion: OuracademicEDtransitionedfromatenure-andage-based,overnightshiftparadigmto anegalitarianbuy-outprogramthatallowsphysicians ﬂexibilityatallcareerstages.Thisapproachcould improvecareersatisfactionandreduceburnoutamongemergencyphysicians.[WestJEmergMed. 2025;26(2)290–294.]

INTRODUCTION

Emergencyphysicians(EP)havethehighestratesof burnoutamongourphysicianpeers.1 Maslachdefines burnoutasthetriadofdepersonalization,emotional exhaustion,anddecreasedsenseofpersonal accomplishment.2 Whilemuchefforthasbeendirected toward findingmeaningfulsolutionstocounteractburnout inour field,theproblemonlyappearstobeworsening.Inthe

2022MedscapePhysicianBurnoutandDepression Report,therewasasigniﬁcantincreaseinburnout amongEPsbetween2021and2022,from43% to60%.3

Priorstudiessuggestthatonefactoraffectingburnoutin medicineisaphysician’sclinicalschedule.Nightshiftshave beenshowntonegativelyinﬂuencejobsatisfactionamong EPs.4 While “exhaustion” oftenrefersto “emotional exhaustion” intheburnoutliterature,sleepdeprivationhas beenidentiﬁedasacontributingfactortodecreasedpersonal well-being,lowerqualityofcare,andharmfulhealth outcomes.5–7 Sequentialnightshifts,inparticular,havebeen associatedwithreducedcognitiveperformanceinEPs,and shiftworkingeneralhasbeenassociatedwithadisruptionin circadianrhythms.8 Whileprovidingcarearoundtheclockis fundamentaltothedutyofemergencydepartments(ED),the 24/7shiftsalsolikelycontributetothehighburnoutrates amongEPs.

Despiteconcernsaboutnightshifts,somephysicianselect toworkonlyovernight.Reasonscitedforchoosinga nocturnistscheduleincludemoreindependence,moretime withfamily,highersalary,andscheduling ﬂexibility.9 Hiring dedicatednocturnistsmayallowsomephysicianstoavoid undesirablenightshiftswhileenablingotherstooptintoa primarilynight-shiftschedule.AccordingtoMaslach’ s theoryofburnout,increasingemployees’ controlovertheir workcandecreaseburnout;allowingphysicianstooptinor outofnightsmaybeawin-winforeveryone’swell-being.2 In ouracademicED,wetransitionedfromatenure-andagebasednightsparadigmtoanegalitarian,nightshiftbuy-out programthatallowsphysicians ﬂexibilityatallcareerstages. Goalsincludedbudgetneutrality,improvingequity(by givingallfaculty,irrespectiveofage,equaloptions),and increasingagency(bygivingallfacultyopportunitytoadjust theirscheduletomatchtheirownneeds).Thisstudyassessed patternsinnightshiftbuy-outsandEPs’ sentimentsabout theprogram.

METHODS

StudyDesignandSetting

Thisretrospective,cohort,institutionalreviewboardexemptstudywasconductedinanEDwithinanacademic, quaternary-carecenterthatseesapproximately100,000adult patientsannually.Ourdepartmentincludesbothapediatric sectionandanadultsection;thisstudyfocusesonthestafﬁng oftheadultsection.Theadultattendinggroupinthestudy EDcomprises56facultyand7–9fellowsperyear.Only facultywereeligiblefortheovernightbuy-outprogram; fellowsdidnothavethisoption.Thereare13adultattending shiftsper24-hourperiod,threeofwhichareovernightshifts. Historicallyinourdepartment,attendingnightshiftswere allocatedbasedonacademicrank,withanadditionaloption tostopworkingnightsaltogetheratage60,regardlessof academicstatus.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencyphysicians(EP)havethehighest ratesofburnoutamongphysicians,withprior literaturesuggestingclinicianschedulescan playasigni ﬁ cantrole.

Whatwastheresearchquestion?

Doesanightshiftbuy-outprogramimprove physiciancareersatisfactionandreduce burnoutamongemergencyphysicians?

Whatwasthemajor ﬁndingofthestudy?

Morethan80%ofphysiciansbuyingoutof nightshiftsreportedthiswaseither “ very important ” or “ criticalforcontinuingin thisjob. ”

Howdoesthisimprovepopulationhealth?

Wetransitionedfromatenure-andage-based overnightparadigmtoanegalitarianbuy-out program.Thiscouldimprovecareer satisfactionandreduceburnoutamongEPs.

NightShiftBuy-outProgram

Wesoughttocreateanewprogramwhereallfacultycould buyoutofnightshifts.Tofacilitatethis,werecognizedthe needtohiremorenocturnists.Ourgoalwasacost-neutral program,requiringcarefulbalancingofincentives. Therefore,severalruleswereestablishedfortheprogram.

Allfacultymemberswereeligibleafteroneyearofservice, regardlessofacademicrank;overtwoyearsourprogram evolvedintothesystemdescribedbelow.Todeterminehow manybaselinenightshiftsEPsinourdepartmentowed,we usedaproratedequationbasedontotalclinicaltime, adjustedeachyeardependingonthemakeupoftheattending rosterandschedulingneedsofthedepartment.Most physiciansinourdepartmentowedbetween12–24night shiftsperyear.Physicianswerethenofferedtheoptionof reducingtheirnumberofnightshiftsfortheyearinexchange forasalaryreductionofaspeciﬁcdollaramount($500)per nightshift.Thisnumberwaschosenbecauseitreﬂectsthe paydifferentialpershiftforanocturnistinourgroup. Physicianscouldbuyoutofanynumberofnightshifts;they coulddecreasetheirnightsbyasingleshift,buyoutofall nightshifts,oranythinginbetween.Totalannualclinical hoursowedbythesephysiciansdidnotchange:bought-out nightshiftswereinsteadconvertedtodaysandevenings.The fundsgeneratedbybought-outnightswereusedtoincrease thesalariesofnocturnistscomparedtonon-nocturnist

attendings,keepingtheprogramcost-neutral.Nocturnists couldalsopicktheexactdaystheywishedtowork,providing totalschedulecontrolasanaddedincentive.

Wedidmaintainanadditionaloptionforfacultyoverthe ageof60.Thesefacultyweregivenachoiceregardinghow theywouldliketodecreasetheirnights:theycouldbuyoutas above,workmoreweekendsinsteadofnightsina1:1 proportion,orincreasetheirtotalclinicalhoursinexchange fordecreasingnights.

TheEMnightshiftbuy-outprogramwasoriginally implementedonJuly1,2022.Allfacultyhadtocommitto theirbuy-outplanforonefullyear,withanoptiontomodify theirchoicesattheendofeachyear.Whilewearecurrentlyin yeartwoatthetimeofwriting,allbuy-outdecisionshave alreadybeenmadefortheprogram’sfullsecondyear.

OutcomeMeasuresandDataCollection

Weanalyzedtwoyearsofprogramdatatoassesspatterns innightbuy-outsamongthefaculty,theprimaryoutcome measure.Wealsoevaluatedthedemographiccharacteristics ofparticipatingEPsseparatedintofourgroups:thosewho1) hadfullbuy-outfromnights;2)hadpartialbuyoutofnights; 3)hadnobuy-outofnights;and4)werenocturnists.

Demographicsassessedincludedthefollowing:yearsinEM, definedasyearssincemedicalschoolgraduation;academic rank,stratifiedasclinicalinstructororassistantprofessorvs associateorfullprofessor;clinicalhoursworked,expressed asapercentageofafull-timeclinicalrequirementinourED; andsex,definedasmale,female,orother.Thisdatawas assembledfromourfacultyhiringdatabaseaswellasour department’sschedulingsoftware,withanalysesperformed inExcel(MicrosoftCorporation,Redmond,WA).

Wealsoperformedasurveyduringtheprogram’ s ﬁrst yearthatincludedallEMfaculty.Thisannualelectronic surveytypicallyassessesthewell-beingofourdepartment.In thewinterof2022,weaddedthefollowingquestionwith multiple-choice,Likertscaleanswerchoicesforfacultywho boughtoutofatleastsomenightshifts: “Howimportantisit foryoutobeabletodecreaseyournightshiftburden?”

Answerchoicesincludedthefollowing:notatallimportant; slightlyimportant;moderatelyimportant;veryimportant; andcriticalforcontinuinginthisjob.Giventhesmallsample size,onlydescriptivestatisticswereperformed.

RESULTS

TrendsinNightBuy-outs

Bytheendoftheprogram’ s ﬁrstyear,ourdepartment increaseditsnocturnistfacultyrosterfromthreetosix attendings.Inthe ﬁrstyear,wecouldnotallowattendings undertheageof60tofullybuyoutofnightsbecauseof clinicalcoverageneeds;thosedesiringfullbuy-outhadtheir nightsdecreasedby75%ratherthan100%.Withthree additionalnocturnistshired,wecouldfullyaccommodate buy-outrequestsforyeartwo.Overthetwoyears,22faculty

(42%)fullyboughtoutofnights,whileanadditional10 (15%)boughtoutofsomenightshifts.Sevenofthe10who choseapartialbuy-outdecreasedtheirnightsby50%, whiletheotherthreeboughtoutforfewerthan50%of theirnightshifts.

DemographicsofPhysiciansBuyingOut

FacultywhoboughtoutfullyhadworkedinEMfor slightlylongeronaverage,hadlowertotalrequiredclinical hoursperyear,weremorelikelytobeassociateorfull professors,andwerelesslikelytobewomen(See Table for totalfacultygroupcharacteristics,aswellasdemographics bybuy-outcategory).Nocturnistshadthehighestmean clinicalhoursofthefourgroupsandthelowestaverage tenureandwereleastlikelytobeassociateorfullprofessors.

FacultyFeedbackAbouttheProgram

Overall,48of56faculty(86%)respondedtothesurveyat theendofyearone.Ofthe32facultywhoboughtoutatleast somenights,26(81%)respondedtothesurvey.Morethan 80%ofthosebuyingoutreportedthattheabilitytoreduce thenightshiftburdenwaseither “veryimportant” or “critical for continuinginthisjob” (Figure).

DISCUSSION

NightshiftscontributetoburnoutforsomeEPsandcan detractfromacademicproductivity.4 Forothers,working morenightshiftscanimprovejobsatisfaction,mainlyif doingsoprovidesadditionalschedulecontroland compensation.9 Manydepartmentscurrentlyreducenight shiftsforphysiciansoveracertainage,andtheAmerican CollegeofEmergencyPhysicianshasrecommended accommodationsforphysiciansintheirpre-retirement years. 10 Moreneedstobewrittenaboutoptionsfor physicianstocustomizetheirovernightshiftsatallstagesof theircareers.Ourdepartmentcreatedaprogramtoallowany facultymembertobuyoutofnightshifts,usingthefunds generatedfrombuy-outstoincentivizenocturnistpositions. Withintwoyearsofinitiatingtheprogram,weallowedevery facultymemberwithatleastoneyearofservicetobuyoutof theirdesirednumberofnightshiftswhilehiringthree additionalnocturnists.

AccordingtoanationalsurveyofacademicEMleaders regardingpoliciesaroundagingphysicians,overhalfofthe surveyedleadersreporteddecreasingoreliminating overnightshiftstoaccommodateagingphysicians.9 While thisisundoubtedlyanimportantoptionforsupporting longevityinEM,itdoesnotaddresstheimpactofnightshifts onyoungerphysicianswho,somestudiessuggest,experience thehighestratesofburnoutwithinmedicine.11 Duringyears whenphysiciansmayberaisingyoungchildrenwhileactively buildingtheircareers,increasedschedulecontrolmightbe beneﬁcialformitigatingburnout.12 Inaddition,theremaybe non-agerelatedreasonsforsomeEPstobe

Table. Demographiccharacteristicsoffacultyineachbuy-outcategory.

Allfaculty(N=56)Fullbuy-out(n=22)Partialbuy-out(n=10)Nobuy-out(n=18)Nocturnist(n=6)

FTE, full-timeequivalent; EM,emergencymedicine.

Figure. Responsesfromfaculty(n=26)whousedthebuy-outprogramregardingtheimportanceofbuyingoutofnightshiftsasreportedon ourannualwell-beingsurvey.

disproportionatelyimpactedbynightshifts,including medicalissues,mentalhealthissues,orcaregiver responsibilities,whichcanbehardtoquantify.

Acriticalgoaloftheprogramwastopromoteequity acrossourfacultygroup.Programsthatreducenightshifts basedonage,academicrankortenuremayinadvertently propagateinequity,asphysicianswhoareolder,withlonger tenure,orofhigherrankmaybemorelikelytobemaleand Whitethanyoungerphysicians.13 Despiteofferingthesame buy-outoptionforallfaculty,wedidobservethatthosewho boughtoutofnightsentirelyweremorelikelytobemale, longer-tenured,andofhigheracademicrankthanourgroup average.Itshouldbenotedthatmalefacultydidhavehigher averageacademicrankthanfemalefaculty,butthisdidnot fullyexplainthegenderdifference;amongonlyhigh-ranking faculty,menwerealsomorelikelytobuyoutofnightsthan women.Thesetrendsmayberelatedtohistoricalpreferences inourdepartmentorto ﬁnancialrealitiesforphysiciansat variouscareerstagesorwithdifferentfamilystructures, amongotherpotentialexplanations.Futureresearchmight explorereasonsfordifferencesinschedulepreferenceamong differentdemographicgroupsinEM.

Forthoseparticipatinginourprogram,mostfaculty reportedthattheabilitytoreducenightswasatleast “ very important,” with39%indicatingthiswascriticalfor

continuingintheirjobs.Priorresearchalsosuggeststhat simplygivingpeoplemorecontrolovertheirworkcanreduce burnout;theremaybebeneﬁtsofincreasedschedulechoice forallfacultywithabuy-outprogram,notjustthosewho reducenightshifts.2 WithrecordburnoutinEMthreatening careerlongevityformany,providingincreasedschedule controlmaybeonestrategyforimprovingfacultyretention. Futureresearchshouldexaminewhetherself-reported answerstosurveyslikeoursultimatelypredictburnoutand careerdecisions.

LIMITATIONS

Thisstudyassessedourexperiencewithapolicy implementedforasinglefacultygroupofphysiciansinone largeED.Thetrendsdiscussedheremay,therefore,be differentfromotherdepartments.Whilethisprogramcould beadoptedatotherinstitutions,theremaybeunique considerationsforimplementationinothersettings.Wealso observedtheeffectsofthepolicyoverarelativelyshort periodandwereonlyabletoassessimpactbasedonselfreport;futureworkmightexaminelongerintervalsalong withobjectivepatternsofhiringandretention.Wealsodid notspeciﬁcallystudythe ﬁnancialimpactsoftheprogramon ourfaculty.Thepersonalimpactofthelossofsalaryfor attendingscouldbeworthinvestigatinginthefuture.

CONCLUSION

InourlargeacademicED,wesuccessfullytransitioned fromatenure-andage-basednightshiftparadigmtoan egalitariannightshiftbuy-outprogramthatallows ﬂexibility forphysiciansatallstagesoftheircareers.Giventhe favorableresultsoftheprogram,wehavecontinuedtoallow thisoptionalovernightbuy-outforourfaculty.This approachhasthepotentialtoimprovecareersatisfaction, promoteequity,andreduceburnoutamong emergencyphysicians.

AddressforCorrespondence:CharlotteW.Croteau,MD,Harvard MedicalSchool,MassachusettsGeneralHospital,Departmentof EmergencyMedicine,55FruitSt.,Austen850,Boston,MA02114. Email: ccroteau1@mgb.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.ShanafeltTD,BooneS,TanL,etal.BurnoutandsatisfactionwithworklifebalanceamongUSphysiciansrelativetothegeneralUSpopulation. ArchInternMed. 2012;172(18):1377–85.

2.MaslachC,JacksonSE,LeiterMP. MaslachBurnoutInventory Lanham,MD:ScarecrowEducation,1997.

3.KaneL.Physicianburnout&depressionreport2022: Stress,anxiety, andanger.Medscape.Availableat: https://www.medscape.com/

slideshow/2022-lifestyle-burnout-6014664?0=reg=1#2 AccessedJanuary2,2024.

4.Smith-CogginsR,BroderickK,MarcoC.Nightshiftsinemergency medicine:theAmericanBoardofEmergencyMedicine longitudinalstudyofemergencyphysicians. JEmergMed. 2014;47(3):372–8.

5.StewartNHandAroraVM.Theimpactofsleepandcircadiandisorders onphysicianburnout. Chest. 2019;156(5):1022–30.

6.HartenbaumNPandZeePC.Shiftworkandsleepoptimizing health,safety,andperformance. JOccupEnvironMed. 2011;53(5):S1–10.

7.MachiMS,StaumM,CallawayCW,etal.Therelationshipbetweenshift work,sleep,andcognitionincareeremergencyphysicians. AcadEmerg Med. 2012;19(1):85–91.

8.DulaDJ,DulaNL,HamrickC,etal.Theeffectofworkingserialnight shiftsonthecognitivefunctioningofemergencyphysicians. AnnEmerg Med. 2001;38(2):152–5.

9.TakakuwaKM,BirosMH,RuddyRM,etal.Anationalsurveyof academicemergencymedicineleadersonthephysicianworkforce andinstitutionalworkforceandagingpolicies. AcadMed. 2013;88(2):269–75.

10.ACEP.Considerationsforemergencyphysiciansinpre-retirement years.2021.Availableat: www.acep.org/patient-care/policystatements/considerations-for-emergency-physicians-in-preretirement-years.AccessedJan2,2024.

11.WestCP,DyrbyeLN,ShanafeltTD.Physicianburnout:contributors, consequencesandsolutions. JInternMed. 2018;283(6):516–29.

12.BaughJJ,TakayesuJK,WhiteBA,etal.BeyondtheMaslach burnoutinventory:addressingemergencymedicineburnout withMaslach’sfulltheory. JAmCollEmergPhysiciansOpen. 2020;1(5):1044–9.

13.MadsenTE,LindenJA,RoundsK,etal.Currentstatusofgenderand racial/ethnicdisparitiesamongacademicemergencymedicine physicians. AcadEmergMed. 2017;24(10):1182–92.

ORIGINAL RESEARCH

ModelingHourlyProductivityofAdvancedPracticeCliniciansin theEmergencyDepartment

BryanA.Stenson,MD*

PeterS.Antkowiak,MD,MPH*

DavidT.Chiu,MD,MPH*

LeonD.Sanchez,MD,MPH†°

JoshuaW.Joseph,MD,MS,MBE‡°

SectionEditor:BrianYun,MD,MBA,MPH

*BethIsraelDeaconessMedicalCenter,DepartmentofEmergencyMedicine, Boston,Massachusetts

† BrighamandWomen’sFaulknerHospital,DepartmentofEmergency Medicine,Boston,Massachusetts

‡ BrighamandWomen’sHospital,DepartmentofEmergencyMedicine, Boston,Massachusetts

° Contributedequallytothisworkintheroleofco-seniorauthor.

Submissionhistory:SubmittedJune7,2024;RevisionreceivedNovember21,2024;AcceptedNovember27,2024

ElectronicallypublishedJanuary31,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.21298

Introduction: Advancepracticeclinicians(APC)playsigniﬁcantrolesinacademicandcommunity emergencydepartments(ED).Inattendingsandresidents,priorresearchdemonstratedthatproductivity isdynamicandchangesthroughoutashiftinapredictableway.However,thishasnotbeenstudiedin APCs.TheprimaryoutcomeofthisstudywastomodelproductivityforAPCsincommunityEDsto determinewhetheritchangesduringashiftsimilartothewayitdoesforattendingsandresidents.

Methods: Thiswasaretrospective,observationalanalysisof10-hourAPCshiftsattwosuburban hospitals,workedby14totalindividuals.Weexaminedthenumberofpatientsseenperhouroftheshift byexperiencedAPCswhoseeallacuityandstaffallpatientswithanattending.Weusedageneralized estimatingequationtoconstructthemodelofhour-by-hourproductivitychange.

Results: Weanalyzed862shiftsoveroneyearacrosstwosites,withthreeshiftstarttimes.Site1 10 AM–8 PM sawanaverageof13.31(95%conﬁdenceinterval[CI]13.02–13.63)patientspershift;Site2 8 AM–6 PM sawanaverageof12.64(95%CI12.32–13.06)patientspershift;Site24 PM–2 AM sawan averageof12.53(95%CI12.04–12.82)patientspershift.Acrossallsitesandshifts,hour1sawthe highestnumberofpatients.Eachsubsequenthourwasassociatedwithasmall,statisticallysigniﬁcant decreaseovertheprevioushours.Thiswasmostpronouncedintheshift’slasttwohours.

Conclusion: TheproductivityofAPCsdemonstratesasimilarpatternofhourlydeclinesobservedin bothresidentandattendingphysicians.Thiscorroboratesprior ﬁndingsthatpatientsperhourisa dynamicvariable,decreasingthroughoutashift.Thisprovidesfurtherexternalvaliditytopriorresearchto includebothAPCsandcommunityEDs.Thesedepartmentsmusttakethisphenomenonintoaccount, asithasschedulingandoperationalconsequences.[WestJEmergMed.2025;26(2)295–300.]

INTRODUCTION

Advancedpracticeclinicians(APC)playasigniﬁcantrole inthecareprovidedinmanyacademicandcommunity emergencydepartments(ED).APCsarenon-physician clinicians,suchasnursepractitioners(NP)andphysician assistants(PA),whoseeandevaluatepatientsunderthe supervisionof,andincollaborationwith,attending

physicians.TheuseofAPCshasincreasedinthepastfew decades,withthemostrecentNationalHospitalAmbulatory MedicalCareSurveyin2020estimatingthat10.1%ofED visitsinvolvedanNP,and13.4%ofvisitsinvolvedaPA.1

PreviousliteratureonAPCsintheEDislimitedbuthas rangedfromanalyzingresourceutilizationtodescribing overalltrendsinhowAPCsareusedandinwhichpractice

settings.2,3 OnegroupfoundthatAPCssawmorepatients perhourandgeneratedmorerelativevalueunits(RVU)per hour bothkeymarkersofproductivity thanaresident physicianinafasttracksetting,whilegeneratingfewer RVUsperpatient.4 Thistrendheldupinahigheracuity settinginthissamegroup.5 However,withsuchasigniﬁcant portionofEDvisitsinvolvinganAPC,thereisstilllimited dataonoverallproductivity.6

Amongthemetricscommonlyusedtomeasureclinical productivity,patientsseenperhourisoneofthemost essentialtoEDoperationsplanning.Itoftenleadsto importantstafﬁngdecisionsatalltypesofEDs,rangingfrom largeacademicEDstosmallcommunityones.7 While productivityisoftenthoughtofasastaticquantitymeasured acrossashift,inrealityitisdynamicandchangesthroughout thecourseofashiftinapredictableway.Thisphenomenon hasbeendemonstratedinemergencymedicine(EM) attendingsandresidents,anditmanifestsasastepwise decreaseinproductivityafterthe ﬁrstfewhoursofashift.8,9 Thisbehaviorwassimilarinbothofthesegroupsandis consistentwiththelivedexperienceofworkinginanED. Whenaphysicianshowsupfreshtoashift,theyhavemore bandwidthtoseenewpatients.Afterafewhours,aseachof thosepatientsstartstohaveresultsreturnandrequire additionaldecisions,thereislesstimetoseenewpatients.

Accountingforthisphenomenoncanhavesigniﬁcant operationalimpacts.Byunderstandingthetruehourly capacityoftheworkforce,administrativeleadershipcan ensurethisbestmatchesupwiththehourlypatient demand.10 Thishasthepotentialtoimprovekeyoperational metricssuchasdoor-to-cliniciantimeandtherateofpatients thatleavewithoutbeingseen,ametricthatisitselfnotstatic andisimpactedbyvariousdepartmentalfactors.11 Todate, however,thispatternhasnotbeenstudiedinAPCs practicingintheED.Ourprimaryoutcomeinthisstudywas todeterminewhetherthispatternwassimilarforAPCs workinginacommunityED,asthiswouldprovidefurther externalvalidationofthepreviousmodeltothecommunity settingandtoarelativelynewgroupoftheworkforce.

METHODS

Weperformedaretrospective,observationalanalysisof APCshiftsattwosuburbanhospitalsintheNortheastern UnitedStatesfromJuly1,2020–June30,2021.Site1sawan averagedailyvolumeof54.46patientswithanEmergency SeverityIndex(ESI)scoremixof1.48%ESI1;30.00%ESI2; 50.65%ESI3;17.28%ESI4,and0.58%ESI5.Site2hadan averagedailyvolumeof79.71patientswithanESIscoremix of1.01%ESI1;26.7%ESI2;49.6%ESI3;20.4%ESI4;and 2.3%ESI5.

Fortheattendingshiftschedule,site1hadashiftschedule of7 AM–4 PM,2 PM–11 PM,and10 PM–7 AM forthe ﬁrstsix monthsofthestudy.Forthesecondsixmonthstheschedule changedto7 AM–2 PM,12 PM–7 PM,4 PM–11 PM,and11 PM–

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Patientsseenperhourisakeyproductivity metric.Forattendingsandresidents,ithas beenshowntobedynamicandchanges throughoutthecourseofashift.

Whatwastheresearchquestion?

Isthisproductivitypatternsimilarfor advancedpracticecliniciansworkingin communityEDs?

Whatwasthemajor ﬁndingofthestudy?

Meannumberofnewpatientsseendecreased ateachhouroftheshiftrelativetothe previoushour(P < 0.01).

Howdoesthisimprovepopulationhealth?

Understandinghowmanypatientsareseenat eachhouroftheday,basedoncliniciantype andhourofshift,couldinformstaf ﬁ ngmodels andhelpthroughput.

7 AM toaddmoreattendingcoverage.Atsite2,theshiftswere 7 AM–3 PM,12 PM–9 PM,3 PM–11 PM,and10 PM–7 AM.The sign-outcultureatbothsitesisthatpatientswillhavean establishedplanfordispositionpriortotransitioningtothe newteam.

Atbothsites,APCshiftsare10hourslong.Atthe ﬁrstsite, thereisasingledailyAPCshiftfrom10 AM–8 PM.Atthe secondsite,thereweretwoAPCshiftsduringthestudy period,from8 AM–6 PM andfrom4 PM–2 AM.Therewere severaldaysduringwhichthe ﬁrstsitehadnoAPCcoverage, andthesecondsitehadonlyasingleshift.FiveAPCsworked theshiftsatsite1,includingamixofbothNPsandPAs,while 10APCsworkedtheshiftsatsite2,consistingsolelyofPAs. OneofthePAsworkedshiftsatbothsitesduringthestudy period.Intotaltherewere14APCs,2NPsand12PAs.The APCssawalllevelsofpatientacuity.Thesesitesemploya shared-visitmodel,andallpatientsseenbyanAPCare presentedto,andthenevaluatedby,anattendingphysician. TheAPCscontinuetopickupnewpatientsthroughoutthe shiftandarenotlimitedindoingsobyattendingavailability tostaff.Over70%oftheAPCsinthestudyhad >5yearsof clinicalexperienceatthestartofthestudyperiod.

Weusedade-identiﬁedqualityassurancedatabaseforthis study,whichisprimarilyusedforoperationsplanning.The databaseisautomaticallypopulatedbythesites’ electronic healthrecord(EHR).Timestampsofpatientarrivals,APC assignments,andpatientdispositionsareautomatically

recordedbytheEHR.Thetimestampdataiscompiledalong withadditionalaggregatedandde-identifiedpatient-level data,inaccordancewithHIPAA-SAFEHARBORcriteria, priortodataanalysis.OnlythepatientsseenbyanAPCwere includedforanalysis,andregistrationanomalieshadalready beenremoved.Thisstudywasgrantedanexemptionof informedconsent,aspartofalargerprojectusiingadeidentifiedadministrativedatasetofEDthroughputfor qualityassurancepurposes.Theexemptionwasgrantedby theinstitutionalreviewboardaffiliatedwiththeclinicalsites, whichincludesdirectinvolvementbypatientandcommunity representativesintheoversightandapprovalofall researchprotocols.

Theprimaryoutcomewasthenumberofnewpatients seenateachhourofastandard10-hourAPCshift.Weuseda generalizedestimatingequationtoconstructthemodelof APCproductivity,withtheindividualshiftasthegroupingin lightoftheuseofmultiplehourlymeasurementsfromthe sameshift.APoissondistributionwithaloglinkwasused,as theoutcomevariable(patientsseeninanhour)reflectsa positivecountvariableina fixedtimeinterval.Weevaluated themodelusinganautoregressivecovariancestructure,with alternatecovariancestructurestestedinsensitivityanalyses. Thehouroftheshiftandtheshifttimeandlocationwereused ascovariates.Wereport finalparsimoniousmodelsas determinedbyquasi-likelihoodscore.Atwo-sided P -value <.05wasconsideredstatisticallysignificant,withstrict correctionformultiplecomparisons.Forthepurposesof modelinterpretability,wereportthecalculatedmodel predictions,withtheraw(exponential)modelcovariatesina supplementalappendix.AnalysiswasconductedinPython 3.11usingtheStatsmodelsandSciPypackages(Python SoftwareFoundation,Wilmington,DE).

RESULTS

Duringthestudyperiod(July1,2020–June30,2021),we analyzed862shifts,ofwhich345wereatSite1(single coverage),and517wereatSite2(two-shiftcoverage).Allthe workedshiftsinthisperiodwereincludedinthestudy,andno aberranttimestampswerefoundinthedatabase,meaning thatthetimestampofAPCassignmentalwaysalignedwith

theshifthoursontheschedule.NoteveryAPCshiftwas staffedduringthestudyperiod,duetofactorsincluding quarantine,operationalreassignmentswithinthenetwork, andstafﬁngshortagesfromtheCOVID-19pandemic.

Sitecharacteristicsaresummarizedin Table1.AtSite1 withasingleAPCshiftfrom10 AM–8 PM,APCssawamean of13.31patientspershift(95%CI13.02–13.63).AtSite2, APCssaw12.64(95%CI12.32–13.06)patientsduring the8 AM–6 PM shift,and12.53(95%CI12.04–12.82) patientsduringthe4 PM–2 AM shift.Whilesmall,these differenceswerestatisticallysigniﬁcant(P < 0.01forall pairwisecomparisons).

Acrossallsitesandshifts,the firsthouroftheshift demonstratedthehighestnumberofpatientsseen(Site1: 2.25[95%CI2.17–2.33],Site28 AM–6 PM:2.12[95%CI 1.98–2.26],andSite24 PM–2 AM:2.10[95%CI1.95–2.26]). Eachhourwasassociatedwithasmall,butstatistically significantdecreaseovertheprevioushours(Table2).This decreasewasmostpronouncedduringthelasttwohoursof theshift,leadingtoanaveragewellbelowasinglepatient seenperhourduringhours9(Site1:0.57[95%CI0.50–0.64], Site28 AM–6 PM:0.54[95%CI0.46–0.62],Site24 PM–2 AM: 0.53[95%CI0.45–0.62])and10(Site1:0.14[95%CI 0.11–0.17],Site28 AM–6 PM:0.13[95%CI0.10–0.17], Site24 PM–2 AM:0.13[95%CI0.10–0.17]).Thistrendcanbe visualizedin Figure. Asensitivityanalysisdidnotrevealany significantdifferenceinhourlyvolumeofpatientsseenby APCsbydayofweek.Priorresearchatthesehospitalshas shownadequatehourlypatientvolumessuggestingthereis notashortageofpatientstobeseen.9

DISCUSSION

Our findingsinthisstudysuggestthatAPCsmay demonstrateasimilarpatternofhourlydeclinesin productivitythathasbeenobservedinbothresidentand attendingphysicians.8,9 Thiscorroboratesprior findingsthat suggestthatpatientsseenperhourisadynamicvariable.An intuitiveexplanationofthis findingfollowsfromthefactthat patientevaluationstakeplaceovermultiplehoursofashift, andthatseeinganewpatientlaterintheshiftrequiresthe APCtobalancethedemandsofseeinganadditionalpatient

Table1. Characteristicsofthestudyparticipantsandsitesevaluated.

Table2. Modelsofnewpatientsseenperhour.

Site1:10 AM–8 PM shift

ShifthourMeannewpatients(95%CI) P-value

1 2.25(2.17–2.33) < 0.01

2 1.96(1.80–2.13) < 0.01 3 1.80(1.65–1.96) < 0.01

4 1.66(1.52–1.81) < 0.01

5 1.42(1.29–1.50) < 0.01

6 1.33(1.21–1.46) < 0.01

7 1.26(1.14–1.39) < 0.01

8 0.98(0.89–1.09) < 0.01

9 0.57(0.50–0.64) < 0.01 10 0.14(0.11–0.17) < 0.01

Site2:8 AM–6 PM shift

ShifthourMeannewpatients(95%CI) P-value

1 2.12(1.98–2.26) < 0.01

2 1.85(1.65–2.07) < 0.01

3 1.69(1.5–1.91) < 0.01

4 1.56(1.38–1.76) < 0.01

5 1.33(1.18–1.50) < 0.01

6 1.25(1.10–1.42) < 0.01

7 1.19(1.04–1.35) < 0.01

8 0.92(0.81–1.06) < 0.01

9 0.54(0.46–0.62) < 0.01 10 0.13(0.10–0.17) < 0.01

Site2:4 PM–2 AM shift

ShifthourMeannewpatients(95%CI) P-value

1 2.10(1.95–2.26) < 0.01

2 1.83(1.63–2.06) < 0.01

3 1.68(1.48–1.90) < 0.01

4 1.55(1.37–1.75) < 0.01

5 1.32(1.16–1.50) < 0.01

6 1.24(1.09–1.41) < 0.01

7 1.18(1.03–1.35) < 0.01

8 0.92(0.80–1.05) < 0.01

9 0.53(0.45–0.62) < 0.01

10 0.13(0.10–0.17) < 0.01

CI, conﬁdenceinterval.

withconcurrentlycaringforexistingpatients.TheAPCsmay seemorepatientsearlierintheshiftpreciselybecausethey havethegreatestcognitivebandwidthatthestartofashift, withnoactivepatients.Asthosepatientsstarttogenerate resultsandrequirere-evaluation,interpretationofimaging

Figure. Meannumberofpatientsseenpershifthourbyadvanced practiceclinicians. APC,advancedpracticeclinician.

orlabs,orproceduresthataddtothecognitiveloadforan APC,theywillseefewernewprimarypatients.

However,therearesubstantialdifferencesinthepatternswe haveobservedinAPCsrelativetopatternsofphysician productivitypreviouslydescribedintheemergencymedicine operationsliterature.8,9 Notably,whileallofthesegroups demonstrateprogressivedeclinesinhourlyproductivityand seeahigherproportionofpatientsinthe ﬁrstfewhoursoftheir shifts,theAPCsinourstudydemonstratedbothasmaller “peak” atthebeginningoftheirshiftscomparedtothose reportedwithattendingphysicians,andamoregradual decreasefromhour-to-hourrelativetoresidentphysicians.The causeofthisislikelymultifactorial;however,intheprior studiesforbothattendingsandresidents,thosegroupswere incentivizedandgradedonproductivity;theAPCsinourstudy didnothavethesameexplicittietoproductivity.

Thishasimportantdownstreamconsequenceswhen creatingstaffingmodels.Whileshiftstypicallyspan10hours andthereisanadministrativeexpectationforequalcapacity duringallhoursofcoverage,the9th and10th hoursofashift donotprovidemuchinthewayofnewpatientevaluations. So,whenhiringandstaffingadepartmentandtryingtobest alignthenumberofhourlyarrivalswiththeavailablestaff (residents,attendingsorAPCs)theadministrationmusttake thispatternintoaccount.Understandinghowmanypatients areexpectedtobeseenataspecifichouroftheday,basedon whatstaffareavailableandthehourofeachperson’sshift, mayhelpthroughput.

LIMITATIONS

Ourstudydoeshavemanylimitations.Itwasonlydoneat twocommunityhospitalsinasimilargeographicregion. Becausetherewereonlythreeshiftstarttimes,therewasless variabilitythanpriorstudiesperformedonresidentand attendingphysicians,whichalsohadagreatervarietyofshift startingandendingtimes,includingovernights.However,as longastherewereadequatepatientstobeseenateachhour oftheday asseeninpriorstudiesofattendingindependent productivityatthesesites thislimitationshouldbe mitigated.Therewerealsotwohoursofoverlapbetween shiftsatthesecondsite,whichmayhavecontributedtosome productivitydrop-offforthe8AM–6PMshiftatsite2. Additionally,withinthisnetworkAPCscaredforalllevelsof patientacuity,andeachvisitrequiredstafﬁngandevaluation byanattendingphysician.Thisdiffersfromothermodels whereAPCscandischargeloweracuitypatientswithoutan attendingevaluation.

Whilethedelayofwaitingforanattendingtoseethe patientmayprolongsometasksanddecisions,thisgroupof APCshadalotofexperienceandindependence(>70%with over ﬁveyearsofexperience)andcontinuedtopickupnew patientsintheinterim.Further,atthetwostudysitesAPCs wereusedtoseepatientsprimarily,andthismaynotbe applicabletootherwaystheyareusedindepartments,such

asmanagingobservationpatients.Lastly,asthisstudywas conductedattwosmallcommunitysitestherewereonlya fewtotalAPCs(14totalindividuals)whoprimarilywork onlyatasinglesite,andthisgroupmaynotberepresentative oflargergroupsofAPCsorthoseworkinginmultiple hospitalorurgentcaresettings.

CONCLUSION

Our findingssuggestthattheproductivityofadvanced practicecliniciansmayfollowapatternofdecreasingover successivehoursofashift,similartobothattendingsand residents.Thisstudyreinforcespriorliteraturethat demonstratesthatpatientsperhourisadynamicvariable, whichstartsatitshighestpointanddecreasessignificantly eachsubsequenthour.Byverifyingthatthispatternis consistentinAPCs,itbroadenstheproductivitymodelof priorresearch.CommunityEDs,whichareoftenstaffedwith APCsandhavenoresidentcoverage,mayneedtotakethis phenomenonintoaccountasithassignificantschedulingand operationalconsequences.

AddressforCorrespondence:BryanA.Stenson,MD,BethIsrael DeaconessMedicalCenter,DepartmentofEmergencyMedicine, OneDeaconessRd.,Boston,MA02215.Email: bstenson@bidmc. harvard.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.CairnsCandKangK.NationalHospitalAmbulatoryMedicalCare Survey:2020emergencydepartmentsummarytables.2022.Available at: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2020-nhamcsed-web-tables-508.pdf.AccessedMay9,2023.

2.AledhaimA,WalkerA,VesselinovR,etal.Resourceutilizationinnonacademicemergencydepartmentswithadvancedpracticeproviders. WestJEmergMed. 2019;20(4):541–8.

3.HookerRS,KlockoDJ,LarkinGL.Physicianassistantsinemergency medicine:theimpactoftheirrole. AcadEmergMed. 2011;18(1):72–7.

4.JeanmonodR,DelcolloJ,JeanmonodD,etal.Comparisonofresident andmid-levelproviderproductivityandpatientsatisfactioninan emergencydepartmentfasttrack. EmergMedJ. 2013;30(1):e12.

5.HamdenK,JeanmonodD,GualtieriD,etal.Comparisonofresidentand mid-levelproviderproductivityinahigh-acuityemergencydepartment setting. EmergMedJ. 2014;31(3):216–9.

6.PinesJM,ZocchiMS,RitsemaT,etal.Theimpactofadvanced practiceproviderstafﬁngonemergencydepartmentcare: productivity, ﬂow,safety,andexperience. AcadEmergMed. 2020;27(11):1089–99.

7.StensonBA,AndersonJS,DavisSR.Stafﬁngandprovider productivityintheemergencydepartment. EmergMedClinNorthAm. 2020;38(3):589–605.

8.JosephJW,HenningDJ,StrouseCS,etal.Modelinghourly residentproductivityintheemergencydepartment. AnnEmergMed. 2017;70(2):185–90.e6.

9.JosephJW,DavisS,WilkerEH,etal.Modellingattendingphysician productivityintheemergencydepartment:amulticentrestudy. Emerg MedJ. 2018;35(5):317–22.

10.StensonBA,JosephJW,AntkowiakPS,etal.Understandingdemand andcapacitymismatchinanacademicemergencydepartmentusinga staircasemodelofprovidercapacityandstaggeredshiftstarttimes. J EmergMed. 2021;61(3):336–43.

11.ChiuDT,StensonBA,AlghamdiM,etal.Theassociationbetweenday ofarrival,timeofarrival,dailyvolumeandtherateofpatientsthat “left withoutbeingseen.” AmJEmergMed. 2023;67:24–8.

ORIGINAL RESEARCH

InjuriesandOutcomesofGround-levelFallsAmongOlder Patients:ARetrospectiveCohortStudy

VincentKan,MD,MSc*

WilsonHuang,MD†

GrettaSteigauf-Regan,MD*

JillAnderson,MPH,MAT*

IvyDang,BS*

ChadDarling,MD,MSc*

SectionEditor:StephenW.Meldon,MD

*UMassChanMedicalSchool,DepartmentofEmergencyMedicine, Worcester,Massachusetts † UniversityofCaliforniaSanFrancisco,DepartmentofEmergencyMedicine, SanFrancisco,California

Submissionhistory:SubmittedSeptember5,2024;RevisionreceivedNovember20,2024;AcceptedNovember20,2024

ElectronicallypublishedJanuary30,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.35281

StudyObjective: Wesoughttodeterminetheoverallratesoftraumaticinjuriesandwhethertheratesof traumaticinjuriesandvariousclinicaloutcomesdifferedamongolderpatientspresentingtoatertiarycareemergencydepartment(ED)afteraground-levelfall(GLF)andwhounderwentwhole-body computedtomography.

Methods: Weconductedaretrospectivecohortstudyofpatients ≥65yearsofagewhopresentedtothe EDwithaGLFandreceivedawhole-bodyCTfromJanuary1–December31,2021.Agewasstratiﬁed intoagegroups:65–74;75–84;and85+.Wepresentedadescriptiveanalysisoftraumaticinjuries, intensivecareunit(ICU)admissions,andall-causemortalityrates.Weusedmultivariablelogistic regressiontodeterminetheassociationbetweenincreasingage,traumaticinjuries,and clinicaloutcomes.

Results: Of638patientsinthecohort,120(18.9%)sustainedthoracicinjuriesand80(12.5%)sustained intracranialhemorrhages.Only ﬁve(0.8%)patientssustainedanintra-abdominalinjury,while134 (21.0%)wereadmittedtotheICU,and31(4.8%)diedduringtheirindexhospitalization.Headinjuries (oddsratio[OR]6.21,95%CI3.65–10.6, P < 0.001)andthoracicinjuries(OR5.25,95%CI3.30–8.36, P < 0.001)wereassociatedwithincreasedoddsofICUadmission,whereasheadinjuries(OR3.21,95% CI1.41–7.31, P < 0.01)andcervicalinjuries(OR3.37,95%CI1.08–10.5, P < 0.05)wereassociatedwith increasedoddsofin-hospital,all-causemortality.Therewerenostatisticallysigniﬁcantdifferencesinthe ratesofinjuriessustainedbetweentherespectiveagegroups.Therewasnoassociationbetween increasingageandICUadmissionsorin-hospital,all-causemortalityrates.

Conclusion: Amongpatientsaged ≥65yearsofagewhopresentedtotheEDafteraground-levelfall andunderwentwhole-bodyCT,thoracicinjuriesandintracranialhemorrhageswereassociatedwith increasedoddsofICUadmissions.Wefoundnosigniﬁcantdifferencesininjuryratesoroutcomesacross agegroups,indicatingthatagealoneshouldnotguideICUadmissiondecisions.These ﬁndingssuggest thattheuseofwhole-bodyCTinthispopulationshouldbeselectiveandguidedbyclinicaljudgment ratherthanapplieduniversally.[WestJEmergMed.2025;26(2)301–306.]

INTRODUCTION

Background

Fallsaretheleadingcauseoffatalandnon-fatalinjuries amongtheelderly.Upto40%ofmenandwomen ≥65years ofageinthecommunityfalleachyear.1 Injuriesrelatedto fallsamongtheelderlyaccountforthreemillionemergency department(ED)visitsand50billiondollarsofUS healthcarespendingannually.2 Ground-levelfalls(GLF), deﬁnedasfallsfromastandingheight,areparticularly commonamongolderpatients.Age-relatedphysiologic changescreatesigniﬁcantfall-relatedmorbidityand mortalityinthispatientcohort.3

Importance

PatientswhopresenttotheEDfortrauma-related complaintsareoftenevaluatedwithcomputedtomography (CT)fortheiraccuracyandreliabilityindetectinginjuries. Theroutineuseofnon-selective,whole-body(headtopelvis) CTisbecominganincreasinglycommondiagnosticmodality inthesepatients,particularlyinthoseinvolvedinhighenergymechanismssuchasmotorvehiclecollisions,dueto themorewidespreadavailabilityofCTimagingand changingclinicalpracticepatterns.4 Whilewhole-body CTisfrequentlyusedinhigh-energytrauma,itsapplication inlow-energymechanismslikeGLFsremainsless clearandmorevariable.Severalstudieshaveshown conﬂictingevidenceastowhetherwhole-bodyCTis warrantedintraumapatients.5,6 Giventhelowkinetic energyimpactfromGLFs,itisunclearwhetherthe indiscriminateuseofwhole-bodyCTinGLFscan improvepatients’ outcomesbydetectingclinically relevantinjuries.

GoalsofThisInvestigation

Ourobjectivesofinthisstudyweretodeterminethe overallratesoftraumaticinjuriesandclinicaloutcomesand whethertheratesoftraumaticinjuriesandclinicaloutcomes wereassociatedwithincreasingageamongpatients ≥65yearsofagepresentingtoatertiary-careEDwithaGLF andwhounderwentwhole-bodyCT.Wehypothesizedthat duetodecreasedphysiologicalreservesandincreased fragility,theincidenceoftraumaticinjuriesandadverse outcomesafteraGLFamongthisselectivepopulationwould increasewithadvancingage.

METHODS

StudyDesignandSetting

ThisstudywasapprovedbytheHumanInstitutional ReviewBoard.Weconductedaretrospectivecohortstudyof patientstreatedatthistertiary-careLevelItraumaacademic medicalcenterwith90,000annualEDvisits.Weadheredto thepreviouslypublishedmethodologicalcriteriaforhealth recordreviewstudies.7

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Fallsaretheleadingcauseofinjuryinolder adults,yetoptimaluseofwhole-bodyCTin low-energymechanismssuchasground-level falls(GLF)isunclear.

Whatwastheresearchquestion?

Dotraumaticinjuryratesandclinical outcomesdifferwithageamongolder patientsundergoingwholebodyCTfor ground-levelfalls?

Whatwasthemajor ﬁndingofthestudy?

Thoracic(OR5.25,95%CI3.30 – 8.36)and headinjuries(OR6.21,95%CI3.65 – 10.6) afteraground-levelfallwereassociatedwith ICUadmissions.Only ﬁ ve(0.8%)patients sustainedanintra-abdominalinjury.

Howdoesthisimprovepopulationhealth?

Selectivewhole-bodyCTuseinGLFpatients canimprovecareef ﬁ ciencybyfocusingon clinicallysigni ﬁ cantinjurieswhilereducing unnecessaryimaging.

StudyPopulation

Weidentifiedallpatients ≥65yearsofagewhopresented totheEDwithaGLFandreceivedawhole-bodyCT betweenJanuary1–December31,2021.Atourinstitution,a whole-bodyCTisdefinedasaCTofthehead,chest, abdomenandpelvis,cervicalspine,thoracicspine,and lumbarspine;itincludesintravenouscontrastadministration toevaluateforsofttissueinjuryofthethoraxandabdomen. AGLFisdefinedasfallingfromastandingheight,chair, wheelchair,oroutofbed.

Measurements

Studyvariablescollectedincludedbasicdemographic characteristics(ageandsexasidentifiedbypatient), antiplateletoranticoagulantuse,medicalcomorbidities, initialGlasgowComaScale(GCS)score,initialheartrate andsystolicbloodpressure,andtraumaticinjuriesfoundon CT.Datawascollectedusingastandardizeddatacollection formthroughtheelectronichealthrecord(EpicSystems, Verona,WI)bytrainedresearchassistants(RA)anda residentphysician(WH).NoneofthetrainedRAsorthe residentphysicianknewthestudyobjectives.Datapoints collectedincludedallacutetraumaticinjuriesidentifiedon the finalCTimagingradiologyreports.Co-authorGS

performedaduplicatereviewof10%ofthehealthrecordsfor interobserverreliabilityassessment.WeusedtheCohen kappatodeterminetheinter-raterreliabilityof dataabstraction.

StudyOutcomes

Ourprimarystudyoutcomemeasuresincludedtherateof variousacutetraumaticinjuries,admissiontotheintensive careunit(ICU),andall-cause,in-hospitalmortality. Traumaticinjuriesincludedintracranialhemorrhages(ICH), thoracicinjuries,intra-abdominalinjuries,cervicalspine fractures,thoracicspinefractures,andlumbarspinefractures. Intracranialhemorrhagesweredefinedasanyepidural, intraparenchymal,intraventricular,subarachnoid,orsubdural hematomasorhemorrhagethatwerebelievedtobetraumatic inetiology.Wedefinedthoracicinjuriesashemothoraces, pneumothoraces,pulmonarycontusions,orribfractures. Intra-abdominalinjuriesweredefinedasanysolidorganor hollowviscousinjuries.Weexcludedminorsofttissueinjuries orhematomas,subacuteorchronictraumaticinjury findings, andnon-traumatic findingsonCTimaging.Foroursecondary outcomemeasures,weanalyzedtheassociationbetweenage, traumaticinjuries,andclinicaloutcomes,includingICU admissionsandin-hospital,all-causemortality.Agewas stratifiedintoagegroups:65–74;75–84;and85+

DataAnalysis

Descriptivestatisticsarepresentedasmeans ± standard deviationsforcontinuousvariables,andcategorical variablesarereportedaspercentages.Incidencesof traumaticinjuries,ICUadmissions,andall-causemortality arereportedasproportionswithaccompanying95% confidenceintervals(CI).Differencesbetweenouragespecificcomparisongroups(65–74,75–84,85+)were examinedusingANOVAforcontinuousvariablesandchisquaredandFisherexacttestsforcategoricalvariables.Twotailedvaluesof P < 0.05wereconsideredstatistically significant.Weperformedbivariateanalysistoidentify variablesassociatedwithclinicaloutcomes.Usingthe65–74 cohortasthereferencegroup,weusedmultivariablelogistic regressiontodeterminetheassociationbetweenage, traumaticinjuries,andclinicaloutcomescontrollingfor medicalcomorbidities,antithromboticuse,andstatistically significanttraumaticinjuries.Dataanalysiswasperformed usingSTATA/MPVersion17(StataCorp,College Station,TX).

RESULTS

BaselinePatientCharacteristics

Atotalof638patientsmetourinclusioncriteriaduringthe one-yearperiodunderstudy.Theaverageageofthestudy populationwas82.1 ± 9.0years;60.0%werewomen,and 62.9%wereonatleastoneantithromboticagent,with33.7%

Antithrombotic,%

1Notstatisticallysigniﬁcant. CHF,congestiveheartfailure; COPD,chronicobstructivepulmonary disease; CVA/TIA,cerebrovascularaccident/transientischemic attack; GCS,GlasgowComaScale; MI,myocardialinfarction; HR, heartrate; SBP,systolicbloodpressure.

onanantiplateletand39.1%onananticoagulant.The averagenumberofcomorbiditieswas1.5 ± 1.3(Table1).

MainResults

Amongthe638patientswhosustainedaGLF,120 patients(18.9%)sustainedthoracicinjuries,and80(12.5%) sustainedICH.Sixty(9.8%)patientssustainedthoracicspine injuries,51(8.0%)ssustainedlumbarspineinjuries,and34 (5.3%)patientssustainedcervicalspineinjuries.Only ﬁve Table1. Studypopulationcharacteristicsaccordingtoage.

Figure. Incidenceproportionamongdifferentinjuries.

(0.8%)patientssustainedanintra-abdominalinjury(Figure). Ofthe fivepatientswithintra-abdominalinjuries,all five werefoundtohavepertinentphysicalexam findings,initial unstablevitalsigns(systolicbloodpressure <90orheartrate 100),orabnormalGCS(<15).Therewerenostatistically significantdifferencesintheratesofvariousinjuries sustainedbetweentherespectiveagegroups(Table2).

Atotalof134(21.0%)patientswereadmittedtotheICU, and31(4.8%)diedduringtheirindexhospitalization.There werenostatisticallysigniﬁcantdifferencesintheratesof clinicaloutcomesbetweentherespectiveagegroups.Using multivariablelogisticregressionmodels,wefoundno associationbetweenincreasingageandICUadmissionsor in-hospital,all-causemortalityrate(Table3).Incontrastto age,headinjuries(oddsratio[OR]6.15,95%CI3.62–10.5, P < 0.001)andthoracicinjuries(OR5.38,95%CI3.37–8.67, P < 0.001)wereassociatedwithincreasedoddsofICU

admission,whereasheadinjuries(OR3.21,95%CI 1.41–7.31, P < 0.01)andcervicalinjuries(OR3.37,95%CI 1.08–10.5, P < 0.05)wereassociatedwithincreasedoddsof in-hospitalmortality.

Inter-raterReliability

Amongthe10%ofthehealthrecordsreviewedbyacoauthor,wefoundthatourratersagreedon88%ofthe informationabstractedfromtherecords,resultingina Cohenkappacoefﬁcientof0.8.

DISCUSSION

Inourstudypopulation,injuriessustainedafteraGLF werebroadlyconsistentamongallagegroups.Wefoundthat asubstantialminorityofolderpatientswhounderwent whole-bodyCTatthediscretionofthetreatingphysicians afteraGLFwerefoundtohaveclinicallysigniﬁcantinjuries

Table2. Traumaticinjuriesandemergencydepartmentdispositionsstratiﬁedbypatientage.

Traumaticinjuries,no.(%)

EDdisposition,no.(%)

Nostatisticalsigniﬁcance betweenallagegroups.

ED,emergencydepartment; ICU,intensivecareunit.

Table3. Associationbetweenincreasingageandclinicaloutcomes.

ICUadmissions

Mortality1

65–743(1.89%)1[Reference]1[Reference] 75–84

1In-hospital,all-causemortality.

ForICUadmissions:adjustedfortotalcomorbidities,headinjuries,thoracicinjuries. Formortality:adjustedfortotalcomorbidities,headinjuries,cervicalinjuries. OR,oddsratio; CI,conﬁdenceinterval; ICU,intensivecareunit.

thatresultedinICUadmissions.Increasingagewasnot associatedwithanincreasedrateofICUadmissionordeath afteraGLF.ThoracicinjuriesandICHwereassociatedwith increasedoddsofICUadmission.Intracranialhemorrhages andcervicalfractureswereassociatedwithincreasedoddsof in-hospitalmortality.

Wefoundthatover30%oftheinjuriessustainedwere eitherICHorthoracicinjuries,bothofwhichwereassociated withincreasedoddsofICUadmissionsinourstudy population.Intracranialhemorrhagesandribfractures amongolderpatientsareinjuriesthatcanresultinhigh mortalityrates,8–10 thusrequiringfrequentmonitoringand necessitatingICUlevelofcare.Our ﬁndingsreinforcethe importanceofusingCTtoidentifytheseinjuriesinpatients presentingwithGLFs,particularlywhenthereisclinical suspicionofthoseinjuries.

Furthermore,ourstudydidnotshowanysignificant associationbetweenincreasingageandICUadmissionand mortality.Thiscontrastswiththeresultsofapreviousstudy, whichshowedastepwiseincrementintherateofcervical spineinjuriesandin-hospitalmortalityassociatedwith increasedageinGLFpatientsfromaninstitutionaltrauma registry.11 Patientsrecordedinatraumaregistrywilllikely havesustainedinjuriesrequiringtraumateamevaluation.In addition,wedidnot findanydifferenceintheratesofvarious injuriesafteraGLFbetweenthedifferentagegroups.Our studydiffersinthatitincludedallpatientswhosustained significantinjuriesandthosewhodidnot.Furthermore,we includedonlypatientswhounderwentwhole-bodyCTatthe discretionofthetreatingphysiciansafteraGLF.Basedon our findings,oneshouldbecautiousaboutusingincreased ageasariskfactoralonetodeterminewhetherapatient warrantswhole-bodyCTwithoutconsideringother clinicalfactors.

Overall,ourratesofdifferentinjuriesarehigherthan reportedintheliterature.Our ﬁndingsontherateofICH afteraGLFwas12.5%,whereastheratesofICHaftera GLFreportedintheliteraturehaverangedfrom 3.5–7%.12–15 Alarger,nationallyrepresentativeretrospective studyfoundtheratesofthoracicandlumbarspineinjuries were1.6%and2.5%,comparedto9.4%and8.0%inour study,respectively.16 Thediscrepancylikelyresultedfrom thefactthatweincludedonlypatientswhowereselectedby treatingphysicianstoundergowhole-bodyCTintheED. Thetreatingphysiciansprobablydeempatientsundergoing whole-bodyCTaftertraumatohavesustainedagreater numberofsigniﬁcantinjuriesduringtheinitialevaluation.

Wefoundthattherateofintra-abdominalinjurieswas low.Thisconclusionisbroadlyconsistentwiththe literature.11,17,18 Ofthe fivepatientsfoundtohaveintraabdominalinjuriesinourstudy,all fivewerefoundtohave eitherunstablevitalsigns,abnormalGCS,orabnormal physicalexamsoninitialevaluation.This findingis consistentwiththeliteraturewherehemodynamicallystable

patientswithnormalphysicalexamsareunlikelytohave intra-abdominalinjuriesafteraGLF.18–20 Performingfewer abdominalCTscansinthispopulationcouldhave substantialcostsavingswithoutreducingdiagnostic accuracy.Giventhesmallnumberofpatientswhosustained intra-abdominalinjuriesinourstudy,wewerenot adequatelypoweredtoidentifypotentialriskfactors associatedwithintra-abdominalinjuriesafteraGLF.Future prospectivestudiesareneededtoidentifyfactorsassociated withintra-abdominalinjuriesanddeterminethecosteffectivenessofaselectiveimagingalgorithminlow-risk GLFpatients.

LIMITATIONS

Ourstudywasretrospectiveandsusceptibletobiases. Non-differentialmisclassiﬁcationcanoccurduringthe queryingofhealthrecords,whichwilllikelybiastheresults towardthenull.However,10%ofthehealthrecordswere reviewedbyco-authorGStolimitthisbias.Furthermore,we demonstratedexcellentinter-raterreliability.Thestudywas alsosusceptibletoselectionbias,andwaslimitedtopatients whoreceivedawhole-bodyCT.Atourinstitution,the decisiontoorderawhole-bodyCTonatraumapatient dependsonthetreatingphysician’spreference.Patientswho receivedawhole-bodyCTarelikelydeemedbythetreating physiciantohavesustainedsigniﬁcantinjuries.Therefore, ourstudylikelyoverestimatesinjuryincidenceduetothe selectivenatureofwhole-bodyCTuse.Moreover,wedidnot obtaininformationonolderpatientswhosustainedaGLF anddidnotreceiveawhole-bodyCT.Thosetwolimitations likelyresultedinourstudyoverestimatingtheincidence proportionofinjuriesreportedafteraGLF.Furthermore, thisstudywasbasedonasingleinstitutionatatertiary-care LevelItraumacenter;thus,itcannotbegeneralizedtoother institutions.Inaddition,thenatureofourquerydidnot allowustoobtainInjurySeverityScores.

CONCLUSION

Amongpatients ≥65yearsofagewhopresentedtotheED afteraground-levelfallandunderwentwhole-bodyCT, thoracicinjuriesandintracranialhemorrhages whilea minorityoftheinjuriessustained wereassociatedwith increasedoddsofICUadmissions.These findingshighlight theimportanceofcarefullyassessingtheseinjuriesinolder adults.Interestingly,wefoundnosignificantdifferencesin injuryratesorclinicaloutcomesacrossagegroups, suggestingthatagealoneshouldnotbethedetermining factorforICUadmissionormortalityriskinthispopulation. Givenour findings,weproposethattheremaybevaluein reassessingtraumascreeningprotocols,especiallyregarding theuseofwhole-bodyCTinpatientswhosustainalowenergyfall.Itsuseshouldbeselectiveratherthanapplied universally.Multicenterprospectivestudiesareneededto determinethebroaderutilityandcost-effectivenessofwhole-

bodyCTuseamongolderpatientswhopresenttotheED aftersustainingaground-levelfall.

AddressforCorrespondence:VincentKan,MD,UMassChan MedicalSchool,DepartmentofEmergencyMedicine,55NLake Ave.,Worcester,MA01655.Email: vincent.kan@umassmed.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.TinettiME,SpeechleyM,GinterSF.Riskfactorsforfallsamongelderly personslivinginthecommunity. NEnglJMed. 1988;319(26):1701–7.

2.BergenG,StevensMR,BurnsER.Fallsandfallinjuriesamongadults aged ≥ 65years UnitedStates,2014. MMWRMorbMortalWklyRep. 2016;65(37):993–8.

3.SpaniolasK,ChengJD,GestringML,etal.Groundlevelfallsare associatedwithsigniﬁcantmortalityinelderlypatients. JTrauma. 2010;69(4):821–5.

4.BunnC,RinghouseB,PatelP,etal.Trendsinutilizationofwhole-body computedtomographyinblunttraumaafterMVC:analysisofthetrauma qualityimprovementprogram(TQIP)database. JTraumaAcuteCare Surg. 2021;90(6):951–8.

5.SalimA,SangthongB,MartinM,etal.Wholebodyimaginginblunt multisystemtraumapatientswithoutobvioussignsofinjury:Resultsofa prospectivestudy. ArchSurg. 2006;141(5):468–73;discussion473–5.

6.SierinkJC,TreskesK,EdwardsMJ,etal.Immediatetotal-bodyCT scanningversusconventionalimagingandselectiveCTscanningin patientswithseveretrauma(REACT-2):arandomisedcontrolledtrial. Lancet. 2016;388(10045):673–83.

7.WorsterA,BledsoeRD,CleveP,etal.Reassessingthemethodsof medicalrecordreviewstudiesinemergencymedicineresearch. Ann EmergMed. 2005;45(4):448–51.

8.BarneaY,KashtanH,SkornickY,etal.Isolatedribfracturesinelderly patients:mortalityandmorbidity. CanJSurg. 2002;45(1):43–6.

9.MaiHT,TranTS,Ho-LeTP,etal.Low-traumaribfractureinthe elderly:riskfactorsandmortalityconsequence. Bone. 2018;116:295–300.

10.StawickiSP,GrossmanMD,HoeyBA,etal.Ribfracturesintheelderly: amarkerofinjuryseverity. JAmGeriatrSoc. 2004;52(5):805–8.

11.BhattacharyaB,MaungA,SchusterK,DavisKA.Theoldertheyarethe hardertheyfall:Injurypatternsandoutcomesbyageaftergroundlevel falls. Injury. 2016;47(9):1955–9.

12.GanetskyM,LopezG,CoreanuT,etal.Riskofintracranialhemorrhage inground-levelfallwithantiplateletoranticoagulantagents. AcadEmerg Med. 2017;24(10):1258–66.

13.NishijimaDK,OffermanSR,BallardDW,etal.Riskoftraumatic intracranialhemorrhageinpatientswithheadinjuryandpreinjury warfarinorclopidogreluse. AcadEmergMed. 2013;20(2):140–5.

14.GrewalK,AtzemaCL,AustinPC,etal.Riskofintracranialhemorrhage betweendifferentdirectoralanticoagulantsinolderpatientsseeninthe emergencydepartmentwithaheadinjury:apopulation-basedcohort study. ThrombRes. 2022;214:47–52.

15.VardarZ,LoHS,MariyampillaiM,etal.Traumaticintracranial hemorrhageonCTafterground-levelfallinadultpatientsreceiving antithrombotictherapy:aretrospectivecase-controlstudy. AmJ Roentgenol. 2022;219(3):501–8.

16. GrabelZJ,LunatiMP,SegalDN,etal.Thoracolumbarspinalfractures associatedwithgroundlevelfallsintheelderly:ananalysisof254,486 emergencydepartmentvisits. JClinOrthopTrauma. 2020;11(5):916–20.

17.BahlAandSchaferS.Utilityofabdominalcomputedtomographyin geriatricpatientsonwarfarinwithafallfromstanding. JEmergTrauma Shock. 2018;11(2):88–91.

18.GartinCG,ReyesJ,HelmerSD,etal.Injurypatternsandincidenceof intra-abdominalinjuriesinelderlygroundlevelfallpatients:IsthePANSCANwarranted? AmJSurg. 2019;218(5):847–50.

19.HaganNE,BerdelHO,TefftA,etal.Torsoinjuriesafterfallfrom standing-empiricabdominalorthoracicCTimagingisnotindicated. Injury. 2020;51(1):20–5.

20.SiseMJ,KahlJE,CalvoRY,etal.Backtothefuture:Reducingreliance ontorsocomputedtomographyintheinitialevaluationofblunttrauma. J TraumaAcuteCareSurg. 2013;74(1):92–7;discussion97–9.

ORIGINAL RESEARCH

RelationshipBetweenSocialRiskFactorsandEmergency DepartmentUse:NationalHealthInterviewSurvey2016–2018

IraaGuleria,BS*

JenniferA.Campbell,PhD,MPH†

AbigailThorgerson,MPH* SanjayBhandari,MD‡

LeonardE.Egede,MD,MS†§

*MedicalCollegeofWisconsin,CenterforAdvancingPopulationScience, Milwaukee,Wisconsin

† UniversityatBuffalo,StateUniversityofNewYork,JacobsSchoolofMedicine andBiomedicalSciences,DepartmentofMedicine,DivisionofPopulation Health,Buffalo,NewYork

‡ MedicalCollegeofWisconsin,DepartmentofMedicine,DivisionofGeneral InternalMedicine,Milwaukee,Wisconsin

§ UniversityatBuffalo,StateUniversityofNewYork,JacobsSchoolofMedicine andBiomedicalSciences,UBMDInternalMedicine,BuffaloGeneralMedical Center,Buffalo,NewYork

SectionEditor:PayalModi,MD,MScPH

Submissionhistory:SubmittedDecember6,2023;RevisionreceivedOctober24,2024;AcceptedOctober25,2024

ElectronicallypublishedDecember31,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18616

Background: Evidenceshowsthatsocialrisksarehighlyprevalentinthepatientpopulationthat presentstotheemergencydepartment(ED)forcare;however,understandingtherelationshipbetween socialriskfactorsandEDutilizationatthepopulationlevelremainsunknown.

Methods: WeusedtheNationalHealthInterviewSurveyfromthe2016–2018sampleadult ﬁles.The sampleincluded82,364individuals,representingapopulationsizeof238,888,238.Theprimary independentvariablesincludedsixsocialriskfactors:economicinstability;lackofcommunity; educationaldeﬁcit;foodinsecurity;socialisolation;andinadequateaccesstocare.Theoutcome includedEDuseintheprioryear.Covariatesincludedage,race/ethnicity,insurancestatus,obesity, mentalhealth(depression/anxiety),andcomorbidities.Weranlogisticregressionmodelstotestthe relationshipbetweentheindependentanddependentvariablesadjustingforcovariates.

Results: Inthestudysample,20%hadatleastoneEDvisitintheprioryear.Inthefullyadjustedmodel, individualsreportingeconomicinstability(oddsratio[OR]1.33,95%confidenceinterval[CI]1.25-1.42), lackofcommunity(OR1.10,95%CI1.05-1.15),educationaldeficit(OR1.12,95%CI1.06-1.18),food insecurity(OR1.77,95%CI1.66-1.89),andsocialisolation(OR1.32,95%CI1.26-1.39)had significantlyhigheroddsofEDuse.Inadequateaccesstocarewassignificantlyrelatedtoloweroddsof EDuse(OR0.75,95%CI0.69-0.81).

Conclusions: SocialriskfactorsaresigniﬁcantlyassociatedwithhigheroddsofEDuseintheUnited Statesadultpopulation.Interventionsthatintegratesocialandmedicalneedsaregreatlyneeded,asis understandingtherolethatpreventivemedicinemayplayinreducingavoidableEDvisits.[WestJEmerg Med.2025;26(2)307–314.]

INTRODUCTION

Emergencydepartment(ED)useintheUnitedStates remainshigh,withthemostrecentnationalestimates showing18%ofUSadultshadatleastonevisitintheprior12 months.1–3 CostofEDutilizationhasremainedover $76billionperyear,4 withanestimated$30billionspenton preventablehospitalizations.4 Althoughtheprimaryroleof anEDisprovidingmedicalservicestohigh-acuityor

life-threateningconditions,overuseandmisuseoftheEDin theUSremainsamajorconcernforpopulationhealth,with increasedattentionbeinggiventotheroleofunmetsocial needsunderlyingEDutilization.5,6

Ithasbeenwell-establishedthatanindividual’ssocialand physicalenvironmentplaysaroleinhealthoutcomesandis becomingincreasinglyimportantforunderstandingaccessto healthservices.7–11 Evidenceshowsthatsocialriskfactors, theadversesocialconditionssuchaseconomicinstability, foodandhousinginstability,andlimitedaccessto transportation,arehighlyprevalentamongpatientswho presenttotheED.6,12–19 Forexample,lowersocioeconomic statusandpovertyareassociatedwithincreasedEDand emergencyserviceutilizationrates,16–18 withevidence showingthatthosepresentingtotheEDaremorelikelytobe lowincome19 andinsuredthroughMedicaid.20 Atthe nationallevel,foodinsecurityisindependentlyassociated witha47%higherEDutilizationrate.14 Similarly, individualswithhousinginsecurityhaveatwo-foldincreased riskofEDuse,15 withahighriskforexperiencing homelessnessayearfollowinganEDvisit.21 Evidencealso showsthattransportationbarriersarehighamongthosewho presenttotheED.22

AsanyincreaseinEDutilizationrepresentsa correspondingincreaseinassociatedcosts,thereisanurgent needtounderstandtheunderlyingsocialdriversofED utilizationtoappropriatelydeveloptargetedinterventionsto accountforsocialriskburdenandtodecreaseEDutilization andimprovepopulationhealth.Whileexistingdatashows thatindividualsocialriskfactorsarelinkedtoincreasedED utilization,littlehasbeendonetounderstandtheprevalence ofmultiplesocialriskfactorsandtheirassociationwithED utilizationatanationallevel.Thepurposeofthisstudy, therefore,istoexaminetherelationshipbetweenmultiple socialriskfactors(economicinstability,lackofcommunity, limitededucationalattainment,foodinsecurity,social isolation,andlimitedaccesstocare)andEDutilizationina nationallyrepresentativesampleofUSadults.

METHODS

DataSource

WeusedtheNationalHealthInterviewSurvey(NHIS), person,adult,andfamilyperson ﬁles.TheNHISgathers informationfrompeopleacrosstheUS.Information gatheredincludesdiseaseandconditionsinformationaswell ashealthcareinformation.23

Measures

Theprimaryindependentvariablesincludethesocialrisk factordomainsinitiallydescribedbyWrayetalin2022.24 Thesedomainsweretreatedasbinary:havingapositive responsetoanyiteminadomainwasconsidereda ‘1’ while havingnopositiveresponsesas ‘0.’ (Missingwasdeﬁnedas missingallitemsinadomain.)Thepromptsandcriteriafor

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Socialriskfactorsplayaroleinaccessto healthcare.Prevalenceofmultiplesocialrisk factorsandtheirassociationwithEDuseata nationallevelremainsunclear.

Whatwastheresearchquestion?

Whatistherelationshipbetweenmultiple socialriskfactorsandEDuseinanationally representativesampleofUSadults?

Whatwasthemajor ﬁndingofthestudy?

Economicinstability,lackofcommunity, educationalde ﬁ cit,foodinsecurity,and isolationincreased(P < 0.001)EDuse.

Howdoesthisimprovepopulationhealth?

Theseresultsprovidetargetsforintervention developmentandclinicalscreening programstoreduceunnecessaryEDuse andhealthcarecosts.

eachdomainarelistedin Table2.Theoutcomewasbinary anddeﬁnedashavinganyvisitstotheEDintheprioryear (0visitsvs ≥1visits).Wealsoincludedthefollowing covariates:age;race/ethnicity;insurancestatus;obesity; mentalhealth(depression/anxiety);andcomorbidities (hypertension,coronaryheartdisease,heartattack,stroke, asthma,ulcer,cancer,emphysema/chronicobstructive pulmonarydisease,kidneydisease,diabetes,liverdisease, arthritis,migraine,andchronicpain).

Analyses

Wecomparedsampledemographics,reportedas percentagesandmeans,usingchi-squareandanalysisof variancestatistics.Logisticregressionmodelswereusedto assesstheunadjustedindependentassociationbetweenED useasabinaryvariableandeachofthesixsocialrisk domains,followedbydomain-adjustedmodels(ie, simultaneouslycontrollingforallsixsocialrisks).Then,we usedthefullyadjustedlogisticregressionmodelstoevaluate theindependentassociationbetweenEDuseasabinary variableandeachofthesixsocialriskdomains,adjustingfor covariates,includingage,race/ethnicity,insurancestatus, obesity,mentalhealth,andcomorbidities.Covariateswere selectedforinclusioninthemodelbasedonpriorevidenceon therelevanceofthesevariablesaswellasbasedon P =<0.25 inbivariateanalyses.Weperformedstatisticalanalysiswith Rv4.0.3(RFoundationforStatisticalComputing,Vienna,

Austria).Toaccountforthecomplexsurveydesignand producepopulationlevelestimates,weightingwasdone usingthesvydesignfunctioninR.Statisticalsigniﬁcancewas setat P =< 0.05.

RESULTS

Thestudysamplewascomprisedof82,364individualsin the2016–2018period,whichrepresents238,888,238adultsin theUSpopulation.Thistimeframewasselectedforits robustsetofsocialriskfactorsavailableinthedataset. Table1 showsdemographiccharacteristicsofourstudy population.Almost20%reportedusingtheEDoneormore times.Middle-agedadults(ages40-64)accountedforabout 42%ofthissample,withyoungadults(ages18-39) representing38%.Olderadults(65+)accountfor approximately20%ofthestudysample.Themajority (64.8%)identiﬁedasnon-HispanicWhite,withHispanic accountingforthesecond-highestgroup(16.1%),followed bynon-HispanicBlacksat12%,andnon-Hispanicotherat 7.2%.About9%oftheadultswereuninsured. Approximately42%had1-2comorbiditiesand23.2%had threeormore,withchronicpain(34%)andhypertension (31%)representingthetwomostcommoncomorbidities.

Table2 showscharacteristicsofsocialriskdomainsinour studypopulation.Atotalof73.5%reportedeconomic instability,40.5%reportedlackofcommunity,23.5% reportedfoodinsecurity,27.2%reportedsocialisolation,and 13.1%reportedinadequateaccesstocare.

Table3 displaysunadjusted,domain-adjusted (controllingforonlysocialrisks),andfullyadjustedmodels (controllingofsocialrisks,comorbidities,andallother covariatesoutlinedinthetable).Allsocialriskfactors (economicinstability,lackofcommunity,educational deficit,foodinsecurity,socialisolation,andinadequate accesstocare)weresignificantlyassociatedwithhigherodds ofEDvisitsintheunadjustedmodels,withfoodinsecurity, economicinstability,andsocialisolationamongthosewith higheroddsratios(OR)(OR2.46,95%confidenceinterval [CI]2.32-2.59;OR2.10,95%CI1.99-2.22;andOR2.02,95% CI1.94-2.11,respectively).Inthefullyadjustedmodels, economicinstability(OR1.33,95%CI1.25-1.42),lackof community(OR1.10,95%CI1.05-1.15),educationaldeficit (OR1.12,95%CI1.06-1.18),foodinsecurity(OR1.77,95% CI1.66-1.89),andsocialisolation(OR1.32,95%CI1.261.39)wereassociatedwithhigheroddsofEDutilization. However,inadequateaccesstocarewasnegatively associatedwithEDuseinbothadjustedmodels(fully adjusted:OR0.75,95%CI0.69-0.81).

DISCUSSION

Overall,~20%ofUSadultshadatleastoneEDvisit,and socialriskfactorswerehighlyprevalentinthestudysample with74%havingeconomicinstability,41%reportinglackof community,37%reportingeducationaldeﬁcits,27%

Table1. Characteristicsofadults,NationalHealthInterviewSurvey, 2016–2018.

COPD, chronicobstructivepulmonarydisease; ED,emergencydepartment.

Table2. Characteristicsofsocialdeterminantsofhealthdomainsin adults,NationalHealthInterviewSurvey,2016–2018.

Table2. Continued.

(Continued onnextcolumn)

SNAP, SupplementalNutritionAssistanceProgram; WIC,Women, InfantsandChildrenProgram.

reportingsocialisolation,24%reportingfoodinsecurity,and 13%reportinginadequateaccesstocare.Inaddition,fully adjustedmodelsshowedthateconomicinstability,lackof community,educationaldeficits,foodinsecurity,andsocial isolationwereindependentlyassociatedwithincreasedodds ofEDvisits,whileinadequateaccesstocarewassignificantly associatedwithloweroddsofEDvisits.Thisisoneofthe firststudiestoourknowledgethathasassessedthe relationshipbetweenmultipledomainsofsocialrisk factorsandEDutilizationinanationallyrepresentative USadultpopulation.

Our ﬁndingsareconsistentwithexistingliteratureonthe associationofsocialriskswithEDutilization.Forexample, studiesbyEstrella25 andDean26 showfoodinsecurityis signiﬁcantlyassociatedwithincreasedEDuseandED expenditureevenafteradjustmentforpotential confounders.25,26 Seim16 hasshownthateconomicinstability andcommunityfactors,throughneighborhoodpoverty,are positivelyassociatedwith9-1-1ambulanceutilization,a surrogateforEDutilization.16 Inanotherstudy,Ku27 providesevidencethatfrequentusersoftheEDmaybe disproportionatelyhomeless.27 Similarly,availableliterature highlightstherelationshipbetweensocialisolationandED use.Inanobservationalstudyofolderpatients,Mosen26 foundthatthosewhoexperiencesocialisolationweremore likelytohaveatleastoneEDvisitthanthosewhorarelyor neverexperiencedsocialisolation.28

Thecurrent ﬁndingsshowlackofaccesstocareis negativelyassociatedwithEDuse.Availableevidenceonthe associationbetweenaccesstohealthandEDuseismixed.29 Evidencesuggeststhatgreateraccesstocarecantranslateinto greaterreceiptofpreventativecareandbeingmorecognizant ofdiseasesandhealth,resultinginincreaseduseacrossED andprimarycarevisits.30 Conversely,lackofaccesscanresult inloweruseoftheED,asthecurrent ﬁndingsshow.Onthe

Table3. Logisticregressionforbinaryemergencydepartmentvisits.

Totalsample

UnadjustedDomainadjustedFullyadjusted

Lack ofcommunity

Age

50–64

*P =< 0.05, **P =< 0.01,***P =< 0.001. COPD,chronicobstructivepulmonarydisease; ED,emergencydepartment.

contrary,someevidenceshowsthatanincreaseinaccessto outpatientcareisassociatedwithadecreaseinEDuse.29 Giventhemixed ﬁndings,thereremainsanurgentneedfor furtherevidenceonhowthepresenceorlackofaccessimpacts EDutilizationacrosspopulations.

Overall,thisstudyprovidesnewevidencefor understandingtherelationshipbetweensocialriskfactors andEDuseforadultsatthenationallevelwithimplications acrossresearch,practice,andpolicy.Speciﬁcally,available evidenceshowsEDvisitratesarehigherforpatientsinlower-

incomeandsociallyvulnerablecommunities,highlighting theneedforspeciﬁcinitiativesaimedatunderstandingthe driversoftheirincreasedEDuse,andtheneedtopayclose attentiontosocialrisksandeffectivewaystoaddressthem.10 FederaleffortstoreduceEDoverusecurrentlyfocuson improvingprimarycare;10 however,initiativesthathave lookedtoincreasetheavailabilityoflow-costoptionsforthe patientsseekingtheseservices,typicallyoflowacuity,have yieldedlittleintermsofreducingcosts.31,32 Whileourstudy underscoresthelinkageofindividualsocialriskswithED utilization,italsohighlightsagreateropportunitytoreduce costsbyaddressingsocialrisks.Furtherresearchcan elucidatewhetheraddressingeachofthesesocialriskswill translateintodecreasedEDuseandcost.

Althoughvariousprofessionalorganizationsrecommend thathealthsystemsandcliniciansincorporatesocial determinantsofhealthandsocialriskscreeningintocare models,10,11 avastmajorityofhealthcaresystemsand hospitals(ie,70%)donothavededicatedfundstoaddress socialneeds,withmanyhealthsystemslackingcommunitylevelsocialneedsdatatoinforminvestment.33,34 Evenwhen asocialriskisidentiﬁed,emergencycliniciansmaynotbe awareoflocalresourcesor ﬁndithardtobestaddressit.25 DoranandcolleaguesdevelopedascreeningtoolforED patientstoidentifytheriskofbecominghomelesstoreferfor servicesandsupportforhomelessnessprevention9;toolssuch asthese,usingmodelsforreferralservices,35 aregreatly neededtoassessacrossthespectrumofsocialriskfactors knowntoimpacthealthandleadtoadditionalED utilization.9 Whileourstudyaddstotheevidenceontherole ofsocialrisksonEDutilization,thereisneedforresearch investigatinghoweachriskisdrivingEDuse,whatinitiatives canbetakenbycommunitiesandpolicymakerstoreduce suchrisks,andhowEDscanbetteraccommodatethe patientswhoareexperiencingtheserisks,bothtoreduce costsandEDburden,andalsotoimprovetheir healthoutcomes.

Physicianscanlooktosocialemergencymedicine(EM), anemerging fieldwithinEM,asapathforwardtoaccount fortheintersectionbetweenemergencycareandsocial determinantsofhealth.36 SocialEMemphasizesamore holisticcaremodelintheEDtobetterservethepopulations whofrequentlyvisittheEDandreceivecarewithout adequateunderstandingbycliniciansofthesocialforcesat play.Our findingssupporttheimportanceofthisevolving fieldasapromisingplatforminmitigatingthesocialrisk burdenonabroaderscaleandreducingEDutilization, especiallyamongsociallyvulnerablepopulations.37

LIMITATIONS

Therearesomelimitationsthatmustbeconsideredwhile interpretatingourstudy ﬁndings.Althoughourstudyis basedonanationallyrepresentativesample,itexcluded institutionalizedindividuals;therefore,the ﬁndingmaynot

generalizetothatsegmentoftheUSpopulation.Secondly,to maintainarobustsetofsocialriskfactors,thedataset includedNHISdatapriortothe2019revision.Forthis reason,thisstudydoesnotcaptureadditionalsocialrisk factorsthatmayhavedevelopedasaresultoftheCOVID-19 pandemic.Inaddition,whileourmodelscontrolledfor relevantconfoundingvariables,wedidnothavedataonall possibleconfounders,whichmayhavebiasedourestimates. Also,sincetheresponsestoallsurveyquestionsarebasedon self-report,theyaresubjecttorecallbias.Finally,giventhat thestudyiscross-sectional,wecannotspeaktocausality.

CONCLUSION

Thisstudyofanationallyrepresentativesampleofadults indicatesthatsocialriskfactorsaresignificantlyassociated withEDutilization.Specifically,economicinstability,lack ofcommunity,educationaldeficit,foodinsecurity,andsocial isolationareassociatedwithhigheroddsofEDuse,whereas inadequateaccesstocareisassociatedwithlowerEDusein fullyadjustedmodels.Furtherresearchisneededtobetter understandpotentialpathwaysandmechanismsthat underlietheseassociations.Interventionsthatcaneffectively addresssocialriskshaveapotentialtoreduceunnecessary EDutilizationandreducehealthcarecosts.Emphasisshould beplacedonbuildinginfrastructureforscreeningand preventionprogramsforhandoffsandreferrals.

AddressforCorrespondence:LeonardE.Egede,MD,MS,UBMD InternalMedicineUniversityatBuffalo,JacobsSchoolofMedicine andBiomedicalSciencesBuffaloGeneralMedicalCenter, DepartmentofMedicine,100HighSt.,D2-76,Buffalo,NY14203. Email: legede@buffalo.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

AssociationsofIndividualandNeighborhoodFactorswith DisparitiesinCOVID-19IncidenceandOutcomes

MargaretE.Samuels-Kalow,MD,MPhil,MSHP* RebeccaE.Cash,PhD,MPH,NRP*

KoriS.Zachrison,MD,MSc* AurioleCorelRodneyFassinou,BS† NormanHarrisII,BS‡

CarlosA.CamargoJr.,MD,DrPH*

SectionEditor:IoannisKoutroulis,MD,MBA,PhD

*HarvardMedicalSchool,MassachusettsGeneralHospital, DepartmentofEmergencyMedicine,Boston,Massachusetts † CornellUniversity,Ithaca,NewYork ‡ TempleUniversity,LewisKatzSchoolofMedicine, Philadelphia,Pennsylvania

Submissionhistory:SubmittedOctober26,2023;RevisionreceivedNovember5,2024;AcceptedNovember6,2024

ElectronicallypublishedJanuary15,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18526

Introduction: Thedisproportionateimpactofcoronavirus2019(COVID-19)onBlackandHispanic communitieshasbeenwidelyreported.Manystudieshaveusedneighborhoodracial/ethniccomposition tostudysuchdisparities,butlessisknownabouttheinterplaybetweenindividualrace/ethnicityand neighborhoodracialcomposition.Therefore,ourgoalinthisstudywastoassesstherelative contributionsofindividualandneighborhoodrisktodisparitiesinCOVID-19incidenceandoutcomes.

Methods: Weperformedacross-sectionalstudyofpatientswithemergencydepartment(ED)and inpatientvisitstoanacademichealthsystem(12hospitals;February1–July15,2020).Theprimary independentvariablewasrace/ethnicity;covariatesincludedindividualage,sex,comorbidity,insurance andneighborhooddensity,poverty,racial/ethniccomposition,educationandoccupation.Theprimary outcomewassevereacuterespiratorysyndromecoronavirus2(SARS-CoV-2)positivity;secondary outcomesincludedadmissionanddeathafterCOVID-19.Weusedgeneralizedestimatingequationsto assesswhetherrace/ethnicityremainedsigniﬁcantlyassociatedwithCOVID-19afteradjustmentfor individualandneighborhoodfactors.

Results: Therewere144,982patients;5,633(4%)wereSARS-CoV-2positive.Ofthose,2,961(53%) wereadmittedand601(11%)died.DiagnosisofCOVID-19,admission,anddeathweremorecommon amongnon-HispanicBlack,Hispanic,Spanish-speakingpatients,andthosewithpublicinsurance.Inthe basemodel(adjustingforrace/ethnicity,age,sex,andcomorbidities),race/ethnicitywasstrongly associatedwithCOVID-19(non-HispanicBlackoddsratio[OR]4.64[95%confidenceinterval(CI) 4.18–5.14],andHispanicOR6.99[CI6.21–7.86]),whichwasslightlyattenuatedbutremainedsignificant afteradjustmentforneighborhoodfactors.AmongpatientswithCOVID-19,therewasnosignificant associationbetweenrace/ethnicityandhospitaladmission,otherthanforpatientswithunknownrace.

Conclusion: Thisdatademonstratesapersistentassociationbetweenrace/ethnicityandCOVID-19 incidence,withBlackandHispanicpatientsatsigniﬁcantlyhigherrisk,whichwasnotexplainedby measuredindividualorneighborhoodfactors.Thissuggeststhatusingexistingneighborhood factorsinstudiesexamininghealthequitymaybeinsufﬁcient,andmoreworkisneededtoquantifyand addressstructuralfactorsandsocialdeterminantsofhealthtoimproveequity.[WestJEmergMed. 2025;26(2)315–325.]

INTRODUCTION

Thedisproportionateimpactofcoronavirus2019 (COVID-19)onBlackandHispaniccommunitieshasbeen extensive.1–9 Alongwiththeassociationwithindividualrace andethnicity,multiplestudieshaveshownassociations betweenneighborhooddemographicsandCOVID-19 incidenceandoutcomes.Areaswithhigherproportionsof BlackandHispanicresidentshavehigherCOVID-19 incidenceandfatalityrates.10–13 Althoughanumberofother neighborhoodvariableshavebeenassociatedwithincreased ratesofCOVID-19,includingpoverty,insurancecoverage,13 unemployment,essentialserviceemployment,14 and neighborhoodeducationlevels,11 theassociationwith neighborhooddemographiccompositionmaybestronger thanthatwithneighborhoodsocioeconomicstatus(SES).15 Importantly,theassociationbetweencommunity-levelsocial determinantsofhealth,suchasneighborhoodpovertyand COVID-19rates,doesnotseemtobeexplainedby differentialtestingrates.14

Theconnectionbetweensocialdeterminantsofhealth, unequalexposuretosevereacuterespiratorysyndrome coronavirus2(SARS-CoV-2),andrace/ethnicityisa reflectionofstructuralracism16 the “discriminatory policies,practices,andsystemsthatreinforceanunequal distributionofpowerandresourcesinsocialinstitutions.”17 Non-Whitepatientshaveincreasedrepresentationinserviceindustryorlow-incomejobs,increased financialinsecurity, morefrequentresidenceinsharedorcongregatehousing,18 andaresultingincreasedriskofexposuretoCOVID-19.In addition,structuralracismalsoaffectspatients’ lived experienceinthecommunityandhealthcaresettings,and specificallytheirabilitytoaccesscare.19 Ourpreviouswork usingdatafromalargeacademichealthsystemhas demonstratedco-location(overlap)ofneighborhoodfactors, suchaspercentageofthepopulationthatwasHispanic,nonHispanicBlack,withouthealthinsuranceorlivingin poverty,andCOVID-19cases.13 However,recentresearch hasdemonstratedthatrelyingonneighborhood-levelsocial riskfactorsalonemayover-attribute findingstothe neighborhood-levelfactor.20 Therefore,ourgoalinthisstudy wastoassesstherelativecontributionsofindividualand neighborhoodrisktothosedisparitiesinadatasetwherewe couldassessindividualdemographics,insurancestatus(asa proxyforindividualSES),andcomorbidities.

METHODS

StudyDesignandPopulation

Weperformedacross-sectionalstudyofallemergency department(ED)andinpatientvisitsfromFebruary1–July 15,2020withinalargeacademichealthsystemof12hospitals, includingtwoacademicmedicalcenters,inNewEngland. Datawereabstractedfromtheelectronichealthrecord (EHR).Visitswereeligibleforinclusioniftheywereeither(1) the ﬁrstencounter(EDvisitoradmission)toanyhealthsystem

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

ThedisproportionateimpactofCOVID-19on BlackandHispaniccommunitieshasbeen widelyreported.

Whatwastheresearchquestion?

Wesoughttoassesstherelativecontributions ofindividualandneighborhoodriskto disparitiesinCOVID-19incidence andoutcomes.

Whatwasthemajor ﬁndingofthestudy?

Race/ethnicitywasassociatedwithCOVID19andremainedsigni ﬁ cantafteradjustment forneighborhoodfactors.

Howdoesthisimprovepopulationhealth?

Thisdatasuggeststhatusingexisting neighborhoodfactorsinstudiesexamining healthequitymaybeinsuf ﬁ cient.

facilityduringthestudyperiodwherethepatientwasSARSCoV-2positiveor(2)the ﬁrstvisitifthepatientwasnever SARS-CoV-2positive.Patientswereeligibleiftheywerea Massachusettsstateresidentbasedonrecordedaddress.We excludedpatientsiftheiraddresswasaPOboxoriftheywere undomiciledornotabletobegeocodedviaEpicorArcGIS (EnvironmentalSystemsResearchInstitute,Inc,Redlands, CA)(foratotalof2,233or2%ofparticipants;seeeFigure1). Eachpatientwasincludedonlyonce.

Ethicsapproval

Allmethodswerecarriedoutinaccordancewith institutionalguidelines;inparticular,thestudywasdeemed exemptfrominformedconsentrequirementsbytheMass GeneralBrighamInstitutionalReviewBoard.Becauseof this,thedatasetsgeneratedandanalyzedduringthecurrent studyarenotpubliclyavailableduetopatientprivacy concernsanddataconﬁdentialityrules.

VariableDeﬁnitions

Theprimarypredictorvariablewasrace/ethnicity.Fora subsetof2,494patientsinthehealthsystem,Hispanic/Latino wasincludedasarace.Patientswereconsideredtobe HispaniciftheirracewasHispanic/Latino,iftheirethnicity wasHispanic/Latinoregardlessofrace,oriftheirethnicity was “Brazilian,”“Dominican,”“Honduran,”“Puerto Rican,”“Salvadoran,”“Guatemalan,”“Columbian,” or “Mexican,MexicanAmerican,Chicano,” regardlessofrace.

Patientswereotherwisecategorizedbasedonreportedrace andcategorizedasnon-HispanicWhite,non-Hispanic Black,Asian,other,missing,orunknown.

Sexwasdefinedasmaleorfemale;dataoneightpatients whosesexassignmentatbirthwasnotknownwascodedas “missing.” Similarly,dataon22patientswhosereportedage was >107yearswasalsorecordedas “missing” asitwas presumedtorepresentanerrorintheEHR.Giventhelimited dataonindividualsocialdeterminantsofhealthintheEHR, wechosetouseinsurancestatusandlanguageasfactorsthat areassociatedwithaccessandutilizationofcare generally21,22 and,specifically,forCOVID-19.13,23 Insurance statuswasdefinedaspublic,privateorother(seeAppendix), andpreferredlanguageabstractedfromtheEHRwas English,Spanish,Portuguese,Creole-Haitian,Arabic,other, ormissing/unknown(null,declined,unavailable).

WeascertainedcomorbiditiesbycalculationoftheCharlson ComorbidityIndex(CCI)calculatedfromInternational ClassificationofDiseases,10th Rev,ClinicalModification codesintheproblemlist,24,25 andbydirectidentificationof obesity,pulmonarydisease,chronickidneydisease,diabetes mellitus,andhypertensionintheproblemlist(seeAppendix). Comorbiditieswerechosenbasedonpreviouslypublished associations2,26,27 andinstitutionalguidanceregardingrisk factorsforpooroutcomesfromCOVID-19.

Neighborhoodfactorstoassesssocialdeterminantsof healthweredrawnfromthe2015–2019American CommunitySurvey ﬁve-yearestimates28 andincluded neighborhoodpoverty,13 educationalattainment,service occupation,29 andpopulationdensity30 aswellasproportion Hispanic/Latino,non-HispanicBlack,non-HispanicAsian, bachelor’sdegreeorhigher,andworkinginservice occupationanalyzedatthecensustractlevel.Wederived quintilesforneighborhoodfactorsforanalysisusingall censustractsinthestateofMassachusettsratherthanthose includedinthesample.

Outcomes

TheprimaryoutcomewasSARS-CoV-2positivity (COVID-19positivity),definedaspolymerasechainreaction testresultofpositiveoradmission/dischargestatus documentedas “COVID-19Positive” or “PatientExpired (COVID-19).” Secondaryoutcomeswerehospitaladmission afterSARS-CoV-2positivity(admissionafterCOVID-19), definedasadmissionduring firstencounterwhereSARSCoV-2positiveorwithin14daysofthe firstencounter;or deathafterSARS-CoV-2positivity(deathafterCOVID-19), definedasdeathatanytimeduringthestudyperiodafterthe firstencounterwheretheSARS-CoV-2testresultwas positive.OutcomeswereascertainedfromtheEHR.

StatisticalAnalysis

WeperformedallstatisticalanalyseswithStataSE15.1 (StataCorp,CollegeStation,TX),with P < 0.05considered

statisticallysigniﬁcant.Continuousvariablesaredisplayed asmean(SD).Categoricalvariablesaredisplayedas numbers(percentage)ofparticipantswithineachgroup. Participantswithmissingdatawereexcludedfrommodels. Wecalculateddescriptivestatisticsforpatientsand neighborhoodcharacteristicsinthesampleoverallandby COVID-19outcomes.

Associationbetweenrace/ethnicityandindividual-level riskfactors

Weusedmultivariablelogisticregressionmodelstoassess theassociationbetweencomorbiditiesandindividualrisk factorsandrace/ethnicity.Giventhatwehypothesizedthat comorbiditieswerelikelyonthecausalpathwaybetween race/ethnicityandincreasedCOVID-19burdenofdisease, wealsoassessedtheindividualcomorbiditiesasmediatorsof theassociationbetweenrace/ethnicityandCOVID-19 incidenceandoutcomes.WeusedtheBaronandKenny methodologytoassessformediation.31 First,weconfirmeda significantassociationbetweenrace/ethnicityandeach outcome(COVID-19positivity,admission,anddeath)and betweenrace/ethnicityandeachmediator.Next,weincluded eachmediatorinamodelwithrace/ethnicityandthe outcome.Weassessedforanymajorchangeinestimates,in particularachangeinmagnitude,direction,orstatistical significance.Completemediationwouldbeindicatedbythe associationbetweenrace/ethnicityandtheoutcome becomingnon-significantoncethemediatorwasincluded.

Accountingforneighborhood-levelfactors

Oncewehaddeterminedthattherewerenosignificant mediationeffects,weassessedneighborhoodfactorsfor multicollinearityusingvarianceinflationfactors(VIF)ina linearregressionmodel.AVIFgreaterthan10was consideredindicationofpotentialmulticollinearity.Weused generalizedestimatingequationstoassesswhetherrace/ ethnicityremainedsignificantlyassociatedwithCOVID-19 positivityafteradjustmentforneighborhoodfactorsand insurancestatus.Weusedalogitlink,binomialdistribution, andworkingindependencecorrelationstructuretoestimate oddsratiosseparatelyforeachoutcome(COVID-19 positivity,admission,anddeath)withrobuststandarderrors andclusteringattheneighborhoodlevel.Foreachoutcome, abasemodelwascreatedthatincludedage,sex,andCCI.We chosetousetheCCIasasummarymeasureofoverall comorbiditystatus.Wethengeneratedmodelsincluding eachneighborhoodfactorindividuallyandafully adjustedmodel.

Sensitivityanalyses

Weconductedsensitivityanalysesstratiﬁedby comorbidityandincludinginsurancestatusinthebase model.Theanalysisstratiﬁedbycomorbiditieswasdesigned toaddresstheconcernthatthedistributionofcomorbidities

inourpopulationwouldbeunequalbyrace32,33 and, therefore,adjustingforcomorbiditiesmightdiminishthe overallimpactofstructuralracismanddisadvantage.The inclusionofinsurancewasdesignedtoassesstheimpactof includingaproxymeasureofindividualSESinthemodel.

RESULTS

Therewere144,982patientswithEDvisitsorhospital admissionsduringthestudyperiodofwhom5,633(4%)were COVID-19positive(Table1).Ofthose,2,961(53%)were admittedand601(11%)died.Althoughnon-HispanicBlack

Table1. PatientcharacteristicsoverallandbyCOVID-19outcomes. AmongCOVID-19positive PatientcharacteristicOverallCOVID-19positiveAdmittedDied

Race/ethnicity, n(%)

Comorbidities,n(%)

, coronavirus2019.

patientswere9%oftheoverallcohort,theyrepresented16% oftheCOVID-19positivepatients,17%oftheadmitted patients,and15%ofthepatientswhodiedaftertesting positiveforCOVID-19.

Similarly,Hispanicpatientswere13%oftheoverall cohort,30%oftheCOVID-19positivepatients,23%ofthe admittedpatientsand10%ofthepatientswhodiedwith COVID-19.Patientswhowerelistedashavingalanguage preferenceofSpanishwere9%oftheoverallcohortbut30% oftheCOVID-19positivepatients,25%oftheadmitted patients,and12%ofthosewhodiedwithCOVID-19. Although36,384patients(25%)intheoverallpopulationhad onlypublicinsurance,39%oftheCOVID-19positive,40% ofthepatientsadmittedafterCOVID-19,and37%ofthe patientswhodiedafterCOVID-19hadonlypublic insurance.Wheninsurancewasexaminedasthosewhohad anypublicinsurance(60,515,42%),therewerehigher percentagesofpatientswithpublicinsurancewhowere COVID-19positive(55%),admittedafterCOVID-19(61%), ordiedafterCOVID-19(70%)thanintheoverallcohort.

Regardingneighborhoodcharacteristics(Table2),there wasagreaterrepresentationofpatientsfromneighborhoods inthehighestquintileofpoverty,percentageHispanic population,percentagenon-HispanicBlackpopulationand percentageserviceoccupation,andlowestquintileofnonHispanicWhitepopulationandeducationalattainment withintheCOVID-19outcomegroups(testedpositive, admitted,died).

Collinearity

FortheoutcomeofCOVID-19positivity,wedetected multicollinearitywhenincludingpatientrace/ethnicityand allneighborhoodrace/ethnicityvariables;excludingvariable forquintilesofnon-HispanicWhitepopulationresolvedthe collinearityissues.Fortheoutcomesofadmissionwithin14 daysof ﬁrstCOVID-19positivepresentationanddeathany timeafter ﬁrstCOVID-19positivepresentation(among COVID-19positivepatients),multicollinearitywasdetected betweenrace/ethnicityvariablesandserviceoccupation. Removingthevariablesforquintilesofnon-HispanicWhite populationandserviceoccupationresolvedthecollinearity.

IndividualComorbidityandRiskFactors:Association andMediation

Thereweresignificantassociationsbetweenrace/ethnicity andeachcomorbidity,withtheexceptionofnon-Hispanic Blackandhypertension(HTN)(eTable1).Intheunadjusted modelforCOVID-19positivity(Table3),race/ethnicitywas asignificantpredictorofCOVID-19positivity(nonHispanicBlackoddsratio[OR]3.36[3.09–3.64]and HispanicOR4.28[4.00–4.58]).Theassociationwithrace/ ethnicityremainedsignificantevenafteradjustmentforeach individualcomorbidityandriskfactor(Table3).Therewas potentialpartialmediationbylanguagepreference(Table3),

astheORwassubstantiallydecreasedbutstillstatistically significantafteradjustmentforlanguagepreference. Intheunadjustedmodelforadmissionamongthepatients withCOVID-19,non-HispanicBlackandHispanicpatients hadloweroddsofbeingadmitted(OR0.62[0.52–0.72]and 0.36[0.32–0.41],respectively),andthedirectionalityand significanceoftheassociationwasnotalteredbyadjustment foranyoftheindividualcomorbiditiesorriskfactors (eTables2and3);asimilarpatternwasseenfordeathsafter COVID-19(eTables4and5).Together,thisdatasuggests thattheindividualcomorbiditiesandsocialriskfactorsare notsignificantmediatorsoftheassociationbetweenrace/ ethnicityandCOVID-19incidenceandoutcomes.

FullModel:Race/Ethnicity,IndividualandNeighborhood Factors,andCOVID-19

Oncetherewaslessconcernforcomorbiditiesservingasa mediatoroftheassociation,wecreatedabasemodelthat includedage,sex,andtheCCItoexaminehowthe associationsbetweenrace/ethnicityandCOVID-19 outcomes wouldchangewiththeinclusionofneighborhood factors.Inthebasemodel(Table4),race/ethnicitywas stronglyassociatedwithCOVID-19positivity(non-Hispanic Black,OR4.64[4.18–5.14],Hispanic,OR6.99[6.21–7.86], whichwasslightlyattenuatedbutremainedsigniﬁcantafter adjustmentforneighborhoodfactors(non-HispanicBlack, OR3.27[2.90–3.69],Hispanic,OR4.10[3.66–4.60]]).Trends forotherracial/ethnicgroupsaredisplayedin Table4 AmongpatientswithCOVID-19,therewasnosigniﬁcant associationbetweenrace/ethnicityandhospitaladmission, otherthanthatpatientswithmissingorunknownracewere lesslikelytobeadmitted,andthatassociationremained consistentafteradjustmentforneighborhoodfactors.For theoutcomeofdeathafterCOVID-19,Hispanic(OR0.62 [0.46–0.83])andAsian(0.46[0.25–0.86])patientshadlower oddsofdyingascomparedtonon-HispanicWhitepatientsin thebasemodel,andthatassociationpersistedafter adjustmentforneighborhoodfactors(HispanicOR0.61 [0.44–0.85],AsianOR0.47[0.25–0.91])(Table4).

Wefurtherexaminedtheassociationbetweenrace/ ethnicityandCOVID-19outcomesinmodelsstratifiedby comorbidity(eTables6–10).Forpatientswithandwithout obesity,race/ethnicityremainedsignificantlyassociatedwith COVID-19positivityinboththebaseandfullyadjusted models,althoughtheassociationwassmallerintheobese patientsforthosewhowereBlackorHispanicandlargerfor thosewhowereAsian.Similartrendswereseenfor pulmonarydisease,althoughwithsmallerchanges.For patientswithchronickidneydisease,diabetesandHTN,the associationwithrace/ethnicitywasweakerinpatientswith theconditionthanthosewithout,althoughitremained significantinallmodels.

Asasensitivityanalysis,wemodeledtheassociation betweenrace/ethnicityandCOVID-19includingnotonly

Table2. NeighborhoodcharacteristicsoverallandbyCOVID-19outcomes.

AmongCOVID-19positive NeighborhoodcharacteristicOverallCOVID-19positiveAdmittedDied Density,mean(SD),populationpersquaremile10,032(11984)16,121(13,592)15,062(13529)12,402(11711)

Families livingbelowpoverty,n(%)

Lowestquintile(0–1.5%)

2(1.6–3.4%)

3(3.5–6.3%)

4(6.4–13.5%)

28,375(20) 634(11) 382(13) 83(14)

29,941(21) 655(12) 391(13) 95(16)

26,173(18) 712(13) 400(14) 80(13)

32,572(22)1,736(31) 902(31)191(32)

Highestquintile(13.6–65.2%) 27,849(19)1,890(34) 882(30)152(25)

Missing 72 6 4 0

Hispanic/Latinopopulation,n(%)

Lowestquintile(0–2.2%) 21,932(15) 363(6) 211(7) 63(10)

2(2.3–4.5%) 27,409(19) 584(10) 379(13) 99(16)

3(4.6–8.3%) 28,998(20) 698(12) 430(15) 82(14)

4(8.4–19.1%) 27,399(19) 962(17) 498(17)110(18)

Highestquintile(19.2–100%) 39,202(27)3,024(54)1,443(49)247(41)

Non-HispanicBlackpopulation,n(%)

Lowestquintile(0–0.6%)

474(8) 292(10) 62(10)

2(0.7–2.0%) 24,281(17) 506(9) 282(10) 73(12)

3(2.1–4.2%)

4(4.3–9.2%) 27,814(19) 970(17) 511(17) 98(16)

Highestquintile(9.3–82.9%)

Non-HispanicAsianpopulation,n(%)

Lowestquintile(0–0.7%) 20,830(14) 556(10) 296(10) 71(12)

2(0.8–2.2%) 22,773(16) 786(14) 422(14)106(18)

3(2.3–4.9%)

4(5.0–10.9%)

Highestquintile(11.0–59.2%)

Non-HispanicWhitepopulation,n(%)

Lowestquintile(0–50.2%)

2(50.3–72.3%)

30,938(21)1,194(21) 602(20)110(18)

37,281(26)1,869(33) 972(33)171(28)

33,118(23)1,226(22) 669(23)143(24)

38,229(26)2,977(53)1,384(47)227(38)

28,958(20)1,098(20) 606(20)129(21)

3(72.4–83.7%) 31,217(22) 742(13) 464(16)105(17)

4(83.8–91.4%)

28,150(19) 574(10) 366(12) 98(16)

Highestquintile(91.5–100%) 18,386(13) 240(4) 141(5) 42(7)

Bachelor’sdegreeorhigherlevelofeducation,n(%)

Lowestquintile(0–22.3%) 24,773(17)1,926(34) 878(30)136(23)

2(22.4–34.4%)

3(34.5–46.5%)

4(46.6–63.9%)

Highestquintile(64.0–95.6%)

Personsinserviceoccupations,n(%)

Lowestquintile(0–10.8%)

21,154(15)1,097(19) 578(20)106(18)

27,471(19) 756(13) 406(14)101(17)

34,611(24) 949(17) 525(18)125(21)

36,930(25) 903(16) 574(19)133(22)

33,289(23) 817(15) 509(17)112(19)

2(10.9–14.8%) 31,728(22) 723(13) 430(15)111(18)

(Continued onnextpage)

Table2. Continued.

AmongCOVID-19positive NeighborhoodcharacteristicOverallCOVID-19positiveAdmittedDied

3(14.9–18.9%)

4(19.0–25.2%)

23,812(16) 565(10) 316(11) 80(13)

23,950(17)1,028(18) 508(17)116(19) Highestquintile(25.3–69.2%)

COVID-19, coronavirus2019.

age,sex,andtheCCI,butalsoinsurancestatusasamarkerof individualSES.Again,raceremainedstronglyassociated withCOVID-19positivity;onlymissingracewasassociated withadmissionforCOVID-19,andHispanicandAsianrace/ ethnicitywereassociatedwithloweroddsofdeathafter COVID-19(Table5).

DISCUSSION

Inthiscross-sectionalstudyofhealthsystemdatafromthe initialstagesoftheCOVID-19pandemic,non-HispanicBlack,

Hispanic,andAsianrace/ethnicityweresignificantly associatedwithincreasedCOVID-19positivity,andthe associationremainedsignificantafteradjustmentforboth individualriskfactors(age,sex,comorbidity,insurance)and neighborhoodriskfactors(density,poverty,racial/ethnic composition,educationalattainment,occupation).These resultsdemonstrateapersistentassociationwithrace/ethnicity afteradjustmentforpotentialexplanatoryfactors(eg, comorbidities).Importantly,wedidnot findthatcomorbidities orindividualinsurancestatus(asamarkerofSES)were

Table3. Associationofrace/ethnicityandCOVID-19positivitya,unadjustedandadjustedforeachcomorbidityandindividualriskfactor.

Race/ethnicity(primaryexposure),OR(95%CI)b

riskfactor

foreachcomorbidity

aCOVID-19positivitywasde finedasPCRtestresultofpositiveoradmission/dischargestatusdocumentedas “COVID-19Positive” or “PatientExpired(COVID-19).” bPresentedareoddsratios(95%CI)fortheoutcome(COVID-19positivity)foreachrace/ethnicitygroupcomparedtonon-HispanicWhites (referent, firstcolumn),withtheunadjustedvaluesinthe firstrowandafteradjustmentforthevariablesseparatelyinfollowingrows. CCI,CharlsonComorbidityIndex; COVID-19,coronavirus2019.

Table4. Oddsratiosa fortheassociationbetweenrace/ethnicityandCOVID-19outcomes. COVID-19positivity (N = 117,589;clustern = 1,447)

Race/ethnicity

AdmissionafterCOVID-19 (n = 4,895;clustern = 848)

DeathafterCOVID-19 (n = 4,895;clustern = 848) BasemodelFullyadjustedb BasemodelFullyadjustedc BasemodelFullyadjustedc

(referent)

aEstimatedusinggeneralizedestimatingequations(binomialdistribution,logitlink,workingindependencecorrelationstructure)withrobust standarderrorsandclusteringattheneighborhoodlevel.Allmodels(baseandfullyadjusted)includerace/ethnicity,age,sex,andthe CharlsonComorbidityIndex.

bIncludesallneighborhoodfactors(density,poverty,Hispanic/Latino,Non-HispanicBlack,Non-HispanicAsian,Bachelor’sdegreeorhigher levelofeducationandserviceoccupation).Non-HispanicWhitepopulationwithinthecensustract(neighborhoodlevelvariable)was excludedduetomulticollinearity.

cIncludesallneighborhoodfactors(density,poverty,Hispanic/Latino,Non-HispanicBlack,Non-HispanicAsian,Bachelor’sdegreeorhigher educationlevel).Non-HispanicWhitepopulationwithinthecensustract(neighborhoodlevelvariable)andserviceoccupationexcludeddue tomulticollinearity.

COVID-19,coronavirus2019.

meaningfulmediatorsoftheassociationbetweenrace/ethnicity andCOVID-19incidenceoroutcomes,meaningthatwedid notseeevidencethattheywereonthecausalpathwayforthis association.Additionally,theassociationwasnotfully explainedbymeasuredneighborhoodrisk.

Fromtheseresultswedrawtwomajorconclusions. Firstly,recognizingthattheresidualassociationwith measuredrace/ethnicityrepresentsstructuralracismrather thanbiologicalvariationandthatthereisnostandard measurementforstructuralracisminadministrative datasets,thisdataemphasizestheneedforimproved measurementofindividual-levelsocialdeterminantsof healthandtheimpactofstructuralracism.Similartoprior reports,wefoundstrongerassociationsbetweenrace/ ethnicityandCOVID-19positivity,againsuggestingthat higherratesinBlackandHispanicpopulationsaredrivenby exposure, 4 andthatthemortalitytrendsaremorecomplex.6,7 Thisdatabuildsuponpriorreportsthatshowaconsistent impactofraceandethnicitythatappearstobemodifiedor mediatedbysocialdeterminantsofhealth.26,30,34,35 Similarly,arecentstudydemonstratedlimitedabilityof insurancetocorrectlyclassifySES,asdefinedbyeducation andincome.36 Additionalworkisneededtodefineand reliablymeasureindividualsociodemographicfactors

associatedwithdiseasevulnerabilityandusethemtodeﬁne areasforpotentialintervention.

Thesecondmajorconclusionofourstudyurgescaution intheuseofneighborhoodsocioeconomicfactorsaloneto examinedisparities.Neighborhoodfactorsrepresentthe ecologicalexposureandnottheindividualexperience,and thisstudydemonstratesthecomplexinterplaybetween theseindividualandneighborhoodfactors.Forexample,a studyexamininghospitalizedpatientswithCOVID-19in Michiganfoundthatthosefromsociallyvulnerable neighborhoodsweremorelikelytopresentwithsevere disease,evenafteradjustmentforage,sex,and comorbidities,butthatneighborhoodvulnerabilitywasnot associatedwithmortality. 37 Overall,thisdataemphasizes theimportanceofmeasuringthefactors(eg,individual housinginsecurity,crowding,andessentialoccupations thatcouldnotbecompletedremotely)thatre ﬂ ectstructural racism,andmayserveaspotentialmediatorsinthe associationbetweenrace/ethnicityandCOVID-19,rather thanrelyingonneighborhood-levelmeasurementsalone. Futuredirectionsforthisresearchcouldincludeusing improvedmeasurementsofindividual-levelsocial determinantsofhealthinfutureinvestigationsinother conditionsandinterventionstoreducethedisproportionate burdenofdisease.

Table5. Oddsratiosa fortheassociationbetweenrace/ethnicityandCOVID-19outcomes,includingadjustmentforinsurancestatus. COVID-19positivity (N = 116,631;clustern = 1,447)

AdmissionafterCOVID-19 (n = 4,895;clustern = 848)

DeathafterCOVID-19 (n = 4,895;clustern = 848) BasemodelFullyadjustedb BasemodelFullyadjustedc BasemodelFullyadjustedc

Race/ethnicity

bIncludesallneighborhoodfactors(density,poverty,Hispanic/Latino,Non-HispanicBlack,Non-HispanicAsian,Bachelor’sdegreeorhigher educationlevelandserviceoccupation).Non-HispanicWhitepopulationwithinthecensustract(neighborhoodlevelvariable)wasexcluded duetomulticollinearity.

COVID-19,coronavirus2019.

LIMITATIONS

Limitationsofthisstudyincludethatthedatawasdrawn fromasinglehealthsystemand,therefore,mayminimize hospital-leveldifferencesanddisparitiesincare38 andmay notfullycapturetheunderlyingpopulation.Thisis particularlyimportantbecausedatafromourcityhasshown differencesintheracial/ethnicmakeupofpatientpopulations byhospital.39,40 However,thehealthsystemincludesthe hospitalthathascaredforthehighestnumberofadmitted COVID-19patientsinthearea,41,42 andourpriorwork showedthatourhealthsystemdataidentiﬁedsimilarclusters tothestatedatawithinourcatchmentarea.13 Earlyinthe pandemicthereweredisparitiesintestingaccess,43,44 althoughotherstudiesinMassachusettshavefound disparitiesthatwerenotfullyexplainedbytestingaccess differences.14 Additionally,notallcomorbiditiesmay havebeencodedintheproblemlist,particularlyfor patientswhowerenewtoourhealthsystem,potentially limitingourabilitytoascertainthem.Weusedinsurance statusasaproxyforindividualSESbecausewedonothave fulldataonsocialdeterminantsofhealthforallpatients inthecohort.

Itischallengingtodeterminewhetherthemeasured differencesinadmissionanddeathwereduetounmeasured

differencesinillnessseverityorcomorbidities,represented ascertainmentbiasduetouseofEHRdata,orwerea manifestationofimplicitbias.Increasedmortalityhasbeen reportedinHispanicpopulations,8,9 whichwasnot demonstratedinourdata,potentiallyreﬂectingunmeasured confoundingfromdifferencesintheHispanicpopulationin ourcohort(eg,healthyimmigranteffect).45 Becausewewere interestedinneighborhoodeffects,wewerenotableto includepatientswithoutanaddress,andtheremaybea differentrelationshipbetweensocialriskandCOVID-19 incidenceandoutcomesinanundomiciledpopulationthat wewereunabletoexamine.Finally,withtheabilityof patientstoaccessvaccination,andtheevolutionofnew COVID-19variants,thedisparitiesinCOVID-19continue toevolve.

CONCLUSION

ThedatashowsapersistentassociationbetweennonHispanicBlack,Hispanic,andAsianrace/ethnicityand higherCOVID-19incidencethatisnotexplainedbyincluded individualorneighborhoodfactors.Theresultsemphasize theimportanceofimprovingthemeasurementofstructural factorsandsocialdeterminantsofhealthandcareful attentiontotheuseofindividual-levelandneighborhood-

levelriskfactorsinstudiestoenableinterventionstoimprove theequityofpandemicresponse.

AddressforCorrespondence:MargaretE.Samuels-Kalow,MD, MPhil,MSHP,HarvardMedicalSchool,MassachusettsGeneral Hospital,DepartmentofEmergencyMedicine,125NashuaSt.,Suite 920,BostonMA,02114.Email: Msamuels-kalow@partners.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisprojectwassupportedbyagrant fromtheMGHExecutiveCommitteeonResearch.Thereareno otherconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

RaymenR.Assaf,MD,MPH,MA*†

ChloeKnudsen-Robbins,MD‡ TheodoreHeyming,MD*§ KellieBacon,MPH*

ShelbyK.Shelton,MPH* BharathChakravarthy,MD,MPH§ SoheilSaadat,MD,MPH,PhD§ JasonA.Douglas,PhD∥ VictorCisneros,MD,MPH,CPH,FAAEM§¶

*Children’sHospitalofOrangeCounty,Orange,California

† UniversityofCaliforniaIrvine,SchoolofMedicine,Departmentof Pediatrics,Irvine,California

‡ UniversityofCincinnatiCollegeofMedicine,Departmentof EmergencyMedicine,Cincinnati,Ohio

§ UniversityofCaliforniaatIrvine,DepartmentofEmergency Medicine,Orange,California

∥ UniversityofCaliforniaIrvine,DepartmentofHealth,Society, &Behavior,Irvine,California

¶ EisenhowerHealth,DepartmentofEmergencyMedicine, RanchoMirage,California

# UniversityofCaliforniaRiverside,SchoolofMedicine,Departmentof EmergencyMedicine,Riverside,California

SectionEditor: RonnieDellWaldrop,MD

Submissionhistory:SubmittedFebruary12,2024;RevisionreceivedNovember5,2024;AcceptedNovember6,2024

ElectronicallypublishedJanuary15,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.19435

Introduction: Foodandhousinginsecurityinchildhoodistroublinglywidespread.Emergency departments(ED)arewellpositionedtoidentifyandsupportfood-andhousing-insecurechildrenand theirfamilies.However,thereisnoconsensusregardingthemostefﬁcientscreeningtoolsormost effectiveinterventionsforEDuse.

Objective: Inthiscross-sectionalstudyweaimedtoinvestigatetheimplementationofafood/housing insecurityscreeningtoolandresourcereferraluptakeinapediatricED.

Methods: Duringthestudyperiod(March1–December9,2021),therewere67,297EDvisitsatthestudy institution,whichisafreestandingchildren’shospital.CaregiversofpatientspresentingtotheEDwere approachedforparticipationinthestudy;1,908familiesparticipated(2.8%ofallEDvisitsduringthe studyperiod)andwerescreenedforfoodandhousinginsecurity.Caregiversurveysincluded demographic,foodandhousinginsecurity,caregiver/patienthealthstatus,andhealthcareutilization questions.Caregiverswhoscreenedpositiveforfoodand/orhousinginsecurityreceivedprinted materialswithfoodand/orhousingresources.Weanalyzeddatausingdescriptivestatistics,one-way analysisofvariance,andthePearsonchi-squaredtest.

Results: Atotalof1,908caregiversweresurveyed:416(21.8%)screenedpositiveforfoodand/or housinginsecurity.Ofthosewhoscreenedpositive,147/416completedfollow-upsurveys.Onfollow-up, 44(30.0%)nolongerscreenedpositiveforfoodand/orhousinginsecurity,while15(10.2%)reported usingatleastoneresourcereferral.Themostfrequentlyreportedreferralutilizationbarrierwaslossor reportednon-receiptofthereferral.

Conclusion: Thisstudydemonstrateshighfood-andhousing-insecurityratesamongfamilies presentingtoapediatricED,emphasizingtheurgencyandnecessityofscreeningandinterveninginthis environment.Thefoodandhousinginsecuritychangebetweenbaselineandfollow-upreportedhereand theoveralllowresourceuptakehighlightschallengeswithED-basedscreeningandinterventionef ﬁcacy. [WestJEmergMed.2025;26(2)326–337.]

INTRODUCTION

OneinsixofallchildrenintheUnitedStates(US)arefood insecure,whileonein18undertheageofsixareunhoused.1 In2017,over1.5millionchildrenenrolledinpublicschools wereunhoused.2,3 Beyondastatisticalrepresentationof societalshortcomingsofmeetingthebasicneedsofchildren, these ﬁguresaredistressingasfoodandhousinginsecurity hasrepeatedlybeenshowntobeassociatedwithadverse mental,physical,anddevelopmentalhealthoutcomes.1,4–12 Foodandhousinginsecuritydisproportionatelyburdens underservedcommunitiesofcolor,particularlythosein whichmorethan20%ofresidentsliveinpoverty,and downstreamhealthdisparitiesarecommon.13

Since2015theAmericanAcademyofPediatricshas advocatedforthescreeningoffoodinsecurityduringwellchildvisits,andthisapproachhasnowexpandedtoavariety ofhealthcaresettings.14 Theemergencydepartment(ED)is particularlywellpositionedtoassessforhealth-relatedsocial needs(HRSN)andtopotentiallyintervene.Over15%ofall USchildrenvisittheEDeachyear,manywithbarriersto routinepreventivecare,andfood/housinginsecurityhasbeen showntobeassociatedwithincreasedEDuse.15–18 Several studieshavedemonstratedthefeasibilityofvariousscreening methodsandresourcereferralforfoodandhousing insecurityintheED.19–25 However,thereisnocurrent consensusregardingthemosteffectivetechniquesfor reliable,widespreadscreeningintheEDor recommendationsforoptimizingcaregiverresource utilization.Inthisstudyweaimedtoinvestigatethe implementationofafoodandhousinginsecurityscreening toolandresourcereferraluptakeinapediatricED.

METHODS

Thiscross-sectionalstudyincludedpatientspresentingto theEDofafreestandingchildren’shospitalwithaLevelII traumacenterbetweenMarch1–December9,2021.This institution,locatedinasuburbancommunityinthe SouthwesternUS,hasanannualEDcensusof approximately100,000visitsperyear;67,297visitsoccurred duringthestudyperiod.Inthestudycounty,approximately 24%ofhouseholdsreportahouseholdincomeofunder $50,000/year,25%report$50,000–100,000,31%report $100,000–$200,000,and19%reportover$200,000.An estimated11%ofchildrenlivebelowthepovertyline.26 This studywasapprovedbythestudyinstitution’sinstitutional reviewboard(IRB#200326).

Usingaconveniencesampleofadultcaregiversofpatients <18,trainedresearchassistants(RA)approached prospectiveparticipantsduringtriage,describedthestudy, invitedthemtoparticipate,andobtainedverbalconsent fromthosewhoagreed.TheRAsapproachedeligiblepatient caregiversduringthehoursof8 AM – 5 PM Mondaythrough Fridayduringthestudyperiod.TheRAsadministered surveysviaREDCap(ResearchElectronicDataCapture

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Foodandhousinginsecurityinterventionsare increasinginthepediatricemergency department(ED)yetlackastandard approachtooptimizingresourceutilization.

Whatwastheresearchquestion?

Whatarebarrierstouptakeoffoodand housinginsecuritycommunity-resource referralsinapediatricED?

Whatwasthemajor ﬁndingofthestudy?

Onfollow-up,only10%ofparticipating familiesreportedusingatleastone resourcereferral.

Howdoesthisimprovepopulationhealth?

Thisstudyidenti ﬁ esmultiplebarriersto communityresourceuseandfollow-upamong familiesparticipatinginapassivereferral approachinapediatricED.

hostedatUCIrvineEmergencyDepartment)onelectronic tablets,inwhichparticipantsdirectlyenteredtheirresponses. SurveyswereavailableinEnglishandSpanish.Thebaseline surveyincludedanexpandeddemographicssectionfollowed by16questionsregardingfoodinsecurity,accesstofood, housinginsecurity,neighborhoodsafety,caregiverselfreportedhealth,caregiver-reportedpatienthealth,and healthcareutilization(SupplementaryMaterialsAppendix A).Wealsogarneredcaregiverself-reportedrace/ethnicityas wellasinsurancestatusfrompatientregistrationdata. SurveysweredevelopedbyRA,VC,andJD,authorswith expertiseinpublichealth.

Weassessedanddefinedfoodinsecuritybasedontwo previouslyvalidatedscreeningquestions: “Withinthepast12 months,IworriedwhethermyfoodwouldrunoutbeforeI gotmoneytobuymore”;and “Withinthepast12months, thefoodIboughtjustdidn’tlastandIdidn’thavemoneyto getmore.”27 Affirmativeresponsestoeitherorboth questionswasconsideredapositivescreen.Weassessed housinginstabilityonanaffirmativeresponseeitherto1) “In thepast12months,haveyouhadtroublepayingyourrent/ mortgage/utilitybills,” or2)aresponseof “Stayatafriend’ s home” or “Idonotliveinstablehousing” tothesurvey question “Inthepast12months,haveyoubeenlivingin stablehousingthatyou ” Thisdefinitionisconsistentwith priorstudies,althoughhistoricallyhousinginstabilityhas beendefinedbyvariouscriteriainfederalbodiesand

scientiﬁcliterature,renderingitmoredifﬁculttoconsistently measurethanfoodinsecurity.4

Allcaregiverswhocompletedthesurveyreceivedcurated printedmaterialswithcurrentlocalfoodand/orhousing resources.TheRAsprovidedtheseresourcesimmediately aftertheparticipantscompletedthesurvey.Direct communicationbetweenresearchpersonnelandcommunity resourcesaboutindividual-levelneed(eg,warmhand-offs) werenotpartofthestudymethods.Thestudyinstitution’ s socialworkteamworkedwithauthorsRAandVCto developdocumentscontaininganextensivelistofvetted localcommunityresources.Additionally,thosewho screenedpositiveforfoodorhousinginsecuritywere contactedbyRAsthreeweeksandsixweeksaftertheindex EDvisittoconductfollow-upsurveys.TheRAsconducted follow-upsurveysviatelephoneandattemptedtocontact familiesuptothreetimes.Follow-upsurveysincluded questionsregardinguseofprovidedresources,barriersto use,andfood/housinginsecurityinthepriorthreeweeks (SupplementaryMaterialsAppendixB).Follow-upstatus (foodinsecure,housinginsecure,orbothfoodandhousing insecure)wasrecordedbasedon ﬁnalresponses(ie,atthree weeksifcaregiversdidn’trespondtothesix-weeksurveyor sixweeksiftheyrespondedtobothsurveys).

StatisticalAnalysis

DatawasscreenedandcleanedpriortoanalysesbyPKP. Descriptivestatisticswereusedtoanalyzedemographic, healthcareutilization,andclinicalcharacteristics.We analyzedpatientageandEDlengthofstay(bothcontinuous variables)usingtheFisher t -testorWelchone-wayanalysis ofvariance.Allothervariables(categorical)wereanalyzed usingthePearsonchi-squaredtestwithMonteCarlo simulationandstandardizedresiduals(z)tointerpret signiﬁcantassociations.

RESULTS

Atotalof2,144adultcaregiversparticipatedinthesurvey. Initialfood/housinginsecuritystatuswasindeterminatefor 236patientsastheircaregiversdidnotrespondtothefood/ housingquestionsdescribedaboveand,thus,thisgroupwas excludedfromdataanalysis.Oftheremaining1,908 respondents(2.8%oftotalEDvisitsduringthestudyperiod), atotalof416(21.8%)screenedpositiveforfoodand/or housinginsecurity.Additionally,164caregivers(8.6%) screenedpositiveforfoodandhousinginsecurity,95(4.98%) forsolelyfoodinsecurity,and157(8.2%)forsolely housinginsecurity.

InitialSurvey

Demographics

Themeanageforallpatientswhosecaregivercompleteda surveywas6.68 ± 5.26years.Onaverage,patientswithfood orhousinginsecurity(7.42 ± 5.40years),foodandhousing

insecurity(7.95 ± 5.44years)wereolderthanthosewithout (6.41 ± 5.18years; P < 0.001).Slightlymorethanhalfofall patientsweremale(52.8%);therewasnosigniﬁcant differencewithrespecttosexamongpatientswithand withoutfoodand/orhousinginsecurity; P = 0.43.Among thosesurveyed,64.1%wereHispanic,20.4%WhitenonHispanic,7.3%Asian,and2.5%Black.Justover75%of caregiverswhoscreenedpositiveforfoodorhousingsecurity wereHispanic,11.5%wereWhitenon-Hispanic,4.4%were Asian,and2.0%wereBlack.Caregiverswhowerebothfood andhousingsecureweremorelikelytoreportWhitenonHispanicraceandethnicity(z = 2.9, P < 0.001).Overtwothirds,67.5%,ofpatientshadpublichealthinsurance; caregiverswhowerefoodand/orhousinginsecureweremore likelytohavepublichealthinsurancethanprivatehealth insurance(z = 4.22, z = 4.41, P < 0.001).Complete demographicsstratiﬁedbytotalpopulation,andthose withandwithoutfoodand/orhousinginsecurityareincluded in Table 1

Neighborhoodsafety

Ofallcaregiverssurveyed,72.9%reportedalwaysfeeling safeintheirneighborhoodand76.2%reportedneverbeing concernedaboutthepatient’ssafetyintheirneighborhood. Caregiversscreeningpositiveforbothfoodandhousing insecuritywerelesslikelytoreportalwaysfeelingsafeintheir neighborhood(z = 4.5)andmorelikelytoreportsometimes beingconcernedaboutthepatient’ssafetyintheir neighborhood(z = 4.5, z = 7.1, P < 0.001).

Healthstatusandhealthcareutilization

Only35.3%ofcaregiversratedthepatient’shealthas excellent,whileevenfewer,25.1%,ratedtheirownhealthas excellent.Thosescreeningpositiveforhousingand/orfood insecuritywerelesslikelytoratethepatient’shealthas excellent(z = 3.1, z = 3.2, P < 0.001)aswellastheirown healthasexcellentorverygood(z = 2.8, z = 3.4, P < 0.001).Caregiverswhoscreenedpositiveforboth housingandfoodinsecurityweremorelikelytoreportthat atsometimeaphysiciantoldthemthepatientwasobese (z = 3.22),hadanxiety(z = 3.82),orhademotional challenges(z = 3.80, P < 0.001).

Inourstudy,68.3%ofcaregiversreportedthepatienthad notvisitedtheEDinthepreviousyear,19.6%reporteda singlevisit,and12.1%reportedtwoormorevisitsduringthe sametimeframe.Caregiversscreeningpositiveforbothfood andhousinginsecurityweremorelikelytoreportvisitingthe EDatleastonce(z = 3.0, P < 0.001).

EDvisitcharacteristics

Themajority(65.1%)ofpatientsweretriagedto EmergencySeverityIndex(ESI)level3anddischargedhome fromtheindexEDvisit(80.9%),whilethemeanlengthof stayintheEDwas4.5 ± 3.19hours.Therewasnosigniﬁcant

Table1. Initialsurvey:demographicsandclinicalcharacteristicsasstratiﬁedbyfoodandhousinginsecuritystatus.

Baselinestatus(N = 1,908)

Characteristics

Demographic

$20,000,n(%)

$60,000 – $79,999,n(%)

Missingorprefernottoanswer, n(%)

Respondent’shighesteducationlevel <0.001

Lessthanhighschool,n(%)

HighschooldiplomaorGED,n(%)499(26.3%)71(28.2%)54(32.9%)374(25.1%)

Somecollege,n(%)

Collegedegree,n(%) 542(28.4%)37(14.7%)21(12.8%)484(32.4%)

Missingorprefernottoanswer, n(%)

Numberoftimesmovedduringpast 12months

0,n(%) 1,294(67.8%)141(56%)88(53.6%)1,065(71.4%) 1,n(%) 274(14.4%)55(21.8%)39(23.8%)180(12.1%)

(Continued onnextpage)

Table1. Continued.

Characteristics Totalpopulation (N = 1,908)

Respondent’sperceptionof neighborhoodsafety: “Doyoufeelsafeinyour neighborhood?”

Respondent’sconcernforpatient’s safetyinneighborhood: “Areyou concernedaboutyourchild’ssafety inyourneighborhood?”

Baselinestatus(N = 1,908)

Respondent’sperceptionof patienthealth

Excellent,n(%)

674(35.3%)60(23.8%)34(20.7%)580(38.9%)

Verygood,n(%) 654(34.3%)97(38.5%)50(30.5%)507(34.0%)

Good,n(%) 442(23.2%)68(27.0%)55(33.5%)319(21.4%)

110(5.8%)24(9.5%)22(13.4%) 64(4.3%)

Respondent’sperceptionof ownhealth <0.001

Excellent,n(%) 479(25.1%)41(16.3%)26(15.9%)412(27.6%)

Verygood,n(%) 676(35.4%)79(31.3%)32(19.5%)565(37.9%) Good,n(%) 594(31.1%)91(36.1%)64(39.0%)439(29.4%) Fair,n(%) 148(7.8%)39(15.5%)37(22.6%) 72(4.8%)

Level3,n(%) 1,243(65.1%)172(68.3%)109(66.5%)962(64.5%) (Continued onnextpage)

Table1. Continued.

Baselinestatus(N = 1,908)

Characteristics

Discharged,n(%) 1,544(80.9%)206(81.7%)138(84.1%)1,200(80.4%)

Admitted,n(%)

Leftagainstmedicaladvice,n(%)1(0.1%)

EDlengthofstay,meanhours(SD)4.52(3.19)4.92(2.80)4.82(2.87) 4.85(3.45)0.95

NumberofEDvisitsduringpast 12months

2ormore,n(%) 230(12.1%)43(17.1%)21(12.8%)166(11.1%)

Adoctorhasstatedthatpatient has(checkallthatapply):

Noneofthoselisted

*Note: Despite thissigniﬁcant P-value,noneofthe z’swere ≥2.58;Type1errorpossible. ED,emergencydepartment; GED,GeneralEducationalDevelopment.

differenceinEDdispositionorlengthofstayamong caregiversreportingfoodand/orhousinginsecurity comparedtothosewhowerefoodandhousingsecure.

Movesintheprecedingyear

Baselinesurveyresultsindicatedthat20caregivers(1.0% ofthesample)reportedmovingthreeormoretimesinthe previous12months.Ofthose,nonescreenedpositivefor solelyfoodinsecurity,35%screenedpositiveforsolely housinginsecurity,40%screenedpositiveforbothfoodand housinginsecurity,and25%didnotscreenpositiveforfood orhousinginsecurity.

Follow-up

Ofthe416familiesscreeningpositiveforfoodorhousing insecurity,contactwassuccessfullymadewith147(35.3%) caregiversatthreeweeks,andofthose,70(47.6%)responded tosurveysatsixweekspost-EDvisit.

Food/housinginsecuritystatus

Ofthe147caregiverswhoparticipatedinfollow-up,25 weresolelyfoodinsecureattheindexEDvisit.Ofthose, seven(28%)continuedtoreportfoodinsecurityatthetimeof follow-up,two(8%)reportedsolelyhousinginstability withoutfoodinsecurity,three(12%)reportedbothfoodand

housinginsecurity,and12(48%)nolongerscreenedpositive foreitherfoodorhousinginsecurity.Ofthe60caregivers whoscreenedpositiveforsolelyhousinginsecurityatthe indexEDvisitandparticipatedinfollow-up,19(31.7%) continuedtoreporthousinginsecurityatthetimeoffollowup,three(5%)reportednewfoodinsecurityonly,11(18.3%) reportedbothfoodandhousinginsecurity,and26(43%)no longerscreenedpositiveforeitherfoodorhousinginsecurity.

Ofthe62caregiverswhoscreenedpositiveforbothfood andhousinginsecurityattheindexEDvisitandparticipated infollow-up,31(50%)continuedtoreportbothfoodand housinginsecurity,15(24.2%)reportedfoodinsecurityonly, 10(16.1%)reportedhousinginsecurityonly,andsix(9.7%) nolongerscreenedpositiveforfoodorhousinginsecurity. Follow-upstatuswasunknownduetomissingdatafortwo families.(Onereportedfoodinsecurity,andtheother reportedhousinginstabilityattheindexEDvisit.)

Transitionsfrompositivefoodand/orhousinginsecurity screeningtonegativescreening

Ofthe147caregiverswhoreportedfoodand/orhousing insecurityattheindexEDvisitandparticipatedinfollow-up, 44(29.9%)nolongerscreenedpositiveforeitherfoodor housinginsecurityatfollow-up.Familiesofthoseinitially screeningpositivewhosubsequentlydidnotscreenpositive appearedgenerallysimilarwithrespecttodemographics, neighborhoodsafety,healthstatus/healthcareutilization, andEDvisitcharacteristics(Table2).Youngerpatientage wasassociatedwithatransitionfromapositivetonegative screen(P = 0.02). Table2 includescomparisonsofall collectedvariablesforthesetwogroups.Giventherelatively lownumberoffamiliesthatfollowedupandreported resourceuse,itwasnotpossibletodeterminewhetherthere wasanyassociationbetweenreferraluseandtransitionfrom positivetonegativescreens.

Reportedbarrierstoresourceuse

Ofthe147caregiverswhoparticipatedinfollow-up,only 15(10.2%)reportedusingatleastoneoftheresource referrals.Themostfrequentlyreportedbarrierforthose reportingabarriertoresourceusewaslosingornotreceiving thereferral(41.7%).Othercommonreasonsincludednot havingtime(15.2%)andresourcesnot ﬁttingtheirneeds (10.6%).The Figure demonstratescaregiver-reported barrierstoreferraluse.

Demographicsofthosewithandwithoutfollow-up

Patientswhosecaregiversparticipatedinfollow-uphad largelysimilardemographicstothosewhodidnot,exceptfor languagespokenathome.Spanish-speakingcaregiverswere lesswellrepresentedamongthosewithfollow-up(z = 3.06, P < 0.001).Supplementary Table1 demonstrates demographics,neighborhoodsafety,healthstatus,

healthcareutilization,andEDvisitcharacteristicsofthose withandwithoutfollow-up.

DISCUSSION

Thisstudydemonstratedhighlevelsofsocialneedin patientspresentingtoapediatricED.Overonein five patientsscreenedpositiveforfoodand/orhousinginsecurity. Thereportedrateoffoodinsecurityfoundinthisstudydoes appearsomewhatlowerthanthenationalaverageaswellas comparedtopreviousstudiesinvestigatingfoodinsecurityin thepediatricED,althoughoverallnumbersvarywidely basedondatasource.1,22,23,25,27 Wedid findhigherfood insecurityratesthanthatofthesurroundingcountyinthe studyyear.28 Still,ourstudydesignwaslimitedby conveniencesamplinganda2.8%responserateof participantsintheED,limitingthegeneralizabilityofour findings.OtherpediatricED-basedstudiesdemonstrate similarchallenges,withlowresponserate(3.6%)29 and health-relatedsocialneed-positivescreeningrate(16%).30 It isimportanttonotethateveniffamiliesscreenpositivefor socialrisk,asubstantialproportionmaystilldecline assistance.31 Similarly,socialneedsnavigationfollow-uphas beenshowntobechallengingintheEDsetting,withlow participationrate(7%)32 andpersistenceofsocialneed(56%) despiteparticipationinnavigationservices.19

Inourstudy,follow-upsurveydatarevealedanoverall reductioninthereportedratesoffoodandhousing insecurity,yetcommunityresourcereferraluptakewaslow. Thislikelyreﬂectsthecomplexityandburdenofpatient socialcircumstancesandamultitudeofenvironmental factors.Amongthosewhowerefoodinsecureatbaseline, almosthalfnolongerscreenedpositiveforfoodorhousing insecurity,andamongthosewhowerehousingunstableat baseline,over40%nolongerscreenedpositiveforfoodor housinginsecurity.Thosewithfoodandhousinginsecurity atbaselinedemonstratedtheleastreductioninsocialneed, withjustunder10%nolongerscreeningpositiveforeither foodorhousinginsecurityatfollow-up.However,despite theseapparentpositiveshifts,itisdifﬁculttoascertain whetherthesedevelopmentswereassociatedwithED interventions.Indeed,itseemsunlikelygiventhatthe majorityofcaregiverswithwhomwefollowedupdidnot endorseresourceuse.

Itisbeyondthescopeofthisstudytodiscerntheetiology ofthistrend.Itispossiblethatcaregiversunder-reported resourceuse,thatcompletionofthesurveyitselfmayhave precipitatedachange,randomchance,orarangeofother explanationsincludinganinterplayofsocialdeterminantsof health.Interestingly,Kanaketaldemonstratedsomewhat similar ﬁndingsusinganinterventionavailableontabletand personalsmartphone(theHelpStepsapp),reportingthat only23%ofcaregiversdescribedusingthetool.19 Only14% contactedatleastonereferralagency,yet44%reportedtheir primaryneedeithercompletelyorsomewhatresolved.19 As

Table2. Follow-upsurvey:demographicsandclinicalcharacteristicsasstratiﬁedbyfood/housinginsecuritystatus. Follow-upstatus* Characteristics

– $39,999,n(%)

– $79,999,n(%)

$80,000 – $99,999,n(%)

Numberoftimesmovedduringpast12months

Respondent’sperceptionofneighborhoodsafety,n(%)

(Continued onnextpage)

Table2. Continued. Follow-upstatus

Adoctorhasstatedthatpatienthas: noneofthoselisted,n(%)

(Continued onnextpage)

Follow-upstatus

*Follow-upstatusunknownduetomissingdatafortwofamilies(onefoodinsecureandonehousinginsecureatbaseline).

**Despite thissigniﬁcant P-value,noneofthe z’swere ≥2.58;Type1errorpossible. ED,emergencydepartment; GED,GeneralEducationalDevelopment.

inthecurrentstudy,Kanaketalfoundhousingneedstobe morepersistentthanfoodinsecurityaswell.19 Libermanetal alsoexaminedsocialneedsinterventionsinthepediatricED withtrainednavigatorsandnotedmuchgreateruseof resources(45.6%ofthosewhofollowedupreported contactingatleastoneresource);however,itwasdifﬁcultto determinewhetherthesewerehousing-andfood-related resourcesastheserepresentedonly21%and20%, respectively,ofreferralresourcesprovided.21

Inthecurrentstudy,themostcommonbarriertoresource usereportedbycaregiverswasthattheyeitherlostordidnot receivethereferral.Whilethisinitiallyappearssomewhat discouragingitalsomaypotentiallyprovethesimplest obstacletoaddressinfuturework.Itmaybehelpfulto provideelectronicformsofresourcesinadditiontowritten copies,assuggestedbycaregiversinotherpediatricEDbasedstudies.21,29 Itisremarkablethatamongcaregiversina studybyCullenetalwhoscreenedpositiveforfood insecurityandoptedtoreceiveadirectphonecallfromafood resourceagency,only35.9%wereabletobereached,andof those,31%werenolongerinterestedinfood-resource referrals.23 Itispossiblethatfutureresearchmayalsoelicit appropriatemethodsofneedsreassessmentandtimingfor suchreassessment.Increasedengagementandcollaboration

Theassociationofageandsocialneedislikely multifactorialandmayincludevariablessuchasreduced Table2. Continued.

withthecommunity,bothwiththoseinneedandwiththose providingresources(ie,foodbanks),maypavethewayfor improvedscreeningdesignandresourceinformation deployment,aswellasmoresuccessfulandincreased useofinterventions.

Thecurrentstudyreinforcesassociationsdemonstrated throughouttheliteraturebetweenfood/housinginsecurityand caregiver/patientphysicalandmentalhealth.1,4–12 Thisserves tounderscoretheimportanceofattemptingtoaddressfood andhousinginsecurityateveryopportunity.Theassociation ofneighborhoodsafetyandfoodandhousinginsecurity,while notunexpected,likelyadditionallycompoundsthechronic illnessessuchasanxiety,obesity,andasthmaalsofoundinthe currentstudytobeassociatedwithfoodandhousing insecurity.Notabledemographicassociationswithfoodand/ orhousinginsecurityincludedolderage;agealsoappearedto beassociatedwiththetransitionfrompositivetonegative screensforfoodand/orhousing.Gonzalezetalalsofound increasingageandpublichealthinsurancetobeassociated withfoodinsecurity;however,unlikeinthecurrentstudythey didnot ﬁndassociationsbetweenfoodinsecurityandchronic healthconditions.25

Figure. Reportedbarrierstoreferraluse.

resourcesavailableforfamilieswitholderchildren,and increasedmonetaryrequirementsofolderchildrenpossibly representmoredeeplyentrenchedsocialneed.Interestingly, despitepreviousliteraturedemonstratinganassociation betweenfoodinsecurityandincreasedhealthcareutilization suchasEDvisits,thecurrentstudyfoundsomewhat equivocaldata.15,17 OneEDvisitwithinthepastyearwas morelikelytobeassociatedwithfoodandhousing insecurity;however,twoormorewasnot.Additionally,the transitionfrompositivetonegativescreenswasalso associatedwithaslightlyincreasedmeannumberofED visitswithintheprioryear.Itisdifﬁculttohypothesizewhat maybedrivingtheseseeminglydiscordantresults;however, itispossiblethatitistheunequalinterplayofmultiple variables;forexample,youngerchildrenwhoarealsomore likelytotransitionfrompositivetonegativescreensaremore likelytovisittheEDoverall.

LIMITATIONS

Therewereseverallimitationsinherenttothedesignof thisstudy,includingtheuseofconveniencesamplingwith datacollectorspresentonlyduringthedayandearlyevening. Thissamplingtechniquemaynothavecapturedthosewith particularlychallengingsocialcircumstances, underestimatingthetrueratesoffoodandhousing insecurity,whileincreasingthelikelihoodofsamplebias andpresenceofconfoundingfactors.Additionally, thisstudyrelieduponself-reportforidentificationoffood/ housinginsecurityaswellasresourceuse;therefore, reportingbiasmayhaveimpactedourresults.Althoughwe attemptedtodesignthestudyinsuchawaytoreduce potentialdiscomfortasmuchaspossible, financialmeans andsocialneedingeneralremainsensitivetopics,and concernsregardingprivacyandstigmamayhavecontributed furthertoreporterbias.Thisisespeciallypertinentasfollowupsurveyswereconductedoverthephonewhileinitial surveyswerecompletedonelectronictablets,possibly contributingto fluctuationsinthereportingoffoodand/or housinginsecurity.

Familieswerecontactedbystudyresearchpersonnel,and thismechanismmaybelesseffectivethanestablishedclosedloopreferralmechanismsinwhichthecommunity-based socialserviceitselfislinkeddirectlywiththehealthcare institution.Thefollow-upperiodofthreetosixweeksmay alsobesomewhatlimited,anditispossiblethatresourceuse, especiallyformorecomplexneedssuchashousing,maynot effectchangewithinthisshortperiod.Itisalsoworth considering,forexample,thatwhilefoodbanksareessential socialresourcestoaddresshunger,theyareatemporary solution,anddonotincreasetheabilityofacaregiverto purchaseadequatefood.Difﬁcultiesincontactingfamilies forfollow-upalsopresentedasigniﬁcantlimitationand restrictedourabilitytoevaluatestudyinterventions.During thestudyperiod,researchersatthesameinstitutionwerealso

conductingastudyexaminingadversechildhood experiences;aspartofthisconcurrentstudy,socialworkers mayhavebeenconsultedforsomeofthesefamilies, potentiallyalteringresourcereferraldistributionforthose families.Lastly,becausethisstudytookplaceduringthe COVID-19pandemictheresultantincreasedsocialneeds andrapidlychangingeconomiclandscapelikelyaffectedour results,possiblyreducingthegeneralizabilityofthiswork.

CONCLUSION

Thisstudysuggeststhatscreeningandinterventionamong twocommonsocialdeterminantsofhealth foodand housinginsecurity maybefeasibleinapediatricEDsetting. Atthesametime,itillustratesthatachievingwidespread participationamongfamiliesmaybeasignificantchallenge. Althoughasignificantproportionofcaregiversreporteda changeinfoodandhousinginsecurityonfollow-up,itis difficulttoascertainwhatmayhavecontributedtothis finding, especiallygiventhelimitedresponserateandreportedresource use.Furthersocialneeds-interventionresearchinthepediatric EDsettingshouldbedesignedtocapturelargerresponserates (includinganassessmentofsocialneeddisclosureindayand overnightperiods),whileassessingtheperformanceofclosedloopreferralandfollow-upmechanismsforthosefamilieswho indicateadesireforassistance.

ACKNOWLEDGMENTS

TheauthorswouldliketothankPhungK.Pham,PhD,for heressentialstatisticalcontributionstothispaper.This researchwaspartiallysupportedthroughthestudy institution’sChiefScientiﬁcOfﬁcerSeedGrant.Thisfunding sourcewasnotinvolvedinstudydesign,datacollection,data analysis, interpretationofdata,manuscriptdrafting,or decisiontosubmitforpublication.

AddressforCorrespondence:VictorCisneros,MD,MPH, EisenhowerHealth,DepartmentofEmergencyMedicine,39000Bob HopeDr.,RanchoMirage,CA92270.Email: vcisneros2@ eisenhowerhealth

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsourcesand financialormanagementrelationshipsthatcouldbeperceivedas potentialsourcesofbias.Thisresearchwassupportedthrougha Children’sHospitalofOrangeCountyChiefScientificOfficer(CSO) SeedGrant(Grant#16962002).Thisfundingsourcewasnotinvolved instudydesign,datacollection,dataanalysis,interpretationofdata, manuscriptdrafting,ordecisiontosubmitforpublication.Thereareno otherconflictsofinterestorsourcesoffundingtodeclare.

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12.CuttsDB,MeyersAF,BlackMM,etal.UShousinginsecurity andthehealthofveryyoungchildren. AmJPublicHealth. 2011;101(8):1508–14.

13.AmegbletorDY,GoldbergD,PopeDA,etal.Foodandnutritionsecurity associaldeterminantsofhealth:fosteringcollectiveimpacttobuild equity. PrimCare. 2023;50(4):633–44.

14.GittermanBA,ChiltonLA,CottonWH,etal.CouncilonCommunity Pediatrics;CommitteeonNutrition.Promotingfoodsecurityforall children. Pediatrics. 2015;136(5):e1431–8.

15.RigdonJ,MontezK,PalakshappaD,etal.Socialriskfactorsinﬂuence pediatricemergencydepartmentutilizationandhospitalizations. JPediatr. 2022;249:35–42.e4.

16.FosterCC,SimonTD,QuP,etal.Socialdeterminantsofhealthand emergencyandhospitalusebychildrenwithchronicdisease. Hosp Pediatr. 2020;10(6):471–80.

17. PeltzAandGargA.Foodinsecurityandhealthcareuse. Pediatrics. 2019;144(4):e20190347.

18.McDermottKW,StocksC,FreemanWJ.(2018). HealthcareCostand UtilizationProject(HCUP)StatisticalBriefsno.242:Overviewof PediatricEmergencyDepartmentVisits,2015.Rockville,MD:Agency forHealthcareResearchandQuality(US).

19.KanakMM,FleeglerEW,ChangL,etal.Mobilesocialscreeningand referralinterventioninapediatricemergencydepartment. AcadPediatr. 2023;23(1):93–101.

20.MurrayE,RooseveltGE,VogelJA.Screeningforhealth-relatedsocial needsintheemergencydepartment:adaptabilityand ﬁdelityduringthe COVID-19pandemic. AmJEmergMed. 2022;54:323.e1–4.

21.LibermanDB,PhamPK,Semple-HessJE.Socialemergencymedicine: capitalizingonthepediatricemergencydepartmentvisittoscreenand connectpatientsandfamiliestocommunityresources. AcadPediatr. 2022;22(6):1049–56.

22.CullenD,WoodfordA,FeinJ.Foodforthought:arandomizedtrialof foodinsecurityscreeningintheemergencydepartment. AcadPediatr. 2019;19(6):646–51.

23.CullenD,AbelD,AttridgeM,etal.Exploringthegap:foodinsecurityand resourceengagement. AcadPediatr. 2021;21(3):440–5.

24.DeMarchisEH,HesslerD,FichtenbergC,etal.Assessmentofsocial riskfactorsandinterestinreceivinghealthcare-basedsocialassistance amongadultpatientsandadultcaregiversofpediatricpatients. JAMA NetwOpen. 2020;3(10):e2021201.

25.GonzalezJV,HartfordEA,MooreJ,etal.Foodinsecurityinapediatric emergencydepartmentandthefeasibilityofuniversalscreening. WestJ EmergMed. 2021;22(6):1295–300.

26.U.S.CensusBureau.Censusreporter.Availableat: https:// censusreporter.org.AccessedNovember9,2023.

27.HagerER,QuiggAM,BlackMM,etal.Developmentandvalidityofa 2-itemscreentoidentifyfamiliesatriskforfoodinsecurity. Pediatrics. 2010;126(1):e26–32.

28.FeedingAmerica.Foodinsecurityamongoverall(allages)populationin California:2021foodinsecurityinCalifornia.Availableat: https://map.feedingamerica.org/county/2021/overall/california AccessedNovember9,2023.

29.AssafRR,AssafRD,PadlipskyPS,etal.Afamily-centeredapproachto socialneedsawarenessinthepediatricemergencydepartment. PEC Innov. 2024;4:100283.

30.TedfordNJ,KeatingEM,OuZ,etal.Socialneedsscreeningduring pediatricemergencydepartmentvisits:disparitiesinunmetsocial needs. AcadPediatr. 2022;22(8):1318–27.

31.KanakMM,StewartAM,ChangL,etal.Health-relatedsocialrisks versusneedsinapediatricemergencydepartment. AmJPrevMed. 2024;67(2):291–5.

32.WallaceAS,LutherBL,SislerSM,etal.Integratingsocialdeterminants ofhealthscreeningandreferralduringroutineemergencydepartment care:Evaluationofreachandimplementationchallenges. Implement SciCommun. 2021;114(2):1–12.

SYSTEMATIC REVIEW

GenderDisparitiesandBurnoutAmongEmergencyPhysicians:A SystematicReviewbytheWorldAcademicCouncilofEmergency Medicine–FemaleLeadershipAcademyforMedicalExcellence

SumanThakur,MD* VivekChauhan,MD†

SagarGalwankar,MD‡ FatimahLateef,MBBS,FRCS§ PiaDaniel,MD∥

ZeynepCakir,MD¶ KatiaM.Lugo,MD#

SamjhanaBasnet,MD** BusraBildik,MD††

Authorscontinuedatendofpaper

SectionEditor: ElisabethCalhoun,MD,MPH

*IndiraGandhiMedicalCollege&Hospital,DepartmentofEmergency Medicine,Shimla,India

† IndiraGandhiMedicalCollege&Hospital,DepartmentofMedicine, Shimla,India

‡ SarasotaMemorialHospital,FloridaStateUniversityCollegeofMedicine EmergencyMedicineResidencyProgram,DepartmentofEmergency Medicine,Sarasota,Florida

§ SingaporeGeneralHospital,DepartmentofEmergencyMedicine,Singapore

∥ DownstateHealthSciencesUniversity,DepartmentofEmergencyMedicine, Brooklyn,NewYork

ﬁliationscontinuedatendofpaper

Submissionhistory:SubmittedJuly16,2024;RevisionreceivedOctober24,2024;AcceptedOctober28,2024

ElectronicallypublishedDecember31,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.29331

Background: TheFemaleLeadershipAcademyforMedicalExcellence,membersoftheWorld AcademicCouncilofEmergencyMedicine,conductedthissystematicreview,whichexploresgender disparitiesinburnoutamongemergencyphysicians(EP)usingtheMaslachBurnoutInventory-Human ServicesSurvey(MBI-HSS).Burnoutisacriticalissueinhealthcare,particularlyinemergencymedicine wherehighstressanddemandingworkenvironmentsprevail.

Methods: FollowingPRISMAguidelines,wesearchedPubMedandEpistemonikosforstudiesusing MBI-HSStomeasureburnoutinEPs.Inclusioncriteriaencompassedpeer-reviewed,English-language articlesreportingburnoutbysex.Dataextractionfocusedonproportionsofburnoutandits subcomponents,meanscores,andoddsratios,withqualityassessedusingJoannaBriggs Institutecriteria.

Results: Weincluded18studiesspanning26,939EPsfrom10countries.Whileoverallburnoutratesdid notsigniﬁcantlydifferbetweenthesexes,theproportionoffemaleEPswithhighemotionalexhaustion (EE)(69%)andlowsenseofpersonalaccomplishment(PA)(45%)weresigniﬁcantlyhighercomparedto maleswithhighEEin57%andlowPAin29%,respectively(P < 0.001forboth).Proportionwithhigh depersonalization(DP)scorewas44%inbothmaleandfemaleEPs.Meanscoresrevealedfemales experiencinghighermeanEE(26.8 ± 15.7)scoresvsmales(25.4 ± 15.9) P < 0.001.Maleshadmean DPscores(8.6 ± 8.0)andmeanPAscores(26.6 ± 12.7)comparedtofemaleswithlowermeanDP scores(7.4 ± 7.2)andhigherPAscores(27.7 ± 11.9),respectively P < 0.001forboth.Oddsratios indicatedvaryingrisks,predominantlyhigherEEoddsamongfemales,varyingfrom0.72to2.3.

Conclusion: Thisreviewunderscoresgender-specificmanifestationsofburnoutamongemergency physicians,withfemalesmoresusceptibletoemotionalexhaustionandlowersenseofpersonal accomplishment.Standardizedreportingmethodsarecrucialforfuturemeta-analysestorefinegenderspecificinterventionscombatingburnoutinemergencymedicine.Targetedstrategiesaddressing distinctmanifestationsofburnoutareimperativetosupportthewell-beingandretentionofEPs,fostering sustainablehealthcaredelivery.[WestJEmergMed.2025;26(2)338–346.]

INTRODUCTION

Theterm “burnout,” introducedbyFreudenbergerin 1974,referstojob-relateddissatisfactionprimarilycausedby work-relatedstress.1 Themostwidelyvalidatedtoolfor measuringburnoutamongphysiciansistheMaslach BurnoutInventory-HumanServicesSurvey(MBI-HSS) 22-itemtool.2 TheMBI-HSSmeasuresburnoutinthree subcomponents:emotionalexhaustion(EE); depersonalization(DP);andpersonalaccomplishment (PA).2 BurnoutissuggestedbyahighscoreinEEandDP, andalowscoreonPA.2

Thereisapalpablegendergapinacademicemergency medicine(EM)wherefemaleemergencyphysicians(EP)are lesslikelytoholdmajorleadershippositions,morelikelyto spendagreaterpercentageoftimeinclinicalandteaching activities,publishlessinpeer-reviewedjournals,andareless likelytoachievesenioracademicranksintheirmedical schools. 3 Evenafteradjustingforfactorssuchasrace, region,rank,yearsofexperience,clinicalhours,corefaculty status,administrativeroles,boardcerti ﬁ cation,and fellowshiptraining,themean(±SD)salaryofwomenwas foundtobe$19,418( ±$3,736)lessthanthatofmen ( P < 0.001). 4 Thisgenderdisparitycannegativelyimpact theretentionoffemaleEPsandpredisposethemto higherburnout.

Althoughtherearesystematicreviewsthathavedescribed burnoutamongEPs,nonehavefocusedonthegendergapin burnoutamongEPs.5–7 Therefore,theFemaleLeadership AcademyforMedicalExcellence(FLAME)membersofthe WorldAcademicCouncilofEmergencyMedicine performedasystematicreviewtodescribethegender disparityinburnoutamongEPsatagloballevel.Tothebest ofourknowledge,thisisthe ﬁrstsystematicreviewfocusing ongenderdisparityinburnoutamongEPsasmeasuredby thevalidatedMBItool.

METHODS

Weperformedasystematicreviewfollowingthe PRISMAmethods8 usingtheprotocolpublishedin PROSPERO(CRD42024558794).

SearchStrategy

Wesearchedtwoopenaccessdatabases,PubMedand EpistemonikosonJune30,2024,forpeer-reviewedarticles onburnoutandemergencyphysicians.Weoperationalized differentpermutationsofeachkeywordasfollows:

Burnout: “Maslachburnoutinventory” ORMBIOR burnoutORburn-outOR “burnedout” OR depersonalizationOR “emotionalexhaustion” OR “compassionfatigue”

EmergencyPhysician: “emergencyphysician*” OR “emergencydoctor*” OR “EMphysician*” OR “EM doctor*” OR “emergencyresident*” OR “EMresident*” OR “emergencyconsultant*” OR “EMconsultant*” OR

“emergencyfaculty*” OR “EMfaculty*” OR “ emergency professor*” OR “EMprofessor*” OR “ emergency attending*” OR “EMattending*”

Weappliedthe ﬁeld “All ﬁelds” forsearchingonPubMed and “TitleandAbstracts” forsearchingthesame combinationofkeywordsinEpistemonikos.

ScreeningandEligibility

Weappliedaseriesofinclusionandexclusioncriteria. Articleswereincludediftheywere1)writteninEnglish, 2) publishedinapeer-reviewedjournal,3)originalarticles, and4)appliedanyversionoftheMBI-HSStomeasure burnout.Theywereexcludedifthey1)didnotdescribethe resultsseparatelybysex,2)didnotincludeEPsintheirstudy, or3)wereasystematicreview.

ExtractionandAnalysis

Extractionwasperformedbytwoinvestigators independently.Thefollowinginformationwasextracted: studycharacteristics(ﬁrstauthor,yearofpublication, country,numberofparticipantsthatresponded); characteristicsofparticipants(meanage,proportionof malesandfemales);andoutcomedata(proportionofhigh burnoutinmalesandfemales,proportionofmalesand femaleswithhighEE,highDPandlowPA,meanscoresin malesandfemalesforEE,DPorPAandoddsofburnoutor itssubcomponents EE,EP,orPA infemaleEPs.

StudyQuality

WeusedtheJoannaBriggsInstitute’scriticalappraisal checklistforevaluationofthequalityoftheprevalence studies.9 Thetoolassessedqualityusingninequestions.A scoreof1wasassignedfora “Yes” asananswer,andascore of0wasassignedforananswerthatwas “No,”“Unclear,” or “NotApplicable.” Thescoresweregradedaslow,moderate orhighifthetotalscorewas ≤ 4,5–7,and ≥ 8,respectively. Thequalityassessmentwasperformedindependently bytwoinvestigators,andanydisagreementwassettled bydiscussion.

RESULTS LiteratureSearch

Ourinitialsearchresultedin331articlesinPubMedand 13inEpistemonikos,whichwereimportedintoEndNote referencemanagementsoftware(ClarivateAnalytics, Philadelphia,PA).Ofthese344articles,ninewerefoundto beduplicates,leavingatotalof335articlesforthescreening andeligibilitystages(Figure).Ofthe335articlesscreened,we excluded226thatdidnotmeettheinclusioncriteria,leaving uswith109articlesforretrieval.Wereviewedthese109full textsforeligibility,resultingintheexclusionofthefollowing:

• 3articlesthatweresystematicreviews

• 7articlesthatwerenotpeer-reviewedoriginalarticles

• 5articlesthatdidnotincludeemergencyphysicians

• 41articlesthatdidnotusetheMaslachBurnout Inventoryformeasuringburnout

• 35articlesthatdidnotreporttheirdatabysex,

Thisleftatotalof18articlesforthe ﬁnalreview.The processofscreeningandselectingstudiesisshowninthe PRISMA ﬂowdiagram(Figure).

STUDYCHARACTERISTICS

Weincluded18studiesfrom10differentcountriesinthe ﬁnalanalysis(Table1).ThetotalnumberofEPsstudiedin these18studieswas26,939,including8,864(33%)female EPs,resultinginamale-to-femaleratioof2:1.Fifteenof thesestudiesusedthe22-itemMBI-HSStoolformeasuring burnout,whiletwostudiesusedthetwo-itemtoolbasedon theMBI-HSS,andoneincludedthenine-itemMBItool (Table1).Allweremulticentricstudiesexceptforone,which wasasingle-centerstudy.IncludedwereEPsofbothsexesin allstudiesexceptforone,whichincludedonlyfemaleEPs.

Allincludedstudieswereconductedinthelast10years(2014 topresent),exceptforonestudyconductedin1996.Six studieswerescoredashighquality,whiletheremaining12 weremoderatequalitystudies.Theresponseratesvaried from30–94.1%.

OUTCOMEANALYSIS

BurnoutcalculatedbyMaslachBurnoutInventory

Sevenstudiesreportedtheburnoutproportionsseparately inmaleandfemaleEPs(Table2).Thestudiesthatincludedthe 22-itemMBI-HSStoolhadatotalof1,181maleand542 femaleEPs,withanaveragepooledproportionofhigh burnoutat58.7%and58.3%,respectively(P = 0.8).Two studiesusedthetwo-itemMBI,includingatotalof4,868male and2,736femaleEPs,withanaveragepooledproportionof highburnoutat27%and34%,respectively(P < 0.001).

SubcomponentsofMBI

SevenstudiesreportedindividualcomponentsoftheMBIHSS,speciﬁcallytheproportionofparticipantswithhigh

Identification of studiesvia databases and registers

Recordsidentified from PubMed (n=331) Epistemonikos (n=13)

Recordsscreened (N=335)

Reportssought for retrieval (n=109)

Reportsassessed for eligibility (n=109)

Recordsremoved before screening:

Duplicate records removed (n=9)

Recordsexcluded by screening Titles and abstracts (n=226)

Reportsnot retrieved (n=0)

Reportsexcluded: Maslach Burnout Inventory not used (n=41)

Data not given by Gender (n=35)

Not original articles (n=7)

Did not study emergency physicians (n=5)

Systematic reviews (n=3)

Studies included in review (n=18)

Table1. Characteristicsoftheincludedstudies.

, MaslachBurnoutInventory.

Table2. Proportionofmaleandfemaleemergencyphysicianswithhighlevelsofburnout.

2-itemMBItool (n=4,868)n=1,502(31.4%)(n=2,736)n=903(33%)

2item4,768 1,478(31%) 2,698 890(33%) 0.05

2item100 24(24%) 38 13(35%)

MBI, Maslach BurnoutInventory.

EE,highDP,andlowPAseparatelyformaleandfemaleEPs (Tables3 and 4).Fourofthesestudiesreportedthe proportionofparticipantswithsubcomponentssuggestiveof burnout(Table3),andthreeofthesestudiesreportedthe meanandstandarddeviationsoftheMBIsubcomponents (Table4).FemaleEPshadproportionatelyhigherEEand lowerPAthanmaleEPs(P < 0.001).TheDPlevelswere similaramongmaleandfemaleEPs(Table3).Thecombined

meanEEscorewashigherinfemaleEPs(P < 0.001),while thecombinedPAscorewashigherandtheDPscorewas lowerinfemaleEPscomparedtomaleEPs(P < 0.001) (Table4).Fourstudiespresentedtheirresultsintheformof oddsorrelativerisk(Table5),andthreeoftheseshowed higheroddsamongfemalesofburnoutwhileonehadlower odds.Threeofthesestudiesreportedonlyonesubcomponent ofMBI-HSS(ie,EE)(Table5).

Table3. Proportionofparticipantswithhighlevelsofemotionalexhaustion,highdepersonalization,andlowsenseofpersonal accomplishment,theindividualcomponentsoftheMaslachBurnoutInventory,amongmaleandfemaleemergencyphysicians.

Author Male (n=371)HighEELowPAHighDP

Female (n=399)HighEELowPAHighDP BaturA18 223135(61%)69(31%)- 166119(72%)83(50%)ElhadiM20 8251(62%)21(25%)39(47%)7253(74%)13(18%)35(49%) SarwarS33 6626(39%)18(27%)27(41%)8440(48%)22(26%)31(37%) SoltanifarA34 0 - - - 7765(85%)62(81%)37(48%)

Total 371212(57%)108(29%)66(44%)399277(69%)180(45%)103(44%) P-value(Fisherexacttest) <0.001 <0.0010.77

EE, emotionalexhaustion; PA,personalaccomplishment; DP,depersonalization.

Table4. Mean(standarddeviation)valuesofsubcomponentsoftheMaslachBurnoutInventoryamongmaleandfemale emergencyphysicians.

Author Male (n=10,837)HighEELowPALowDP

Female (n=4,691)HighEELowPAHighDP

LovellLP28 4929.4(11.7)45.5(8)11.8(5.7)6232.5(12.1)43.4(6.8)13(6.7)

YanS35 10,65025.4(16.1)26.5(12.8)8.5(8.1)4,59326.8(15.7)27.6(11.9)7.4(7.2) ErdurB21

Unpaired t-test P-value <0.001 <0.001 <0.001 EE, emotionalexhaustion; PA,personalaccomplishment; DP,depersonalization.

Table5. Oddsorrelativeriskofburnoutoritssubcomponentsbygenderamongemergencyphysicians.

AuthorsMalesFemalesReportedparameterValue

DISCUSSION

ThestressfulenvironmentofEMisaknowncontributor tothenegativeimpactsofburnout.10 Burnoutcanbethe resultofgood-intentionedphysicianswhostrivefor perfectionatwork.10 Emergencyphysiciansbecome frustratedwhentheirworkenvironmentfallsshortof supportingwell-meaninggoals,leadingtoEPburnout.10

Moralinjuryisnowrecognizedasasigniﬁcantfactor contributingtoburnoutamongEPs.Theyoftenface challengingdecisionssuchasprioritizingcareinlife-or-death situations,dealingwithresourcelimitations,andfrequently witnessingsufferinganddeath.Theemotionaltollofmoral injurycanleadtosymptomsofdepression,anxietyandstress disorders,whicharecloselylinkedtoburnout.FemaleEPs, inaddition,facesex-baseddiscrimination,bias,unequal treatment,andfeweropportunitiesforcareeradvancement.3 Theyaremoreburdenedwithbalancingprofessionaland

familyresponsibilities.Femalesareexpectedtodisplaymore empathyandprovideemotionalsupporttopatientsand colleagues,whichcanincreaseemotionallaborandmoral injuryiftheyareunabletomeettheseexpectations.

TheMBIassessestheseverityofthethreeprimary symptomsofburnout:exhaustion;depersonalization;andlack ofpersonalaccomplishment.Developedinthe1970s,ithas becomethegoldstandardformeasuringburnoutacross variousprofessionsandindustries.TheMBI-HSSisspeciﬁcally designedforuseinhumanservicesprofessionssuchassocial work,counseling,andhealthcare.2 Aburnoutsurveyof7,288 USphysiciansfromallspecialties,usingtheMBI-HSStool, showedthathighburnoutwasreportedby38%ofUS physiciansandthatburnoutismorecommonamong physiciansthanotherUSworkers.11 Amongallspecialties,EM hadthehighestburnoutrates,withover60%ofEPsreporting highburnoutlevels.11 Emergencymedicineisafrontline

specialty,andseveralfactorscontributetohighburnoutinEPs, includingnightshifts,sleepdisorders,job-relatedstrain,fearof makingmistakes,andworkplaceviolence.12

Inrecentyears,morefemalephysicianshaveenteredthe workforce,leadingtoincreaseddataavailabilityforstudying sexdifferencesinburnoutsymptoms.Insomecultures,female patientspreferentiallyaskforfemaleEPstoattendtothemin theED.13 ArecentlyconductedsystematicreviewofUS physiciansfoundthatwomenphysicianshaveahigher likelihoodofexperiencingburnoutcomparedtomale physicians,particularlywithrespecttotheEEdimensionof burnout.14 StudiesfocusingonEPscorroboratethis ﬁnding, indicatingthatfemaleEPsareathigherriskofburnout comparedtomaleEPs.Additionally,femaleshavehigher attritionratescomparedtotheirmalecounterparts.3,4,15 Factors citedascontributingtothediscrepancyinburnoutinclude greaterlevelsofwork-familyconﬂict,greatertendenciesto emotionallyinvestinpatients/work,andgreaterdiscrimination insalariesandpromotionsbyfemalephysicians.14

Incontrasttotheabovestudies, findingsfromasystematic reviewof16,016physiciansfromtheEasternMediterranean regionindicatednosignificantdifferenceinburnoutrates betweenmaleandfemalephysicians.16 However,noneofthe studiesinDoraiswamy’ssystematicreviewweredesignedto comparedifferencesbysex,limitingtheinterpretationsofthe findings.15 Anothersystematicreviewthatincluded109,628 physiciansconcludedthatinconsistenciesindefinitionsand assessmentmethodsforburnoutacrossstudiespreventeda reliabledeterminationoftheassociationbetweenburnout andthesexofthephysician.17

Thesereviewshighlightvariabilityin findingsacross differentregionsandcontexts,suggestingthatthe relationshipbetweenburnoutandsexmayvarydepending onfactorssuchasculturalnorms,healthcaresystem characteristics,andstudymethodologies.Therefore,while somestudiesmayindicateagenderdisparityinburnout, othersmaynot findsuchdifferences,emphasizingtheneed fornuancedinterpretationandcontext-specific understandingofburnoutinhealthcareprofessions.

Weconductedthissystematicreviewtoaddress inconsistentdataonthegendergapinburnoutamongEPs. Rotensteinetalhavehighlightedintheirreviewthe inconsistenciesinthedeﬁnitionsandassessmentmethodsof burnout;therefore,wefocusedspeciﬁcallyonstudiesthat usedtheMBI-HSStoolforassessingburnout.17 Despite usingacommonassessmenttool,theincludedstudies employedvariousmethodsforreportingburnoutscores.Of the18studiesincludedinourreview,18–35 sevenreported burnoutasthepercentageofparticipantswithhighburnout; fourreportedthepercentageofparticipantswithhigh individualcomponentsofburnout(EE,DP,PA)butnot overallburnout;threereportedthemeanscoresforEE,DP, andPA;andfourreportedoddsratiosandrelativerisksfor EE(Tables2–5).Thisapproachallowedusto

comprehensivelyexamineandcomparethegender disparitiesinburnoutamongEPsacrossdifferentstudies.

Wecollateddatafromstudiesreportingburnoutasa percentageofthepopulationhavinghighburnoutandfound thatof1,181maleEPsand542femaleEPs,highburnoutwas reportedin58.8%and58.4%,respectively,whichindicates nearlyequalratesofburnoutbetweenmaleandfemale EPs22–24,26,27 (Table2).Thetwo-itemtool,knownforits brevityandeaseofadministration,caneffectivelyidentifyatriskEMresidentsshowingearlysignsofburnout.36 Thistool usestwoquestionsfromtheMBI-HSSandenables consistent,widespread,andlongitudinalmonitoringof burnoutamongEMresidentsatlocal,regional,andnational levels.36 Inoursystematicreview,weincludedtwostudies thatusedthetwo-itemtooltomeasureburnoutamong4,778 maleand1,502femaleEPs.Thereportedburnoutrateswere 31%amongmaleEPsand33%amongfemaleEPs (P = 0.05).29,32 Thisslightdifferencesuggestsatrendtoward higherburnoutamongfemaleEPs,asindicatedbythese speciﬁcstudiesusingtheabbreviatedMBItool.

Fouradditionalstudiesincludedinoursystematicreview, totalling317maleand399femaleEPs,reportedindividual componentsofburnout(EE,DP,PA)aspercentagesof participantswithhighorlowscores(Table3).18,20,33,34 These studiesfoundthattheproportionoffemaleEPswithhighEE andlowPAwassigniﬁcantlyhighercomparedtomaleEPs (P < 0.001).However,levelsofDPwerecomparable betweenbothgenders(P = 0.77).Thisindicatesthatfemale EPsmayexperiencegreaterEEandlowerPA,highlighting potentialareasofconcernforgender-speciﬁcburnout interventionsinemergencymedicine.

Lastly,amongtheremainingstudiesthatreportedodds ratiosorrelativerisksforburnout,3of4studiesindicateda higherriskofburnoutamongfemaleEPs,whileonestudy showedahigherriskamongmaleEPs(Table5).19,25,30,31 Speciﬁcally,femaleEPswerefoundtohaveahigherriskfor theEEcomponentofburnoutcomparedtomaleEPs,as suggestedbythese ﬁndings.Thisunderscoresthegender disparityinburnoutriskwithintheEMprofession, emphasizingtheneedfortargetedinterventionstomitigate thesedisparitiesandsupportthewell-beingofallEPs.

Inoursystematicreview,weencounteredchallengesin performingameta-analysisduetothevariabilityinhow authorsreportedtheir ﬁndingsusingtheMBItooltomeasure burnoutamongEPs.Speciﬁcally,therewerelimitations stemmingfromthelimitednumberofstudiesthatreported resultsseparatelyformaleandfemaleEPs,aswellasthe diversityinhowparametersofburnoutwerereportedacross thesestudies.Thevariationinreportingincludeddifferences inthefollowing:

• Whetherburnoutwasreportedasoverallscoresor individualcomponents(EE,DP,PA)

• Thespeciﬁcmetricsusedtodeﬁnehighburnout

• Themethodsusedtoanalyzeandpresentdata (percentages,means,oddsratios,etc).

Thisvariabilitymakesitchallengingtoaggregatedata acrossstudiesforameta-analysis,whichtypicallyrequiresa consistentapproachtodatareportingandstatistical measures.Asaresult,whileourreviewprovidesvaluable insightsintothegenderdisparitiesinburnoutamongEPs,the heterogeneityinreportingpreventsaquantitativesynthesis ofthe ﬁndings.

Movingforward,standardizingthereportingofMBIHSSresultsandburnoutparametersinfuturestudieswould facilitatemorerobustmeta-analyticalapproachestofurther elucidatethegendergapinburnoutamongEPsandinform targetedinterventionstomitigateburnoutinthiscritical healthcarespecialty.

AspertheoriginatorsoftheMBI-HSSthepre-2016 versionsofthetoolusedarbitraryclassificationsofhigh burnout,dividingthenormativepopulationintotertiles labelledashigh,moderate,andlowburnout.Thisapproach waslateracknowledgedasamistake,leadingtotheremoval ofthesecutoffclassificationsfromallversionsoftheMBIHSSstartingwiththefourtheditionin2016.Thischange allowedresearcherstoviewburnoutasacontinuumwithin thecontextofspecificpopulations.37

Inoursystematicreview,despiteincluding14studies conductedafter2016,onlythreestudiesreportedthemean (±SD)scoresofindividualcomponentsofburnoutseparately formaleandfemaleEPs.21,28,35 Notably,thesestudies highlightedsignificantdifferences:femalesexhibited significantlyhigherEEscores,whilemalesshowed significantlyhigherDPandlowerPAscores(P < 0.001).21,28,35 ItisimportanttonotethatthestudybyYanetalinChina includedalargecohortof15,243participants,whichmayskew theoverall findingstowardthisstudy’sresults.35

Inmostotherstudiesincludedinourreview,researchers derivedcutoffsbycombiningresultsfromindividual components(EE,DP,PA),whichcouldexplainwhyoverall burnoutscoresappearedequivocalacrossthesestudies (Table2).Thisvariabilityinreportingunderscoresthe ongoingchallengeofharmonizingburnoutmeasurements acrossdifferentstudiesandemphasizestheneedfor standardizedreportingpracticestofacilitateclearer comparisonsandmeta-analysesinfutureresearch.

Twelveofthearticlesincludedinourstudywerepublished in2020orlater,and ﬁvestudieswereconductedduringthe peakoftheCOVID-19pandemicin2020–2021.Itislikely thatthepandemiccausedunusualfatigueandburnout, resultingindifferentburnoutlevelsamongmalesandfemales acrossdifferentregions.

LIMITATIONS

Thissystematicreviewencounteredseverallimitations. Onemajorchallengewasthevariabilityinhowstudies

reportedburnout,evenwhenusingtheMBI-HSStool.Some studiesfocusedonoverallburnout,whileothersreported individualcomponentssuchasEE,DPandPA. Additionally,studiesemployeddifferentmetrics (percentages,means,oroddsratios),makingitdifficultto aggregate findingsforameta-analysis.Thelimited numberofstudiesreportinggender-specificdatafurther constrainedourabilitytomakedefinitiveconclusionsabout thegendergapinburnoutamongEPs.Moreover,some studiesusedoutdatedversionsoftheMBI-HSS,whichrelied onarbitrarycutoffsforhighburnout,affectingtheaccuracy ofburnoutclassification.Finally,severalstudieswere conductedduringtheCOVID-19pandemic,aperiod markedbyincreasedfatigueandburnout,potentially skewingthe findingsandlimitingtheirgeneralizability beyondthattimeframe.

CONCLUSION

Thisreviewhighlightsthatthescienceofexamining physicianburnoutiscomplexandinﬂuencedbyawide rangeoffactors.Notwostudiesareperfectlycomparable, evenwhenusingsimilarassessmenttools,suchasthe MaslachBurnoutInventory-HumanServicesSurvey. Variableslikethetypeofwork,workload,acuityoftasks,job satisfaction,hoursworked,frequencyofrapiddecisionmaking,criticalthinkingdemands,work-lifebalance, competinginterests,culturalbeliefs,andsocietal norms suchaspowerdistanceandhierarchy all impactburnoutdifferently.

Despitethe findingsthatfemaleemergencyphysicians reporthigheremotionalexhaustionandlowersenseof personalaccomplishmentthantheirmalecounterparts, itisessentialforsocietiesandcountriestodelvedeeperinto thisissue,tailoringstudiestotheirspecificcontexts andcultures.Thisreviewunderscorestheneedfor gender-specificstrategiestocombatburnoutamongEPs. Whilebothmenandwomenexperiencesignificantburnout, thenatureoftheirburnoutdiffers,necessitatingtargeted interventionstosupportthewell-beingofallEPs.

RecommendationsforResearch

1. UniformReportingofResults: Futurestudieson burnoutamongEPsshoulduniformlyreportresults, includingthemean(±SD)fortheindividual componentsoftheMBI-HSStool EE,DPandPA forbothmaleandfemaleEPs.Thisstandardized approachwillfacilitateaclearerunderstandingof thegendergapinburnoutacrossdifferentsettings and populations.

2. FurtherResearchFocus: Thereisacriticalneedfor furtherresearchtodelveintotheunderlyingreasons behindthedisparitiesinEE,DP,andPAbetween maleandfemaleEPs.Understandingthesefactorsis essentialfordevelopingtargetedinterventionsthat

addressthespeciﬁcneedsofeachgender,thereby effectivelymitigatingburnout.

3. MoveAwayfromArbitraryCutoffScores: Thepractice ofusingarbitrarycutoffscores(high,moderate,low burnout)tocategorizeburnoutlevelsshouldbe abandoned.Thisapproach,discouragedbythe originatorsoftheMBI-HSStool,doesnotaccurately capturethenuancedexperiencesofburnoutandmay leadtomisleadingconclusions.

4. HolisticAssessmentofBurnout: Ratherthanfocusing solelyonoverallburnoutscores,futurestudiesshould emphasizethedetailedassessmentofEE,DP,andPA. Thisholisticapproachprovidesamorecomprehensive understandingofburnoutdynamicsamongEPsand allowsfortargetedinterventionsbasedonspeciﬁc componentsofburnout.

CalltoActionbyFLAME

Basedontheobservationsregardingburnoutamong womeninEMandfemaleEPs,weareproposingthe followingmeasures:

1. IncreasedAwarenessandEducation:

○ Enhanceawarenessandrecognitionofburnout withintheEMcommunity.

○ Incorporateburnout-relatedsessionsintoEM residencytrainingandcorecurriculum.

2. ProactiveFacultyandLeadership:

○ FacultyandEMleadershipshouldcloselymonitor allstaff,includingbothfemaleandmaleEPs,for signsofwork-relatedstress,cognitiveoverload, andotherrelevantcommitments.

○ Emphasizeaddressingburnoutasawork-related issueratherthanagender-relatedone,especially whenthereisnoconﬁrmedevidenceofgenderspeciﬁccauses.

3. OpenDiscussionsonBurnout:

○ Fosteranopen,non-judgmentaldialogueabout burnoutduringdepartmentalpeer-reviewsessions.

○ Ensurethatstaffatalllevelscansharetheir experienceswhilemaintainingpsychologicalsafety.

○ Addressburnoutopenlytopreventitfrombecoming a “silentcrisis.”

4. PsychologicalWellnessInitiatives:

○ Leadershipandmanagementshouldimplement psychologicalwellnessinitiatives,suchas “Joy@ Work,” iTHRIVEinitiatives,andwellnessgrants.

5. Peer-SupportCommittees:

○ Establishinterprofessionalpeer-supportcommittees orteams.

○ Encouragestafftodiscussburnoutwithpeers,who maybemoreapproachable,andsharebestpractices formanagingburnout.

AUTHORSANDAFFILIATIONSCONTINUED

SihamAzahaf,MD‡‡ SevilayVural,MD§§ BusraH.Difyeli,MD∥∥ LisaMoreno-Walton,MD¶¶

¶ AtaturkUniversity,DepartmentofEmergencyMedicine, Erzurum,Türkiye

# HCA/USFMorsaniCOM:GMEOakHillHospital, DepartmentofEmergencyMedicine,Brooksville,Florida **DhulikhelHospitalKathmanduUniversityHospital, DepartmentofGeneralPracticeandEmergencyMedicine, Kavre,Nepal

†† KarabukUniversity,FacultyofMedicine,Departmentof EmergencyMedicine,Karabuk,Türkiye

‡‡ AmsterdamUniversityMedicalCenters,Departmentof InternalMedicine,Amsterdam,Netherlands

§§ YozgatBozokUniversity,DepartmentofEmergency Medicine,Azizli,Türkiye

∥∥ AlmusStateHospital,DepartmentofEmergencyMedicine, Almus/Tokat,Türkiye

¶¶ LouisianaStateUniversityHealthSciencesCenter, SectionofEmergencyMedicine,NewOrleans,Louisiana

AddressforCorrespondence:SumanThakur,MD,IndiraGandhi MedicalCollege&Hospital,DepartmentofEmergencyMedicine, Shimla,India,171001.Email: Suman_thakur13@yahoo.com

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

UseandOutcomesofSugammadexforNeurologicalExamination afterNeuromuscularBlockadeintheEmergencyDepartment

StephenD.Hallisey,MD*†

ChristianaK.Prucnal,MD,ScM†‡§

AnnetteM.Ilg,MD*†

RaghuR.Seethala,MD,MSc*†

PaulS.Jansson,MD,MS*†

SectionEditor:ChristopherR.Tainter,MD

*BrighamandWomen’sHospital,DepartmentofEmergencyMedicine, DivisionofEmergencyCriticalCareMedicine,Boston,Massachusetts

† HarvardMedicalSchool,DepartmentofEmergencyMedicine, Boston,Massachusetts

‡ BrighamandWomen’sHospital,DepartmentofEmergencyMedicine, Boston,Massachusetts

§ MassachusettsGeneralHospital,DepartmentofEmergencyMedicine, Boston,Massachusetts

Submissionhistory:SubmittedJuly12,2024;RevisionreceivedNovember20,2024;AcceptedNovember26,2024

ElectronicallypublishedJanuary30,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.29328

Introduction: Non-depolarizingagentssuchasrocuroniumandvecuroniumarefrequentlyusedinthe emergencydepartment(ED)tofacilitateintubationbutmayleadtodelayinneurologicexaminationand intervention.Sugammadexisusedforreversalofneuromuscularblockadebynon-depolarizingagents butitsroleinthereversalofneuromuscularblockadeforneurologicexaminationintheEDis poorlydeﬁned.

Methods: Thiswasamulticentercohortstudyusingretrospectivechartreview.WereviewedallED encountersfromJune21,2016–February9,2024oftheelectronichealthrecordofMassGeneral Brigham,alargemultistatehealthsystem,andabstractedallEDadministrationsofsugammadexto facilitateneurologicexamination.Wecalculateddescriptivestatisticsandassessedoutcomes.

Results: In3,080,338EDvisitsduringthestudyperiod,48patientsreceivedsugammadextofacilitate neurologicexamination.Ofthosepatients,23(47.9%)underwentaprocedurewithin24hours.Three (6.3%)hadbradycardia,andone(2.1%)hadhypotensionfollowingsugammadexadministration.Atotal of23patients(47.9%)ultimatelydiedduringtheiradmission,and24(50%)diedwithin30days.

Conclusion: PatientswhoreceivedsugammadexintheEDtofacilitateneurologicexaminationduring thestudyperiodhadrareassociatedadverseeffects,highratesofprocedureswithin24hoursof administration,andsigniﬁcantin-hospitalmortality.Prospectivedataisneededtoassesstheimpactof sugammadexondecision-making.[WestJEmergMed.2025;26(2)347–352.]

INTRODUCTION

Neuromuscularblockade(NMB)isfrequently administeredaspartofrapidsequenceinductioninthe emergencydepartment(ED)andprehospitalsettings.Nondepolarizingaminosteroidneuromuscularblockingagents (NMBA)suchasrocuroniumandvecuroniumare commonlyadministeredtofacilitateintubationintheED,1 butadministrationmayleadtoprolongedparalysis anddelayinneurologicexaminationandsurgical

decision-makinginpatientspresentingwithneurological injury.Sugammadexisamodiﬁedgamma-cyclodextrinused forthereversalofNMBfromaminosteroidNMBAs.2 When comparedtoacetylcholinesteraseinhibitorssuchas neostigmine,sugammadexisassociatedwithfastertimeto reversal,longerdurationofaction,andlowerratesof cholinergicsideeffectssuchasbradycardia,nausea,and vomiting.3 Asaresult,itdoesnotrequirethe co-administrationofatropineorglycopyrrolate.Itis

currentlyrecommendedoverneostigmineasa ﬁrst-lineagent forthereversalofrocuroniumintheoperatingroom.4 Despitethisrecommendation,littleisknownabouttheuseof sugammadexintheED.

Tworecentstudieshavehighlightedthepotentialforits useintheEDsetting.5,6 Ourrecentreviewoftheuseof sugammadexintheEDfoundthatthemostcommon indicationwasforneurologicexamination,with93.7%of patientsreceivingsugammadexforthisindication.7 Inthat series,wefoundthattheuseofsugammadexforother indicationswasrare:onepatientreceivedsugammadexafter inadvertentNMBadministration;onereceivedsugammadex tofacilitateterminalextubation;andonereceived sugammadexfollowingincompletereversalofNMBatan ambulatorysurgerycenter.Nopatientsreceived sugammadexforacannot-intubate-cannot-ventilate scenario.Onlytwosmallstudieshavedescribedtheuseof sugammadextofacilitateneurologicalexamination.A retrospectivestudyof11patientsreceivingsugammadexin theEDforneurologicalexaminationfoundthatthe majorityofpatientswhoreceivedsugammadexhad achangeintheirexaminationandconcludedits administrationtobeuseful.8 Asecondretrospectivestudy thatevaluateditsusein24patientsfoundthatdosingof2 milligramsperkilogram(mg/kg)and4mg/kgwereequally effectiveinachievingatrainoffour(TOF)offour.9 We soughttofurtherdeﬁnethesafety,efﬁcacy,andoutcomesof sugammadexusetofacilitateneurologicexaminationin theED.

METHODS

Thiswasamulticentercohortstudyusingretrospective chartreview.Weadheredtoallelementsofoptimal retrospectivechartreviewinemergencymedicineresearchas previouslydefinedbyWorsteretalwiththeexceptionof interobserverreliabilityuseandtesting,aschartabstraction wasperformedbyoneauthor.10 Weperformedastructured chartabstractionofallEDencountersbetweenJune21,2016 (thedateofsugammadexadditiontotheformulary)and February9,2024,intheelectronichealthrecord(EHR)(Epic Systems,Verona,WI)ofMassGeneralBrigham,alarge multistateregionalhealthsystemwithtwoaffiliated academicmedicalcentersandsevenaffiliatedcommunity, acutecarehospitals.

Weusedchartabstractiontoidentifyalladministrations ofsugammadexduringanEDencounter.Chartswere manuallyreviewedbytheseniorauthor(PSJ)toverifyusage ofsugammadextofacilitateneurologicalexamination. Patientdemographics,dosingweight,andlaboratoryvalues wereautomaticallyabstractedfromtheEHRforthelinked EDencounter.ForNMBAsadministeredwithinthe healthsystem,dosingweight,doseadministered, andtimeofadministrationwereautomatically abstractedfromthelinkedrecordoftimeofmedication

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Littleisknownabouttheuseofsugammadex intheED.Priordatahasshownitismost commonlyusedtofacilitateneurologicexam.

Whatwastheresearchquestion?

Whataretheoutcomesofpatientswhoreceive sugammadexforneurologicexamintheED?

Whatwasthemajor ﬁndingofthestudy?

47.9%ofpatientswhoreceivedsugammadex intheEDultimatelyunderwentaprocedure within24hours,and50%diedwithin30days.

Howdoesthisimprovepopulationhealth?

Thisstudyprovidesinputontheoutcomesof patientsreceivingsugammadexintheEDfor neurologicexam,whichisdonerarelyandin high-acuityandtime-sensitive clinicalsituations.

administrationintheEHR.ForNMBAsadministered outsideofthehealthsystem,linkedEHRs, triagenotes,andambulancerunreportsweremanually reviewedtodeterminedoseandtimingof NMBadministration.

Manualchartreviewandabstractionwasthenperformed bythe ﬁrstauthor(SDH)todeterminetheneurological injurytype,proceduretypeandtiming,majoradverseevents, mortality,andin-hospitalchangestoacomfort-oriented codestatus.

Wherepossible,GlasgowComaScale(GCS)was abstractedfromnursingandphysiciannotes.Wecalculateda modiﬁedRankinScale(mRS)basedonthephysical examinationandphysicaltherapynotesincludedinthe dischargesummary.Descriptivestatisticswerecalculated. ThisresearchwasapprovedbytheMassGeneralBrigham institutionalreviewboard.

RESULTS

PatientDemographics

FromJune21,2016–February9,2024,therewere 3,080,338EDvisitsatMassGeneralBrigham-afﬁliated acute-carehospitals.Forty-eightpatientsreceived sugammadextofacilitateneurologicalexamination.The mean(±SD)ageatadministrationwas59.9(±20.9) yearsofage(range21–94years).Sixteenpatients (33.3%)werefemale,and32patientsweremale (66.7%)(Table).

Table. Patientcharacteristics.

Age,mean(SD),years

Sex, n(%)

59.9(20.89)

Male 32(66.7%)

Female

Weight,mean(SD)kg

Sugammadexdose,mean(SD),mg 345.63(200)

Sugammadexdose,mean(SD),mg/kg 4(2.8)

Neurologicinjury,n(%)

Subduralhematoma 6(12.5%)

Subarachnoidhemorrhage 7(14.6%)

Multicompartmentalhemorrhage 15(31.3%)

Intraparenchymalhemorrhage 11(22.9%)

Ischemicstroke 3(6.3%)

Cervicalspineinjury

Other 3(6.3%)

Trauma,n(%) 25(52%)

Mortality,n(%)

Within72hoursofsugammadex

Within30daysofsugammadex

Changetocomfortmeasuresonly,n(%)

Within72hoursofsugammadex 16(33.3%)

Duringhospitalization 22(45.8%)

Locationofparalytic,n(%)

Outsidehospital

GCS,median,whenrecorded

Pre-sugammadex

Post-sugammadex

Changepre-/post-sugammadex

Procedureperformed,n(%)*

Craniotomy

Externalventriculardrain 7(14.6%)

Angiogram/embolization/thrombectomy 4(8.3%)

Spinalfusion/decompression 3(6.3%)

Other 5(10.4%)

*Somepatientshadmorethanoneprocedure.

GCS, GlasgowComaScore; kg,kilogram; mg,milligram.

Dosing,Timing,andLocation

Themeandosingweight(±SD)was77.3kgs(±18.9kg). RocuroniumwasthemostcommonNMBAtobereversed, usedin46ofthe48patients(95.8%).Wewereabletoabstract accuratedosingofrocuroniumfor35patients,andthemean

(±SD)dosewas104.7mg(±18.3mg)orameanof 1.37mg/kg(±0.30mg/kg).Accuratedosingofvecuronium wasobtainedfromonepatient,whoreceived 10mg(0.13mg/kg).

Sugammadexwasgivenatameandoseof346mg(range 100–2,000mg,interquartilerange[IQR]200–377.5mg).The mostcommondosewas4mg/kg(25patients)withamean doseof4mg/kg(range2–18mg/kg,IQR2.8–4mg/kg).The NMBandsugammadexwereadministeredinthesameED encounterfor15patients.ForNMBgiveninalternate contexts,themostcommonlocationwasprehospital (18patients),atareferringhospital(13patients),andduring interfacilitytransport(twopatients).Alldosesof sugammadexwereadministeredinthetwoacademicmedical centerEDs.Wewereabletoobtainaccuratetimeof administrationforbothNMBandsugammadex for22patients.Themean(range, ±SD)timefrom NMBtosugammadexadministrationwas109.9 (31–283, ±66.8)minutes.

Withregardtohepaticandrenalclearance,allpatients hadacreatininelevelobtainedduringtheEDvisit,and46of 48(96%)hadtransaminaselevelsobtained.Thirty-three patientshadnormaltransaminaselevels(deﬁnedasboth aspartateaminotransferaseandalanineaminotransferase < 50unitsperliter)and35patientshadnormalcreatinine levels(deﬁnedas < 1.2mg/deciliter).

NeurologicalInjury

Theprimaryneurologicalinjuryvaried,butthemajority (40,83.3%)ofpatientspresentedwithintracranial hemorrhage.Three(6.3%)presentedwithacuteischemic strokes;twopatients(4.2%)hadextracranialvascularinjury; onewithaTypeAaorticdissectioncausingcommoncarotid arteryocclusionandonewithavertebralarterydissection andpseudoaneurysm.Two(4.2%)patientshadprimary spinalcordtrauma,andonepatient(2.1%)presentedwitha brainmass.Twenty-ﬁve(52.1%)ofthepatientspresented followingtrauma.

Outcomes

AnaccurateGCSwasobtainedbeforeadministrationof sugammadexin43(89.6%)patientsandwas3tinallbutone (whowas4t).AnaccurateGCSwasobtainedafter administrationofsugammadexin35(72.9%)patientswitha mean(±SD)of6.4(±2.4).Thirty-four(70.8%)hadareliable GCSobtainedbeforeandafteradministrationof sugammadex;themean(range, ±SD)increaseinGCSwas 3.38( 1to +8, ±2.5)points.

Twenty-threepatients(47.9%)underwentaninvasive procedurewithin24hoursofsugammadexadministration, andanotherthree(totalof26or54.2%)underwenta procedurewithin72hours(Table1).Twelvepatients(25.0%) died within72hoursofsugammadexadministration,while 24patients(50%)diedwithin30days.Thecodestatuswas

changedto “comfortmeasuresonly” for16patients(33.3%) within72hoursofsugammadexadministration,andfor22 patients(45.8%)duringthehospitalization.Adverseevents wererare,withtwo(4.1%)patientsexperiencinghypotension aftersugammadexadministration,four(8.2%)patients experiencingbradycardia,andnopatientsexperiencing cardiacarrest.

ThemRSforneurologicdisability11,12 atdischarge (rangingfrom0–6,withhigherscoresindicatingmoresevere disability),excludingallpatientswithadischargemRSof6 (deceased),wasanaverageof3.9(SD ±1.36),whereascore of4indicatesmoderatelyseveredisability.

DISCUSSION

Non-depolarizingNMBAsarefrequentlyusedinboththe EDandprehospitalsettingduringairwaymanagementof neurologicallyinjuredpatients.Theuseofnon-depolarizing NMBAsleadstoprolongedparalysis,whichimpairs accurateneurologicexaminationessentialtoguideemergent andtime-sensitivetherapyforneurologicinjury.Beyond neurologicexaminationbeingacriticalpartofdecisionmakingregardingtherapy,prognosisrelatedtoinitial neurologicexaminationmaybevaluabletofamiliesasthey considerearlygoalsofcare.Thisisreﬂectedinourdatasetas 33.3%ofpatientsreceivingsugammadexwhosestatuswas changedto “comfortmeasuresonly” within72hoursof receivingsugammadex.

Rocuronium,themostcommonlyusedNMBAinour cohort,hasanexpecteddurationofactionof30–60 minutes.13 However,longerdurationofactionhasbeenwell described.14–17 Thetimetoadministrationofsugammadexin ourstudyreﬂectsthis,aspatientsreceivedsugammadexas longas283minutesfollowingrocuroniumadministration withchangeinneurologicexamination.Additionally,we wereunabletoobtainaccuratetimesforsomeprehospital andreferringhospitaladministrationsofneuromuscular blockade,whichmayhavebiasedtheresultstowardthose administeredinthesameEDencounter.Thispotentially extendeddurationofactionforNMBwasunlikelydueto impairmentsofrenalorhepaticmetabolismasthesewas predominantlynormalinourcohort;instead,itmayhave beenduetohigherNMBdosesused,greaterpatientage,or touncharacterizedhypothermiaorhypovolemia,thelatter ofwhichwasnotcapturedinourstudy.18–20 Alldosesof sugammadexoccurredatthetwoacademicmedicalcenters. Weattributedthistobothhospitalsbeingreferralcentersfor neurosurgicaltraumaandforpost-strokecare.Becauseof this,weareunabletodrawanyconclusionsaboutitsusein communityhospitals.

Ourstudyreplicatedprevious ﬁndingsseenintherelevant literatureincludingthatsugammadexuseintheEDfor neurologicexamisoverallrareandappearsmostprevalentat academicmedicalcenters.Thislikelyreﬂectsthecapacityfor advancedtherapeuticsandneurosurgicalinterventionfor

whichrapidNMBreversalforneurologicexamisindicated atthesecentersandthatadverseeffectsassociatedwithitsuse arerare.5,7

LIMITATIONS

AlimitationofourstudywaslackofrecordedTOF monitoring.WithoutTOFmonitoring,itisdifﬁcultto commentonwhetherthesugammadexdosesadministered wereadequateatfullyreversingNMB.Becauseofthe retrospectivenatureofthestudy,wewereunableto determinetheexacttimeofneurologicalexamination. Additionally,itispossiblethatdocumentedchangeinGCS wasduetootherfactorssuchaschangesinsedationor underlyingneurologicstatus.Anadditionallimitationofour studywasthatrecordedGCSwasbasedonexamsperformed bymanydifferentindividualswithvariabletraining backgroundsincludingnursing,emergencymedicine residentsandattendings,neurologyandneurosurgery residents,andneurosurgeryattendings.Further,thepre-and post-GCSwasoftenbasedonexaminationsperformedby separateindividuals,andvariationinexambetween clinicianscouldhavecontributedtochangeinGCS,rather thantrueclinicalchange.TimeofGCSexaminationswas alsonotrecorded,whichalsomayhaveaffectedtheresultsof theexamaftersugammadexadministration.Althoughour cohortdescribessugammadexuseamongpatientswitha rangeofneurologicalpathology,wedidnotcaptureany patientswithstatusepilepticusastheunderlyinginjury,one potentiallyrelevantdiseasecategoryforwhichNMBreversal hasbeenpreviouslydescribed.5

Anadditionallimitationwaslackofbispectralindex monitoringordataregardingawarenessduringparalysis. AwarenessduringparalysisisknowntooccurinEDpatients receivingmechanicalventilation,withrocuroniumbeing associatedwithincreasedfrequencyofawarenessduring paralysis.21 Furthermore,theimpactoftheuseof sugammadexonclinicaldecision-makingwasdifﬁcultto determinegiventheretrospectivenatureofthestudy. Accurateneurologicalexaminationisanessential aspectofclinicaldecision-makingduringneurologic emergenciesandlikelyplayedanimportantroleinclinical courseregardlessofwhetherinterventionwasperformed followingrepeatexam.Prospectiveresearchisneededto determinetheimpactofsugammadexonclinical decision-making.

Despitetheselimitations,sugammadexadministration waswelltolerated,withrareadverseeffects.Althoughthere weretwoepisodesofhypotensionandfourepisodesof bradycardia,itwasdifﬁculttodeterminewhetherthesewere attributabletosugammadexgivenpossibleconfounderssuch assedationadministrationandunderlyingcriticalillness. Overall,thecohortwasassociatedwithhighacuityreﬂective ofthecriticalnatureofneurologicemergenciesrequiring intubation.Mortalitywashighinthiscohort,andmRSat

dischargewasreﬂectiveofmanypatientshavingsevere disabilityatdischarge.Despitehighmortalityandsevere disabilityinsurvivors,itisdifﬁculttoconsidersugammadex administrationandsubsequentproceduresasfutileassome patientsmaygoontorecoverconsiderablywith aggressiverehabilitation.

CONCLUSION

Administrationofsugammadextofacilitateneurologic examinationisarareoccurrenceintheED.Inthis multicenter,retrospectivestudy,wefoundthatpatientswho receivedsugammadexintheEDduringthestudyperiodhad infrequentassociatedadverseeffects,highratesof procedureswithin24hoursofadministration,andsigniﬁcant in-hospitalmortality.ChangeinGlasgowComaScalewas observeddespitemostpatientsinthiscohortreceiving sugammadexgreaterthanonehourafterNMB administrationwithamaximalobservedintervalofgreater thanfourhoursafterNMBadministration.Codestatus ultimatelychangedto “comfortmeasuresonly” fornearly halfofthesepatientsand,onaverage,patientsdischarged fromahospitalizationwheresugammadexhadbeen administeredintheEDhadmoderatelysevereneurologic disability.Prospectivedataisneededtoassesstheimpactof sugammadexondecision-making.

AddressforCorrespondence:StephenD.Hallisey,MD,Brigham andWomen’sHospital,DepartmentofEmergencyMedicine, DivisionofEmergencyCriticalCareMedicine,75FrancisSt., Boston,MA02115.Email: shallisey@mgb.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.BrownCA,BairAE,PallinDJ,etal.Techniques,success,andadverse eventsofemergencydepartmentadultintubations. AnnEmergMed. 2015;65(4):363–70.e1.

2.NicholsonWT,SprungJ,JankowskiCJ.Sugammadex:anovelagent forthereversalofneuromuscularblockade. Pharmacotherapy. 2007;27(8):1181–8.

3.IwasakiH,RenewJR,KunisawaT,etal.Preparingforthe unexpected:specialconsiderationsandcomplicationsafter sugammadexadministration. BMCAnesthesiol. 2017;17(1):140.

4.ThilenSR,WeigelWA,ToddMM,etal.2023AmericanSocietyof Anesthesiologistspracticeguidelinesformonitoringandantagonismof neuromuscularblockade:areportbytheAmericanSocietyof AnesthesiologistsTaskForceonNeuromuscularBlockade. Anesthesiology. 2023;138(1):13–41.

5.ChenB.Sugammadex:alimitedbutimportantrole inemergencymedicine. PediatrEmergCare. 2020;36(6):296–301.

6.LentzS,MorrissetteKM,PorterBA,etal.Whatistheroleof sugammadexintheemergencydepartment? JEmergMed. 2021;60(1):44–53.

7.JanssonPS,PimentelMPT,SeethalaRR.Emergencydepartment usageofsugammadexinalargeregionalhealthsystem. AcadEmerg Med. 2024;31(7):713–5.

8.FalksenJAandSchomerKJ.Neurologicexaminationfacilitatedby reversalofrocuroniumwithsugammadex. JPharmPract. 2024;37(4):880–4.

9.HileGB,OstinowskyME,SanduskyNP,etal.Evaluationof sugammadexdosingforneurologicalexaminationintheemergency department. JPharmPract. 2024;37(4):838–44.

10.WorsterA,BledsoeRD,CleveP,etal.Reassessingthemethodsof medicalrecordreviewstudiesinemergencymedicineresearch. Ann EmergMed. 2005;45(4):448–51.

11.BanksJLandMarottaCA.Outcomesvalidityand reliabilityofthemodiﬁedRankinscale:implicationsforstroke clinicaltrials:aliteraturereviewandsynthesis. Stroke. 2007;38(3):1091–6.

12.vanSwietenJC,KoudstaalPJ,VisserMC,etal.Interobserver agreementfortheassessmentofhandicapinstrokepatients. Stroke. 1988;19(5):604–7.

13.TevaParentalMedicines.(2008). Rocuronium[packageinsert].Irvine, CA:TevaParentalMedicines,Inc.

14.MoralesMartínAC,VaqueroRonceroLM,MurielVilloriaC.Extremely prolongedneuromuscularblockadeafterrocuronium:Acasereport. ActaAnaesthesiolScand. 2009;53(7):957–9.

15.OlivieriLandPlourdeG.Prolonged(morethantenhours) neuromuscularblockadeaftercardiacsurgery:reportoftwocases. Can JAnaesth. 2005;52(1):88–93.

16.CooperRA,MaddineniVR,MirakhurRK,etal.Timecourseof neuromusculareffectsandpharmacokineticsofrocuronium bromide(Org9426)duringisoﬂuraneanaesthesiainpatients withandwithoutrenalfailure. BrJAnaesth. 1993;71(2):222–6.

17.RobertsonEN,DriessenJJ,BooijLHDJ.Pharmacokineticsand pharmacodynamicsofrocuroniuminpatientswithandwithoutrenal failure. EurJAnaesthesiol. 2005;22(1):4–10.

18.JainA,WermuthHR,DuaA,etal.Rocuronium.In: StatPearls[Internet] TreasureIsland,FL:StatPearlsPublishing,2024.

19.BaykaraN,SolakM,TokerK.Predictingrecoveryfromdeep neuromuscularblockbyrocuroniumintheelderly. JClinAnesth. 2003;15(5):328–33.

20.VestedM,PapeP,KristensenCM,etal.Rocuronium0.3or0.9mg/kg comparingonsettime,durationofaction,andintubatingconditionsin patients80yearsandolder:arandomizedstudy. ActaAnaesthesiol Scand. 2022;66(7):811–7.

21.PappalRD,RobertsBW,MohrNM,etal.TheED-AWARENESSstudy: aprospective,observationalcohortstudyofawarenesswithparalysisin mechanicallyventilatedpatientsadmittedfromtheemergency department. AnnEmergMed. 2021;77(5):532–44.

AnalysisoftheHighestAltmetrics-scoredArticlesinEmergency MedicineJournals

Ba ¸ sakBayram,MD*

MuratCetin,MD†

ÖnderLimon,MD‡

BritLong,MD§

MichaelGottlieb,MD∥

* IzmirMetropolitanMunicipalityE ¸ srefpa ¸ saHospital,Izmir,Türkiye

† Dr.BehçetUzChildren’sEducationandResearchHospital,DepartmentofEmergency Medicine,Konak,Izmir,Türkiye

‡ IzmirUniversityofEconomics,FacultyofMedicine,MedicalpointHospital,Departmentof EmergencyMedicine,Kar ¸ sıyaka,Izmir,Türkiye

§ SanAntonioUniformedServicesHealthEducationConsortium,DepartmentofEmergency Medicine,FortSamHouston,Texas

∥ RushUniversityMedicalCenter,DepartmentofEmergencyMedicine,Chicago,Illinois

SectionEditor:SoheilSaadat,MD,MPH,PhD

Submissionhistory:SubmittedMay15,2024;RevisionreceivedDecember6,2024;AcceptedDecember13,2024

ElectronicallypublishedFebruary14,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.21201

Introduction: Alternativemetrics(altmetrics)haveemergedasinvaluabletoolsforassessingthe inﬂuenceofscholarlyarticles.InthisstudyweaimedtoevaluatecorrelationsbetweenAltmetricAttention Scores(AAS),andsourcesandactualcitationsinarticlesdisplayingthehighestAASwithinemergency medicine(EM)journals.

Methods: WeconductedananalysisofEMjournalslistedintheScienceCitationIndexExpanded (SCIE)usingtheAltmetricExplorertool.Weanalyzedthejournalsthatreceivedthehighestnumberof mentions,thesourcesofAAS,theregionsmostfrequentlymentioned,andthegeographicaldistribution ofmentions.Inthesubsequentstageofouranalysis,weconductedanexaminationofthe200toprankedarticlesthathadreceivedhighAASandwerepublishedinSCIEEMjournalsfromJanuary1, 2013–January1,2023.WesoughttodeterminethecorrelationsbetweentheAASandthecitationcounts ofarticlesonGoogleScholarandtheWebofScience(WOS).

Results: Of40,840researchoutputsevaluated,therewere510,047sharesacrossmultipleplatforms. TheAASwerepresentfor36,719articles(89.9%),while10.1%hadnoscore.Inthereviewofthetop200 articleswiththehighestAAS,themedianscorewas382.5(interquartilerange301.3–510.8).Ofthe researchoutputevaluated,38%wereobservationalstudies,13%casereports,and13%reviews/metaanalyses.Themostcommonresearchtopicswereemergencydepartment(ED)managementand COVID-19.TherewasnocorrelationbetweenAASandWOScitationnumbers(rs = 0.041, P = 0.563, 95%conﬁdenceinterval[CI] 0.175–0.087).TherewasaweakcorrelationidentiﬁedbetweenWOS citationsandmentionsonX,andamoderatecorrelationobservedforWOScitationsandblogmentions (rs = 0.330, P < .001,95%CI0.174to0.458;rs2 = 0.109,andrs = 0.452, P < .001,95%CI0.320–0.566; andrs2 = 0.204,respectively).However,wefoundastrongpositivecorrelationbetweenWOScitations andthenumberofMendeleyreaders(rs = 0.873, P < .001,95%CI0.82–0.911,rs2 = 0.762).

Conclusion: WhilemostarticlesinEMjournalsreceivedanAAS,wefoundnocorrelationwithtraditional citationmetrics.However,Mendeleyreadershipnumbersshowedastrongpositivecorrelationwith citationcounts,suggestingthatacademicplatformengagementmaybetterpredictscholarlyimpact. [WestJEmergMed.2025;26(2)353–363.]

INTRODUCTION

Alternativemetrics(altmetrics)emergedintheearly2010s inresponsetothelimitationsoftraditionalcitation-based metrics.1 Altmetricsuseabroadersetofindicatorssuchas pageviews,downloads,socialmediamentions,newsmedia coverage,andexpertrecommendationstoprovideamore comprehensiveunderstandingofanarticle’sinfluence. 2 PlatformslikeAltmetric.comandPlumAnalyticsprovide toolsforevaluatingthereachandimpactofscholarly articles,helpingtotracktheironlinedisseminationinreal time.Anincreasingamountofevidenceindicatesthat maintaininganactiveonlinepresencecandirectlyinfluencea researcher’scredentialsasevaluatedbyconventional measures. 3 Byconsideringvariousaspectsbeyondcitations alone,altmetricsprovidesresearchersandinstitutionswitha moreholisticassessmentoftheirwork’ssocietalimpact. Whilethepurposeofthesemetricsistomeasuresocial impact,earlysocialmediavisibilityafterpublicationcanalso increaseandpredictcitations.4 Assessingtheseactivities couldprovidefasterevaluationsofanarticle’simpactand predictcitations,servingasanearlyidentifierforemerging areasofresearchgrowth.5

Withinthemedical fieldspecifically,thesemetricsoffer insightsintobothscholarlyrecognitionandpublicreception ofresearch findings.Moreover,therelationshipbetween thesemetricsunderscoresthechanginglandscapeof scholarlycommunication,asresearchers,clinicians,andthe publicalikeengagewithandcontributetothedissemination ofresearch findingsthroughonlineplatforms.Withthe growthofdigitalcommunicationandsocialmedia,thespeed andthescaleofinformation-sharinghaveaccelerated, makingaltmetricsaninvaluabletoolforassessingreal-time impactofarticles.6 Emergingtrendscanbekeytoamore efficientlyfunctioning fieldofmedicine.7 Emergencymedicine(EM)thrivesonthetimely disseminationofresearchandinformationthatdirectly impactspatientcare.8 The firstaltmetricsanalysisinEM conductedbyBarbicetalfoundthatthemost-citedarticles onsocialmediainEMfrom2011wereoftenpublishedin non-EMbiomedicaljournals.9 Althoughthismaysuggest thatauthorsinthe fieldofEMselecthigh-impactjournalsto increasetheeffectivenessoftheirpublications,altmetric scoresandjournalimpactfactorsarenotcorrelated.10 The socialimpactofanarticlemaybebetterassessedbyfocusing onindividualaltmetricscoresourcesratherthantheoverall score. 11 Thiswassupportedbyarecentstudythatfounda directcorrelationbetweenX(formerlyTwitter)mentions andarticlecitationsamongEMresearch.12 Ouraiminthis studywastoinvestigatethecorrelationsbetweenthe altmetricscores,theirsources,andcitations.

METHODS

Inthe ﬁrststageofthestudy,weusedtheAltmetric ExplorertoolfromAltmetric.com(AltmetricLLP,London,

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Altmetricsemergedinthe2010stoaddress thelimitationsoftraditionalcitation-based metricsinevaluatingresearchimpact.

Whatwastheresearchquestion?

Weexploredthecorrelationsbetween AltmetricAttentionScores,theirsources,and citationcountsforarticlespublishedin EMjournals.

Whatwasthemajor ﬁndingofthestudy?

NocorrelationwasfoundbetweenAASand WebofScience;itwasweakforXmentions, moderateforblogs,butstrongforMendeley readership(r s = 0.873,95%CI0.822 – 0.911).

Howdoesthisimprovepopulationhealth?

Focusingonarticledisseminationthrough individualaltmetricsources,ratherthantotal scores,canhelpresearchersmoreeffectively reachtheirtargetaudiences.

UK)toassesstheAltmetricAttentionScores(AAS)of scholarlyarticlespublishedinEMjournalsindexedinthe ScienceCitationIndexExpanded(SCIE).TheAASisa metricthatevaluatestheattentionaresearchoutputreceives usingaweightedsystemthatassignsdistinctvaluestovarious sources,suchasnewsoutlets,blogs,andsocialmedia platforms.Sourceswithgreaterimpact,suchasnewsarticles, areattributedhigherweightscomparedtosocialmedia mentions.Thescoreiscalculatedbyasophisticated algorithmthatfactorsinnotonlythenumberofmentionsbut alsovariablessuchasduplicatepostsandthecredibilityof thenewssources.13

AllAltmetricExplorerassessmentswereconductedand downloadedasaCSV ﬁleonSeptember2,2023.Theinitial analysisfocusedonexaminingthedistributionofaltmetric databycountryandjournal,aswellasevaluatingthesources ofAASscoresovertime.The2022JournalCitation Indicator(JCI)scoresforthejournalswereobtainedfromthe WebofScience(WOS)MasterJournalList.TheseJCIscores representtheaveragecitationimpactofarticlespublished between2019–2021.

Inthesecondstageweidentiﬁedthetop200articleswith thehighestAASpublishedinSCIEEMjournalsbetween January1,2013–January1,2023.WeassessedtheAASof thesearticlesalongwiththesourcesoftheirmentions. Citationcountsforthesearticleswereevaluatedusingboth

WOSandGoogleScholar.Tocalculatetheannualcitation number,wedividedthetotalcitationcountsobtainedfrom thesearchenginesbythenumberofyearssincethearticles’ publication.Weobtainedfull-textaccessforthearticlesto determinethearticle’ssubject(eg,emergencydepartment management,trauma,toxicology,resuscitation,criticalcare, COVID-19)andtype(randomizedcontrolledtrial, observationalstudy,casereports,reviews(systematicreview andmeta-analysis).Additionally,wedeterminedthecountry ofthe ﬁrst-namedauthorofeacharticle.

WeassessedthecorrelationbetweentheAASandcitation countsofthearticles.Furthermore,twoEMspecialistsfrom theresearchteamindependentlyreviewedtheAASandall screeningprocessesofthestudy.Incaseswherethetwo evaluatorsdidnotreachaconsensus,athirdEMspecialist conductedtheevaluation.Thestudywasapprovedbythe LocalEthicsCommitteeof ˙ IzmirProvincialHealth DirectorateDr.BehcetUzPediatricDiseasesandSurgery TrainingandResearchHospital.

StatisticalAnalysis

WeperformedstatisticalanalysisusingSPSS29.0for Windows(SPSSStatistics,IBMCorp,Armonk,NY). CategoricalvariableswereevaluatedusingtheKolmogorovSmirnovtest.Amongthevariables,thosethat ﬁtthenormal distributionwerepresentedasthemean ± standard deviation,andthosethatdidnot ﬁtthenormaldistribution werepresentedasmedian(interval)ormedian(interquartile range[IQR]).WeusedMann-WhitneyUandKruskalWallisteststocomparenumericalvariables.Spearman correlationanalysiswasusedtoassesstherelationship betweenAAS,theirsources(mentions),andWOSand GoogleScholarcitationnumbers.Spearmancorrelation analysiswasusedtoanalyzedistributionsofAAS,thesource ofthescores(mentions),andWOSandGoogleScholar

citationnumbers.Weinterpretedthecorrelationsasweak, moderate,strong,andverystrongbasedontheresulting coefﬁcients.14 Statisticalsigniﬁcancewasrecognized whenP < 0.05.

RESULTS

Ofthe40,840researchoutputsevaluated,510,047were sharedacrossmultipleplatforms.AltmetricAttentionScores werepresentfor36,719articles(89.9%),while10.1%hadno score.Theonlineengagementforthiscontentincluded 459,391tweetsfrom114,708uniquetweetersin206 countries,14,355Facebookpostson2,141uniquepagesin 60countries,19,571newsstoriesby1,988uniqueoutletsin86 countries,and2,791policydocumentsfrom79unique sourcesin18countries.Thetop10journalshadnomentions onPinterest,Syllabi,orLinkedIn.Onlytwojournals receivedmentionsontheChinesemicrobloggingplatform Weibo,eachmentionedonce. Figure illustratesthe frequencyofmentionscorrespondingtothe publicationyears.

TheAltmetrics–Xdemographicsdatarevealedthetop five countriescontributingtomentionsfortheanalyzedcontent. Thecountrywasnotspecifiedin193,148posts(42.0%)and 54,517profiles(47.5%).Thelargestnumberofpostswere fromtheUnitedStates(Table1).

Overall,90%ofthe36,780articleshadanAAS ≥ 1.The median(IQR)valuesforthesearticleswereasfollows:AAS3 (1–9),Xmentions3(1–9);Mendeleyreadership24(9–50); Dimensionscitations5(1–15);andblogmentions0(0–24). WefoundastrongcorrelationbetweenAASandXmentions (rs = 0.712,95%CI0.707–0.717, P < .001)andaweak correlationbetweenAASandthenumberofMendeley readers(rs = 0.338to356, P < .001).

WefoundtwojournalsthatlackedAAS.Themediantotal mentionsforEMjournalswere14,154(rangingfrom

Table1. Countrydistributionofaltmetrics-Xdemographics.

Spain 13,538(2.9%) 3,863(3.4%)

*Apostreferstoanindividualmentionorengagementonasocialmediaplatform(suchasanXmention,Facebookpost,blogentry,etc) where aspeciﬁcresearchoutputissharedordiscussed.

**Aproﬁlereferstotheuniquesocialmediaaccountoruser(eg,anXorFacebookaccount)thatmadethepostormention.

57–77,460).MentionsonXhadamedianof12,284(ranging from56–68,078),Facebookmentionshadamedianof234 (rangingfrom0–2,180),blogmentionshadamedianof126.5 (rangingfrom0–1,866),andnewsmentionshadamedianof 288(rangingfrom0–5,040).

TheEMjournalswiththehighesttotalnumberof mentionswere AnnalsofEmergencyMedicine, Resuscitation,andtheAmericanJournalofEmergency Medicine .Conversely,theAASperarticlewashighestfor AcademicEmergencyMedicine,AnnalsofEmergency Medicine,andtheEmergencyMedicineJournal , respectively(Table2).Wefoundamoderatecorrelation (rs = 0.518, P = 0.07,95%CI0.152–759)betweenthe2022 JCIandthetotalnumberofmentions.

Inthereviewofthetop200articleswiththehighestAAS, themedianscoreofthearticleswas382.5(IQR301.3–510.8). TheAASwithsourcesandnumberofcitationsofthetop50 articlesareprovidedin Table3.ThemedianWOScitations forthearticleswas16(IQR5–39),withanannualcitation countof4.7(IQR1.8–8.9).ThemedianGoogleScholar citationswas29(IQR11–65),withanannualcitationcount of7.5(IQR3.2–15.1).Amongthesearticles,38%were observationalstudies,whilecasereportsandreviews/metaanalysesconstituted13%.Themostcommonresearchtopics wereEDmanagementandCOVID-19(Table4).

TheAASofreviewsandguidelineswerelower,while observationalstudiesandcasepresentationswerehigher (P = 0.02).TheAASwashigherfortopicsrelatedto toxicology,COVID-19,andcriticalcare(P = 0.02).While therewasanincreaseinAASandWOScitationsin COVID-19-relatedpapers,thesevariationswerenot signiﬁcant(P = 0.09and P = 0.08,respectively).

TherewasnosigniﬁcantcorrelationbetweenAASand WOScitationnumbers(rs = 0.041, P = 0.56,95%CI 0.175–0.087,rs2 = 0.0017)orGoogleScholarcitations (rs = 0.038, P = 0.59,95%CI 0.174–0.101,rs2 = 0.0014). However,therewasaverystrongpositivecorrelation betweenWOSandGoogleScholarcitationnumbers(rs = 0.973, P < .001,95%CI0.955–0.984,rs2 = 0.947).Despite theweakcorrelationidentiﬁedbetweenWOScitationsandX

mentions,andthemoderatecorrelationobservedforblog mentions(rs = 0.330, P < .001,95%CI0.174to0.458, rs 2 = 0.109,andrs = 0.452, P < .001,95%CI0.320to0.566, rs 2 = 0.204,respectively),therewasaverystrongpositive correlationobservedinthenumberofMendeleyreaders. (rs = 0.873, P < .001,95%CI0.822–0.911,rs2 = 0.762). Nocorrelationwasobservedbetweennewsmentions (rs = 0.107, P = 0.10,95%CI 0.246–0.046,rs2 = 0.0012), andvideomentions(rs = 0.037, P = 0.60,95%CI 0.078to 0.145,rs2 = 0.0013).

DISCUSSION

ThisstudyexaminedaltmetricsofEMjournalarticles fromthe2013–2023.TenpercentofEMjournalarticleswere nevermentionedonsocialmedia.ComparedtoBarbicetal’ s investigationsfrom2011,AASforthemostcited publicationshaveincreasedsignificantlyinthesubsequent decade.9 SocialmediafollowersforEMjournalarticleshave increasedsignificantlyinrecentyears.Interestingly,threequartersofthe200most-citedarticleswerepublishedafter thisstudy,with45%publishedaftertheCOVID-19 pandemic.SocialmediafollowersforEMjournalarticles haveincreasedsignificantlyinrecentyears.

Kolahietalidentiﬁedaweakbutpositivecorrelation betweenAASandcitationsintheirmeta-analysis;the authorsemphasizedtheimportanceofcontinuingtoexamine thetemporaldynamicsofthisrelationship.15 Inourstudy, althoughnocorrelationwasfoundbetweenAASand traditionalcitationcounts,weobservedaweakcorrelation betweenAASandXmentions,andamoderatecorrelation betweenAASandblogmentions.Notably,therewasavery strongcorrelationobservedbetweenAASandtheMendeley readershipnumbers.

TheAASiscalculatedbasedonthesourceandfrequency ofsharing.Inthiscalculation,news,blogmentions,Wiki pages,policydocuments,andpatentshavethemostweight, whileXhaslessweight.Mendeleyreadershipandcitations arenotconsidered.16 Itshouldbenotedthattheprimary purposeofaltmetricsistomeasuresocialinterestinagiven topic,ratherthantopredictthepotentialcitationcountofan

Table2. Journalswiththehighesttotalnumberofmentions.

1.56 46,94523.972,3321,1091995841,615101,17899258225061

2.377,46020.855,0401,8662215868,078191,8301361074016051

1.246,19616.921,0251,0941591642,30321,37480114182010

Journaltitle

AcademicEmergency Medicine

AnnalsofEmergency Medicine

Resuscitation1.8764,94115.081,53284540015159,34112,1801492183229361

1.0620,34514.917933901062818,29835201018123021

TheWesternJournal ofEmergency Medicine

0.7525,41414.882653901771523,7911620107375107

CanadianJournalof EmergencyMedicine

1.3216,90114.81224145481816,02132864975193010

ScandinavianJournal ofTrauma, Resuscitationand EmergencyMedicine

1.235,63412.661,2987981473332,356363118894285251

JournalofEmergency Medicine

1.4750,0289.632,1561,1903355544,442161,502172681710164

AmericanJournalof EmergencyMedicine

0.7716,9215.5230843097614,43441,534431204050

PediatricEmergency Care

Δ JCI:JournalCitationIndicator. δ Thejournalsarerankedbasedonthetotalmentionsperarticle.

Med

Table3. Top50articleswithhighestaltmetricscores.

1N95respiratorcleaningandreusemethodsproposed by theinventoroftheN95maskmaterial

2Associationbetweendelaystopatientadmissionfrom theemergencydepartmentandall-cause30-day mortality

4Vaccine-inducedmyocarditisintwointerndoctorsin thesamenightshift

5 Loperamideabuseassociatedwithcardiac dysrhythmiaanddeath

6Alayperspectiveandcommentaryontheassociation betweendelaystopatientadmissionfromthe emergencydepartmentandall-cause30-daymortality

7Characteristicsofpaediatricout-of-hospitalcardiac arrestintheUnitedStates

8Acoronavirusdisease2019(COVID-19)patientwith bilateralorchitis

9Theassociationoftreatmentwithhydroxychloroquine andhospitalmortalityinCOVID-19patients

10Priapisminapatientwithcoronavirusdisease2019 (COVID-19)

11Esophagealruptureafterghostpepperingestion

12Accidentaloccupationalexposuretoalargevolumeof liquidfentanylonacompromisedskinbarrierwithno resultanteffect

13VitaminDde ﬁ ciencyisassociatedwithhigherrisksfor SARS-CoV-2infectionandCOVID-19severity: aretrospectivecase –controlstudy

14Characterizationofinﬂ ightmedicaleventsinvolving childrenoncommercialairline ﬂ ights

15Interrogationofpatientsmartphoneactivitytracker toassistarrhythmiamanagement

16 AWARE AWArenessduringREsuscitation A prospectivestudy

17AlarmingtrendsinUSdomesticviolenceduringthe COVID-19pandemic

18Useofantibioticcoatedintramedullarynailsinopen tibiafractures:aEuropeanmedicalresourceuseand cost-effectivenessanalysis

19Bilateralretinaldetachmentsinahealthy22-year-old womanafterModernaSARS-COV-2vaccination

20 Stoppinghaemorrhagebyapplicationofrope tourniquetoringuinalcompression(SHARCstudy)

Theuseoftheword “ quiet ” in theemergency departmentisnotassociatedwithpatientvolume: arandomizedcontrolledtrial

Med

22Aromatherapyversusoralondansetronforantiemetic therapyamongadultEmergencydepartmentpatients: arandomizedcontrolledtrial

23Cyclicvomitingpresentationsfollowingmarijuana liberalizationinColorado

24Removalofiliosacralscrews:thewasherproblem

25Persistenthiccupsasanatypicalpresentingcomplaint ofCOVID-19

26Itisn ’ tlikethisonTV:revisitingCPRsurvivalrates depictedonpopularTVshows

27In-hospitalcardiacarrestoutcomesamongpatients withCOVID-19pneumoniainWuhan,China

28 Identifyingsafecorridorsforanteriorpelvic percutaneousinstrumentationusingcomputed tomography-basedanatomicalrelationships

29Riskofacutekidneyinjuryafterintravenouscontrast mediaadministration

30 Acutekidneyinjuryaftercomputedtomography: ameta-analysis

31Trendsininequitiesinthetreatmentofandoutcomes forwomenandminoritieswithmyocardialinfarction

32Singleversusdualincisionapproachesfordualplating ofbicondylartibialplateaufractureshavecomparable ratesofdeepinfectionandrevisionsurgery

33Comparisonoforalibuprofenatthreesingle-dose regimensfortreatingacutepainintheemergency department:arandomizedcontrolledtrial

34 Youngwomanwithparaplegiafollowingamotor vehiclecrash

Med

35Associationbetweentheopeningofretailclinicsand low-acuityemergencydepartmentvisits

36STEMImimic:focalmyocarditisinanadolescent patientaftermRNACOVID-19vaccine

Med

37 One-yearmortalityofpatientsafteremergency departmenttreatmentfornonfatalopioidoverdose

38Academicemergencymedicinephysicians ’ anxiety levels,stressors,andpotentialstressmitigation measuresduringtheaccelerationphaseofthe COVID-19pandemic

39 BystanderCPRisassociatedwithimproved neurologicallyfavourablesurvivalincardiacarrest followingdrowning

withmorequestionsthananswers

waittimesintheemergencydepartment

externalde ﬁ brillatorsinEngland?

workforceanalysis

inhospitalsthatprovideemergencycare

LongitudinaltrendsinU.S.drugshortagesfor medicationsusedinemergencydepartments (2001 –2014)

ofurinarycatheterusein18emergencydepartments

Rapidadoptionoflow-thresholdbuprenorphine treatmentatCaliforniaemergencydepartments participatingintheCABridgeProgram

ﬁ rstaiddecreasesskingrafting requirementsinpediatricburns:acohortstudyoftwo thousandfourhundredninetyﬁ vechildren

Table4. Thecitationsarecategorizedbasedonthetopicsandtypesofthetop200articleswiththehighestAltmetricAttentionScores.

Articletype

Topics EDmanagement39(19.5)369.0(295.0–

–

AnalysisofCOVID-19articles

ED, emegencydepartment; IQR,interquartilerange; WOS,WebofScience.

article.Traditionalcitationsremainthegoldstandardfor academicrecognition.However,therelationshipbetween socialmediaandcitationssupportsthepositiveimpactof researchersandscientiﬁcjournalsusingsocialmediato enhancethevisibilityandinﬂuenceoftheirarticles. Incorporatingtheimpactofsocialmediaintothegold standardofcitationcountscouldbeawaytoacknowledge thisevolvinglandscape.

Theresultsofastudyexaminingtheimpactofpromoting Cochranesystematicreviewsinthe fieldofpediatricEM usingXandblogpostsrevealedasignificantincreaseof 10timesintheAASofthereviews.17 Thedistribution patternofarticlesonsocialmediamightvarybasedonthe natureofthesharing.Infographicsarevisualrepresentations ofdatameanttoenhanceengagementandstreamlinethekey elementsofagivenstudy.18 Somedatasuggeststhat presentingresearch findingsvisuallyonsocialmediamay leadtoa5–7timeshighernumberofinteractionscompared tostudieswithoutvisualcontent.19,20 Althoughusingvisual presentationstoshareresultscanreachalargeraudience,this effectmayonlyapplytospecificareasofexpertise.

Theextenttowhichsharinginﬂuencesthenumberof downloadsandcitationsofapaperremainsuncertain.21

However,altmetricstodayplayacrucialroleasmarkersfor assessingthespreadofcontentviasocialmediatoreachthe intendedaudience.Temporalpatternsinarticlealtmetrics

exhibitvariationacrossdifferentdatasources.Astudy investigatingaltmetricstemporaltrendsreportedthatX engagementstartedandendedquickly,whileMendeley readershipincreasedsteadilyoverthenextfewyears.22 An excellentwaytomaintaininterestinpublishedarticlesistouse altmetricsdatasourcesincombinationwithmethodsthat engagethetargetaudienceandregularlyupdatethecontent.

DuringtheCOVID-19pandemic,therewasanotable increaseinthedisseminationofinformationonsocialmedia platforms,withhealthcareprofessionalsusingthese platformsmorefrequently.Ouranalysisshowsthatnearly halfofthetop200publicationsinEMjournalswere publishedaftertheonsetofthepandemic.Additionally, whenevaluatingthecomprehensivealtmetricsofarticlesin EMjournals,wefoundtherewasaclearriseinmentions during2020–2021.Theevaluationundertakeninthisstudy encompassesreferencesmadeuntilthestartof2023.While futurestudieswilldeterminewhetherthisupwardtrendwill persist,itisforeseeablethatthesurgeinresearchersusing socialmediatomonitorscientiﬁcinformationwillcontinue asaresultoftheCOVID-19pandemic.Thisrisecanbe linkedtothesurgeinsharingactivitiesassociatedwith COVID-19.Nevertheless,ourinvestigationfoundno discernibledistinctionbetweenAASandWOScitations whencomparingpaperslinkedtoCOVID-19andthose unrelatedtoit.

LIMITATIONS

Thisstudyhasseverallimitations,particularlyits emphasisonquantitativedataanalysisandtheuseofasingle datasource.ThecurrentAltmetricdatabasemainly emphasizesthenumberofmentions,andouranalysis exclusivelycomparedthesemetrics.Inapproximately50%of thementionsonXwewereunabletodeterminethecountry associatedwiththeaccount.Inadditiontotheincreased interactionoftheattributesofsocialmediashares,itismore importanttoevaluatetherelationshipoftheinformationto thetargetaudience,reference,anddownload.20 Intheearly partofthestudy,weanalyzedallarticlespublishedinEM journals,butwemadecomparisonswithtraditional referencesforonly200articles.Incontrasttoprevious studies,weevaluatedarticleswiththehighestAASinsteadof thealtmetricsofthemostcitedarticlesintraditional referenceindices.Anotherlimitationofthisstudyisthe inabilitytofullydifferentiatetheimpactofincreasedsocial mediausageduringtheCOVID-19pandemiconAAS.The surgeinonlinecontentandinteractionsduringthepandemic mayhaveartiﬁciallyinﬂatedAASvalues,particularlyfor articlespublishedduringthisperiod,potentiallyaffectingthe relationshipbetweenAASandtraditionalcitationcounts.

CONCLUSION

TherehasbeenanotableriseinAltmetricsAttention Scoresinrecentyears,drivenbyincreaseduseofsocialmedia forfollowingscientiﬁcresearch,particularlyduringthe COVID-19pandemic.Articlesfocusingontoxicology, COVID-19,andresuscitation/criticalcaretendtoreceivethe highestAAS.Whilenocorrelationwasfoundbetweentotal AASandcitationcountsfromWOSandGoogleScholar, thereisastrongpositivecorrelationbetweenWOScitations andthenumberofMendeleyreaders.Additionally,weak andmoderatecorrelationswereobservedformentionson Xandblogs,respectively.Furtherresearchisneededto exploretherelationshipbetweenaltmetricsandtraditional citationmetrics,aswellastheimpactofsocialmediaon academicresearchvisibilityinEM.

ACKNOWLEDGMENTS

TheauthorswishtoacknowledgeAltmetric.comfor generouslyprovidingno-costaccesstoessentialdatathrough theAltmetricResearcherDataAccessProgram.Altmetric hadnoinvolvementinthedesignofthestudy,thedata analysis,orthewritingofthemanuscript.Additionally,they didnotparticipateinreviewingorapprovinganyversionof themanuscript.

AddressforCorrespondence:MuratÇetin,MD,Dr.BehçetUz Children'sEducationandResearchHospital,Departmentof EmergencyMedicine,Konak,35210,Izmir,Türkiye.Email: muratcetinn@gmail.com

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.PriemJ,TaraborelliD,GrothP,etal.Altmetrics:amanifesto.2010. https://zenodo.org/records/12684249.AccessedSeptember15,2024.

2.PriemJ,GrothP,TaraborelliD.Thealtmetricscollection. PLoSOne. 2012;7(11):e48753.

3.BikHMandGoldsteinMC.Anintroductiontosocialmediaforscientists. PLoSBiol. 2013;11(4):e1001535.

4.PriemJ,PiwowarHA,HemmingerBM.Altmetricsinthewild:using socialmediatoexplorescholarlyimpact. arXiv:1203.4745.

5.EysenbachG.Cantweetspredictcitations?Metricsofsocialimpact basedonTwitterandcorrelationwithtraditionalmetricsofscientiﬁc impact. JMedInternetRes. 2011;13(4):e123.

6.MaloneTandBurkeS.Academiclibrarians’ knowledgeofbibliometrics andaltmetrics. EvidBasedLibrInfPract. 2016;11(3):34–49.

7.WuDandZhangQ.Analtmetricsstudyofartiﬁcial ıntelligencein medicine.In: Proceedingsofthe2021InternationalConferenceon ComputationalScienceandComputationalIntelligence (p196-8). LasVegas,NV(2021).

8.HueckerMR,ShrefﬂerJ,PlattM,etal.Emergencymedicinehistoryand expansionintothefuture:anarrativereview. WestJEmergMed. 2022;23(3):418–23.

9.BarbicD,TubmanM,LamH,etal.Ananalysisofaltmetricsin emergencymedicine. AcadEmergMed. 2016;23(3):251–68.

10.FassoulakiA,VassiA,KardasisA,etal.Altmetricsshouldnotbeused forrankingofanaesthesiajournals. BrJAnaesth. 2018;121(2):514–6.

11.ThelwallM,HausteinS,LarivièreV,etal.Doaltmetricswork?Twitter andtenothersocialwebservices. PLoSOne. 2013;8(5):e64841.

12.DemirHAandDoganS.Correlationbetweenacademiccitationsin emergencymedicinejournalsandTwittermentions. AmJEmergMed. 2022;58:33–8.

13.Altmetric.com.Howisthealtmetricattentionscorecalculated?2024. Availableat: https://help.altmetric.com/support/solutions/articles/ 6000233311-how-is-the-altmetric-attention-score-calculated-T AccessedSeptember13,2024.

14.SchoberP,BoerC,SchwarteLA.Correlationcoefﬁcients:appropriate useand ınterpretation. AnesthAnalg. 2018;126(5):1763–8.

15.KolahiJ,KhazaeiS,IranmaneshP,etal.Meta-analysisofcorrelations betweenaltmetricsattentionscoreandcitationsinhealthsciences. BiomedResInt. 2021;2021:6680764.

16.Garcia-VillarC.Acriticalreviewonaltmetrics:canwemeasurethe socialimpactfactor? InsightsImaging. 2021;12(1):92.

17.GatesA,FeatherstoneR,ShaveK,etal.Disseminationof evidenceinpaediatricemergencymedicine:aquantitativedescriptive evaluationofa16-weeksocialmediapromotion. BMJOpen. 2018;8(6):e022298.

18.GottliebM,IbrahimAM,MartinLJ,etal.Educator’sblueprint:a how-toguideforcreatingahigh-qualityinfographic. AEMEducTrain. 2022;6(4):e10793.

19.IbrahimAM,LillemoeKD,KlingensmithME,etal.Visualabstractsto disseminateresearchonsocialmedia:aprospective,case-control crossoverstudy. AnnSurg. 2017;266(6):e46–8.

20.OskaS,LermaE,TopfJ.Apictureisworthathousandviews:atriple crossovertrialofvisualabstractstoexaminetheir ımpact onresearchdissemination. JMedInternetRes. 2020;22(12):e22327.

21.SoreideK.Numbersneededtotweet:socialmediaandimpacton surgery. EurJSurgOncol. 2019;45(2):292–5.

22.SlowTaylorM.Slow,quick,quick,slow: ﬁvealtmetricssources observedoveradecadeshowevolvingtrends,byresearchage, attentionsourcematurityandopenaccessstatus. Scientometrics. 2023;128(4):2175–200.

EffortDuringEthanolBreathTestingImpactsCorrelationwith SerumEthanolConcentration

SamuelJ.Stellpﬂug,MD*

WilliamH.Menton,PhD†

BjornC.Westgard,MD*

RyanD.Johnsen,MD*

AlexanderM.Coomes,MD*

RobertC.LeFevere,MD*

MichaelD.Zwank,MD*

SectionEditor:JeffreyR.Suchard,MD

*RegionsHospital,DepartmentofEmergencyMedicine,SaintPaul,Minnesota † VAHealthcareSystem,Minneapolis,Minnesota

Submissionhistory:SubmittedJune28,2024;RevisionreceivedSeptember2,2024;AcceptedNovember27,2024

ElectronicallypublishedFebruary6,2025

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.24998

Introduction: Thegoldstandardforquantifyingethanolintoxicationinpatientsisserumtesting. However,breathtestingisfaster,lessexpensive,andlessinvasive.Itisunknownwhetherperceived effortduringabreathethanoltestimpactstheaccuracyofthetestandthecorrelationwithserum concentration.Inthisstudyweanalyzedwhetherperceived “poor” effortduringbreathethanoltesting wouldresultinworsecorrelationthanperceived “normal” breath-testingeffortwithrespecttoserum ethanolconcentration.

Methods: Subjectswereidentiﬁedretrospectivelyovera49-monthperiodiftheyhadbothabreath ethanoltestandaserumethanoltestobtainedduringthesameEDvisitwithin60minutesofeachother,if theyhadtheireffortduringthebreathtestrecordedas “normal” or “poor” bythepersonadministeringthe test,andhadnon-zerobreathandserumethanolconcentrations.Wecompleteddescriptiveand correlationanalyses.

Results: Atotalof480patientswereenrolled,245withnormaland235withpooreffort.Thepatientswith normalbreath-testefforthadmeanbreathandserumconcentrationsof0.19gramsperdeciliter(g/dL) and0.23g/dL,respectively.Thepatientswithpoorbreath-testefforthadmeanbreathandserum concentrationsof0.19and0.29g/dL,respectively.Thecorrelationcoefﬁcientbetweenbreathandserum ethanolvalueswas0.92(95%conﬁdenceinterval(CI)0.84–0.96)forgoodeffortand0.63(95%CI 0.53–0.74)forpooreffort.

Conclusion: Theassessmentofbreathexhalationeffortismeaningfulindetermininghowwella patient’sbreathethanollevelcorrelateswiththeserumethanolconcentration.Poorbreatheffort,when comparedtonormalbreatheffort,wasassociatedwithhigherethanollevelsaswellasalargerdifference andagreatervariabilitybetweenbreathandserumvalues.Ifanaccurateethanollevelisimportantfor clinicaldecision-making,aphysicianshouldnotrelyonapoor-effortbreathalyzervalue.[WestJEmerg Med.2025;26(2)364–366.]

INTRODUCTION

Breathtestingforethanolhasbeendiscussedinmedical literaturefornearly150years.1 Ethanoltestingisoftenused inemergencydepartments(ED)andhashistoricallyincluded bloodtesting,breathtesting,orboth.Breathtestinghasbeen usedasasurrogateforthegoldstandardserumtestingand hasdistinctadvantagesoverblood:itisfaster,lessinvasive, andlessexpensive.2 Despitelongstandingstudyofthetopic

andwideacceptanceofitsuse,ithasnotbeenwellestablished whetherapoorexpiratoryeffort,asjudgedbythetester, affectstheaccuracyofthetest.

Whenadministeringabreathethanoltest,theoperatorsof thedevicewilloftencommentontheexpiratoryeffortofthe patient.Theinferenceisthataneffortdeemed “ poor ” bythe testerwillnotbeasaccurateasa “normal”-appearing expiratoryeffort.Theimpactofapparentexhalationeffort onthecorrelationbetweenbreathandserumlevelshasnot beenclearlyestablished.Clarifyingthiscouldimpactpatient careandcouldprovideutilityinforensicevaluation.Our primaryobjectiveinthisstudywastodeterminewhethera patient’sexpiratoryeffort,asperceivedbythetester,affected thebreathethanoltestresultswhencomparedtoserum. Secondaryobjectivesincludeddeterminingoverall correlationsbetweenbreathandbloodtestingwithinasingle hospitalencounter.

METHODS

ThisstudywasapprovedbytheHealthPartners institutionalreviewboard.Aretrospectiveelectronichealth record(EHR)inquirywasperformedtoincludeallpatients overa49-monthperiodwhohadbreathethanoltestingwith documentedperceivedexhalationeffort(“normal” or “ poor ”)andserumethanoltestingcompletedduringasingle EDvisitatalarge,tertiary-carehospital.Atthishospital,the individualperformingthebreathtest,typicallyanemergency medicinetechnicianorregisterednurse,choosesoneofthese twoeffortcategoriesasanelectroniccheckboxwhenentering theethanolvalueintotheEHR.Theassessmentofeffortis doneusingtheirownclinicaljudgment.Allbreathethanol testswereperformedusingtheAlco-SensorFST(AlcoPro Inc,Knoxville,TN).Allserumethanoltestsweredoneusing theARCHITECTc8000(AbbottLaboratories,Abbott Park,IL).

Datacollectedforthisstudyincludedthefollowing:time ofbreathethanoltest;thepatient’sperceivedbreathtesting effort;theresultofthebreathethanoltest;thetimeofthe blooddrawforserumethanoltesting;andtheresultofthe serumethanoltest.Subjectswereincludediftheyhadbotha bloodandbreathethanoltestdonewithina60-minutetime

interval.Subjectswereexcludedifeitherthebreathorserum concentrationwas0gramsperdeciliter(g/dL).Thiswasdone becausesomeoftheblooddrawandbreathtestshadenough timebetweentheminthesamesubjectsuchthata0g/dL valuemayhaveinaccuratelyimpactedthecorrelation calculations,asthepatientmayhavenaturallyreacheda levelof0g/dLwellbeforethesecondtestoccurred.

Statistics

Theassociationsbetweenbreathandserumethanollevels, controllingforbreatheffort,appearedhighlylinearoninitial graphicalvisualizationofthedata.Therefore,the relationshipsbetweenthesevariableswereexploredfurther usingacombinationofzero-orderPearsoncorrelationsand linearregression.Weexaminedthepropertiesofbreath ethanolconcentrations,serumethanolconcentrations,and theassociationsbetweenthem.

RESULTS

Atotalof480subjectswereincludedinthestudy.Ofthese subjects,245showednormaleffortand235were documentedaspooreffort.Additionally,237patientshada timeintervaloflessthan15minutesbetweenbreathand serumvalues,112hadatimeintervalof16–30minutes,and 131hadatimeintervalof31–60minutes.Therewere184 patientswhohadblooddrawnbeforethebreathalyzerand 288whohadblooddrawnafterthebreathalyzer;eight patientsweretestedconcurrently.Amongallpatients,the meanbreathethanolwas0.19g/dL,whilethemeanserum ethanolwas0.26g/dL.Thepatientswithnormalbreathtest efforthadmeanbreathandserumconcentrationsof 0.19g/dLand0.23g/dL,respectively.Thepatientswithpoor breathtestefforthadmeanbreathandserumconcentrations of0.19and0.29g/dL,respectively.Thecorrelation coefficientbetweenbreathandserumwas0.92(95% confidenceinterval[CI]0.84-0.96)withnormaleffortand 0.63(95%CI0.53-0.74)withpooreffort.Descriptiveresults andcorrelationanalysisbetweenthetestsarepresentedinthe Table. Aplotdisplayingindividualbreathandserumvalues, aswellaslinesofbest fitbyeffortgroup,ispresentedin the Figure

Patientethanollevels(breathandserum;gramsperdeciliter)andcorrelationcoefﬁcients.

Correlationcoefﬁcientbetweenbreathandserum[95%CI]0.75[0.7,0.82]0.92[0.84,0.96]0.63[0.53,0.74] EtOH, ethanol; CI,conﬁdenceinterval.

Table.

Figure. Plotofbreathandserumethanolvaluesandlinesofbest ﬁt for “normal”-and “poor” effortgroups.

DISCUSSION

Ourprimaryobjectiveinthisstudywastodetermine whethertheperceivedlevelofexpiratoryeffortduringa breathethanoltestimpactstheaccuracyofthebreathtest whencomparedtoaserumethanoltest.Wedocumentedthe subject’seffortasperceivedbythetesterbecauseitreﬂectsa commonassessmentintheclinicalsetting.Cliniciansare oftengiventheresultofthebreathtestalongwiththe assessor ’ssubjectivedescriptionofthebreatheffort.

Theresultsofthisstudyindicatethattheassessmentof breathexhalationeffortismeaningfulindetermininghowwell apatient’sbreathethanollevelcorrelateswiththeirserum ethanolconcentration.Whilebreathethanolvalueswere generallylowerthanserumethanolvalues(regardlessof effort),thisdifferencewasbothgreaterandmorevariable amongpatientswithpooreffort.Thisisshownbyagreater differenceinvaluesforthosepatientswithpooreffort(Table), byahigherstandarddeviationindifferencevalues,andbya lowercorrelationcoefficientinthisgroup(Table and Figure). Thisisconsistentwithprior findingsinastudybyGibbetal whoexaminedwhether “cooperativeness” withthe breathalyzerwasassociatedwithdifferencesinbreathvs serumvalues.2 Cooperationwasdefinedaswhetherapatient “understoodandfollowedthroughwiththeinstructionsto performasmooth,forcedexpirationintotheanalyzer.” While thiswasaninformativestudy,inpractice,documentationis relatedtoeffortandnottocooperation.Thus,ourstudyisa morepracticalassessmentofreal-worldexperience.

The “pooreffort” groupalsodemonstratedsubstantially higherserumalcoholconcentrationsthanthe “normaleffort” group(0.29g/dLvs0.23g/dL).Thisisperhapsunsurprising andsuggestspossiblyreducedabilitytocoordinateagood expiratoryeffortorlessmotivationtoparticipateintesting. Wedidnotextendtheanalysispasta60-minuteinterval betweenbreathandserumtestsbecauseanyconclusions

beyondthistimeframewerenotfelttobeclinicallyapplicable. Analysisofsubjectswithanarrowtimedifferencebetween breathandserumtestingisimportanttominimizeanypossible impactofongoingethanolmetabolismbetweenexecutionof thedifferenttestingmodalities.

LIMITATIONS

Assessmentofpatientexpiratoryeffortinbreathethanol testingisasubjectivemeasure.However,itisthesame subjectivemeasureassessedduringrealpatientcare.More formalmeasurementofexpiratorycapacitycouldadd perspectiveandpotentiallyaccuracyaswell.Inaddition, giventheretrospectiveobservationalnatureofourdata, breathtestingandbloodsamplesforserumtestingwereoften notperformedsimultaneously.Wediduseanarrowtime frameforanalysis,thusnegatingmuchmetabolism.A prospectivestudyobtainingbloodsamplesforserumethanol testingatthetimeofbreathethanoltestingwouldbe necessarytoeliminatethispotentialconfounder.Finally, whilethebreathalyzerusedatourhospitalisacommonly useddevice,otherdevicesmaybeusedelsewhere,andtheir measurementpropertiesmayvary.

CONCLUSION

Breathethanolconcentrationsweregenerallylowerthan serumethanolconcentrations.Poorexhalationefforton breathethanoltestingcorrelatedwithalargerdifference betweenbreathandserumethanolconcentrationsandwith greatervariabilityinthedifferencebetweenthetwo.Thiscan berelevantinclinicalandforensicsettings.

AddressforCorrespondence:SamuelJ.Stellpﬂug,MD,Regions Hospital,DepartmentofEmergencyMedicine,640JacksonSt.,Saint Paul,MN55101.Email: samuel.j.stellpﬂug@healthpartners.com

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.AnstieFE.Finalexperimentsontheeliminationofalcoholfromthebody. Practitioner. 1874;13:15–28.

2.GibbKA,YeeAS,JohnstonCC,etal.Accuracyandusefulnessofa breathalcoholanalyzer. AnnEmergMed. 1984;13(7):516–20.

ORIGINAL RESEARCH

BloodPressureVariabilityandOutcomePredictorsforTraumatic BrainInjuryPatientswithDiffuseAxonalInjury:

ARetrospectiveCohortStudy

ChristineE.Ren,MD*†

AnastasiaTernovskaia,BS‡

FatimaMikdashi,BS‡

HassanSyed,MD§

IshaVashee,BS‡

VainaviGambhir‡

NatalieChao,BA§

JessicaV.Downing,MD∥*

DavidDreizin,MD¶

QuincyK.Tran,MD,PhD‡∥#

*R.AdamsCowleyShockTraumaCenter,UniversityofMarylandMedicalCenter, DepartmentofEmergencyMedicine-SurgicalCriticalCare,Baltimore,Maryland † OregonHealthandScienceUniversity,DepartmentofEmergencyMedicineand CriticalCareMedicine,Portland,Oregon

‡ UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, ResearchAssociateProgram,Baltimore,Maryland

§ UniversityofMarylandSchoolofMedicine,Baltimore,Maryland

∥ UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, Baltimore,Maryland

¶ UniversityofMarylandSchoolofMedicine,DepartmentofDiagnosticRadiologyand NuclearImaging,DivisionofEmergencyandTraumaImaging,Baltimore,Maryland

# R.AdamsCowleyShockTraumaCenter,UniversityofMarylandMedicalCenter, PrograminTrauma,Baltimore,Maryland

SectionEditor: PierreBorczuk,MD

Submissionhistory:SubmittedApril20,2024;RevisionreceivedOctober29,2024;AcceptedOctober30,2024

ElectronicallypublishedDecember31,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20346

Background: Diffuseaxonalinjury(DAI),afeatureseeninseveretraumaticbraininjury(TBI),is associatedwithsubstantialmorbidityandmortality.Althoughbloodpressurevariability(BPV)hasbeen showntoimpactTBIoutcomesoverall,itsrelevanceinDAIcasesremainsuncertain.Weinvestigated whether24-hourpost-injuryBPVandotherclinicalfactorswerelinkedtopatientoutcomes.

Methods: WeconductedaretrospectiveanalysisofLevelItraumacenter-admittedTBIpatientswith radiographicDAIdiagnosis(computedtomography/magneticresonanceimaging).Hospitaldisposition (home,nursingfacility,hospice/death)andGlasgowComaScale(GCS)onhospitalday5(HD5GCS) wereoutcomesofinterest.Weassessedassociationswithclinicalfactorsusingordinallogisticregression.

Results: Among153patients(meanage49 ± 20years,74%male),medianadmissionGCSwas5.0 (3.0-12.5),HD5GCSwas8.0(6.0-11),andmedianhospitalstaywas25(15.5-34.5)days.TheBPV, measuredassuccessivevariationinsystolicbloodpressure(SBPSV)andstandarddeviationinsystolic bloodpressure(SBPSD),wasnotsignificantlyassociatedwithhospitaldisposition.SBPSV andSBPSD werealsonotassociatedwithoursecondaryoutcomeofHD5GCS.Initialinternationalnormalizedratio (INR)(Coefficient-3.67,oddsratio[OR]0.03,95%confidenceinterval[CI]0.00-0.70),cerebralcontusion (Coeff-2.39,OR0.09,95%CI0.01-0.75),andHD5GCS(Coeff0.59,OR1.80,95%CI1.30-2.49)were associatedwithincreasedoddsofdischargetohospiceordeath.Administrationofbloodproducts(Coeff 1.06,OR2.89,95%CI1.10-7.60),vasopressors(Coeff1.40,OR4.05,95%CI1.37-11.96),and hyperosmolartherapy(Coeff1.23,OR3.41,95%CI1.36-8.54),andconcurrentintraventricular hemorrhage(Coeff0.99,OR2.70,95%CI0.86-6.49)werelinkedtopoorerHD5GCS.

Conclusion: Bloodpressurevariabilitywasnotcorrelatedwithoutcomesinpatientswithdiffuseaxonal injury.LowGlasgowComaScoreonhospitalday5,highinitialINR,andconcomitantcerebralcontusion wereassociatedwithpooreroutcomes.[WestJEmergMed.2025;26(2)367–377.]

BACKGROUND

Diffuseaxonalinjury(DAI),alsoreferredtoastraumatic axonalinjury,isanincreasinglyrecognizedcomponentof traumaticbraininjury(TBI),nowestimatedtooccurinover 40%ofpatientshospitalizedwithotherformsofTBI.1,2 DAI iscausedbyrotationalacceleration-decelerationinertial forcesthatshearthewhitemattertractsinthebrain.This mechanismdisruptsaxonaltransport,leadingtoaxonal swelling,secondaryaxonaldisconnection,andsubsequent degeneration.3 Thisinjuryismostoftenassociatedwith high-velocityevents,suchasmotorvehiclecollisions orlongfallsfromheight.Clinicalmanifestationscanvary widely,rangingfromminimalsigniﬁcanceto profoundneurologicalimpairment,dependingon injuryseverity.

SeverecasesofDAIoftenleadtopersistentcomasor substantialdeficitsinneurologicalrecoveryandare associatedwithsignificantmortality.4 Lesionsassociated withDAImaynotinitiallybeapparentordetectableon computedtomography(CT);patientswithsuspectedDAI oftenduetopersistenceofpoormentalstatusintheabsence ofsignificantedemaonCTorfollowingneurosurgical evacuationofextra-axialhematoma areoftenevaluated withmagneticresonanceimaging(MRI)fordiagnosis.4,5 TheseverityofDAIappreciatedonMRIischaracterized accordingtothedegreeandlocationofidentifiedwhite matterlesions;Grade1isprimarilyassociatedwithlesionsin thecortex,Grade2inthecorpuscallosum,andGrade3in thebrainstem.6

Giventhevariabilityinclinicalmanifestationsand potentiallyhighratesofcognitivemorbidityandmortality associatedwithDAI,numerousstudieshavesoughtto identifyfeaturesassociatedwithimprovedorpoorpatient outcomes,suchasradiographic findings,initialGlasgow ComaScale(GCS)scores,andhypertension(definedas systolicbloodpressure[SBP] ≥160millimetersofmercury (mmHg),amongothers.4,7–9 Theroleofbloodpressure variability(BPV)hasnotyetbeeninvestigatedinpatients withDAI;BPVdescribesoscillationsinbloodpressure betweenconsecutivemeasurementsorwithinadefined timeframe.Variationsinbloodpressurearecommonafter TBI,possiblyduetoimpairedcerebrovascular autoregulationordecreased “baroreflexsensitivity” asa resultoftheinjury,andpriorresearchsuggestsalinkto pooroutcomes.10

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Bloodpressurevariability(BPV)hasbeen associatedwithpooreroutcomesinpatients withtraumaticbraininjury(TBI).

Whatwastheresearchquestion?

IsBPVassociatedwithworsedisposition outcomesinTBIpatientswithdiffuseaxonal injury(DAI)?

Whatwasthemajor ﬁndingofthestudy?

ForTBIpatientswithDAI,blood pressurevariabilitydidnotimpact dischargedestination.

Howdoesthisimprovepopulationhealth?

WhileBPVwasnotassociatedwithpoorer outcomesinourstudy,furtherstudiesare neededtodeterminewhetherother interventionscanimpactoutcomesin thesepatients.

Bloodpressurevariabilityhasbeenassociatedwith deviationsfromoptimalcerebralperfusionpressures (CPPopt),whichareinturnlinkedtounfavorableoutcomes inTBIpatients.11 Wehavepreviouslyinvestigatedthe connectionbetweenBPVandoutcomesinpatientswith traumaticintraparenchymalhemorrhageandfoundan associationwithlowerratesofdischargetohome,indicating worsefunctionaloutcomesupondischarge.12 Inadditionto TBI,BPVhasbeenpreviouslyassociatedwithadverse outcomesinischemiccerebrovascularaccidentsand spontaneousintracranialhemorrhage(ICH).13–17

InthisstudyweinvestigatedtheimpactofBPVinthe initial24hoursfollowinghospitalarrivalonoutcomesin patientswithDAIandevaluatedclinicalfeaturesthatmay correlatewithpatientoutcomes,withthegoalofimproving theaccuracyofprognosticassessmentsandproviding importantinformationtoguidefuturestrategiesinmanaging post-injuryTBIandpatientsdiagnosedwithorsuspectedof havingDAI.

METHODS

StudySetting

ThisstudywasperformedatR.AdamsCowleyShock TraumaCenter,aregional,quaternarytraumacenterand neurotraumaspecialtycenterthatadmitstraumapatients directlyfromthe fieldandactsasareferralcenterforother hospitalswithinthestate.Uponarrivalatourinstitution, patientsare firstevaluatedbythetraumateamandundergo appropriatescreeningimagingstudies,includingCT,as clinicallyindicated.PatientswithidentifiedICHorcontusion areevaluatedemergentlybytheneurosurgeryteam.Patients withCTorclinicalcharacteristicssuggestiveofDAI subsequentlyundergoabrainMRIforconfirmationand furthercharacterizationofdiseaseseveritywhentheyare clinicallystableenoughtotolerateMRI.Previousstudies haveidentifiedthatradiographicpresenceofDAIonMRIis

itselfindependentlyassociatedwithpooroutcomes7,18;thus, wechosepatientswhoalsohadanMRIperformedduring theiracutehospitalizationwithin30daysfromtheir admissionevenifDAIwassuspectedontheirinitialCT images.Thisapproachallowedustobetterevaluatespeciﬁc radiographicfeaturessuchashemorrhagicvolumeofburden andlesionlocation.

StudyDesign,PatientSelection,andDataCollection

Weconductedaretrospectivecohortstudyofalladult traumapatients(≥18yearsold)admittedtoourhospital betweenJanuary1,2016–December31,2019withthe diagnosisofTBI.Patientswithradiographicevidenceof DAIwhounderwentbothCTandMRIwithin30daysof admissionwereeligible.Weexcludedpatientswhodidnot havecompleteclinicalinformationorimagingstudies.

PatientswitharadiographicdiagnosisofDAIwereidentiﬁed fromourinstitution’sRadiologyInformationSystem,a databaseusedforthemanagementofradiographicimages; furtherdatawascollectedfromthepatient’selectronichealth record(EHR).

Dataabstractionfollowedpreviouslypublished methodologicalguidelinesonretrospectivechartreview.19 Priortodatacollection,investigatorsevaluatedsetsof five patientchartsanddirectlycomparedtheir findingstothoseof theseniorinvestigatorandprincipalinvestigator(Q.T.)until accuracyreached90%.Datacollectorswerenotblindedto thehypothesis.Radiographicinformationwasinterpreted andprovidedbyanattendingradiologist.AnExcel spreadsheet(MicrosoftCorporation,Redmond,WA)with standardizedcategorieswasusedtorecordclinicaldatafrom de-identifiedpatients.

Demographicsandclinicaldataofinterest,selecteda prioriaccordingtoapreviousstudy,18 includedthe following:patient’sage;sex;pastmedicalhistory;serum lactatelevel;internationalnormalizedratio(INR); mechanismofinjury;initialGCSatadmissionandhighest recordedGCSathospitalday5(HD5GCS);administration ofbloodproducts(packedredbloodcells,freshfrozen plasma,platelets,cryoprecipitate);vasopressors (norepinephrine,vasopressin,orepinephrinearethemost commonlyusedvasopressorsforthispatientpopulationat ourinstitution);hyperosmolartherapy(hypertonicsalineor mannitol);intravenous(IV)antihypertensives,antiepileptic medications,locationandvolumeofDAIburden; concurrentpresentationwithseizures,intracranial contusion,intracerebralhemorrhage,intraventricular hemorrhage(IVH),orsubarachnoidhemorrhage(SAH); andallrecordedSBPmeasurementswithinthe ﬁrst24hours ofadmission.Forpatientswholeftthehospitalorexpired beforehospitalday5,theirHD5GCSlevelswereinputas3 (forexpiredpatients)orthelastrecordedGCSpriorto hospitaldischarge.

BloodPressureVariability

Allbloodpressuremeasurementswerecollectedasthey wererecordedinpatients’ chartsbynursingstaff.Our institution’sclinicalstandarddictatesthatpatientsadmitted tointensivecareunitshaveatleastonesetofvitalsigns documentedperhour.Wecollectedallbloodpressure measurements,asdocumentedbyournursingstaff,evenif theyexceededmorethanonesetofvitalsignsperhour. Methodologyofobtainingbloodpressure,eitherbymanual bloodpressurecuff,automaticbloodpressurecuff,orby arterialbloodpressuremonitoring(radialorfemoralaccess) wasdecidedbythebedsideclinicians.Atourinstitution, invasivemonitoringwitharterialbloodpressuremonitoring isstronglyencouragedforallpatientswhoreceive antihypertensivesorvasopressorinfusions.Forpatientswho haddocumentationofbotharterialbloodpressureandcuff pressure,wecollectedthearterialbloodpressurevalues.

Bloodpressurevariabilityquantifiesbloodpressure fluctuationsoveraspecifiedtimeinterval.TheBPVcanbe studiedwithrespecttoSBP,diastolicbloodpressure,and meanarterialpressure(MAP).Here,weexaminedvariability inSBP,asspecificSBPgoalsaretraditionallyusedfor managementofpatientswithICHorTBI.20 Weevaluated threedifferentmodalitiesofmeasuringandreportingsystolic BPV:successivevariationofsystolicbloodpressure(SBPSV); standarddeviationinsystolicbloodpressure(SBPSD);and coefficientofvariationinsystolicbloodpressure(SBPCV).21 WealsocollectedSBPmax andSBPmin fromthe first24hours ofadmission.TheSBPSV isthesquarerootoftheaveraged squareddifferencebetweenanytwosuccessiveSBP measurementsanddemonstratestherateofchangebetween consecutivemeasurements.TheSBPSD representstheextent ofvariationordispersionofindividualSBPmeasurements aroundtheaverageSBPwithinagiventimeframe,indicating thelevelof fluctuationorstabilityinbloodpressurevalues. TheSBPCV iscalculatedastheratioofthestandarddeviation ofSBPtothemeanSBPandoffersastandardizedmeasureof SBPvariabilityrelativetotheaverageSBP.

ImagingAnalysis

ThepresenceofDAIwasestablishedbasedonMRI findings,whichwereinterpretedanddocumentedbyan attendingradiologist.Theimaginginformationprovided includedthelocationofDAIwithinsevenregions:thecorpus callosum;basalganglia;thalami;parahippocampalregion; cerebellum;brainstem;andgray-whitejunction.Thevolume ofDAIhemorrhageburdennotedonsusceptibilityweighted imageswasmeasuredineachlocationusingthe3Dslicer version4.102(https://www.slicer.org)spherebrushpaint toolandquantificationmodule.Additionally,presenceor absenceofconcomitantinjuries,specificallycontusion,SAH, IVH,andintraparenchymalhemorrhage,weredocumented usingradiologyreports.

Outcomes

Ourprimaryoutcomewashospitaldischargedisposition, usedasasurrogatemarkerforneurocognitivedisabilityat dischargeamongpatientswithTBI.Dischargedestinations includedhome,rehabilitationfacilities,andhospice/death. Beingdischargedhomedirectlyfromthehospitalsignifiesa favorableoutcomewithahigherlikelihoodoffunctional recoveryandpreservationofindependentliving.Onthe otherhand,beingdischargedtoarehabilitationfacility suggeststheneedforongoingsupportandtherapydue tosignificantneurologicdeficits.22 Hospice/death representsthepoorestoutcome.Thesecondaryoutcomeof HD5GCShasbeenshowntohaveprognosticvaluein predictinglong-termoutcomesandisconsideredan importantindicatorofneurologicalrecoveryinpatients withspontaneousICH.23,24

StatisticalAnalysis

Weuseddescriptivestatisticstopresentcontinuousdata asmean(standarddeviation)ormedian(interquartilerange), dependingonthedistributionofthedataafterthedata’ s histogramswereinspected.The t -testorMann-WhitneyU testwasemployedforcontinuousdatacomparisons,while categoricaldatacomparisonswereconductedusingthechisquaretestorFisherexacttest,asappropriate.Weused ordinallogisticregressionsfortheoutcomesofbothhospital dispositionandHD5GCS.Hospitaldispositionwasranked inthreeordersfromlowesttohighestseverity:0(home); 1(rehabilitation);and2(hospice/death).Patients’ HD5GCS scoreswererankedinorderfrom0(GCS3-8),1(GCS9-12), 2(GCS13-14),or3(GCS15).Fortheordinallogistic regressions,thecoefficientsrepresenttheassociationofthe independentvariablesandtheoutcomes.Apositive coefficientindicatedincreasedoddsofassociationwiththe lowestnumberrank(rank0),whileanegativecoefficientwas associatedwiththehighestrankoftheoutcomes.

Weperformedalldescriptiveanalysesandordinal regressionswithMinitabversion19(MinitabLLC,State College,PA).Allanalyseswith2-tail P =< 0.05were consideredstatisticallysigniﬁcant.

RESULTS

PatientCharacteristics

Fromtheinitial174patientsidentifiedintheEHR fitting ourinclusioncriteria,weincluded153inthe finalanalysis. Theremaining23patientswereexcludedduetoinadequate recordingofbloodpressure,laboratory,orotherclinicaldata (Figure).Themeanageofincludedpatientswas49years (SD20),and113(74%)weremale(Table1).Motorvehicle collisionswerethemostcommonmechanismofinjury, accountingfor66%ofthepatients’ causeofinjuries.Median GCSatadmissionwas5(3-13).Amongthestudypopulation, 141patients(92%)requiredmechanicalventilationduring theirstay,and94patients(61%)underwentatracheostomy

Figure. Flowdiagramforpatientselection.

TBI,traumaticbraininjury; CT,computedtomography; MRI, magneticresonanceimaging; PACS,picturearchivingand communicationsystem.

procedure.ThemostcommonlocationofDAIburdenwas thecorpuscallosum(58%)followedbytheparahippocampus (35%),basalganglia(27%)andthalami(25%)(Table1). Withinthe ﬁrst24hours,allpatientshadreceivedsomeform ofopioidmedication,98%ofthepatientsreceivedIV ﬂuids (IVF),95%receivedasedativemedication,87%receivedan anti-epilepticmedication,and82%requiredvasopressor support(Table2).

PrimaryOutcome:HospitalDisposition

Ouranalysisidentifiednosignificantassociationbetween twoseparatemeasurementsofBPV– SBPSV (Coefficient0.02,OR0.98,95%CI0.87-1.10, P = 0.74)andSBPSD (Coeff 0.03,OR0.97,95%CI0.81-1.16, P = 0.74)–andhospital dispositionamongpatientsadmittedforTBIanddiagnosed withDAI.Wefoundthat11.8%ofpatientswithDAIeither diedinthehospitalorweredischargedtohospicecare.This groupofpatientshadahighermeanageof63(19)andlower GCSscoresat24hoursand5days(5[4-6.3]forboth)than survivors(Table1).Allthesepatientsrequiredintubation,all werediagnosedwithaconcurrentbraincontusion,and94% hadaconcurrentIVH.Thecorpuscallosumwasidentifiedas thepredominantlocationofDAIamongpatientswhodied, andahighervolumeofhematomawasobservedinthe corpuscallosumofthisgroupwhencomparedtosurvivors (Table1).Nosignificantdifferenceswerefoundintermsof sex,pastmedicalhistoryofhypertensionanddiabetes,or mechanismofinjury.

Weusedordinallogisticregressionanalysistoinvestigate therelationshipbetweendemographicandclinicalfactors andthelikelihoodofasigniﬁcantdiscrepancyintheprimary

Table1. Demographicsandclinicalfeaturesofpatientswithdiffuseaxonalinjuriesfortheoutcomeofmortality.

Sex, N(%)

Pastmedicalhistory,N(%)

Clinicalvariables

Volumeofburdenbylocationofinjury,(mm3)median[IQR]

Continued onnextpage

Table1. Continued.

Boldedvaluesindicatestatisticalsigniﬁcance.

CI, conﬁdenceinterval; IQR,interquartilerange; GCS,GlasgowComaScore; mg,milligram; dL,deciliter; INR,internationalnormalizedratio; EVD,externalventriculardrain; IPH,intraparenchymalhemorrhage; IVH,intraventricularhemorrhage; SAH,subarachnoidhemorrhage; ARDS,acuterespiratorydistresssyndrome; MVC,motorvehiclecollision; mm,millimeter.

Table2. Clinicalfeatureswithin24hoursforpatientswithdiffuseaxonalinjuries.

Bloodpressurevariability

Hospitaldisposition,N(%)

DAI, diffuseaxonalinjury; IVF,intravenous ﬂuid; PRBC,packedredbloodcells; FFP,freshfrozenplasma; SBP,systolicbloodpressure; max, maximum; min,minimum; SBPSV,systolicbloodpressuresuccessivevariation; SBPSD,systolicbloodpressurestandarddeviation; SBPCV, systolicbloodpressurecoefﬁcientofvariation.

Table3. Resultsfromordinallogisticregressionassessingassociationbetweenpatients’ demographicandclinicalfactorsandpatients’ disposition,whereorderofhospitaldispositionwasrankedfrom0 = home,1 = acuterehab,to2 = hospice/death.Allindependentvariables reportedinthistablewereaddedinthemodel.

Pastmedicalhistory

Bolded P-values indicatestatisticalsigniﬁcance.

OR,oddsratio; CI,conﬁdenceinterval; GCS,GlasgowComaScore; INR,internationalnormalizedratio; AED,antiepilepticdrugs; IPH,intraparenchymalhemorrhage; IVH,intraventricularhemorrhage; SAH,subarachnoidhemorrhage.

Table4. Resultsfromordinallogisticregressionassessingassociationbetweenbloodpressurevariabilityandpatients’ disposition,where orderofhospitaldispositionwasrankedfrom0 = home,1 = acuterehab,to2 = hospice/death.

OR, oddsratio; CI,conﬁdenceinterval; SBP,systolicbloodpressure; SBPSV,systolicbloodpressuresuccessivevariation; SBPSD,systolic bloodpressurestandarddeviation; SBPCV,systolicbloodpressurecoefﬁcientofvariation.

outcomeofdisposition(Table3).TheSBPvariation measurementsdidnotdemonstrateanassociationwiththe dispositionoutcome(Table4).Otherclinicalfactorssuchas age,contusions,GCSscores,basalgangliainvolvement,and thepresenceofSAHwerefoundtobeassociatedwith dischargedestination.

Amongthedemographicfactors,agedemonstrateda marginalassociationwiththeoutcome(OR0.97,95%CI 0.93-1.00, P = 0.05,Coeff-0.03),suggestingthatyounger patientsmaybemorelikelytoachievefavorableoutcomesin termsofdisposition.Thepresenceofanycerebralcontusion (OR0.09,95%CI0.01-0.75, P = 0.03,Coeff-2.39)and higherinitialINR(OR0.03,95%CI0.00-0.70, P = 0.03, Coeff-3.67)correlatedwithpoordispositionoutcomes. Thesenegativecoefﬁcientsindicatethatifthereis contusionpresentorthevalueoftheinitialINR increases,theassociationwithhigheroutcomenumbers strengthens;inthiscasethehighestoutcomenumber ishospice/death.

Additionally,weidentifiedGCSat fivedaysasa significantfactoraffectingtheoutcomesofdisposition(OR 95%CI1.30-2.49, P =< 0.001,Coeff0.59).HigherGCS scoresat fivedayswerestronglyassociatedwithanincreased probabilityofachievingmorefavorableoutcomes,suchas dischargetohomeorrehabilitation.Regardingthelocation ofburden,patientswithinvolvementofthebasalgangliahad poorerprognosis(OR5.02,95%CI1.02-24.62, P = 0.05, Coeff1.61).ThepresenceofSAHwasunexpectedly identifiedwithbetterdispositionoutcomes(OR7.26,95%CI 1.14-46.42, P = 0.04,Coeff1.98).

SecondaryOutcome:GCSatHospitalDay5

TheSBPSV (Coeff0.02,OR1.02,95%CI0.95-1.1, P = 0.51)andSBPSD (Coeff0.02,OR1.02,95%CI0.91-1.13, P = 0.75)werenotassociatedwithoursecondaryoutcomeof HD5GCS(Table5).Receivinganybloodproducts(OR2.89, 95%CI1.10-7.60, P = 0.03,Coeff1.06),aswellastreatment withvasopressors(OR4.05,95%CI1.37-11.96, P = 0.01, Coeff1.40),hyperosmolartherapy(OR3.41,95%CI1.368.54, P = 0.01,Coeff1.23),andthepresenceofconcurrent IVH(OR2.70,95%CI0.86-6.49, P = 0.03,Coeff0.99)were allassociatedwithanincreasedlikelihoodofalower

HD5GCS(Table6).Ontheotherhand,theuseof antiepilepticdrugs(OR0.27,95%CI0.07-0.99, P = 0.05, Coeff-1.31)wasassociatedwithanincreasedlikelihood ofahigherHD5GCS.

DISCUSSION

Inthisstudyweinvestigatedtheimpactof24-hoursystolic BPVonoutcomesinpatientsdiagnosedwithDAIand soughttoidentifyrelevantclinicalfeaturesthatmaycorrelate withpatientoutcomestoimproveprognosticassessments. Wedidnot findasignificantassociationbetweenBPVand outcomesinpatientswithDAI.Thisstandsincontrastto priorstudies,suchasthatbySvedungWetterviketal,who linkedBPVtodeviationsfromoptimalCPPoptand unfavorableoutcomesinpatientswithTBI.25 Ithasbeen proposedthatthenegativeimpactofBPVonpatient outcomesmaybeattributedtothedevelopmentof compromisedcerebralblood flowregulationinTBIandthe potentialforsecondaryinjuriessuchascerebral hypoperfusionorhyperemia;however,theexactpathways andunderlyingprocessesarenotfullyunderstood.26,27 There arealsoseveralnuances,suchasthedurationandfrequency ofBPVmonitoring,thetimingofBPVinrelationtotheonset ofinjury,andthesensitivityofdifferentBPVparameters, suchasdiastolicbloodpressureorMAPvariability,that requireadditionalinvestigationandmayalsoplayarolein predictingoutcomes.28,29

Itisalsounknownwhatrolebloodpressuremanagement mightplayinmitigatingtheimpactsofBPV.Itisstandard practiceatourinstitutiontomanagehypertension(deﬁnedat thetimeofthisstudyasSBP >160mmHgforpatientswith TBI)andhypotension(MAP <65mmHg)inpatientswith TBIusingtitratableinfusionsofantihypertensivesand vasopressors.Strictmanagementofbloodpressuremayhave dampenedBPVandlimitedourabilitytodetectaneffecton patientoutcomes.Lastly,BPVmayhavenoimpacton improvingthedamagecausedbyaxonalshearinginDAI,or inpreventingsecondaryaxotomy.Additionalstudiesare neededtoclarifytheinterplaybetweenBPV,cerebral hemodynamics,andDAIpathology,aswellastodetermine themostrelevantandsensitiveBPVparametersfor predictingoutcomes.

Table5. Resultsfromordinallogisticregressionassessingassociationbetweenbloodpressurevariabilityandpatients’ hospitalday ﬁve GlasgowComaScore(GCS),whichwasrankedinorderfrom0(GCS3-8),1(GCS9-12),2(GCS13-14),3(GCS15).

GCS, GlasgowComaScore; OR,oddsratio; CI,conﬁdenceinterval; SBP,systolicbloodpressure; SBPSV,systolicbloodpressure successivevariation; SBPSD,systolicbloodpressurestandarddeviation; SBPCV,systolicbloodpressurecoefﬁcientofvariation.

Table6. Resultsfromordinallogisticregressionassessingassociationbetweenpatients’ demographicandclinicalfactorsandpatients’ hospitalday ﬁveGlasgowComaScore(GCS),whichwasrankedinorderfrom0(GCS3-8),1(GCS9-12),2(GCS13-14),3(GCS15).All independentvariablesreportedinthistablewereaddedinthemodel.

Pastmedicalhistory

Bolded P-values indicatestatisticalsigniﬁcance. GCS,GlasgowComaScore; OR,oddsratio; CI,conﬁdenceinterval;INR,internationalnormalizedratio; AED,antiepilepticdrugs; IPH,intraparenchymalhemorrhage; IVH,intraventricularhemorrhage; SAH,subarachnoidhemorrhage.

Ourstudyrevealedseveralclinicalfactorscorrelatingwith patientoutcomes,specificallyincreasedinitialINR, concurrentcerebralcontusion,andlowGCSathospital day5.OuridentificationofinitialINRasapoorprognostic factorwithrespecttohospitaldispositioncontributestothe growingbodyofevidenceontheassociationbetween coagulopathyandpoorclinicaloutcomesinpatientswith TBI,specificallythosewithDAI.30,31 Thedisturbancein coagulationstatusatadmissionmayexacerbatebleedingand contributetoapoorerprognosis.Coagulopathyinducedby TBIfollowsadistinctpathogenicpathway,separatefrom coagulopathyinducedbyextracranialtraumaand hemorrhagicshock.Itcaninvolvedisruptionsinthe

blood-brainbarrier,whichallowleakageof ﬂuidandrelease procoagulantsubstances.Thesesubstancesmayalso accelerateandenhance ﬁbrinolysis.Earlymonitoringand managementofcoagulationabnormalitieshold thepotentialtoimprovepatientsurvivalandreducerates ofmortality.30

Concurrentcerebralcontusions,whichcontributeto secondarybraininjury,andlowGCSscoresatday5of hospitalization,whilenotalwaysintervenable,playcrucial rolesinidentifyingpatientsathigherriskofpoorneurologic outcomes.Althoughour ﬁndingsshowthatconcurrentIVH inpatientswithDAIwasnotassociatedwithincreased mortality,itwasassociatedwithlowerHD5GCS,whichisa

predictorofpooroutcomes.Theseresultsalignwithprior researchthatsuggeststhatthepresenceofIVHisassociated withsevereDAI.32

Thisstudyalsohighlightedthatpatientswhoreceived bloodproducts,vasopressors,orhyperosmolartherapyin the first24hoursofadmissionhadahigherlikelihoodofa lowGCSscoreathospitalday5.Thisfollowsclinical reasoninginsuggestingthatthesetherapiesandinterventions aremorecommonamongpatientswithmoresevere impairmentinneurologicalfunctionwhoareathigherrisk forpooreroutcomes,althoughbasedonour findingswe cannotconcludewhetherthesetherapiesthemselvesmaybea driverofpooroutcomes.ThepresenceofIVHwasalso associatedwithahigherlikelihoodofalowerGCSscore, furtheremphasizingtheimpactofconcurrentIVHon neurologicalimpairment.Incontrast,theuseofantiepileptic drugs(AED)wasassociatedwithahigherlikelihoodof achievingahigherGCSscoreonhospitalday5,suggestinga potentialbeneficialeffectofAEDsinpreservingneurological function.Withinthiscontext,itisinterestingtonotethat therewasnosignificantassociationbetweenseizureduring admissionandHD5GCS.Furtherstudiesareneededto establishaconclusiveassociationbetweenAEDuseand improvedGCSscoresinDAIpatients,andtoinvestigate whetherthisassociationvariesacrossdifferentAEDs.(Our institutiontypicallyusesaprophylacticregimenof levetiracetam1.5grams[g]followedby1gBIDforseven days.)ThepotentialneuroprotectiveeffectsofAEDs warrantadditionalinvestigation.

LIMITATIONS

Theretrospectivedesignofourstudyandtherelianceon EHRfordatacollectionintroducedinherentbiasesand constraintstoaccuracyofdatacollectionthatwewere unabletoaudit,suchasthepossibilityofmanualinputerrors orinaccuratetimemeasurements.Itisimportantto acknowledgethatthecollectionofbloodpressurevaluesin ourstudylackedstandardization.Variationsinthetypeof equipmentused,whetherinvasiveornon-invasive readingswereemployed,andthetimingofdatacollection couldhaveintroducedvariabilityintothemeasured BPvalues.

AspatientswithDAIareassociatedwithsevereTBI,our populationwasalsolikelytohavebeenmorecriticallyill. Thisisalsoevidencedbythepercentageofourstudy populationrequiringmechanicalventilation(92%)and eventualtracheostomy(61%).Thismayhaveintroducedan indicationbias,inwhichtherewasclosermonitoringand tightercontrolofbloodpressureparameters.Another limitationisthatouranalysiswasconductedatasingle center,whichisaregional,quaternarytraumaand neurotraumaspecialtycenter.Thissettingpotentiallylimits thegeneralizabilityofour ﬁndingstopatientswithDAI presentinginotherhealthcaresettings.Variationsinpatient

characteristics,treatmentprotocols,andaccesstoresources acrossdifferentcentersmayin ﬂuencetheobserved associations.Additionally,therelativelysmallsamplesizeof ourstudymayhavelimitedthestatisticalpowertodetect smallerassociationsbetweenBPVandDAIoutcomes.

CONCLUSION

Patientswithradiographicallydiagnoseddiffuseaxonal injuriesfacehighratesofmorbidityandmortality;only8% ofpatientswithinourstudypopulationweredischarged homedirectlyfromthehospital.Bloodpressurevariability wasnotidentiﬁedasapredictorofdischargedisposition.We identiﬁedthatGlasgowComaScoreathospitalday5,initial INR,andconcurrentcerebralcontusionaspotentialdrivers ofpooroutcomes.Itisunclearfromourstudywhether interventionsaimedatthesevariables(eg,correctingan elevatedINR)wouldhaveaffectedpatients’ outcomes,or whethertightcontrolofpatients’ bloodpressureswith titratableinfusions(bothantihypertensivesand vasopressors)mayhavemaskedtheimpactofBPV onoutcomes.

AddressforCorrespondence:ChristineE.Ren,MD,OregonHealth andScienceUniversity,DepartmentofEmergencyMedicineand CriticalCareMedicine,3181SWSamJacksonParkRd.,Portland, OR97239.Email: rench@ohsu.edu

ConflictsofInterest: Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

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