Volume 25 Issue 4 by Western Journal of Emergency Medicine

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

Indexed in MEDLINE

444 Attitudes, Beliefs, Barriers, and Facilitators of Emergency Department Nurses Toward Patients with Opioid Use Disorder and Naloxone Distribution

Collin Michels, Thomas Schneider, Kaitlin Tetreault, Jenna Meier Payne, Kayla Zubke, Elizabeth Salisbury-Afshar

449 Pragmatic Emergency Department Intervention Reducing Default Quantity of Opioid Tablets Prescribed

Drake Gotham Johnson, Alice Y. Lu, Georgia A. Kirn, Kai Trepka, Yesenia Ayana Day, Stephen C. Yang, Juan Carlos C. Montoy, Marianne A. Juarez

457 Accessibility of Naloxone in Pharmacies Registered Under the Illinois Standing Order

P. Quincy Moore, Kaitlin Ellis, Patricia Simmer, Mweya Waetjen, Ellen Almirol, Elizabeth Salisbury-Afshar, Mai T. Pho

465 Improving Healthcare Professionals’ Access to Addiction Medicine Education Through VHA Addiction Scholars Program

Zahir Basrai, Manuel Celedon, Nathalie Dieujuste, Julianne Himstreet, Jonathan Hoffman, Cassidy Pfaff, Jonie Hsiao, Robert Malstrom, Jason Smith, Michael Radeos, Terri Jorgenson, Melissa Christopher, Comilla Sasson

470 Initiation of Buprenorphine in the Emergency Department: A Survey of Emergency Clinicians

Ariana Barkley, Laura Lander, Brian Dilcher, Meghan Tuscano

477 A Novel Use of the “3-Day Rule”: Post-discharge Methadone Dosing in the Emergency Department

Jenna K. Nikolaides, Tran H. Tran, Elisabeth Ramsey, Sophia Salib, Henry Swoboda

483 Variability in Practice of Buprenorphine Treatment by Emergency Department Operational Characteristics

Grant Comstock, Natalia Truszczynski, Sean S. Michael, Jason Hoppe

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed

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

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

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

Cardiac Care

Fred A. Severyn, MD

University of Colorado School of Medicine

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

Nicholas Pettit, DO, PhD

Indiana 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

Gabriel Wardi, MD University of California, San Diego

Joseph Shiber, MD University of Florida-College of Medicine

Matt Prekker MD, MPH Hennepin County Medical Center

David Page, MD University of Alabama

Erik Melnychuk, MD Geisinger Health

Quincy Tran, MD, PhD University of Maryland

Disaster Medicine

John Broach, MD, MPH, MBA, FACEP University of Massachusetts Medical School

UMass Memorial Medical Center

Christopher Kang, MD Madigan Army Medical Center

Education

Danya Khoujah, MBBS University of Maryland School of Medicine

University of Colorado

Mark I. Langdorf, MD, MHPE, Editor-in-Chief University of California, Irvine School of MedicineIrvine, California

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

Rick A. McPheeters, DO, Associate Editor

Gentry Wilkerson, MD, Associate Editor University of Maryland

Michael Epter, DO

Maricopa Medical Center

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

Cameron Gettel, MD Yale School of Medicine

Stephen Meldon, MD Cleveland Clinic

Luna Ragsdale, MD, MPH

Duke University

Health Equity

Emily C. Manchanda, MD, MPH Boston University School of Medicine

Faith Quenzer

Temecula Valley Hospital San Ysidro Health Center

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

Shadi Lahham, MD, MS, Deputy Editor Kaiser Permanente- Irvine, California

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

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

Washington University School of Medicine

Victor Cisneros, MD, MPH Eisenhower Medical Center

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

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

Rick Lucarelli, MD Medical City Dallas Hospital

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

Neurosciences

Antonio Siniscalchi, MD Annunziata Hospital, Cosenza, Italy

Pediatric Emergency Medicine

Paul Walsh, MD, MSc University of California, Davis

Muhammad Waseem, MD Lincoln Medical & Mental Health Center

M. Zeretzke-Bien, MD University of Florida

Public Health

Henry Ford Hospital

John Ashurst, DO Lehigh Valley Health Network

Tony Zitek, MD Kendall Regional Medical Center

Trevor Mills, MD, MPH Northern California VA Health Care

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

Technology in Emergency Medicine

Nikhil Goyal, MD Henry Ford Hospital

Phillips Perera, MD Stanford University Medical Center

Trauma

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

Shane Summers, MD Brooke Army Medical Center

Robert R. Ehrman Wayne State University

Ryan C. Gibbons, MD Temple 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

Cristina

Western Journal of Emergency :

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Integrating Emergency with Population Health

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

Amin A. Kazzi, MD, MAAEM

Gayle Galleta, MD

The American University of Beirut, Lebanon

The American University of Beirut, Beirut, Lebanon

Beirut,

Brent King, MD, MMM University of Texas, Houston

Brent King, MD, MMM University Texas, Houston

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

Christopher E. San Miguel, MD 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, Emory University

Emory University

Douglas Ander, MD 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 MD, MPH University South Alabama

Edward Panacek, MD, MPH University of 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

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog,

Hjalti Björnsson, MD

Editorial Board

Board

Editorial Board

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Hjalti Björnsson, MD Icelandic Society of Emergency Medicine

Hjalti MD Icelandic Society of Emergency Medicine

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 Hospital, Miyazaki, Japan

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

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

Leslie Zun, MD, MBA Chicago Medical School

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

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

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

Advisory Board

Elena Lopez-Gusman, JD

California ACEP

Elena Lopez-Gusman, JD California ACEP

California ACEP

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

Langdorf, MAAEM, FACEP

Tufts University School of Medicine

Niels K. Rathlev, Tufts University School of Medicine

Niels K. Rathlev, MD Tufts University School of Medicine

Scott Zeller, MD

Scott Zeller, MD University of California, Riverside

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de Bell,

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

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

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

Peter A. Bell, DO, MBA Baptist Health University

Peter Sokolove, MD University of California, Francisco

Peter Sokolove, MD University of California, San Francisco

University of California, San Francisco

Rachel A. Lindor, MD, JD

Rachel A. Lindor, MD, JD Mayo Clinic

Robert Suter, DO, MHA

Robert Suter, DO, UT Southwestern Medical Center

Robert Suter, DO, MHA UT Southwestern Medical Center

Robert W. Derlet, MD University of California, Davis

University of California, Davis

Rosidah Ibrahim, MD Hospital Serdang, Selangor, Malaysia

Rosidah Ibrahim, MD Hospital Serdang, Malaysia

Rosidah Ibrahim, MD Hospital Serdang, Selangor, Malaysia

Scott Rudkin, MD, MBA

Scott Rudkin, MD, University of California, Irvine

Scott Rudkin, MD, MBA University of California, Irvine

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

Singapore

Steven H. Lim, Changi General Hospital, Simei, 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

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

Wirachin Hoonpongsimanont, MD, MSBATS

Siriraj Hospital, Mahidol University, Bangkok, Thailand

Editorial Staff

Staff Advisory Board

Isabelle BS Executive Editorial Director

Isabelle Nepomuceno, BS Executive Editorial Director

American of Emergency Physicians

American College of Emergency

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

DeAnna McNett, CAE

American College of Osteopathic Emergency Physicians

UC Irvine Health School of Medicine

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

Kimberly Ang, MBA

UC Irvine Health School of Medicine

American College of Emergency Physicians Kaiser Permanente

J. American College of Emergency Physicians Kaiser Permanente

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

UC Irvine Health School of Medicine

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

UC Irvine Health School of Medicine

Robert Suter, DO, MHA American College of Osteopathic

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

Shahram Lotfipour, MD, MPH FAAEM, FACEP

UC Irvine Health School of Medicine

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

Jorge Fernandez, MD, FACEP

UC San Diego Health School of Medicine

Visha Bajaria, BS WestJEM Editorial Director

Emily Kane, MA WestJEM Editorial Director

Stephanie Burmeister, MLIS JEM Liaison

Visha Bajaria, BS WestJEM Editorial Director WestJEM

Stephanie Burmeister, MLIS WestJEM Staff Liaison

Cassandra Saucedo, MS Executive Publishing Director

Nicole Valenzi, BA WestJEM Publishing Director

Cassandra Saucedo, MS WestJEM Publishing Director

Nicole Valenzi, WestJEM Publishing Director

June Casey, BA Copy Editor

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

in Melvyl,

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

Editorial and Publishing Office: JEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA

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.

490 Harm Reduction in the Field: First Responders’ Perceptions of Opioid Overdose Interventions

Callan Elswick Fockele, Tessa Frohe, Owen McBride, David L. Perlmutter, Brenda Goh, Grover Williams, Courteney Wettemann, Nathan Holland, Brad Finegood, Thea Oliphant-Wells, Emily C. Williams, Jenna van Draanen

500 Bystanders Saving Lives with Naloxone: A Scoping Review on Methods to Estimate Overdose Reversals

Andrew T. Kinoshita, Soheil Saadat, Bharath Chakravarthy

Cardiology

507 Impact of Bystander Cardiopulmonary Resuscitation on Out-of- Hospital Cardiac Arrest Outcome in Vietnam

Co Xuan Dao, Chinh Quoc Luong, Toshie Manabe, My Ha Nguyen, Dung Thi Pham, Tra Thanh Ton, Quoc Trong Ai Hoang, Tuan Anh Nguyen, Anh Dat Nguyen, Bryan Francis McNally, Marcus Eng Hock Ong, Son Ngoc Do, The Local PAROS Investigators Group

Critical Care

521 End-tidal Carbon Dioxide Trajectory-based Prognostication of Out-of-hospital Cardiac Arrest

Chih-Hung Wang, Tsung-Chien Lu, Joyce Tay, Cheng-Yi Wu, Meng-Che Wu, Chun-Yen Huang, Chu-Lin Tsai, Chien-Hua Huang, Matthew Huei-Ming Ma, Wen-Jone Chen

533 Low Stroke Volume Predicts Deterioration in Intermediate-Risk Pulmonary Embolism: Prospective Study

Anthony J. Weekes, Parker Hambright, Ariana Trautmann, Shane Ali, Angela Pikus, Nicole Wellinsky, Sanjeev Shah, Nathaniel O’Connell

548 Role of the Critical Care Resuscitation Unit in a Comprehensive Stroke Center: Operations for Mechanical Thrombectomy During the Pandemic

Quincy K. Tran, Robinson Okolo, William Gum, Manal Faisal, Vainavi Gambhir, Aditi Singh, Zoe Gasparotti, Chad Schrier, Gaurav Jindal, William Teeter, Jessica Downing, Daniel J. Haase

Emergency Department Operations

557 Assessing Team Performance: A Mixed-Methods Analysis Using Interprofessional in situ Simulation

Ashley C. Rider, Sarah R. Williams, Vivien Jones, Daniel Rebagliati, Kimberly Schertzer, Michael A. Gisondi, Stefanie S. Sebok-Syer

Education

565 A Measure of the Impact on Real-Time Patient Care of Evidence-based Medicine Logs

Jeffrey B. Brown, Ajay K. Varadhan, Jacob R. Albers, Shreyas Kudrimoti, Estelle Cervantes, Phillip Sgobba, Dawn M. Yenser, Bryan G. Kane

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

25, No. 4: July 2024

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

574 What the Fika? Implementation of Swedish Coffee Breaks During Emergency Medicine Conference

Jesse Zane Kellar, Hanna Barrett, Jaclyn Floyd, Michelle Kim, Matthias Barden, Jason An, Ashley Garispe, Matthew Hysell

Ethical and Legal Medicine

579 Sued, Subpoenaed or Sworn in: Use of a Flipped-Classroom Style Medicolegal Workshop for Emergency Medicine Residents

Kathleen S. Williams, Tatiana Griffith, Sean Gaynor, Thomas Johnson, Alisa Hayes

Global Health

584 The Evolution of Board-Certified Emergency Physicians and Staffing of Emergency Departments in Israel

Noaa Shopen, Raphael Tshuva, Michael J. Drescher, Miguel Glatstein, Neta Cohen, Rony Coral, Itay Ressler, Pinchas (Pinny) Halpern

Health Equity

593 RISE-EM: Resident Instruction in Social Emergency Medicine, a Cohort Study of a Novel Curriculum

Heidi Roche, Brandon A. Knettel, Christine Knettel, Timothy Fallon, Jessica Dunn

602 Rural and Ethnic Disparities in Out-of-hospital Care and Transport Pathways After Road Traffic Trauma in New Zealand

Rebbecca Lilley, Gabrielle Davie, Bridget Dicker, Papaarangi Reid, Shanthi Ameratunga, Charles Branas, Nicola Campbell, Ian Civil, Bridget Kool

614 Acceptance of Automated Social Risk Scoring in the Emergency Department: Clinician, Staff, and Patient Perspectives

Olena Mazurenko, Adam T. Hirsh, Christopher A. Harle, Cassidy McNamee, Joshua R. Vest

Patient Safety

624 “Let’s Chat!” Improving Emergency Department Staff Satisfaction with the Medication Reconciliation Process

Kurt Schwieters, Richard Voigt, Suzette McDonald, Lori Scanlan-Hanson, Breanna Norman, Erin Larson, Alexis Garcia, Bo Madsen, Maria Rudis, Fernanda Bellolio, Sara Hevesi

Pediatrics

634 Pediatric Burns – Who Requires Follow-up? A Study of Urban Pediatric Emergency Department Patients

Theodore Heyming, Andrea Dunkelman, David Gibbs, Chloe Knudsen-Robbins, John Schomberg, Armin Takallou, Bryan Lara, Brooke Valdez, Victor Joe

Prehospital Care

645 Perceived Versus Actual Time of Prehospital Intubation by Paramedics

Daniel Shou, Matthew Levy, Ruben Troncoso, Becca Scharf, Asa Margolis, Eric Garfinkel

Toxicology

651 Compartment Syndrome Following Snake Envenomation in the United States: A Scoping Review of the Clinical Literature

John Newman, Colin Therriault, Mia S. White, Daniel Nogee, Joseph E. Carpenter

Trauma

661 Bicarbonate and Serum Lab Markers as Predictors of Mortality in the Trauma Patient

Matthew M. Talbott, Angela N. Waguespack, Peyton A. Armstrong, John W. Davis, Krishna K. Paul, Shania M. Williams, Georgiy Golovko, Joshua Person, Dietrich Jehle

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

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:

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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

Wake Forest University Winston-Salem, NC

Wake Technical Community College Raleigh, NC

Wayne State Detroit, MI

Wright State University Dayton, OH

Yale School of Medicine New Haven, CT

Uniformed Services Chapter Division of the American Academy of Emergency Medicine

Virginia Chapter Division of the American Academy of Emergency Medicine

for Emergency Medicine

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WestJEM Staff Liaison

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Sociedad Chileno Medicina Urgencia Thai Association

BRIEF RESEARCH REPORT:OPIOID USE DISORDER

Attitudes,Beliefs,Barriers,andFacilitatorsofEmergency DepartmentNursesTowardPatientswithOpioid

UseDisorderandNaloxoneDistribution

CollinMichels,MD*

ThomasSchneider,BS†

KaitlinTetreault,MB‡

JennaMeierPayne,BSN*

KaylaZubke,MSN,RN*

ElizabethSalisbury-Afshar,MD,MPH§∥

*UniversityofWisconsin,SchoolofMedicineandPublicHealth, BerbeeWalshDepartmentofEmergencyMedicine,Madison,Wisconsin

† UniversityofWisconsin,SchoolofMedicineandPublicHealth, Madison,Wisconsin

‡ UniversityofWisconsin,SchoolofMedicineandPublicHealth, DepartmentofBiostatisticsandMedicalInformatics, Madison,Wisconsin

§ UniversityofWisconsin,SchoolofMedicineandPublicHealth, DepartmentofFamilyMedicineandCommunityHealth, Madison,Wisconsin

∥ UniversityofWisconsin,SchoolofMedicineandPublicHealth, DepartmentofPopulationHealthSciences,Madison,Wisconsin

SectionEditor:GentryWilkerson,MD

Submissionhistory:SubmittedMarch30,2023;RevisionreceivedJanuary26,2024;AcceptedFebruary16,2024

ElectronicallypublishedMay21,2024

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

DOI: 10.5811/westjem.18020

Introduction: Asopioidoverdosedeathscontinuetorise,theemergencydepartment(ED)remainsan importantpointofcontactformanyatriskforoverdose.Inthisstudyourpurposewastobetter understandtheattitudes,beliefs,andknowledgeofEDnursesincaringforpatientswithopioiduse disorder(OUD).Wehypothesizedadifferenceintrainingreceivedandattitudestowardcaringfor patientswithOUDbetweennurseswith <5yearsand ≥6yearsofclinicalexperience.

Methods: WeconductedasurveyamongEDnursesinalargeacademicmedicalcenterfromMay–July 2022.AllEDstaffnursesweresurveyed.Dataentryinstrumentsforthenursingsurveyswere programmedinQualtrics,andweanalyzedresultsRusingachi-squaretestorFisherexacttestto comparenurseswith <5yearsand ≥6yearsofclinicalexperience.A P-valueof < 0.05wasconsidered statisticallysigniﬁcant.

Results: Wedistributed74surveys,and69werecompleted(93%).Attitudestowardnaloxone distributionfromtheEDwerepositive,with72%ofrespondentsreportingtheywere “very” or “extremely” supportiveofdistributingnaloxonekitstoindividualsatriskofoverdose.Whileattitudeswerepositive, barriersincludedlimitedtime,lackofsystemsupport,andcost.Levelofcomfortincaringforpatientswith OUDwashigh,with78%ofrespondents “very” or “extremely” comfortable.Moreeducationisneededon overdoseeducationandnaloxonedistribution(OEND)withrespondents38%and45% “alittle” or “somewhat” comfortable,respectively.Nurseswith <5yearsofexperiencereportedreceivingmore trainingonOENDinnursingschoolcomparedtothosewith ≥6yearsofexperience(P = 0.03).There werenosigniﬁcantdifferencesinreportedattitudes,knowledge,orcomfortincaringforpatients withOUD.

Conclusion: Inthissingle-centersurvey,wefoundEDnursesweresupportiveofoverdoseeducation andnaloxonedistribution.Thereareopportunitiesfortargetededucationandaddressingsystemic barrierstoOEND.Allinterventionsshouldbeevaluatedtogaugeimpactonknowledge,attitudes,and behaviors.[WestJEmergMed.2024;25(4)444–448.]

INTRODUCTION

Opioidusedisorder(OUD)isassociatedwitha20-fold riskofearlydeathduetooverdose,infection,trauma,or suicide.1 Nationally,anestimated68,000peoplediedof opioid-relatedoverdosein2020,and2.7millionsuffered fromOUD.2 Theimpactofnon-medicalopioiduseand OUDcanbeseeninmanyhealthcaresettings,includingthe emergencydepartment(ED),asopioid-relatedvisitsinthe EDhadanestimatedcostof$1.47billionperyear between2016–2017.2,3

PatientspresentingtotheEDforopioid-related encounters,includingopioidoverdose,areathighriskfor negativeoutcomes.Emergencydepartment-based interventionssuchasoverdoseeducationandnaloxone distribution(OEND)canhaveasigniﬁcantimpacton opioid-relatedmorbidityandmortality.Naloxoneisan opioidreceptorantagonistthatisusedtoquicklyreversethe effectsofopioidoverdose.In2018,theUSSurgeonGeneral recommendedincreasingaccesstonaloxoneforthosewho areatanincreasedriskofanopioidoverdose.4 TheAmerican CollegeofEmergencyPhysiciansalsorecommends providingnaloxoneforpatientsatincreasedriskofopioid overdose,includingthosedischargedfromtheEDafteran opioid-relatedvisitaswellasanypatientwithahistory ofOUD.5

Emergencydepartment-basedtake-homenaloxone programshavebeenaneffectivemeansofdistributing naloxonetopatientsatriskforfutureoverdose6,7;and OENDfromtheEDhasbeenshowntohavepositiveimpact ontrainedlaypersonsinadditiontopatientsandtheirsocial network.8 Large-scaleOENDhasbeenshowntobean effectivepublichealthintervention.9 Patienteducation relatedtooverdosepreventionandnaloxonedistributioncan beprovidedbyEDnurseswhoroutinelyspendmoretime withpatientsthanthetreatingclinician.Clinicalnurse specialist-ledOENDintheEDhavebeeneffectiveacrossan integratedhealthcaresystem.10 Whilemuchisknownabout thebeliefs,attitudes,andbarriersofprescriberstoward naloxonedistribution,includingtime,cost,andclinical decisionsupport,lessisknownaboutnurseperspectivesin theED.6,7,11–15 Wesoughttoevaluatenurseattitudes, beliefs,barriers,andfacilitatorstonaloxonedistributionin anacademicEDintheMidwest.

METHODS

FromMay–July2022weconductedasurveyofEDnurses ataquaternary-care,academicEDintheMidwestthatsees approximately60,000patientsperyear.Theresearchteam, whichincludedanemergencyphysicianandanaddiction medicinephysician,createdasurveytoolincollaboration withsurveymethodologyexpertsfromtheUniversityof WisconsinSurveyCenter.Mostitemsonthesurveywere developedbytheteam,butthestigmaquestionswere adaptedfromavalidatedmentalhealthstigmasurvey.15–17

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencydepartmentsplayacrucialrolein caringforpatientswithopioidusedisorder (OUD)withinterventionssuchasoverdose educationandnaloxonedistribution.

Whatwasthemajorresearchquestion?

WhatareattitudesofEDnursesrelatedto caringforpatientswithOUD,andtrainingin overdoseeducationandnaloxone distribution(OEND)?

Whatisthemajor ﬁndingofthestudy?

EDnurseshavepositiveattitudes(72%) towardnaloxonedistribution.Earlycareer nurses( < 5years)hadmoreOENDtraining.

Howdoesthisstudyimprove populationhealth?

Resultshighlightopportunitiesfortargeted nursingeducation,addressingbarriersand facilitatorstoOENDintheED,thereby improvingcareforpatientswithOUD.

ResearchcoordinatorsintheEDdistributed74paper surveystofullandpart-timeEDstaffnursesatdailystaff huddlesduringthestudyperiod.Eachrespondentwas allowedtocompleteonlyonesurvey.A$5pre-incentivewas includedwiththesurveyatthetimeofdistribution.

Weusedachi-squaretestorFisherexacttesttoassessthe differenceinnurseattitudes,basedonrelativejobexperience (≤5yearsv ≥6years),regardingperception,knowledge,and barriersfornaloxonedistributionandcaringforpatients withOUD.AllanalysesweredoneinRv4.1.12021 (RFoundationforStatisticalComputing,Vienna,Austria). A P -valueof <0.05wasconsideredstatisticallysigniﬁcant.

Disclosures

ThisstudywasreviewedbytheUniversityofWisconsinMadisonMinimalRiskResearchInstitutionalReview Boardanddeemedexempt.Noneoftheauthorshaveany ﬁnancialconﬂictsofinteresttodisclose.

RESULTS

Surveysweredistributedto74EDnurses,witha93% responserate.Respondentshadabreadthofclinical experience,with60%havingbeenapracticingnurseforsix yearsormore.Ofthatgroup,21%hadbeenapracticing

nursefor ≥16years.ThemajorityoftheEDnursesreported completingtheirnursingtrainingintheMidwest(83%). OtherregionsrepresentedweretheWest(7.6%),Southwest (1.5%),Southeast(4.5),andNortheast(3%).

Overall,theleveloftrainingonOENDduringnursing schoolwaslow,with77%reportingnooralittleeducation received.Nurseswith0–5yearsofexperiencereported receivingmoreeducationcomparedtonurseswith ≥6years ofexperience(P = 0.03).Whenaskedaboutlevelofcomfort providingeducationrelatedtonaloxoneforoverdose preventionimmediatelyfollowingnursingschool,67%felt “notatall” or “onlyalittle” prepared.Despitemorerecent nursingschoolgraduatesreportingmoreeducationin nursingschool,therewerenodifferencesinhowprepared theyfelttoprovideOEND(P = 0.63).

Responsesweremixedwhentheywereaskedaboutthe perceivedeffectivenessofnaloxonekitsasapublichealth intervention,with55%ofallnursesreportingnaloxonekits are “alittle” or “somewhat” effective.However,themajority (66%)feltthatnaloxonekitswouldnotincreasebehavior thatputpeopleatriskforoverdose.Additionalresponsesto questionsaboutattitudes,beliefs,barriers,andfacilitatorsto naloxonedistributionfromtheEDareavailableinthe Table Responsestoallquestionswerecomparedbetweenthenurses with0–5years’ experiencetothosewith ≥6years’ experience, andnostatisticallysigniﬁcantdifferenceswereappreciated.

Overallcomfortlevelforcaringforpatientswhousenonprescribedopioidswashigh,with78%ofrespondentsveryor extremelycomfortable.Again,nodifferenceswere appreciatedbetweennurseswith0–5years’ experienceand thosewith ≥6years’ experience.

Barriersandfacilitatorstonaloxonedistributioninthe EDarevariedandrelatedtotime,education,andcost concerns.Staffreportedthemostsigniﬁcantbarrierwas limitedstafftime,with47%reportingthiswasan “extremely” impactfulbarrier.Thesearesimilarto previouslydescribedbarriersandfacilitatorsthatprescribers reportfacing;responsesareincludedinthe Table 14–18

DISCUSSION

Emergencydepartmentnursesarecriticaltothe effectivenessofED-basedOENDprograms.Althoughthere havebeenmultiplestudieslookingatemergencyclinician attitudes,beliefs,barriers,andfacilitatorstonaloxone distribution,littleisknownaboutEDnurse-speciﬁcfactors forOEND.Althoughnursesinpracticefor ≤5yearsreported receivingmoreeducationonnaloxoneforoverdose preventionwhileinnursingschool,theadditionaleducation didnotrelatetostatisticallysigniﬁcantdifferencesin attitudes,comfort,orperceivedbarriersorfacilitators. Furtherresearchisneededtoprovideabetterunderstanding ofwhyreceivingmoreeducationdidnotleadtoincreased

Table. Responsesofemergencydepartmentnursestoquestionsaboutattitudes,beliefs,barriers,andfacilitatorstonaloxonedistribution fromtheED. NotatallAlittleSomewhatVeryExtremely

AttitudesHowmuchdoyousupportgivingnaloxonekitsto individualswhomightbeatriskforopioidoverdose?

Howeffectiveisgivinganaloxonekittopeoplewho usedrugsasapublichealthintervention?

Howlikelyisgivinganaloxonekittopeoplewhouse drugsgoingtoleadtobehaviorsthatincreaseriskfor overdose,eg,usingmoreopioidsorusingin combinationwithotherdrugs? 41.8%(28)23.9%(16)25.4%(17)9.0%(6)0.0%(0)

ComfortAskingscreeningquestionsaboutnon-prescribed opioiduse?

Caringforpatientswhousenon-prescribedopioids?0.0%(0)1.4%(1)20.3%(14)46.4%(32)31.9%(22) Offeringanaloxonekittobeabletoreversean overdose?

1.4%(1)5.8%(4)33.3%(23)31.9%(22)27.5%(19)

Teachingalaypersontoadministernaloxone?2.9%(2)10.1%(7)27.5%(19)34.8%(24)24.6%(17) Providingcaretoapersonwithanopioiduse disordercomparedtohelpingapersonwitha physicalillness?

Educatingpatientsaboutopioidoverdose prevention?

Educatingpatientsaboutoverdoseresponseand naloxoneadministration?

3.0%(2)4.5%(3)26.9%(18)47.8%(32)17.9%(12)

0.0%(0)5.8%(4)36.2%(25)44.9%(31)13.0%(9)

4.3%(3)15.9%(11)29.0%(20)37.7%(26)13.0%(9)

Educatingpatientsaboutoverdoseprevention?2.9%(2)18.8%(13)30.4%(21)34.8%(24)13.0%(9) (Continuedonnextpage)

Table. Continued.

NotatallAlittleSomewhatVeryExtremely BarriersLimitedstafftime?0.0%(0)4.5%(3)18.2%(12)30.3%(20)47.0%(31)

Lackofsystemssupportingittohappeninatime efﬁcientway?

Lackofclinicaldecisionsupporttoensureconsistent process?

Howmuchofabarriertodispensingnaloxonekits fromtheEDislackofinsuranceorlimitedinsurance coverageleadingtohighcoststopatients?

Concernsaboutbeingabletoidentifypatientsatrisk foroverdose?

Concernsthatalaypersonwon’tbeableto administeritappropriately?

Concernsthatprovidinganaloxonekitwillleadto moreorriskierdruguse?

Concernsthatpatientswillbeoffendedbyitbeing offered?

1.5%(1)4.6%(3)21.5%(14)43.1%(28)29.2%(19)

31.%(2)10.9%(7)25.0%(16)39.1%(25)21.9%(14)

9.4%(6)10.9%(7)17.2%(11)39.1%(25)23.4%(15)

FacilitatorsFundingtoensurepatientsdon’thavetopayco-pays forcostofthenaloxonekit? 3.1%(2)7.8%(5)20.3%(13)32.8%(21)35.9%(23)

Clinicaldecisionsupportthatmakestheprescription anautomatedprocess?

Educationforstaff?1.6%(1)3.1%(2)43.8%(28)35.9%(23)15.6%(10)

Howmuchofafacilitatortodischargingapatient fromtheEDwithanaloxonekitispatienteducation materialstoteachaboutoverdosepreventionand naloxoneadministration?

ED,emergencydepartment.

comfortorknowledgeandwhetherofferingmoretargeted educationcanimprovethesemetrics.Despitereceivingmore education,earlycareernurseshavehadlessexperiencecaring forpatientswithOUD,whichmayhavecontributed totheresults.

Overall,mostrespondentswerecomfortablecaringfor patientswithOUD,includingaskingOUDscreening questions.Slightlylessthanhalffeltnaloxoneisa “ very ” or “extremely” effectivepublichealthintervention,whichisan importantareaforfutureeducationaleffortsandevaluation. Additionalareasforeducationalfociincludetrainingson overdosepreventioneducationandnaloxonetrainingfor patientsandtheirfriends/familywhileintheED.Thisdata providesabaselineunderstandingandcanbere-assessed afterfurthereducationalinitiatives.

Wefoundnursing-identiﬁedbarriersweresimilarto previouslydescribedprescriberbarriersincludinglimited time,cost,andlackofefﬁcientsystemsupport.18–20 Someof thesebarrierscanbeaddressedwithclinicaldecisionsupport, includingpromptstoordernaloxoneforpatientswith opioid-relateddiagnosticcodes.Providingstandardized, easy-to-followinstructionsonoverdosepreventionand

3.2%(2)7.9%(5)27.0%(17)44.4%(28)17.5%(11)

naloxoneadministrationcanbeneﬁtboththepatientsand thestaffmemberprovidingtheeducation.Although handoutsarehelpful,regulareducationbycontentexperts wouldprovidecontinuededucationtoensureallstaffare comfortablewithoverdosepreventioneducationand naloxoneusemovingforward.

Overall,EDnurseswereopentoreceivingmore education,andmostnursesidentiﬁedthisasafacilitatorto expandingnaloxonedistributionintheED.Usingbaseline surveysliketheoneourteamusedcanguideEDleadership whendevelopingeducationalandsystemsinterventionsfor nursingstaff.

LIMITATIONS

Limitationsofthisstudyincludeevaluatingasingle, academicLevelItraumacenter;soresultsmaynotapply morebroadlytootherEDs.Wedidnotevaluatefornursing experienceinareasoutsidetheED.Additionally,thenumber ofEDnursessurveyedwassmall(69);soitispossiblethatthe samplesizewastoosmalltoenableustoidentifydifferences betweenthenurseswithlessexperienceascomparedtothose withmoreexperience.

CONCLUSION

Understandingattitudes,beliefs,barriers,andfacilitators ofnaloxonedistributionamongEDnursesisimportantfor successfulimplementationofoverdoseeducationand preventionprogramming.Emergencydepartmentnurses surveyedweregenerallysupportiveofnaloxonedistribution andcomfortablecaringforpatientswithOUD.Thereare opportunitiesforaddressingsystemicbarriersandproviding targetededucationtofacilitateED-basednaloxone distribution.Theseresultsshowopportunitiestoimprove careforpatientswithOUD,althoughfutureresearchis neededtodeterminewhethereducationimpactsknowledge, attitudes,andbehaviors.

AddressforCorrespondence:CollinMichels,MD,Universityof Wisconsin,SchoolofMedicineandPublicHealth,BerbeeWalsh DepartmentofEmergency,800UniversityBayDr.,Suite310, Madison,WI53705.Email: ctmichels@medicine.wisc.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisworkwassupportedbythe UniversityofWisconsinDepartmentsofFamilyMedicineand CommunityHealthandPopulationHealthSciencesaswellasthe UniversityofWisconsinBerbeeWalshDepartmentofEmergency Medicine.Therearenootherconflictsofinterestorsourcesof fundingtodeclare.

REFERENCES

1.NationalAcademiesofSciences,Engineering,andMedicine. MedicationsforOpioidUseDisorderSaveLives.WashingtonDC:The NationalAcademiesPress,2019.

2.SubstanceAbuseandMentalHealthServicesAdministration.Key SubstanceUseandMentalHealthIndicatorsintheUnitedStates: Resultsfromthe2020NationalSurveyonDrugUseandHealth. 2022.Availableat: https://www.samhsa.gov/data/sites/default/ﬁles/ reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/ 2020NSDUHFFR1PDFW102121.pdf.AccessedJanuary20,2023.

3.WeinerSG,BakerO,BernsonD,etal.One-yearmortalityofpatients afteremergencydepartmenttreatmentfornonfatalopioidoverdose. AnnEmergMed. 2020;75(1):13–7.

4.OfﬁceoftheSurgeonGeneral.U.SSurgeonGeneral’sAdvisoryon NaloxoneandOpioidOverdose.2022.Availableat: https://www.hhs. gov/surgeongeneral/reports-and-publications/addiction-andsubstance-misuse/advisory-on-naloxone/index.html AccessedJanuary10,2023.

5.DuberHC,BarataIA,Cioè-PenaE,etal.Identiﬁcation,management, andtransitionofcareforpatientswithopioidusedisorderinthe emergencydepartment. AnnEmergMed. 2018;72(4):420–31.

6.EswaranV,AllenKC,CruzDC,etal.Developmentofatake-home naloxoneprogramatanurbanacademicemergencydepartment. JAM PharmAssoc. 2020;60(6):324–31.

7.EswaranV,AllenKC,BottariDC,etal.Take-homenaloxoneprogram implementation:lessonslearnedfromsevenchicago-areahospitals. AnnEmergMed. 2020;76(3):318–27.

8.DwyerK,WalleyA,LangloisB,etal.Opioideducationandnasal naloxonerescuekitsintheemergencydepartment. WestJEmergMed. 2015;16(3):381–4.

9.WalleyAY,XuanZ,HackmanHH,etal.Opioidoverdoseratesand implementationofoverdoseeducationandnasalnaloxonedistributionin Massachusetts:interruptedtimeseriesanalysis. BMJ. 2013;346:f174.

10.MullennixSC,IselerJ,KwiatkowskiGM,etal.Aclinicalnursespecialistledemergencydepartmentnaloxonedistributionprogram. ClinNurse Spec. 2020;34(3):116–23.

11.LowensteinM,KilaruA,PerroneJ,etal.Barriersandfacilitatorsfor emergencydepartmentinitiationofbuprenorphine:aphysiciansurvey. AmJEmergMed. 2019;37(9):1787–90.

12.HawkKF,D’OnofrioG,ChawarskiMC,etal.Barriersandfacilitatorsto clinicianreadinesstoprovideemergencydepartment-initiated buprenorphine. JAMANetwOpen. 2020;3(5):e204561.

13.EllisK,WaltersS,FriedmanSR,etal.Breachingtrust:aqualitative studyofhealthcareexperiencesofpeoplewhousedrugsinarural setting. FrontSociol. 2020;5:593925.

14.LacroixL,ThurgurL,OrkinAM,etal.Emergencyphysicians’ attitudes andperceivedbarrierstotheimplementationoftake-home naloxoneprogramsinCanadianemergencydepartments. CJEM. 2018;20(1):46–52.

15.KassamA,PapishA,ModgillG,etal.Thedevelopmentand psychometricpropertiesofanewscaletomeasurementalillness relatedstigmabyhealthcareproviders:theOpeningMindsScalefor HealthCareProviders(OMS-HC). BMCPsychiatry. 2012;12:62.

16.EzellJM,WaltersS,FriedmanSR,etal.Stigmatizetheuse,notthe user?Attitudesonopioiduse,druginjection,treatment,andoverdose preventioninruralcommunities. SocSciMed. 2021;268:113470.

17.KellyT,HawkK,SamuelsE,etal.Improvinguptakeofemergency department-initiatedbuprenorphine:barriersandsolutions. WestJ EmergMed. 2022;23(4):461–7.

18.BarbourK,McQuadeM,SomasundaramS,etal.Emergencyphysician resistancetoatake-homenaloxoneprogramledbycommunityharm reductionists. AmJEmergMed. 2018;36(11):2110–2.

19.PenmJ,MacKinnonNJ,LyonsMS,etal.Combattingopioidoverdoses inOhio:emergencydepartmentphysicians’ prescribingpatternsand perceptionsofnaloxone. JGenInternMed. 2018;33(5):608–9.

20.LaneBH,LyonsMS,StolzU,etal.Naloxoneprovisiontoemergency departmentpatientsrecognizedashigh-riskforopioidusedisorder. AmJEmergMed. 2021;40:173–6.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

PragmaticEmergencyDepartmentInterventionReducingDefault QuantityofOpioidTabletsPrescribed

DrakeGothamJohnson,MS° AliceY.Lu,MSL°

GeorgiaA.Kirn, °

KaiTrepka,AM°

YeseniaAyanaDay, °

StephenC.Yang,DDS°

JuanCarlosC.Montoy,MD,PhD

MarianneA.Juarez,MD

SectionEditor:GentryWilkerson,MD

UniversityofCaliforniaSanFrancisco,DepartmentofEmergencyMedicine, SanFrancisco,California

°Johnson,Lu,Kirn,Trepka,Day,andYangareco-ﬁrstauthors.

Submissionhistory:SubmittedApril1,2023;RevisionreceivedJanuary24,2024;AcceptedFebruary9,2024

ElectronicallypublishedMay20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18040

Introduction: TheopioidepidemicisamajorcauseofmorbidityandmortalityintheUnitedStates.Prior workhasshownthatemergencydepartment(ED)opioidprescribingcanincreasetheincidenceofopioid usedisorderinadose-dependentmanner,andsystemicchangesthatdecreasedefaultquantityof dischargeopioidtabletsintheelectronichealthrecord(EHR)canimpactprescribingpractices.However, EDleadershipmaybeinterestedintheimpactofcommunicationaroundtheinterventionaswellas whethertheinterventionmaydifferentiallyimpactdifferenttypesofclinicians(physicians,physician assistants[PA],andnursepractitioners).Weimplementedandevaluatedaqualityimprovement interventionofanannounceddecreaseinEHRdefaultquantitiesofcommonlyprescribedopioidsata large,academic,urban,tertiary-careED.

Methods: WegatheredEHRdataonallEDdischargeswithopioidprescriptionsfromJanuary1, 2019–December6,2021,includingchiefcomplaint,clinician,andopioidprescriptiondetails.Datawas capturedandanalyzedonamonthlybasisthroughoutthistimeperiod.OnMarch29,2021,we implementedanannounceddecreaseinEHRdefaultdispensequantitiesfrom20tabletsto12tabletsfor commonlyprescribedopioids.Wemeasuredpre-andpost-interventionquantitiesofopioidtablets prescribedperdischargereceivingopioids,distributionbypatientdemographics,andinter-clinician variabilityinprescribingbehavior.

Results: TheEHRchangewasassociatedwitha14%decreaseinquantityofopioidtabletsper dischargereceivingopioids,from14to12tablets(P =<.001).Wefoundnostatisticallysignificant disparitiesinprescriptionsbasedonself-reportedpatientrace(P = 0.68)orgender(P = 0.65).Nurse practitionersandPAsprescribedmoreopioidsperencounterthanphysiciansonaverageandhada statisticallysignificantdecreaseinopioidprescriptionsassociatedwiththeEHRchange.Physicianshad alesserbutstillsignificantdropinopioidprescribinginthepost-interventionperiod.

Conclusion: DecreasingEHRdefaultsisarobust,simpletoolfordecreasingopioidprescriptions,with potentialforimplementationinthe42%ofEDsnationwidethathavedefaultsexceedingthe recommended12-tabletsupply.Consideringsigniﬁcantinter-clinicianvariability,futureinterventionsto decreaseopioidprescriptionsshouldexaminetheeffectsofcombiningEHRdefaultchangeswith targetedinterventionsforcliniciangroupsorindividualclinicians.[WestJEmergMed.2024;25(4) 449–456.]

INTRODUCTION

Theopioidepidemicisamajorcauseofmorbidityand mortalityintheUnitedStates,includinginCalifornia.1 Opioidprescriptionsinitiatedintheemergencydepartment (ED)andotherclinicalcaresettingscanincreasethe incidenceofopioidusedisorder(OUD)inadose-dependent manner themoretabletsprescribed,thegreatertheriskof futuredevelopmentofOUD.2–4 Inaddition,thepresenceof excessopioidtabletsinthehomeislinkedtodiversionand overdose.5 Decreasingthetotalquantityoftabletsprescribed fromtheEDmayhelpdecreasetheriskoftheseharms.

Manyinterventionsattempttodecreaseandalleviatethe risksofopioidprescriptionsinEDsettings,fromelectronic clinicaldecisionsupportalertstoco-prescriptionofnaloxone, butmostexistingEDinterventionsfocusondecreasing prescriptionratesratherthandecreasingthequantityofopioid tabletsprescribedwhenEDpatientsaredischargedwith opioids.6–8 Priorresearchhasshownthatdecreasingthe defaultquantityoftabletsprescribedintheelectronichealth record(EHR)withoutannouncingthechangetoclinicians candecreasethenumberofopioidsperprescriptiongivenat discharge.Inthesestudies,clinicianswerenotnotiﬁedof alteredEHRdefaultprescriptionseitherforconvenienceorto testtheeffectofadefaultchangealone,orduetoconcernthat clinicianswouldconsciouslyoverridethedefaults.9–13

BecauseprotocolchangesintheEDarecommonly arrivedatbyconsensusandareusuallyimplemented transparentlyratherthanunannounced,studyingtheeffect ofanannouncedEHRchangemorecloselymirrorsrealworldscenarios.Anannouncementaboutthechangemay havetheaddedbeneﬁtofeducatingcliniciansaboutopioid prescribingguidelines,therisksofprescribingopioids,and signalswhatothercliniciansarethinkingaboutopioid prescriptions.Further,thereisevidencethatnurse practitioners(NP)andphysicianassistants(PA)aremore likelythanphysicianstoprescribeopioidsinprimarycare settings,14 buttherelationshipbetweencliniciantypeand opioid-prescribingbehaviorintheEDsettingremains unknown.Inaddition,priorworkhasnotshownwhether thesedifferenttypesofcliniciansrespondsimilarlytodefaultdirectedattemptstodecreaseopioidprescribing.

Toaddressthesegaps,weimplementedaquality improvement(QI)interventiondecreasingEHRdefault quantitiesofcommonlyprescribedopioidsatalarge, academic,urban,tertiary-carecenter.Ourgoalwasto determinewhetherthisEHRchangewasassociatedwith decreasedopioidprescribingandwhetherthisassociation variedbycliniciantype.

METHODS

Design

Weimplementedasingle-site,QIinterventionatalarge, academic,urbantertiary-careEDalteringthedefaultquantity ofsixcommonlyprescribedopioids.ThiswasaprospectiveQI

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencydepartment opioidprescriptions increasetheincidenceofopioidusedisorderin adose-dependentmanner,potentially exacerbatingtheopioidepidemic.

Whatwastheresearchquestion?

Thisstudyevaluatedtheimpactofa qualityimprovementinterventiondecreasing defaultopioidquantitiesintheEHRfrom 20pillsto12,onaverageopioidsprescribed atdischarge.

Whatwasthemajor ﬁnding ofthestudy?

TheEHRchangewasassociatedwitha14% decreaseinquantityofopioidtabletsper dischargereceivingopioids(P < .001),driven mostlybynursepractitioners ’ andphysician assistants ’ changes.

Howdoesthisimprovepopulationhealth?

Wedemonstrateasimpleinterventionother emergencydepartmentscanimmediately implementtoreducetheburdenopioid prescribinghasontheopioidepidemic.

studywheredatawaspulledfromchartreviewandanalyzed bothduringstudydesignandcontinuouslyduring implementation.Wecollectedpre-interventiondataonallED dischargesreceivingthesesixopioidsatdischargefrom January1,2019–March28,2021,andcomparedthiswith post-interventiondatafromMarch29,2021–December5, 2021.ThisworkwasconsideredQIactivityaccordingtothe UniversityofCalifornia,SanFranciscoinstitutionalreview boardpolicy.Asaresult,therequirementforindividual researchHIPAAauthorizationandsignedconsentformswas waivedforallsubjectsastheresearchpresentednomorethan minimalriskofharmtothesubjects’ privacy.

Intervention

Wedecreasedthepre-populatedEDdischargedispense quantitiesintheEHRfrom20tabletsto12tabletsforthe followingsixcommonlyprescribedopioids:oxycodone 5milligrams(mg);oxycodone-acetaminophen5–325mg; oxycodone10mg;tramadol50mg;hydrocodoneacetaminophen5–325mg;andhydrocodone-acetaminophen 10–325mg.Changesweremadeatthesystemleveland appliedtoallEDpatientsandclinicians.Cliniciansdecided

forwhomtoprescribeopioidsandcouldchooseanyquantity byalteringthedefaultsetting.CliniciansintheEDwere informedofthestudyandquantitychangesusingtwo communicationmethods:bytwoemailannouncementssent toallphysicians,PAs,andNPs;andbytwoin-person announcementsduringtheweeklyall-staffEDmeetings attendedby10–12totalphysicians,PAs,andNPs.Theemail andweeklyall-staffannouncementsweremadeoveraperiod oftwoweekspriortotheintervention.

Participants

WeincludedEDpatientencountersinwhichpatientswere dischargedfromtheEDwithaprescriptionforoneofthesix opioidmedicationsincludedintheintervention.Wealso recordedthetotalnumberofpatientsdischargedfromthe EDeachmonthduringtheperiodofourstudy,regardlessof whethertheyweregivenaprescriptionattheendoftheir visit.Eachencounterwasrecordedasanobservation, regardlessofwhetherthesepatientshadotherEDvisits.

Outcomes

FromallEDencountersthathadanopioidmedication prescribedatdischarge,weextractedthefollowingdatafrom theEHR:dateofvisit;patientdemographics(race,age, gender,insurancetype);acuity(basedontheassigned EmergencySeverityIndexscoreintheEHR),chief complaint,prescribingcliniciantype,opioidmedication prescribedandquantityoftablets.Insurancetypewas categorizedasMedicaid,Medicare,commercial,self-pay,or other.Chiefcomplaintswereclassiﬁedintothefourmost commonchiefcomplaintsseeninourEDoverthestudy period(backpain,abdominalpain, ﬂankpain,falls),withthe remainingchiefcomplaintsgroupedas “other.” Prescribing cliniciantypeswerecategorizedasphysician,NP,orPA.

Ourprimaryoutcomemeasurewasthedifferenceinmean numberofopioidtabletsprescribedatdischargebeforeand afterourintervention.Oursecondaryoutcomesincluded differencesinthismeasuregiventhepatient’sself-reported raceandself-reportedgender,aswellasprescribingclinician typefortheencounter(physician,NP,PA).Wealsotested thedifferenceinmeanmorphinemilligramequivalents (MME)prescribedatdischargebeforeandafter ourintervention.

Analysis

WecalculatedMMEsusingtheconversionfactors providedbytheUSCentersforDiseaseControland Prevention(CDC).4 Frequencytablesweregeneratedfor categoricalvariables.Medianandinterquartilerangewere generatedforageandmeans,andstandarddeviationswere calculatedforallothercontinuousvariables.Weperformed twosample t -teststocomparemeanopioidtabletsprescribed beforeandafterourinterventionandcalculated95% conﬁdenceintervals(CI).GiventheeffectoftheCOVID-19

pandemiconthevolumeofEDdischargesduringourpreinterventiondatacollection,weperformedsensitivity analysesrestrictingthestudyperiodtodifferentstarttimes, includingafterthestartoftheCOVID-19pandemic(in March2020).Weperformedchi-squaretestsof independenceforage,race,insurancetype,andacuitybefore andafterintervention,andtheFisherexacttestforgender. Two-wayanalysisofvariance(ANOVA)wasperformedto analyzetheinteractionbetweencliniciantypeand interventiononmeanopioidtabletsprescribed. P values < 0.05werereportedassigniﬁcant.Weperformedallanalyses usingPython3(PythonSoftwareFoundation, Wilmington,DE).

RESULTS

Therewere3,575EDdischargeswithanopioidprescribed duringthestudyperiod,ofwhich3,274(91.6%)had prescriptionsforoneofthesixopioidstargetedbyour intervention,including2,666dischargespre-interventionand 608dischargespost-intervention. Opioidsnottargeted byour interventionincludedmorphine(2.5%),hydromorphone (1.4%), oxycodone (1.3%),hydrocodone(<1%),codeine (<1%), tramadol (<1%),methadone(<1%),andfentanyl (<1%).ThepatientpopulationseenintheEDpre-andpostinterventionhadsimilardistributionsofdischargediagnoses, age,gender,self-reportedrace,acuity,insurancetype,and prescribingcliniciantype(Table1).Therewereno statisticallysigniﬁcantdifferencesinprescriptionsbetween individualswithdifferentself-reportedraces(chi-squared P = 0.68)orbetweengenders(Fisherexact P = 0.65)before andafterimplementationofourintervention.

ThenumberofEDencountersassociatedwithanopioid prescriptionupondischargewasproportionaltothetotal numberofdischargesfromtheEDthroughoutthestudy period,althoughbothexperiencedaprecipitousdeclineat thestartoftheCOVID-19pandemic(Figure1).

DecreasingtheEHRdefaultquantityofcommonly prescribedopioidswasassociatedwithadecreasefrom14.01 to12.00tabletsperdischargeprescriptionwithopioidsfrom theED,adifferenceof2.01tablets(95%CI1.44–2.58) (Table2).Sensitivityanalysisshowedtherewasastatistically signiﬁcantdifferenceintabletsprescribedregardlessofhow manymonthswereincludedinthepre-interventiondataset (SupplementalTable1).Thisdecreaseintabletsismirrored byan11.0MMEdecreaseperdischargeprescriptionwith opioids(95%CI5.74–16.22)from94.25to83.27(Table2).

For2,666pre-interventionencountersinthedataset, physicianswrote47.6%ofstudyprescriptions,NPswrote 26.8%,andPAswrote25.6%ofstudyprescriptions.Forthe 608 post-interventionencountersinthedataset,physicians wrote50%ofstudyprescriptions,NPswrote24.3%,andPAs wrote25.7%ofstudyprescriptions.Allcliniciantypes prescribedsigniﬁcantlyfeweropioidsperencounterafterthe interventioncomparedtoprior,withPAsandNPsaffected

Table1. Patientdemographicsofopioidprescriptionsintheemergencydepartment.

Female1,707(0.522)1,395(0.5242)312(0.514)

Male1,561(0.478)1,266(0.4758)295(0.486) Race,n(%)

White1,719(0.525)1,393(0.5225)326(0.536)

Black423(0.129)353(0.1324)70(0.115)

Asian467(0.143)382(0.1433)85(0.14)

Other665(0.203)538(0.2018)127(0.209)

Acuity,n(%)

Emergent286(0.087)243(0.0912)43(0.071)

Urgent2,013(0.615)1,618(0.6071)395(0.65)

Lessurgent947(0.289)781(0.2931)166(0.273)

Non-urgent27(0.008)23(0.0086)4(0.007)

Commercial1,448(0.442)1,172(0.4396)276(0.454)

Medicaid801(0.245)662(0.2483)139(0.229)

Medicare702(0.214)571(0.2142)131(0.216)

Self-pay167(0.051)140(0.0525)35(0.058)

Other156(0.048)121(0.0454)27(0.044)

Physician1,573(0.481)1,269(0.476)304(0.5)

NP862(0.263)714(0.268)148(0.243)

PA839(0.256)683(0.256)156(0.257)

Dischargediagnosis,n(%)

Abdominalpain425(0.130)345(0.129)80(0.131)

Backpain324(0.0990)258(0.0968)66(0.109)

Flankpain292(0.0892)248(0.0930)44(0.0724)

Fall190(0.0580)41(0.0559)149(0.0674)

Other2,043(0.624)1,666(0.624)377(0.620)

IQR, interquartilerange; NP,nursepractitioner; PA,physicianassistant.

themost(Figure2, Table3).Atwo-wayANOVAofthe cliniciantypeandinterventionconﬁrmedstatistically signiﬁcanteffectsoftheintervention,cliniciantype,and interactionbetweeninterventionandcliniciantypeonthe numberoftabletsperdischargeprescriptionwith opioids(P < 0.001).

DISCUSSION

WeimplementedanannounceddecreaseinEHRdefault quantitiesofsixcommonlyprescribedopioidsatalarge, academic,urban,tertiary-careED.Theanalysisofour primaryoutcomeshowedthatthisQIinterventionwas associatedwithastatisticallysigniﬁcantdecreaseinopioid

tabletsperdischargeprescriptionwithopioidsfromtheED, from14to12tablets,andacorresponding11-pointdecrease inmeanMMEsprescribed.Whilenostudieshaveprecisely quantifiedtheclinicalsignificanceofthislevelofdecrease, priorliteratureandCDCguidelinesnoteadose-dependent relationshipbetweenprescriptionsandriskofdeveloping OUD,suggestingthateverypillmattersatapopulation level.2–4 Further,giventhatthiscenter’spre-intervention meantabletsperEDdischargeopioidprescriptionwasonly 14,themaximumexpecteddecreasefromadefaultchangeto 12wasonlyadecreaseoftwotabletsperdischarge prescription.However,theseinterventionsmightconfera largerclinicalsignificanceatotherinstitutionswithahigher

Figure1. DecreasingdefaultopioidquantitiesintheelectronichealthrecordisassociatedwithlowerEDprescriptionofopioidsinthe emergencydepartment.Numberoftotaldischarges(blue)anddischargesinwhichopioidswereprescribed(orange)overthestudytimeline. TheinterventionbeganonMarch19,2021.

Table2. Tabletsandmorphinemilligramequivalentsperdischargeprescriptionwithopioids.

Opioidprescriptions

CI, conﬁdenceinterval; MME,morphinemilligramequivalent.

Figure2. Cliniciantypeisassociatedwithopioidprescriptionquantitiesintheemergencydepartment.Averagenumberoftablets perdischargeinwhichopioidswereprescribed,groupedbycliniciantypeandinterventiontime(blue = pre-intervention, orange = post-intervention).

Table3. Numberoftabletsperdischargeprescriptionwithopioids,bycliniciantype.

NP, nursepractitioner; PA,physicianassistant; CI,conﬁdenceinterval.

startingmeantabletsperdischarge.Importantly,we observedthatNPsandPAsintheEDsettingaremorelikely thanphysicianstoprescribehigherlevelsofopioidsat baseline,consistentwithpreviousresultsinprimary caresettings.14

Ourresultssuggestthatauniversaldefaultchangeis associatedwithdecreasedopioidprescriptionsacrossall clinicians,withlargerdecreasesforNPsandPAscompared tothechangeobservedforphysicians.Thehigherratesof opioidprescriptionsamongNPsandPAscouldbeduetoa varietyoffactors,includingdifferencesintheacuityortypes ofillnessesandinjuriesevaluated.Additionally,evenafter theintervention,thehighaverageopioidsprescribedinthe NPgroupwasdrivenbyafewcliniciansstillfarexceedingthe default(SupplementalFigure1).Theexistenceofinterclinicianvariabilityinprescriptionsmayprovide opportunitiesformoretargetedfutureinterventions,suchas NP-orPA-speciﬁcinterventionsinconjunctionwithEHRdriveninterventions.

Wechosetoanalyzetheaveragenumberoftablets prescribedperencounterinwhichopioidswereprescribed ratherthanperEDvisitorpermonth.Averagenumberof tabletsalignsmoredirectlywithourintervention,whichwas aimedatreducingthequantityofopioidsprescribedaftera clinicianhadalreadydeterminedaneedforopioidanalgesia. Additionally,thenumberoftabletsprescribedperopioid encounterislessimpactedbytemporalandseasonal variationinprescribingpatternsandvisitacuity,including theeffectoftheCOVID-19pandemic.

Inmostpriorstudies,clinicianswerenotnotiﬁedofaltered EHRdefaultprescriptionseitherforconvenienceortotest theeffectofadefaultchangealone,orduetoconcernthat clinicianswouldconsciouslyoverridethedefaults.9–13 However,wefoundthatdecreasingdefaultEHRopioid quantitiesto12tabletscoupledwithinformingcliniciansof theEHRchangeresultedinadecreaseinthetotalnumberof opioidsprescribedatEDdischarge.Weobserveddecreases intheaveragenumberoftabletsprescribedperpatientand theaverageMMEoftabletsprescribedperpatient.This suggeststhattransparencywithcliniciansregardingbest practicesinopioidprescribingdoesnotnegatetheeffectof alteringEHRdefaults.Itispossiblethatanannouncementto cliniciansabouttheEHRchangeandtherationalebehindit mayserveasaneducationalfeedbackcomponenttothe

intervention.Clinicianswhoappreciatethepurposeofthe defaultchangemaybemorelikelytousethedefault,golower thanthedefault,orevenwritefewerprescriptionsastheysee ﬁtforeachclinicalscenario,consistentwithpriorwork demonstratingthatauditandfeedbackapproachescan decreaseopioidprescribing.15

Becausepriorworkhasdemonstratedtheexistenceof racialdisparitiesinopioidprescribing,weinvestigated whetherclinicians’ opioidprescribingbehaviordiffered basedonpatientdemographics.16 Ouranalysisshowedthat therewasnostatisticallysigniﬁcantdisparityinopioid prescriptionamountsbasedonpatientdemographics, includingage,race,andgender,forboththepre-andpostinterventiondata.

ItisalsoimportanttonotethattheCOVID-19pandemic startedduringourpre-interventionphase,whichresultedin anoveralldecreaseinEDutilization.17 However,our outcomeissomewhatinsulatedfromchangesinEDvolume, astabletsperprescriptionshouldnotbedependentonthe numberofpatientdischarges.TheCOVID-19pandemicmay haveledtoothermoresubtlechangesinprescribingbehavior secondarytochangingpatientpopulationsseen,butthe majorchiefcomplaintsdidnotdifferinthepre-and post-interventionperiod,andtheresultsofoursensitivity analysisconﬁrmedthattheeffectseenwasstillpresent evenafterrestrictingourdatatoanentirely post-COVID-19timeframe.

Ultimately,werecognizethatopioidsremain ﬁ rst-line treatmentsforcertainindicationssuchasshort-termpain reliefforacutefracturesandcancerpainandareoften necessaryatdischargefromtheED.However,giventhe risksofdiversion,overdose,andOUDassociatedwith dischargingpatientswithlargequantitiesofopioidtablets, itisimportanttoencourageemergencycliniciansto dischargepatientswithaclinicallyappropriateyetsafe quantityoftablets.Itisalsoimportanttousediscretionas opioidsareoftennotindicatedforcertainothercausesof paininpatientspresentingtotheED,includingthe commonchiefcomplaintsofabdominalpainandlower backpain.18 Recommendationsforacutepainsuggest dischargingpatientswithathree-daysupplyofopioid medications,whichcorrespondsto12tabletsorless.19 Our approachisapragmatic,transparent,andscalable interventionthatoffersatoolthatcanbeimplementedin

the42%ofEDsnationwidethatcurrentlyhavedefaults exceeding12tablets.19

LIMITATIONS

Ourstudydesignofasingle-site,pre/poststudydoesnot allowforacausalinterpretationandlimitsgeneralizability. MuchoftheprojectoccurredduringtheCOVID-19 pandemic,inwhichopioidprescribingincreasednationwide; however,patternsforEDdischargeprescriptionshavenot beenstudied.20 Ourdesigndidnotallowustomeasure associatedharmsorbeneﬁts,suchaswhetherpaincontrol wasadequateorwhetherdiversiondecreased.21 Neitherdid ourdesignallowustotestfordifferencesinwhetherpatients wereprescribedopioids,whichisalsoanimportant considerationforopioidstewardship.Additionally,the 12-tabletdefaultquantitywaschosentoapproximatea three-daysupply,butthislengthmayvarybasedonthe frequencyprescribedofagivenopioid,andthereislimited evidencetosupporttheoptimaltimecourseofopioids atdischarge.22

Finally,thestudydesigndidnotallowustomeasurethe precisenumberofclinicianswhowereexposedtothe clinician-facingannouncement,differentiatewhetherthe effectsobservedwereattributabletotheEHRchangesalone, theclinician-facingannouncementalone,oracombination ofthetwo.

CONCLUSION

Wedemonstratedthataqualityimprovement interventioncouplingdecreaseddefaultopioidquantitiesin theelectronichealthrecordwithinformingcliniciansofthe EHRchangewasassociatedwithadecreaseinthetotal numberofopioidsprescribedfromtheED.Whileall cliniciantypes(NPs,PAs,andphysicians)decreasedtheir quantitiesofopioidsprescribedperdischargefollowingthe defaultchange,NPsandPAsprescribedmoreopioidsthan physiciansinitiallyandexperiencedalargerdecreasein opioidprescriptions.Futureinterventionsseekingtoaddress EDopioidprescribingshouldmeasurethetotalquantityof opioidsleavingtheEDoverlongerperiodsoftime,usea robust,patient-centeredmetricforpainmanagementfollowup,andattempttocorrelateEDopioidprescriptionswith negativeopioid-associatedoutcomesinbothindividual patientsandtheircommunities.

AddressforCorrespondence:MarianneJuarez,MD,Universityof CaliforniaSanFrancisco,DepartmentofEmergencyMedicine,521 ParnassusAvenue,7th ﬂoor,SanFrancisco,CA94143.Email: Marianne.Juarez@ucsf.edu

ConﬂictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallafﬁliations,fundingsources

and ﬁnancialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.KaiTrepkawassupportedbygrant T32GM007618fromtheNationalInstituteofGeneralMedical SciencesoftheNationalInstitutesofHealth.Therearenoother conﬂictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.SchieberLZ,GuyGP,SethP,etal.Trendsandpatternsofgeographic variationinopioidprescribingpracticesbystate,UnitedStates, 2006–2017. JAMANetwOpen.2019;2(3):e190665.

2.ShahA,HayesCJ,MartinBC.Characteristicsofinitialprescription episodesandlikelihoodoflong-termopioiduse UnitedStates, 2006–2015. MMWRMorbMortalWklyRep.2017;66(10):265–9.

3.HoppeJ,KimH,HeardK.Associationofemergencydepartment opioidinitiationwithrecurrentopioiduse. AnnEmergMed 2015;65(5):493–9.

4.JohnsonDG,HoVT,HahJM,etal.Prescriptionquantityandduration predictprogressionfromacutetochronicopioiduseinopioid-naïve Medicaidpatients.MattieH,ed. PLOSDigitHealth 2022;1(8):e0000075.

5.Kennedy-HendricksA,GielenA,McDonaldE,etal.Medicationsharing, storage,anddisposalpracticesforopioidmedicationsamongUSadults. JAMAInternMed.2016;176(7):1027.

6.DaoustR,PaquetJ,MarquisM,etal.Evaluationofinterventionsto reduceopioidprescribingforpatientsdischargedfromtheemergency department:asystematicreviewandmeta-analysis. JAMANetwOpen 2022;5(1):e2143425.

7.RathlevN,AlmomenR,DeutschA,etal.Randomizedcontrolledtrialof electroniccareplanalertsandresourceutilizationbyhighfrequency emergencydepartmentuserswithopioidusedisorder. WestJEmerg Med.2016;17(1):28–34.

8.DowellD,HaegerichTM,ChouR.CDCguidelineforprescribingopioids forchronicpain UnitedStates,2016. JAMA.2016;315(15):1624.

9.MontoyJCC,CoralicZ,HerringAA,etal.Associationofdefault electronicmedicalrecordsettingswithhealthcareprofessionalpatterns ofopioidprescribinginemergencydepartments:arandomizedquality improvementstudy. JAMAInternMed.2020;180(4):487.

10.CarlsonA,NelsonME,PatelH.Longitudinalimpactofapre-populated defaultquantityonemergencydepartmentopioidprescriptions. JAm CollEmergPhysiciansOpen.2021;2(1):e12337.

11.ZivinK,WhiteJO,ChaoS,etal.Implementingelectronichealthrecord defaultsettingstoreduceopioidoverprescribing:apilotstudy. Pain Med.2019;20(1):103–12.

12.DelgadoMK,ShoferFS,PatelMS,etal.Associationbetweenelectronic medicalrecordimplementationofdefaultopioidprescriptionquantities andprescribingbehaviorintwoemergencydepartments. JGenIntern Med.2018;33(4):409–11.

13.SantistevanJ,SharpB,HamedaniA,etal.Bydefault:theeffectof prepopulatedprescriptionquantitiesonopioidprescribinginthe emergencydepartment. WestJEmergMed.2018;19(2):392–7.

14.LozadaMJ,RajiMA,GoodwinJS,etal.Opioidprescribingbyprimary careproviders:across-sectionalanalysisofnursepractitioner, physicianassistant,andphysicianprescribingpatterns. JGenIntern Med.2020;35(9):2584–92.

15.AndereckJW,ReuterQR,AllenKC,etal.Aqualityimprovement initiativefeaturingpeer-comparisonprescribingfeedbackreduces emergencydepartmentopioidprescribing. JtCommJQualPatientSaf 2019;45(10):669–79.

16.KeisterLA,StecherC,AronsonB,etal.Providerbiasinprescribing opioidanalgesics:astudyofelectronicmedicalrecordsatahospital emergencydepartment. BMCPublicHealth.2021;21(1):1518.

17.VenkateshAK,JankeAT,Shu-XiaL,etal.Emergencydepartment utilizationforemergencyconditionsduringCOVID-19. AnnEmergMed 2021;78(1):84–91.

18.KamperSJ,LoganG,CopseyB,etal.Whatisusualcareforlowback pain?Asystematicreviewofhealthcareprovidedtopatientswithlow backpaininfamilypracticeandemergencydepartments. Pain 2020;161(4):694–702.

19.BlutingerEJ,ShoferFS,MeiselZ,etal.Variabilityinemergency departmentelectronicmedicalrecorddefaultopioidquantities:A nationalsurvey. AmJEmergMed.2019;37(10):1963–4.

20.LeeB,YangKC,KaminskiP,etal.Substitutionofnonpharmacologic therapywithopioidprescribingforpainduringtheCOVID-19pandemic. JAMANetwOpen.2021;4(12):e2138453.

21.DuncanRW,SmithKL,MaguireM,etal.Alternativestoopioids forpainmanagementintheemergencydepartmentdecreases opioidusageandmaintainspatientsatisfaction. AmJEmergMed 2019;37(1):38–44.

22.McCarthyDM,KimHS,HurSI,etal.Patient-reportedopioidpill consumptionafteranEDvisit:Howmanypillsarepeopleusing? Pain Med.2021;22(2):292–302.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

AccessibilityofNaloxoneinPharmaciesRegistered UndertheIllinoisStandingOrder

P.QuincyMoore,MD*†

KaitlinEllis,MD‡

PatriciaSimmer,MD§

MweyaWaetjen,BA∥

EllenAlmirol,MPH,MA¶

ElizabethSalisbury-Afshar,MD,MPH#**

MaiT.Pho,MD,MPH††

*PermanenteMedicalGroup,Oakland,California

† KaiserPermanenteOaklandMedicalCenter,Departmentof EmergencyMedicine,Oakland,California

‡ BrownUniversity,DepartmentofObstetricsandGynecology, Providence,RhodeIsland

§ UniversityofChicago,DepartmentofMedicine,Chicago,Illinois

∥ UniversityofChicagoPritzker,SchoolofMedicine,Chicago,Illinois

¶ UniversityofChicago,ChicagoCenterforHIVElimination, Chicago,Illinois

# UniversityofWisconsin-Madison,SchoolofMedicineandPublic Health,DepartmentofFamilyMedicineandCommunityHealth, Madison,Wisconsin

**UniversityofWisconsin-Madison,SchoolofMedicineandPublic Health,DepartmentofPopulationHealthSciences,Madison,Wisconsin

†† UniversityofChicago,DepartmentofMedicine,SectionofInfectious DiseasesandGlobalHealth,Chicago,Illinois

SectionEditor:GentryWilkerson,MD

Submissionhistory:SubmittedMarch16,2023;RevisionreceivedJanuary24,2023;AcceptedFebruary9,2024

ElectronicallypublishedMay21,2024

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

DOI: 10.5811/westjem.17979

Introduction: Toexpandaccesstonaloxone,thestateofIllinoisimplementedastandingorderallowing registeredpharmaciestodispensethedrugwithoutanindividualprescription.Toparticipateunderthe standingorder,pharmacieswererequiredtooptinthroughaformalregistrationprocess.Inourstudywe aimedtoevaluatetheavailabilityandpriceofnaloxoneatregisteredpharmacies.

Methods: Thiswasaprospective,de-identiﬁed,cross-sectionaltelephonesurvey.Trainedinterviewers posedaspotentialcustomersandusedastandardizedscripttodeterminetheavailabilityofnaloxone betweenFebruary–December,2019.Theprimaryoutcomewasdeﬁnedasapharmacyindicatingit carriednaloxone,currentlyhadnaloxoneinstock,andwasabletodispenseitwithoutan individualprescription.

Results: Of948registeredpharmacies,886(93.5%)weresuccessfullycontacted.Ofthose,792(83.4%) carriednaloxone,659(74.4%)hadnaloxoneinstock,and472(53.3%)allowedpurchasewithouta prescription.Naloxonenasalspray(86.4%)wastheformulationmostcommonlystocked.Chain pharmaciesweremorelikelytocarrynaloxone(adjustedoddsratio[aOR]3.16,95%conﬁdenceinterval [CI]1.97–5.01, P < 0.01)andhavenaloxoneinstock(aOR2.72,95%CI1.76–4.20, P < 0.01),butnomore likelytodispenseitwithoutaprescription.Pharmaciesinhigherpopulationareas(aOR0.99,95%CI 0.99–0.99, P < 0.05)andruralareasadjacenttometropolitanareas(aOR0.5,95%CI025–0.98, P < 0.05) werelesslikelytohavenaloxoneavailablewithoutaprescription.Associationsofnaloxoneavailability basedonotherurbanicitydesignations,overdosecount,andoverdoseratewerenotsigniﬁcant.

Conclusion: AmongpharmaciesinIllinoisthatformallyregisteredtodispensenaloxonewithouta prescription,theavailabilityofnaloxoneremainslimited.Additionalinterventionsmaybeneededto maximizethepotentialimpactofastatewidestandingorder.[WestJEmergMed.2024;25(4)457–464.]

INTRODUCTION

Theriseofopioid-relatedoverdosehashadadevastating effectoncommunitiesacrosstheUnitedStates.In2020alone, over68,000peoplediedfromopioid-relatedoverdose,ofwhich almost3,000occurredinthestateofIllinois.1,2 Therapidly evolvingdrugmarket,withtheintroductionoffentanyl, fentanylanalogues,andxylazineintotheillicitdrugsupply,has contributedtotheincreasingopioidoverdosefatalityrates, with64%ofUSdrugoverdosedeathsduringMay2020–April 2021involvingillicitlymanufacturedfentanyl.3–5

Inresponsetotheopioidoverdoseepidemic,amultiprongedapproachhasbeenenactedtoreducemorbidityand mortality.Amongtheseareseveralharmreduction strategies,includingsyringeserviceprograms,infectious diseasescreening,drugchecking(eg,fentanyltest-strip distribution),supervisedconsumptionsites,anddistribution ofnaloxone.Multiplestudieshavedemonstratednaloxone’ s abilitytobeusedeffectivelyandappropriatelybypeople withnoformalmedicaltraining.6 Forexample,Enteenetal foundthatofthe24%ofpatientswhoreturnedfornaloxone reﬁllsoverasix-yearperiod,11%ofthosereportedusing naloxoneduringanoverdoseevent,withan89%successrate ofoverdosereversal.7 Further,studieshaveshownthat naloxonedistributiondoesnotleadtoincreasedopioid consumptionandmayevenleadtodecreaseduse.7,8 Recognizingitssafetyandefﬁcacy,theUSSurgeonGeneral issuedanadvisorynoticein2018encouragingitsuseand availability.9 Despitewidespreadsupportbyleading healthcareorganizationsandfederalagencies,naloxone accessremainslimited,andopportunitiestohelpindividuals atriskforoverdosearefrequentlymissed.10,11

Asof2017,all50stateshadpassedlegislationexpanding publicaccesstonaloxone.12 Inadditiontolegislation protectingagainstcivil,criminal,orprofessionalliabilityfor bothprescribersandlayadministratorsofnaloxone,some stateshaveintroducedpoliciestoincreasetheaccessibilityof thelife-savingdrug.Studieshavedemonstratedthat pharmacistsarewillingtoprovidenaloxonetothepublic underastandingorderorothersimilarprocess(Stewartetal, 2018;Nielsenetal,2016;Greenetal,2017).Toexpand accesstonaloxone,theIllinoisDepartmentofPublicHealth (IDPH)implementedastatewidestandingorderin2017 (PublicAct99–0480),allowingregisteredpharmaciesto distributenaloxonetopatientswithoutanindividual prescriptionintheirname.ToregisterundertheIllinois NaloxoneStandingOrder,licensedpharmaciesmust participateinapre-approvedtrainingandagreetoreport anydispensednaloxonetotheIllinoisPrescription MonitoringProgram.13

Illinoisisnowoneof49statesthatallowpharmaciststo dispensenaloxonewithoutapatient-speciﬁcprescription fromaclinician,44ofwhichuseastandingorder.14 Despite this,studiesfromotherstateshaveshownlimiteduptakeof

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Moststatesoffernaloxoneatpharmacies withoutaprescription,butuptakeislimited.

Whatwastheresearchquestion?

Whichpharmaciesregisteredunderthe IllinoisNaloxoneStandingOrder hadnaloxoneavailablewithout aprescription?

Whatwasthemajor ﬁndingofthestudy?

Only53.3%ofregisteredpharmacies(1/8 th of allIllinoispharmacies)hadnaloxoneinstock andavailablewithoutaprescription.

Howdoesthisimprovepopulationhealth?

Statewidestandingordersareanimportant butinsuf ﬁ cientsteptowardwidespread naloxonepossession.Moreeffortisneededto improveparticipation.

thesenewprotocolsandwidevariationsinavailabilityof naloxoneatregisteredpharmacies.15–22 Inthiscrosssectionalstudyweaimedtoevaluatetheaccessibilityof naloxoneatpharmaciesregisteredunderthestatewide standingorderbydeterminingwhichpharmaciesreported routinelycarryingnaloxone,whichpharmacieshad naloxonecurrentlyinstock,whichpharmacieswerewilling todispensenaloxonewithoutaprescription,which formulationswerecarried,andtheout-of-pocketcostof naloxone.Ourprimaryoutcomewastodeterminewhich pharmacieshadnaloxoneavailablewithoutaprescriptionon thedayoftheinquiry.Wefurthercomparedpharmacies’ naloxoneavailabilitybypharmacytype(chainvsnon-chain), urbanicity,populationofZIPCode,andopioidoverdose ratesinthepharmacies’ surroundingregion.Thisstudy expandsontheexistingliteraturebyusingasamplethat includedallpharmaciesthatoptedintoregisteringunderthe IllinoisNaloxoneStandingOrder.Wealsoanalyzedfactors thatmayaffectthelikelihoodthatapharmacyhadnaloxone availablewithoutaprescription,whichwasrarelydonein previousstudies.

METHODS StudyDesign

Aprospective,anonymous,cross-sectional “secretshopper” telephonesurveysamplingallIllinoispharmacies

thathadregisteredunderthestate-levelstandingorderwas performedbysixtrainedcallers.Thelistofpharmacies registeredunderthestandingorderwasaccessedon February17,2019(Chicago)andMay23,2019(remainder ofIllinois)viatheIDPHOpioidDataDashboard.2 Thelist ofpharmacies,theircities,andtheircontactnumberswere transposedfromthedashboardintoanExceldocument (MicrosoftCorp,Redmond,WA)fortrackingpurposes.For eachpharmacy,weobtainedaZIPCodeandevidenceof continuedoperationviaGooglesearches.Ifapharmacywas foundtonolongerbeinexistence,thepharmacywasmarked asunabletocontact.

DataCollection

Sixstudypersonnel(oneattendingphysician,oneresident physician,threemedicalstudents,andonemaster’slevel researchassociate)underwentthreehoursoftraining consistingofreviewingthecallscript,discussingthelogic behindeachquestion,discussingspeciﬁclanguagetouse,and conductingatleastthreepilotcallstopharmaciesnot includedinthestudysample.Pilotcallsweredebriefedas agroup.

Thecallersposedaspotentialcustomersanduseda standardizedscripttoasktargetedquestions.Callers followedautomatedpromptsorrequestedtobeconnectedto thepharmacy.Callersspokewithwhicheverpharmacystaff ﬁrstansweredthecallandcontinuedtousethescriptifthe callwastransferredtootherpharmacystaff.Ifplacedon hold,thecallerwaitedupto10minutesbeforeterminating thecall.Ifthecallwasinterruptedorthepharmacywas unreachableontheinitialattempt,thepharmacywas contacteduptotwoadditionaltimes.Ifapharmacywas unreachablethreetimes,itwasconsideredinactiveandnot includedinouranalyses.Callswerecompletedfrom February–December2019.Datawascollectedeitherdirectly intoREDCap9.5.35LTS(ResearchDataCapturehostedat UniversityofChicagoMedicine)orintoMicrosoftExceland latertransposedintoREDCap.

Thescriptforthecallswascreatedusinganiterative processbythegroupofinvestigators.Wedesignedthescript toaddressthestudyquestionswhilemaintainingthe appearanceofalaycaller.Thegenericnameofthe medication(naloxone)wasusedinitially.Ifstaffseemed uncertainofthemedicationinquestion,thebrandnameof Narcanwasusedafter ﬁrstrepeatingthegenericname.See Appendix1forthescriptforthesecret-shoppertelephone surveyofpharmaciesthatareregisteredundertheIllinois NaloxoneStandingOrder.

Measures

Wecollectedcharacteristicsforeachpharmacybasedon pharmacytype,urbanicity,populationofpharmacyZIP Code,andtheoverdoserateinthepharmacyZIPCode. Pharmacieswereclassiﬁedas “chain” iftheyhadfouror

morelocationsundersharedownership,and “non-chain” if theyhadfewerthanfourlocations.15,16 Wedeﬁned urbanicityusingtheUSDepartmentofAgriculture2013 Rural-UrbanContinuumCodes(RUCC)thatassign countiesascoreonascaleof1-9basedoncountypopulation sizeandadjacencytoametropolitanarea.17 Ascommonly practicedelsewhereintheliterature,wedividedthis continuumintothreegroups:1)urban;2)ruraladjacenttoa metropolitanarea;and3)ruralandnonadjacenttoa metropolitanarea.

WeusedZIPCodescorrespondingtoeachpharmacyto analyzethedatausingoverdoseratesandpopulation. Numberofcombinedfatalandnon-fatalopioid-related overdoseeventsin2018byZIPCodewasobtainedfromthe IDPHOpioidDashboard.2 WeobtainedpopulationbyZIP Codefor2018fromtheUSCensusBureau.18 Usingthe populationsizeandthenumberofoverdoses,wecalculateda 2018rateofcombinedfatalandnon-fatalopioid-related overdoseper10,000peopleforeachZIPCodeinoursample.

StatisticalAnalyses

Weperformedbivariateanalysestodeterminewhether differencesinnaloxoneavailabilityonthedayofthecallwere signiﬁcantlydifferentbasedonthefollowingcovariates: pharmacytype;urbanicityusingRUCCcode;populationof pharmacyZIPCode;andthe2018overdosecountand overdoserateper10,000residentsinthepharmacyZIP Code.WeanalyzeddatausingSTATAMPv17statistical softwarerelease15(StataCorp,LLC,CollegeStation,TX). ThisstudywasreviewedbytheUniversityofChicago InvestigationalReviewBoardanddeterminedtobeexempt fromreview.

RESULTS

Weidentiﬁed948pharmaciesregisteredundertheIllinois NaloxoneStandingOrderandsuccessfullycontacted886 (93.5%)(Figure1).Ofthe886pharmaciesthatwere successfullycontacted,806(91.0%)werechainpharmacies and80(9.0%)werenon-chain.Ofthe886contacted pharmacies,807(91.1%)werelocatedinurbanZIPCodes, 57(6.4%)inruralZIPCodesadjacenttoametropolitanarea, and22(2.5%)inruralZIPCodesthatwerenonadjacenttoa metropolitanarea.Additionally,ofthecontacted pharmacies,792(89.4%)reportedcarryingnaloxone,with 659(74.4%)reportingthemedicationtobeinstockatthe timeofthecall,and472(53.3%)respondingthatthecaller didnotneedaprescriptionfromadoctortopurchasethe naloxone.The472pharmacies(53.3%)thatcarried naloxone,hadnaloxoneinstock,andofferednaloxone withoutrequiringaprescriptionwereconsideredpositivefor theprimaryoutcome.Pharmacycharacteristicsare summarizedin Table1

Figure2 displaysthecascadeofnaloxoneavailabilityby pharmacytypeandRUCC.PharmaciesinurbanRUCC

Figure1. AvailabilityofnaloxoneandneedforaprescriptioninIllinoispharmaciesregisteredundertheIllinoisNaloxoneStandingOrder.

Table1. Pharmacytype,urbanicity,andnaloxoneavailabilityofpharmaciesregisteredundertheIllinoisNaloxoneStandingOrderthatwere successfullycontacted(n = 886).

Successfully contacted, n = 886(Col%)

Carry Naloxone n = 792(Row%)

CarryNaloxone, instock n = 659(Row%)

RUCC

Rx, prescription; RUCC,Rural-UrbanContinuumCodes.

codeshadthehighestnaloxoneavailabilitywithouta prescription(63.7%).Alargerproportionofchain pharmaciescarriednaloxone(90.3%)comparedtononchainpharmacies(80.0%)(P < 0.01).Ofthe772pharmacies thatstockednaloxoneandprovidedaresponsetothetypeof naloxone,624(78.8%)carriednaloxonenasalspray (see Table2).

Intheadjustedanalyses,wefoundthatchainpharmacies hadgreateroddsofcarryingnaloxone(adjustedoddsratio [aOR]3.16,95%conﬁdenceinterval[CI]1.97–5.01, P < 0.01) andhavingnaloxoneinstock(aOR2.72,95%CI1.76–4.20,

P < 0.01)comparedtonon-chainpharmacies(Table3). However,therewerenodifferencesbetweenpharmacytype andnaloxoneavailabilitywithoutaprescription.With regardtoRUCC,ruraladjacenttoametroareahadlower oddscomparedtourbanareasofprovidingnaloxone withoutaprescription(aOR0.50,95%CI0.25–0.98, P = 0.05).WealsoobservedthatmoredenselypopulatedZIP Codeswerelesslikelytohavenaloxoneavailablewithouta prescription(aOR0.99,0.99–0.99, P < 0.01).Neither overdose(OD)countnorODratewereassociatedwith naloxoneavailability.

Figure2. Pharmacytype,countyurbanicity,andnaloxoneavailabilityofpharmaciesregisteredundertheIllinoisNaloxoneStandingOrder thatweresuccessfullycontacted. Rx,prescription.

Table2. Ofthosewhocarrynaloxone,availableformulationsof naloxoneandmedianprice.

Naloxone types N = 722 (%) Medianprice [IQR]

Naloxone nasal spray

IMvials

Naloxone autoinjector

624(86.4)$135.99[$89.99,$4,500]

71(9.8)$39.50[$21.99.$239.00]

27(3.8)$4,000[$399.59,$6,000.00]

IQR, interquartilerange; IM,intramuscular.

DISCUSSION

Standingordersareanimportantsteptowardreducing opioid-relatedmortality,butour ﬁndingssuggestthis legislationhasnothadthedesiredeffectinstateresidents’ accesstonaloxone.In2019,twoyearsafterthe implementationoftheorder,therewasanaverageof3,861 licensedpharmaciesstatewide.19 Ofthese,only948(24.6%)

wereregisteredunderthestandingorderatthetimeofour study.Wesuccessfullycontacted91%oftheregistered pharmaciesandfoundthatjustoverhalf(53.3%)had naloxoneavailableonthedayofcontactandappropriately offereditwithoutrequiringaprescription.Giventhatall pharmaciesonourcontactlistunderwentpre-approved trainingtoregisterwithIDPHasanaloxonedistributionsite underthestandingorder,our ﬁndingsindicatethereis substantialroomforimprovement.

Studiesfromotherstateswithcomparablestatewide naloxoneaccesspolicieshaveshownlimiteduptakewith widevariationsinavailabilityofnaloxone.Across California,Texas,Pennsylvania,Massachusetts,andNew York,theproportionofpharmaciesthathadnaloxonein stockrangedfrom23.5–70%,withsomevariationbasedon stateandthespeciﬁcsampleofpharmaciesstudied.20–24 Few studieshaveanalyzedspeciﬁccharacteristicsthatmayaffect anindividualpharmacy’slikelihoodofhavingnaloxone available.22,25 InPennsylvania,Gravesetalfoundthatchain

Table3. Associationbetweenpredictorsandcarrynaloxone,instock,andnoprescriptionneeded.

Pharmacytype

Non-chain Ref Ref Ref Chain

RUCC

Urban Ref Ref Ref

Ruraladjacenttoametroarea1.77(0.79,3.98)0.171.27(0.69,2.36)0.44 0.50(0.25,0.98)0.05

Rural,nonadjacenttoametroarea1.16(0.41,3.30)0.781.15(0.47,2.82)0.750.48(0.17,1.36)0.17

PopulationbyZIPCode

1.00(0.99,1.00)0.611.00(0.99,1.00)0.40 0.99(0.99,0.99)0.003

ODcount 1.00(0.99,1.00)0.741.00(0.99,1.00)0.420.99(0.98,1.00)0.09

ODrate 0.99(0.98,1.00)0.160.99(0.99,1.00)0.360.99(0.98,1.00)0.27

Bold, P ≤ 0.05; Adjustedanalysesincludecontrollingforpharmacytype,RUCC,andpopulationbyZIPCode. Rx,prescription; aOR,adjustedoddsratio; CI, conﬁdenceinterval; RUCC,Rural-UrbanContinuumCodes; OD,overdose.

pharmaciesweremorelikelytocarrynaloxone,butODrate andurbanicitydidnotinﬂuencenaloxoneavailability.22 In Indiana,Meyersonetalfoundthatchainpharmacies, pharmacieswithmorethanonefull-timepharmacist,and thosewherepharmacistshadreceivednaloxone-related continuingeducationwereassociatedwithincreased likelihoodofstockingnaloxone.25

Asystematicreviewofthetopicfoundthata heterogeneousgroupof30studieshadwide-ranging ﬁndings, butoverallone-thirdofpharmaciesauditeddidnotcarry naloxoneandalmosthalfdidnotoffernaloxonewithouta prescription.26 Whilepreviousstudieshaveexploredthe availabilityofnaloxoneunderastandingorderindifferent states,analysisoffactorsthatmaycontributetothe likelihoodthatapharmacyhasnaloxoneavailablewithouta prescriptionremainslimited.Ourstudyisalsouniqueforits highresponserateaswellasouruseofasampleincludingall pharmaciesthatoptedintoformalizedtrainingand registrationunderthestandingorder.

Improvedaccesstonaloxonethroughcommunity pharmaciesmaycomethroughmultipleapproaches.First, withlessthanaquarterofpharmaciesregistered,our findings highlighttheneedformorewidespreadparticipationinthe IllinoisNaloxoneStandingOrder.Itappearsthatthepublic goodandthe financialincentivesattachedtoincreased dispensingofnaloxoneareinsufficienttoincentivize pharmaciestotakethestepsnecessarytoregisterunderthe standingorder.Ofnote,IllinoisMedicaidplansarerequired tocoveratleastoneformulationofnaloxone,withthe intranasalformulationthemostcommonlycovered formulation.IllinoisMedicaiddoesnotchargeacopayfor receiptofnaloxone.Additionalincentivesmaybenecessary tomobilizegreaterpharmacyparticipationstatewide.

Ruralareasappearedtohaveparticularlypooraccessto naloxonethroughcommunitypharmacies.While11.5%of Illinoisresidentsliveinruralareas,wefoundthatonly22 (2.3%)ofthepharmaciesregisteredunderthestandingorder wereinruralareas.27 Whiletherewasnosigniﬁcant differenceintheprimaryoutcomeinruralvsurban pharmacies,theoverallpaucityofregisteredpharmaciesin ruralareashighlightsalackofaccessthatmayputrural peoplewhousedrugsathigherriskofdeathfromoverdose. Thismayfurtherexacerbatethedisproportionateimpactof theopioidcrisisonruralareas.28,29

Oftheregisteredpharmacieswecontacted,our ﬁndings highlightspeciﬁctrendsthatmayinformeffortstoimprove accesstonaloxone.Wefoundthatchainpharmacieswere morelikelythannon-chainpharmaciestocarrynaloxone andhaveitinstockbutwerenomorelikelytohaveitinstock withoutaprescriptionrequired.Thissuggeststhatthereare policiesuniquetochainpharmaciesthatfacilitateregistering underthestandingorderandstockingnaloxone,butthat perhapstrainingforcustomer-facingstaffhasbeen inadequate.Thisledultimatelytosimilaroutcomestonon-

chainpharmacieswhenitcametocustomersseekingto purchasenaloxonewithoutaprescription.These ﬁndings havesomeconsistencywithonePennsylvaniastudy,which foundchainpharmaciestobemorelikelytocarrynaloxone andanswerquestionscorrectlyaboutthestandingorderfor naloxone.22 Chainpharmaciesmayhavemorestandardized trainingprogramsforcertainstaffmembers,maintain robustsupplychainsfornaloxone,orhaveastronger responsetopublicpressuretocontributetoreducingopioidrelateddeaths.

Therewasnostatisticallysigniﬁcantassociationbetween thenumberorrateofODsinaZIPCodeandlikelihoodof naloxoneavailability.This ﬁndingsuggeststhattheremaybe additionaloutreachorincentivesnecessarytoencourage pharmaciesinareaswiththehighestratesofODtoincrease accesstonaloxoneviathestandingorder.

Costandavailableformulationmayhaveasignificant impactonhowlikelyacustomeristoobtainnaloxone.Inour sample,bothcostandformulationwerevariable.The majorityofpharmaciesthathadnaloxoneinstockcarried thenasalnaloxonespray(brandnameNarcan)foran averagecostof$135.99foratwo-pack.WhileIllinois Medicaidplanscoveratleastoneformulationofnaloxone withoutcopay,privateinsuranceandMedicarePartDplans havevariablecopaystructuresandformulationcoverage. Foruninsuredindividuals,thosewhodon’twanttousetheir insuranceto fillthismedication,orthoseforwhomnaloxone isnotacoveredmedication,theout-of-pocketcostmaybea significantdeterrenttoobtainingnaloxone.Vialsof naloxone,whichcanbeusedwithaneedleandsyringeand injectedintramuscularly,orwithanatomizerfornasal administration,hadalowermedianpriceof$39.50;however, only9%ofpharmacieshadthisformulationinstock,andthe availabilityandcostofothernecessarysuppliessuchas syringes,intramuscularneedles,and/ornasalatomizerswas unclear.Wedobelievethatsomeofthehighpricesthatwere reportedbypharmacystaffareinaccurateandforthisreason wepresentthemedianprice,whichwebelieveaccurately reflectswhatmostconsumerswouldpayoutofpocket. Ourstudyhighlightstheneedforadditionalstrategiesto maximizeaccesstonaloxone.Giventhatruralareasareless likelytohavecommunity-basednaloxonedistribution(often aserviceofferedatharmreduction/syringeservice programs),thisneedisparticularlygreatinruralareas.30–32 Futureresearchisneededtounderstandwhethernaloxone availabilityinpharmaciesisassociatedwithincreased utilizationand,ifso,howtoincreaseavailabilityofnaloxone viastandingorderinretailpharmacies.Possible considerationscouldincludethefollowing:publiceducation campaignsthatwouldworktoincreasedemandfornaloxone inpharmacies,therebyencouragingpharmaciestoregister andstocknaloxone;offering financialincentivesorother publicrecognitionforpharmaciesthatregisterforthe standingorderandstocknaloxoneformulations;and

improvedpublichealthoutreachandeducationalprograms (eg,academicdetailing)toincreaseawarenessamong pharmacies,pharmacists,andpharmacystaffaboutthe purposeofandevidencebaseofnaloxoneasitrelatesto reducingopioid-relatedmortalityatthecommunitylevel.

Researchhasfoundthatpharmacists’ discomfort dispensingnaloxonetocustomersremainsanimportant barrierandoftenresultsfrominadequatetraining(Green, 2017;Thornton,2017;Rudolph,2018).AsofNovember20, 2017,only19stateshadmandatednaloxoneeducationfor pharmacists(Roberts,2019).33 Illinoisregulationrequires participatingpharmaciststocompleteanIllinois DepartmentofHumanServices-approvedtrainingmodule orto “understandtheNaloxoneStandardizedProcedures” andwatchtwotrainingvideos(IDPHNaloxoneFAQ),butit isunclearhowmuchofthistrainingispassedalongtostaff whodirectlyinteractwithcustomers.Onestudycomparing trainingmaterialprovidedbystatesfoundthatwhilemost materialcoveredthepurposeanduseofnaloxoneaswellas thestandingorderlegislation,fewprovidedthorough educationonhowtocommunicatethisinformationto customers(Carpenter,2018).Overall,whiletherehasbeen anincreaseinnaloxonedispensedacrossallstateswith expandedaccesspolicies,retailpharmacynaloxone distributionisstillunderusedandvariesstateby state(Xu,2018).

LIMITATIONS

Ourstudyhasseverallimitations.Wedidnotclarifythe roleofthestaffmemberwithwhomwewerespeaking.Itis possiblethatifwehadaskedtospeakdirectlytothe pharmacist,wewouldhaveobtainedmoreaccurate information;however,wefeltitwasmostusefultomimica morenaturalconsumerinteraction.Itispossible,however, thatresponseswouldvarybetweenstaffmembersatan individualpharmacy.Informationmayalsohavebeenmore accuratehadweidentiﬁedourselvesasacademicresearch staff.Fiveofsixcallershadatleastsomemedical background,butwebelievethatotherstudiescouldachieve thesamegoalinananalogousstudyusingstaffwithno medicalbackground.

Wedidnotcallpharmaciesthatwerenotlistedonthe IDPHwebsite;sofutureresearchmayincludeanalysisofthe percentageoftotalpharmaciesindifferentregionsthatoffer naloxone.Wecollectedonlyinformationaboutout-ofpocketcost,whichislikelyonlyrelevanttopatientswithout insurance,thosewhodon’twanttouseinsurancewhen receivingnaloxone,orthosewithoutnaloxoneincludedin theirpharmacybeneﬁt.Lastly,andperhapsmostrelevantto futureresearch,werecognizethatavailabilityofnaloxonein retailpharmaciesmaynotdirectlycorrelatewithincreased utilizationbypeoplewhousedrugs(PWUD).Futurestudies shouldincorporateinputfromPWUDtodelineate preferencesinsourcesofnaloxone.

CONCLUSION

Wefoundthattwoyearsafterimplementationofthe IllinoisNaloxoneStandingOrder,onlyone-eighthofall pharmacieshadnaloxoneinstockandavailablewithouta prescription.Withinthisgroup,chainpharmaciesweremore likelytocarrynaloxoneandhaveitinstockbutwerenomore likelytoprovideitwithoutaprescription.Pharmaciesin moredenselypopulatedZIPCodesandthosewithaRuralUrbanContinuumCodereﬂectingruralareasthatare adjacenttometroareaswerelesslikelytohavenaloxone availablewithoutaprescription.Overdoseratesinthe surroundingcommunityhadnoeffectonnaloxone availability.Ourstudyillustratesauniquesampleofall pharmaciesstatewidethathavegonethroughformaltraining andregistrationunderthestandingorder.

Increasedaccesstonaloxoneinretailpharmaciesin Illinoiswillrequireimprovedeffortsrelatedtoawarenessand implementationofthestandingorder,aswellasfurther investigationintothereasonsthatapharmacythathasgone throughtheprocessofapplyingtobeabletousethestanding orderdoesnotreliablystocknaloxoneandmakeitavailable withoutprescription.Speciﬁcattentionshouldbe giventoareaswherethereislimitedaccesstonaloxone throughcommunity-baseddispensingprograms andwhereratesofoverdoseandpotentialforimpact arehighest.

AddressforCorrespondence:P.QuincyMoore,KaiserPermanente OaklandMedicalCenter,DepartmentofEmergencyMedicine,3600 Broadway,Oakland,CA94611.Email: paul.q.moore@kp.org

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

REFERENCES

1.NationalInstituteonDrugAbuse.Drugoverdosedeathrates.2023. Availableat: https://nida.nih.gov/research-topics/trends-statistics/ overdose-death-rates.AccessedJanuary19,2022.

2.IllinoisDepartmentofPublicHealth.IDPHdata.Availableat: https://dph. illinois.gov/topics-services/opioids/idph-data-dashboard.html AccessedJanuary19,2022.

3.O’DonnellJ,TanzLJ,GladdenRM,etal.Trendsinandcharacteristicsof drugoverdosedeathsinvolvingillicitlymanufacturedfentanyls-United States,2019–2020. MorbMortalWklyRep.2021;70(50):1740–6.

4.KariisaM,PatelP,SmithH,etal.Notesfromthe ﬁeld:xylazinedetection andinvolvementindrugoverdosedeaths-UnitedStates,2019. MorbMortalWklyRep.2021;70(37):1300–2.

5.ChhabraN,MirM,HuaMJ,etal.Notesfromthe ﬁeld:xylazine-related deaths-CookCounty,Illinois,2017–2021. MorbMortalWklyRep 2022;71(13):503–4.

6.WalleyAY,XuanZ,HackmanHH,etal.Opioidoverdoseratesand implementationofoverdoseeducationandnasalnaloxonedistribution inMassachusetts:interruptedtimeseriesanalysis. BMJ 2013;346:f174.

7.EnteenL,BauerJ,McLeanR,etal.Overdosepreventionandnaloxone prescriptionforopioidusersinSanFrancisco. JUrbanHealth 2010;87(6):931–41.

8.BazaziAR,ZallerND,FuJJ,etal.Preventingopiateoverdosedeaths: examiningobjectionstotake-homenaloxone. JHealthCarePoor Underserved.2010;21(4):1108–13.

9.OfﬁceoftheSurgeonGeneral.U.S.SurgeonGeneral’sAdvisoryon NaloxoneandOpioidOverdose.2018.Availableat: https://www.hhs. gov/surgeongeneral/priorities/opioids-and-addiction/naloxoneadvisory/index.html.AccessedJanuary1,2020.

10.GuyGPJr.,HaegrichTM,EvansME,etal.Vitalsigns:pharmacy-based naloxonedispensing UnitedStates,2012–2018. MorbMortalWkly Rep.2019;68(31):679–86.

11.FollmanS,AroraVM,LyttleC,etal.Naloxoneprescriptionsamong commerciallyinsuredindividualsathighriskofopioidoverdose. JAMA NetwOpen.2019;2(5):e193209.

12.TheNetworkforPublicHealthLaw.Legalinterventionstoreduce overdosemortality:naloxoneaccesslaws.2021.Availableat: https:// www.networkforphl.org/wp-content/uploads/2021/05/NAL-Final-4-29. pdf.AccessedJune7,2022.

13.IllinoisDepartmentofPublicHealth.IDPH-NaloxoneStandingOrder Form.Availableat: https://idph.illinois.gov/Naloxone/ AccessedJune7,2022.

14.PrescriptionDrugAbusePolicySystem(PDAPS).Availableat: http:// www.pdaps.org/datasets/laws-regulating-administration-ofnaloxone-1501695139.AccessedJune7,2022.

15.SchommerJC.APhAcareerpathwayevaluationprogramforpharmacy professionals2012.2013.Availableat: https://aphanet.pharmacist. com/sites/default/files/files/Profile_06%20Chain%20pharmacy% 20Final%20071713.pdf.AccessedJanuary19,2022.

16.HatemiPandZornC.IndependentpharmaciesintheU.S.aremoreon therisethanonthedecline.2020.Availableat: https://www.pcmanet. org/wp-content/uploads/2020/03/FINAL_Independent-Pharmaciesin-the-U.S.-are-More-on-the-Rise-than-on-the-Decline.pdf AccessedJanuary19,2022.

17.U.S.DepartmentofAgricultureEconomicResearchService.RuralUrbanContinuumCodes.2020.Availableat: https://www.ers.usda.gov/ data-products/rural-urban-continuum-codes/documentation/ AccessedJanuary19,2022.

18.U.S.CensusBureau.Availableat: https://www.census.gov/ Accessed June7,2022.

19.SmithSteven.IllinoisDepartmentofFinancialandProfessional Regulation.PublishedonlineFebruary1,2023.

20.PuzantianTandGasperJJ.Provisionofnaloxonewithoutaprescription byCaliforniapharmacists2yearsafterlegislationimplementation. JAMA.2018;320(18):1933–4.

21.EvoyKE,HillLG,GroffL,etal.Naloxoneaccessibilitywithouta prescriberencounterunderstandingordersatcommunitypharmacy chainsinTexas. JAMA.2018;320(18):1934–7.

22.GravesRL,AndreyevaE,PerroneJ,etal.Naloxoneavailabilityand pharmacystaffknowledgeofstandingorderfornaloxonein Pennsylvaniapharmacies. JAddictMed.2019;14(4):272–8.

23.StopkaTJ,DonahueA,HutchesonM,etal.Non-prescriptionnaloxone andsyringesalesinthemidstofopioidoverdoseandhepatitis Cvirusepidemics:Massachusetts,2015. JAmPharmAssoc(2003) 2017;57(2S):S34–44.

24.CorrealA.Overdoseantidoteissupposedtobeeasytoget.It’sNot. 2018.Availableat: https://www.nytimes.com/2018/04/12/nyregion/ overdose-antidote-naloxone-investigation-hard-to-buy.html AccessedJanuary1,2020.

25.MeyersonBE,AgleyJD,DavisA,etal.Predictingpharmacynaloxone stockinganddispensingfollowingastatewidestandingorder,Indiana 2016. DrugandAlcoholDependence.2018;188:187–92.

26.LaiRK,FriedsonKE,RevelesKR,etal.Naloxoneaccessibilitywithout anoutsideprescriptionfromU.S.communitypharmacies:asystematic review. JAmPharmAssoc(2003).2022;62(6):1725–40.

27.U.S.CensusBureau.2010CensusofPopulationandHousing, PopulationandHousingUnitCounts,CPH-2-15.2012.Availableat: https://www2.census.gov/library/publications/decennial/2010/cph-2/ cph-2-15.pdf.AccessedFebruary2,2023.

28.JenkinsRA,WhitneyBM,NanceRM,etal.TheRuralOpioidInitiative Consortiumdescription:providingevidencetounderstandthefourth waveoftheopioidcrisis. AddictSciClinPract.2022;17(1):38.

29.BergoCJ,EpsteinJR,HoferkaS,etal.AVulnerabilityassessmentfora futureHIVoutbreakassociatedwithinjectiondruguseinIllinois, 2017–2018. FrontSociol.2021;6:652672.

30.WhiteHouseOfficeofNationalDrugControlPolicy(ONDCP).Vermont DrugControlUpdate.Availableat: https://obamawhitehouse.archives. gov/sites/default/files/docs/state_profile_-_vermont_0.pdf AccessedJune7,2022.

31.BuerLesly-Marie. RXAppalachia:StoriesofTreatmentandSurvivalin RuralKentucky.Chicago,IL:HaymarketBooks;2020.

32.OstrachB,BuerLM,ArmbrusterS,etal.COVID-19andruralharm reductionchallengesintheUSsouthernmountains. JRuralHealth 2021;37(1):252–5.

33.LegislativeAnalysisandPublicPolicyAssociation.NaloxoneAccess: SummaryofStateLaws.2020.Availableat: https://legislativeanalysis. org/wp-content/uploads/2020/10/Naloxone-summary-of-state-lawsFINAL-9.25.2020.pdf.AccessedFebruary3,2023.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

ImprovingHealthcareProfessionals’ AccesstoAddiction MedicineEducationThroughVHAAddictionScholarsProgram

ZahirBasrai,MD*

ManuelCeledon,MD*

NathalieDieujuste,MA†

JulianneHimstreet,PharmD§ JonathanHoffman,PharmD∥ CassidyPfaff,PharmD¶ JonieHsiao,MD*

RobertMalstrom,PharmD# JasonSmith,PharmD**

MichaelRadeos,MD,MPH†† TerriJorgenson,RPh‡‡

MelissaChristopher,PharmD§§ ComillaSasson,MD,PhD†‡

*VAGreaterLosAngelesHealthCareSystem,VeteransHealthAdministration, DepartmentofEmergencyMedicine,LosAngeles,California

† VAEasternColoradoHealthCareSystem,VeteransHealthAdministration, Aurora,Colorado

‡ UniversityofColorado,AnschutzMedicalCampus,Aurora,Colorado

§ VAPharmacyBeneﬁtsManagementAcademicDetailingService, Eugene,Oregon

∥ VAVISN19RockyMountainNetwork,SaltLakeCity,Utah

¶ VISN19AcademicDetailingService,VeteransHealthAdministration, Tulsa,Oklahoma

# VAPharmacyBeneﬁtsManagementAcademicDetailingService, Martinez,California

**VISN19AcademicDetailingService,VeteransHealthAdministration, Denver,Colorado

†† NYCHealth + Hospitals/ConeyIsland,DepartmentofEmergencyMedicine, Brooklyn,NewYork

‡‡ PharmacyBeneﬁ tsManagement,ClinicalPharmacyPracticeOfﬁce, Washington,DC

§§ VAPharmacyBeneﬁtsManagementAcademicDetailingService, SanDiego,California

SectionEditor:GentryWilkerson,MD

Submissionhistory:SubmittedFebruary2,2023;RevisionreceivedJanuary26,2024;AcceptedFebruary16,2024

ElectronicallypublishedMay20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.17850

Introduction: Theseeminglyinexorableriseofopioid-relatedoverdosedeathsdespitethereduced numberofCOVID-19pandemicdeathsdemandsnovelresponsesandpartnershipsinourpublichealth system’sresponse.Addictionmedicineispracticedinabroadrangeofsiloedclinicalenvironmentsthat needtobeincludedinaddictionmedicinetrainingbeyondthetraditionalfellowshipprograms.Our objectiveinthisprojectwastoimplementaknowledge-based,livevirtualtrainingprogramthatwould providecliniciansandotherhealthcareprofessionalswithanoverviewofaddiction,substanceuse disorders(SUD),andclinicaldiagnosisandmanagementofopioidusedisorder(OUD).

Methods: TheVeteransHealthAdministration(VHA)EmergencyDepartmentOpioidSafetyInitiative (EDOSI)offeredafour-daycourseforhealthcareprofessionalsinterestedingainingknowledgeand practicalskillstoimproveVHA-basedSUDcare.Thecoursetopicscenteredaroundthediagnosisand treatmentofSUD,withafocusonOUD.Additionally,traineesreceivedsixmonthsofsupporttodevelop addictionmedicinetreatmentprograms.Evaluationsofthecoursewereperformedimmediatelyafter completionoftheprogramandagainatthesix-monthmarktoassessitseffectiveness.

Results: Atotalof56cliniciansandotherhealthcareprofessionalsparticipatedintheAddictionScholars Program(ASP).TheparticipantsrepresentednineVeteranIntegratedServiceNetworksand21different VHAmedicalfacilities.Nearly70%ofparticipantscompletedtheinitialpost-survey.Thirty-eight respondents(97.4%)felttheASPseriescontainedpracticalexamplesandusefulinformationthatcould beappliedintheirwork.Thirty-eightrespondents(97.4%)felttheworkshopseriesprovidednew informationorinsightsintothediagnosisandtreatmentofSUD.Elevencapstoneprojectsbasedonthe

informationacquiredduringtheASPwerefunded(atotalof$407,178).Twentyparticipants(35.7%) completedthesix-monthfollow-upsurvey.Notably,90%ofrespondentsreportedincreasednaloxone prescribingand50%reportedincreasedprescribingofbuprenorphinetotreatpatientswithOUDsince completingthecourse.

Conclusion: TheASPprovidedhealthcareprofessionalswithinsightintomanagingSUDandequipped themwithpracticalclinicalskills.Thestudentstranslatedtheinformationfromthecoursetodevelop medicationforopioidusedisorder(M-OUD)programsattheirhomeinstitutions.[WestJEmergMed. 2024;25(4)465–469.]

INTRODUCTION

Thenationalopioidepidemicisoneoftheleading preventablecausesofmorbidityandprematuredeathinthe UnitedStates.In2017,theUSDepartmentofHealthand HumanServices(HHS)declaredtheopioidcrisisapublic healthemergency.1 TheCOVID-19pandemichas exacerbatedthiscrisiswithanincreasedprevalenceofopioid usedisorder(OUD)anddeathsfromprescriptionandnonprescriptionopioids.2 Veteransareatnearlytwicetheriskof fataldrugoverdosewhencomparedtonon-veterans.3 As partofthe ﬁveprioritiestocombattheopioidcrisisHHS highlightedtheimportanceofimprovingaccessto prevention,treatment,andrecoverysupportservices.1 However,thereremaincriticalshortagesofhealthcare professionalswhocanprovidetheselife-savingservices.4 Improvingaccesstosubstanceusedisorder(SUD)careat anytime,anyplaceisanimportantpartoftheVeterans HealthAdministration’s(VHA)strategy.Asaresult,thereis agrowingneedfortraininghealthcareprofessionalsoutside thetraditionaladdictionmedicinespecialtyonkey componentsofaddictionmedicineandSUD.

TheVHAisAmerica’slargestintegratedhealthcare system,providingcareat1,298healthcarefacilitiesincluding 171medicalcentersand1,113VHAoutpatientclinics.More thanninemillionenrolledveteransareservedbytheVHA eachyear.5 Despiteitssize,theVHAsystemhasashortageof addictionspecialistsandSUDclinics.Asaresult,the responsibilityofprovidingSUDcarefallsonavarietyof specialties,includingpharmacyandmentalhealth,and primarycareandemergencymedicine.However,the educationopportunitiesforthesepractitionerstoobtain advancedtraininginaddictionmedicineislimited.

Currently,addictionmedicineisnotarequiredgraduate medicaleducationcourseforinternalmedicine,family medicine,oremergencymedicineresidencies.Asaresult, traineesreceivevariableexposuretoSUDcareduring residency,leadingtosuboptimalpreparationmanaging patientswithaddictionwhenpracticingindependently.6,7 Thetraditionalpathwayforaddictionmedicinetrainingisto completea12-monthdedicatedfellowshipatoneofthe90

sitesaccreditedbytheAccreditationCouncilforGraduate MedicalEducation.8 Thissigniﬁcantcommitmentlimitsthe abilityforfrontlineclinicianstoobtainfurthertrainingin addictionmedicine.Thereisaneedtocreateaccessible didacticandpracticalclinicaleducationinaddiction medicinetoincreasefrontlinecliniciancomfort.

LackofbasictraininginSUDisasigniﬁcantbarrierto physicianengagementofmedicationforopioidusedisorder (M-OUD)programs.9,10 Asaresult,theAddictionScholars Program(ASP)wasdevelopedtoprovideadditionaltraining forphysicianassistants,nursepractitioners,clinical pharmacists,academicdetailingpharmacists,and physicians.Theeducationaltopicsincludedafoundational understandingofthetreatmentofOUD,complexpain,and complexpersistentopioiddependence.Ourobjectiveinthis studywastomeasuretheeffectiveness,immediatelyandat sixmonths,ofahybrideducationalinterventionpairedwith creationofmultidisciplinaryteamsonknowledgeretention andwillingnesstoprescribeM-OUD.

METHODS

Thiswasapost-implementationstudyoftheASP,anovel hybrideducationalapproachandfacilitated,team-based qualityimprovement(QI)project.Surveyswereperformed attheconclusionofthecourseandatthesix-monthmark. Thesurveysfocusedonthecourse’seffectivenessandthe trainee’swillingnesstoinitiateanaddictionmedicineproject attheirsite.Weuseddescriptivestatisticstointerpretthe resultsofthesurvey.TheEmergencyDepartmentOpioid SafetyInitiative(EDOSI)programwasdesignatedasaQI projectthroughtheOfﬁceofPharmacyBeneﬁts ManagementAcademicDetailingServicefromthe institutionalreviewboardoftheEdwardHines,Jr.VA HospitalandapprovedbytheRockyMountainRegional VAMedicalCenterResearchandDevelopmentservice.

AddictionScholarsProgram

TheASPisapartoftheVHAEDOSIandwasdeveloped asanintensivecourseforcliniciansinterestedin understandingVHA-basedSUDcare.Frontlineclinicians

andotherhealthcareprofessionalswhowerecurrent employeesoftheVHAwereinvitedtoapplytoattendthe ASP.Fortywereacceptedtoattendtheprogram.Thecourse consistedoffourvirtualsessionsthatwereeachfourhours long.Eachsessioncoveredfundamentalandadvancedtopics ofaddictionmedicineforemergencyandacutecaresettings.

Theentirecoursewasdeliveredvirtuallyusingthe MicrosoftTeams(MicrosoftCorp,Redmond,WA) application.TopicsincludedclinicalmanagementofOUD, opioidoverdosemanagement,buprenorphineinduction, naloxonedistribution,painmanagementinpatientswith OUD,andopioid-inducedchronicpainsyndrome.The programusedacombinationoflecturesandcase-based breakoutsessionstoreinforcekeyconcepts.Lecturerswere selectedbasedontheirexperienceandexpertiseinspeciﬁc areasofaddictionmedicine.Interdisciplinarygroupswere strategicallyassembledforthecase-basedbreakoutsessions withmembersfromthesameVHAsiteandVeteran IntegratedServiceNetworks(VISN).Thisallowedfora networkingopportunitywheregroupmemberscouldbuild connectionsthatwouldleadtothedevelopmentofM-OUD programslocallyattheirVHAsiteorattheirVISN.The groupswerepairedwithamemberoftheVHAEDOSIteam whowouldfacilitatediscussionofthecases.

Aftersuccessfulcompletionofthecourse,trainees receivedsixmonthsofsupporttodevelopandimplement addictionmedicinetreatmentprograms.Traineeswerealso encouragedtosubmitcapstoneprojects,whichwereeligible forfundingupto$50,000(uptotwoyears)tohelpimplement addictionmedicineprojectsattheirlocalVHAsite.

RESULTS

Atotalof56individualsparticipatedintheASP,including 32clinicians,10clinicalpharmacypractitioners,and14 academicdetailingpharmacists.Thecliniciansrepresented nineVISNsand21differentVHAfacilities.Theclasswas composedof15physicians,sevennursesandnurse practitioners,31pharmacists,andthreephysicianassistants. Participantsrangedinagefrom30–65(mean46.2years)and hadbeeninclinicalpracticeforanaverageof11years (Table1).Additionally,attendeesrepresentednumerous clinicalserviceareasincludingemergencymedicine,urgent care,primarycare,painmanagement,mentalhealth,and substanceusetreatment.

Ofthe56participants,39(almost70%)respondedtothe initialpost-survey.Thirty-eightrespondents(97.4%) reportedthattheASPseriescontainedpracticalexamples andusefulinformationthatcouldbeappliedintheirwork. Thirty-eightrespondents(97.4%)feltthattheworkshop seriesprovidednewinformationorinsightsintothediagnosis andtreatmentofSUD.Thirty-ﬁverespondents(89.7%)were veryorsomewhatsatisﬁedwiththeASPseries. TwentyindividualswhoparticipatedintheASP respondedtothesix-monthfollow-upsurvey.Themajority

ofrespondents(85.0%)reportedfeeling “comfortable” or “verycomfortable” initiatingM-OUDsincecompletingthe ASP.Fourteen(70%offollowuprespondents)pursued additionalM-OUDtrainingsincecompletingtheASP.Of the20respondents,fourworkedindepartmentswithoutan activeM-OUDprogram;threeofthefour(75%)are currentlyworkingtodevelopanM-OUDprogram.Eighteen (90%)oftherespondentsreportedincreasednaloxone prescribingsincecompletingtheASP.Ten(50%)ofthe respondentsincreasedprescribingofbuprenorphinetotreat patientswithOUDsincecompletingthecourse(Table2).

AttheconclusionoftheASP,11capstoneprojectswere submittedandawardedatotalof$407,178.Seven(63.6%)of theprojectsfocusedonthedevelopmentofnaloxoneor buprenorphineprograms.Otherprojectswerefocusedon harmreductionwiththedevelopmentofasyringeservice program,theuseoffentanyltestingstrips,developmentofa VISN-widevirtuallearningprogramforSUDtraining,urine point-of-caretestingforcontrolledmedications,andmusicandmovement-basedinterventionstoengagehigh-risk veteransinsubstanceusetreatment.

DISCUSSION

OurstudydemonstratedtheASPsuccessfullyprovided additionaladdictionmedicinetrainingtocliniciansandother healthcareprofessionalsandthatthereisadesirefor additionaladdictionmedicinetrainingwithintheVHA

Table2. Resultsofinitialandsix-monthfollow-upsurvey.

Initialfollow-up(N = 39)

TheASPseriescontainedpracticalexamplesandusefulinformationthatcanbeappliedintheirwork. 38(97.4%)

The workshopseriesprovidednewinformationorinsightsintothediagnosisandtreatmentofSUD. 38(97.4%)

“Very” or “somewhat” satisﬁedwiththeASPseries.

6-monthfollow-up(n = 20)

“Comfortable” or “verycomfortable” initiatingM-OUDsincecompletingtheASP. 17(85%) PursuedadditionalM-OUDtrainingsincecompletingtheASP. 14(70%) WorkindepartmentswithoutanactiveM-OUDprogram. 4(20%) IncreasednaloxoneprescribingsincecompletingtheASP. 18(90%)

IncreasedprescribingofbuprenorphinetotreatpatientswithOUDsincecompletingtheASP. 10(50%)

ASP, AddictionScholarsProgram; SUD,substanceusedisorder; OUD,opioidusedisorder; M-OUD,medicationforopioidusedisorder.

system.TheASPwasdesignedasaneducationalprogram withanemphasisonpromotingfacility-levelteambuilding toenhancecross-functionalclinicalcare.These ﬁndingsare encouragingas,aftercompletingtheASP,healthcare professionalswithoutformaladdictionmedicinetraining wereabletoadvocateforOUDtreatmentinnon-SUD specialtyclinicalsettingsattheirlocalVHAsite.Successful treatmentofpatientswithOUDrequiresamultidisciplinary approachinvolvingboththeaddictionmedicineserviceand theoutpatientprimarycareteam.Empoweringnon-SUD specialtyclinicswiththeknowledgeandpracticalskillsto treatOUDisessentialinimplementingthe “nowrongdoor” approachtoOUDtreatment.11 Thesupportandnetworking opportunitiesprovidedbytheASPsuccessfullyledtothe developmentoflocaladdictionmedicineprogramsat VHAsitesasevidencedbythe11capstoneprojectsthat werefunded.

ThesuccessoftheASPwasdueinparttotheblended learningstructureofthecourse.Lectureswerecuratedand deliveredbyexpertsinthe ﬁeldandrangedfrombasic addictionmedicinetopicstomoreadvancedtopics.This allowedforengagementofalllearnersregardlessoftheir specialtyorleveloftraining.Thecoursealsoleverageda team-basedlearningapproachthroughthebreakout sessions,whichreinforcedkeycomponentsoftreating complexpatientswithOUD.Team-basedlearninghasbeen showntohavepositiveoutcomesforstudentsintermsof studentexperience.12

Thee-learningplatformalsoallowedforengagementbya wideraudiencethanwouldhaveotherwisebeenpossibleby anin-personcourse.TheASPgaveadditionaladdiction medicinetrainingtothosewhowouldotherwisenothave beeneligibleforafellowshipbythetraditionalpathway.This allowedforengagementofkeystakeholderswhocould implementprogramsatlocalfacilitiesinareasthatare separatefromdedicatedSUDclinics.TheASPisascalable programthatcanbefurtherdevelopedandreplicatedoutside oftheVHAsystem.

LIMITATIONS

Althoughtheprogramdidreceivefavorableratings,itis importanttonotethatattendeesdidself-selecttoattend;asa result,theymayhavebeenmorebiasedintheirratingsofan addictionmedicineprogram.Futureeffortswillbemadeto recruitcliniciansandotherhealthcareprofessionalswhomay beresistantorhesitanttotheadditionofsubstanceuseand opioidsafetymeasuresintheirpractice.Furtherstudiesare neededtoassessactualinterestinadditionaladdiction medicinetrainingthroughouttheVHAsystem.Itshouldbe noted,too,thatthisstudyprovidedonlyasix-monthfollowup,atwhichpointtheparticipants’ surveyresponseratewas low.Additionally,theresultsofthisstudyaresurveybased, andthusthelimitationsthatapplytosurveysalsoapplyhere. Thesurveydidnotcontainknowledge-basedquestionsto assessretentionofknowledge.Futureiterationsofthecourse willcontainknowledge-basedquestionstoassessfor acquisitionofknowledge.Futurestudieswillalsoneedto lookathowtheASPinﬂuencedthedevelopmentofaddiction medicineprogramsintheVHAsystem.Studieswillalsoneed toexaminehowsuccessfulthemanagementofOUDisin nontraditionalsettingsthatareoutsidetheSUDclinics. Futurestudiescanalsobeconductedtocomparelong-term outcomesforpatientswhosehealthcareprofessionals participatedinASPcomparedtothosewhodidnot.

CONCLUSION

ThisfeasibilitystudyhasshownthatASPequipped cliniciansandotherhealthcareprofessionalswithan intensiveoverviewofaddictionmedicine.Thestudents translatedtheinformationfromthecoursetodevelop M-OUDprogramsattheirhomeinstitutions.

AddressforCorrespondence:ZahirBasraiMD,VAGreaterLos AngelesHealthCareSystem,VeteransHealthAdministration, DepartmentofEmergencyMedicine,11301WilshireBLVD, LosAngeles,CA90073.Email: Zahir.basrai@va.gov

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.ComillaSassonMD,PhDisemployed bytheAmericanHeartAssociation.Thisworkwassupportedby CARAfundsthroughthePainManagement,OpioidSafetyand PrescriptionDrugMonitoringProgram(PMOP)Office.Thereareno otherconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.HarganED.DeterminationthataPublicHealthEmergencyExists.2017. Availableat: https://aspr.hhs.gov:443/legal/PHE/Pages/opioids.aspx AccessedJanuary18,2024.

2.USCentersforDiseaseControlandPrevention.IncreaseinFatalDrug OverdosesAcrosstheUnitedStatesDrivenbySyntheticOpioidsBefore andDuringtheCOVID-19Pandemic.2020.Availableat: https://stacks. cdc.gov/view/cdc/98848.AccessedApril25,2021.

3.BohnertAS,IlgenMA,GaleaS,etal.Accidentalpoisoningmortality amongpatientsintheDepartmentofVeteransAffairsHealthSystem. MedCare. 2011;49(4):393–6.

4.DepartmentofVeteransAffairsOfficeofInspectorGeneral.OIG DeterminationofVeteransHealthAdministration’sOccupational StaffingShortagesFiscalYear2021.2021.Availableat: https://www. oversight.gov/sites/default/files/oig-reports/VA/VAOIG-21-01357-271. pdf.AccessedJanuary18,2024.

5.USDepartmentofVeteransAffairs.VeteransHealthAdministration. 2008.Availableat: https://www.va.gov/health/ AccessedApril25,2021.

6.MillerNS,SheppardLM,ColendaCC,etal.Whyphysiciansare unpreparedtotreatpatientswhohavealcohol-anddrug-related disorders. AcadMed. 2001;76(5):410–8.

7.PolydorouS,GundersonEW,LevinFR.Trainingphysicians totreatsubstanceusedisorders. CurrPsychiatryRep. 2008;10(5):399–404.

8.AmericanCollegeofAcademicAddictionMedicine.Accredited AddictionMedicineFellowships.Availableat: https://www.acaam.org/ fellowship-training.AccessedApril25,2021.

9.TaylorEN,TimkoC,BinswangerIA,etal.Anationalsurveyofbarriers andfacilitatorstomedicationsforopioidusedisorderamonglegalinvolvedveteransintheVeteransHealthAdministration. SubstAbus. 2022;43(1):556–63.

10.KimHSandSamuelsEA.Overcomingbarrierstoprescribing buprenorphineintheemergencydepartment. JAMANetwOpen. 2020;3(5):e204996.

11.SubstanceAbuseandMentalHealthServicesAdministration. SubstanceUseDisorderTreatmentforPeoplewithCo-Occurring Disorders.2020.Availableat: https://store.samhsa.gov/sites/default/ ﬁles/SAMHSA_Digital_Download/PEP20-02-01-004_Final_508.pdf AccessedApril25,2021.

12.BurgessA,vanDiggeleC,RobertsC,etal.Team-basedlearning: design,facilitationandparticipation. BMCMedEduc. 2020;20(Suppl2):461.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

InitiationofBuprenorphineintheEmergencyDepartment: ASurveyofEmergencyClinicians

ArianaBarkley,MD*

LauraLander,MSW†

BrianDilcher,MD* MeghanTuscano,MPH†

SectionEditor:GentryWilkerson,MD

*WestVirginiaUniversity,DepartmentofEmergencyMedicine, Morgantown,WestVirginia † WestVirginiaUniversity,DepartmentofBehavioralMedicineandPsychiatry, Morgantown,WestVirginia

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedFebruary5,2024;AcceptedFebruary16,2024

ElectronicallypublishedJune27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18029

Introduction: Initiationofbuprenorphineforopioidusedisorder(OUD)intheemergencydepartment (ED)issupportedbytheAmericanCollegeofEmergencyPhysiciansandisshowntobebeneﬁcial.This practice,however,islargelyunderutilized.

Methods: Toassessemergencyclinicians’ attitudesandreadinesstoinitiatebuprenorphineintheED weconductedacross-sectional,electronicsurveyofclinicians(attendings,residents,andnon-physician clinicians)inasingle,academicEDofatertiary-carehospital,whichservesaruralpopulation.Our surveyaimedtoassessemergencyclinicians’ attitudestowardandreadinesstoinitiatebuprenorphinein theEDandidentifyclinician-perceivedfacilitatorsandbarriers.Oursurveytookplaceaftertheinitiation oftheIMPACT(InitiationofMedication,PeerAccess,andConnectiontoTreatment)project.

Results: Ourresultsdemonstratedthelevelofagreementthatbuprenorphineprescribingiswithinthe emergencyclinician’sscopeofpracticewasinverselycorrelatedtoaverageyearsinpractice(R2 = 0.93). X-waiveredcliniciansindicatedfeelingmorepreparedtoadministerbuprenorphineintheEDR2 = 0.93. However,theywerenotmorelikelytoreportorderingbuprenorphineornaloxoneintheEDwithinthe priorthreemonths.Thosewhoreportedhavingafamilymemberorclosefriendwithsubstanceuse disorder(SUD)werenotmorelikelytoagreebuprenorphineinitiationiswithintheclinician’sscopeof practice(P = 0.91),norweretheymorelikelytoobtainanX-waiver(P = 0.58)orreportordering buprenorphineornaloxoneforpatientsintheEDwithinthepriorthreemonths(P = 0.65, P = 0.77). Cliniciansidentiﬁedavailabilityofpharmacists,inpatient/outpatientreferralresources,andsupportstaff (peerrecoverysupportspecialistsandcaremanagers)asprimaryfacilitatorstobuprenorphineinitiation. Inabilitytoensurefollow-up,lackofknowledgeofavailableresources,andinsufﬁcienteducation/ preparednesswereprimarybarrierstoEDbuprenorphineinitiation.Eighty-threepercentofclinicians indicatedtheywouldbeinterestedinadditionaleducationregardingOUDtreatment.

Conclusion: Ourdatasuggeststhatnewergenerationsofemergencycliniciansmayhaveless hesitancyinitiatingbuprenorphineintheED.Intime,thiscouldmeanincreasedaccesstotreatmentfor patientswithOUD.Understandingclinician-perceivedfacilitatorsandbarrierstobuprenorphineinitiation allowsforbetterresourceallocation.Clinicianswouldlikelyfurtherbeneﬁtfromadditionaleducation regardingmedicationsforopioidusedisorder(MOUD),availableresources,andfollow-upstatistics. [WestJEmergMed.2024;25(4)470–476.]

INTRODUCTION

Morethan564,000individualsdiedofopioidoverdosein theUSfrom1999–2020,1 accordingtotheUSCentersfor DiseaseControlandPrevention;morerecent,provisional datasuggeststhatannualoverdoseratescontinuedtorisein 2021.2 Aswouldbeexpected,withincreasedratesof overdose,emergencydepartment(ED)visitsforopioid overdosealsoincreasedin2020.3 Patientswithopioiduse disorder(OUD)arefrequentlyseenintheEDwithboth overdoseandotherlessemergentconditions.Patientsseenin theEDafteranon-fatalopioidoverdosehave >5%one-year mortalityrat.4 TheEDisalow-barrieraccesspointtothe healthcaresystem,andEDvisitsrepresentavaluable opportunitytoengagepatientswithOUDinpotentially lifesavingtreatment.

Buprenorphine,aUSFoodandDrugAdministration (FDA)-approvedmedicationforOUD(MOUD),hasbeen showntobeeffectiveindecreasingoverallopioiduse, reducingriskofopioidoverdose,andreducingbothopioidassociatedandall-causemortality.5 Buprenorphinehasbeen availabletoemergencycliniciansforthetreatmentofopioid withdrawalsince2002,andresearchhasshownthebeneﬁts ofbuprenorphineinitiationintheED.6 Speciﬁcally,in comparisontoreferraltotreatmentorbriefEDintervention, initiationofbuprenorphineintheEDresultsinincreased ratesofengagementinaddictiontreatmentat30daysand decreasedillicitopioiduse.7 TheAmericanCollegeof EmergencyPhysicians(ACEP)recommendstheinitiationof buprenorphineinappropriatepatients.Additionally,the ACEPconsensusstates: “Detectingandofferingevidencedbasedtreatmentsforpatientswithopioidusedisorderis alignedwiththegoalsofemergencymedicinetointerveneon high-mortalitydiseaseprocesses.”8

Unfortunately,MOUDsincludingbuprenorphineare largelyunderutilized,andthemajorityofpeoplewithOUD donotreceivedtreatmentwithMOUDs.9 Substanceuse disorders(SUD)areoneofthemosthighlystigmatized medicalconditionsintheworldamongcliniciansandthe generalpublic.10,11 Astudylookingatemergencyphysicians’ attitudestowardpatientswithSUDfoundthatemergency physicianshadalowerregardforpatientswithSUDthan othermedicalconditionswithbehavioralcomponents.12 The MOUDs,includingbuprenorphine,arealsostigmatized, whichimpactstreatmentaccessandprescribingpracticesfor thesemedications.13 Previous ﬁndingsidentifythemost signiﬁcantbarrierstoprescribingbuprenorphineintheED includelogisticalorsystemicfactorsaswellasperceived patientfactors(ie,socialbarriersandlackofinterestin treatment).14 Clinicianlackofknowledge,aswellastheir attitudesandbiases,canimpactwillingnesstoprescribe medicationssuchasbuprenorphineforpatientswithOUD, despiteMOUDbeingawellstudiedandeffective treatment.6,15 NotonlyarepatientsonMOUDstigmatized

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

InitiationofbuprenorphineintheEmergency Department(ED)foropioidusedisorder (OUD)hasbeenshowntobebene ﬁ cial,butis largelyunderutilized.

Whatwastheresearchquestion?

Whatareclinicians ’ attitudestoward initiatingbuprenorphineintheED,andwhat arethebarrierstoprescribing?

Whatwasthemajor ﬁndingofthestudy?

Clinicianlikelihoodofinitiatingtreatmentin theEDwasinverselycorrelatedtoyearsin practice.Theprimarybarriertoinitiating buprenorphinewasinabilityto ensurefollow-up.

Howdoesthisimprovepopulationhealth?

Eliminatingbarriersandimprovingclinician readinesstoinitiatebuprenorphineintheED couldincreaseaccesstocareforpatients withOUD.

buttheprescriberswhoprovidethemwithmedicationsare alsostigmatized.16

Topromoteengagementinandreferraltotreatmentfor OUD,ouracademicEDinitiatedtheIMPACTproject (InitiationofMedication,PeerAccess,Connectionto Treatment)in2020.KeyelementsoftheIMPACTproject includedelectronichealthrecord(EHR)promptsandorder sets,peerrecoverysupportspecialistsintheED,and availabilityofinpatientandoutpatientreferral,allofwhich arebarriersidentiﬁedinpreviousstudies.15,17–18 Additionally,whentheIMPACTprojectwasintroducedto theED,clinicianswereoffereda ﬁnancialincentivetoobtain aUSDrugEnforcementAdministrationX-waiver.The primarygoalofourstudywastoassessemergencyclinicians’ attitudestowardandreadinesstoinitiatebuprenorphinein theED,aswellasidentifyperceivedfacilitatorsandbarriers toinitiatingbuprenorphinetreatmentinanacademicED, afterimplementationoftheIMPACTprojectandits associatedresources.

METHODS

ThisstudywaspartofaStateOpioidResponse ImplementationprojectcalledIMPACT.Theprimary objectiveoftheprojectwastointegratepeerrecovery

supportspecialists(PRSS)intheED,toincrease buprenorphineprescribingforpatientswithOUD,andto increaseengagementandreferralstotreatmentforall patientswithSUD.WeextracteddatafromtheEHR regardingpatientdemographics,PRSSinteractionwith patients,andprescribingpracticesoveratwo-yearperiod fromMarch2020–March2022.Amixed-methodsmodelwas usedtoevaluatethedata.Thisprojectwasapprovedbythe institutionalreviewboard.

Weconductedacross-sectionalelectronic-basedsurvey regardingbuprenorphineprescribingintheEDwithall potentialEDprescribersincludingattendingphysicians, residentphysicians,physicianassistants,andnurse practitioners.Wedevelopedthesurvey,adaptingfrom previouslypublishedresearch.15,17–18 Priorsurveyshadbeen conductedinlargeurbanareasbuthadnotbeendeployedin amoreruralsetting.Oursurveywasdesignedtoidentify prescribers’ attitudestowardandreadinesstoinitiate buprenorphineintheEDandidentifyperceivedfacilitators andbarrierstoinitiatingbuprenorphinetreatmentinan academicEDofalarge,tertiary-carehospital,whichservesa ruralpopulation.Cliniciansweremadeawareofthestudy throughaninitialemail,twoemailreminders,aone-time announcementatourweeklydidacticconference,and ﬂyers postedthroughouttheED.Participantswereincentivized,as the ﬁrst100participantsreceiveda$10giftcard,andall participantswereenteredforachancetowina$100giftcard.

Thesurveycompletedbyemergencycliniciansincluded10 questionsfocusingonyearsinpractice,X-waiverstatus, prescribingpracticesintheEDinthepriorthreemonths, comfortwithtreatmentofOUDandprescribing buprenorphineintheED,andpersonalexperiencewith SUD.TwoadditionalLikert-scalequestionsassessedfor barriersandfacilitatorstoprescribingbuprenorphine.(See AppendixA forfullsurvey).Thesurveywaspublished March23,2022,andclosedMay15,2022.Surveyresponses wererecordedviaQualtrics(Qualtrics,Provo,UT),andthe datawasexportedtoasecureExcel ﬁle(MicrosoftCorp, Redmond,WA)foranalysis.Wethenorganizedand analyzedthedatausingSAS9.4(SASInstituteInc,Cary, NC)withchi-squaredorFisherexacttests.Wede-identiﬁed andextractedadditionaloperationalpatientdataonthe IMPACTprogramonarollingbasisfromtheEHR.

RESULTS

Atotalof95surveysweredistributedtoallemergency clinicians(attendingphysicians,residents,physician assistants,andnursepractitioners)Therewereatotalof43 respondentsandaresponserateof45%(16/50attendings, 21/30residents,6/15physicianassistantsandnurse practitioners).Threesurveyswerepartiallycompleted.We includedtwothathad >50%ofthequestionsansweredand excludedonesurveywithonlytwoquestionscompletedas thelatterrespondent’sintenttocompletewasinterpretedas

questionable.Ofthosewhoresponded,theiryearsinpractice rangedfrom1-50withanaverageof7.3years.Ofthe43 respondents,31indicatedtheywerefamiliarwiththe IMPACTprojectand12saidtheywerenot.Allthe respondentswhoindicatedtheywerenotfamiliarwiththe IMPACTprojectwereEDresidents.(See Tabl.)Notably, 83%ofallrespondentsindicatedtheywouldbeinterestedin additionaleducationrelatedtomedicationandresourcesfor OUDtreatment.

A ﬁve-pointLikertscalewasusedtoassessrespondents’ levelofagreementthatprescribingbuprenorphinewaswithin theirscopeofpractice.While78.6%ofrespondentsagreed thatprescribingbuprenorphinewaswithintheirscope,the levelofagreementwasfoundtobeinverselycorrelatedwith averageyearsinpractice(R2 = 0.93162)(Figure1).Regarding X-waiverstatus,16individualsidentiﬁedashavingtheir X-waiverand26indicatedtheywerenotX-waivered.When askedwhytheywerenotwaivered,fourindividualsindicated theywere “notinterested,” threesaidcostwasabarrier,seven saidtimewasabarrier,and12responded “other.” Inthe “other” category,tworespondedtheywereunsurehowto obtainthewaiver;twoquestionedwhetheritwasneeded;one said “intheprocess”;threesaid “justhaven’tdoneit” ;one indicatedtheyhadcompletedthetrainingbutwerenotyet licensed;andonesaid “Iknowthedatashowsitworks,butI

Table. Datasummaryofemergencyclinicianswhoparticipatedina surveyregardingED-initiatedbuprenorphine.

CountPercentage

Figure1. Agreementthatbuprenorphineiswithintheemergency clinician’sscopeofpracticeasassessedona5-pointLikertscalein comparisontoaverageyearsinpractice.

stillfeellikeadrugdealer.” Wefoundthatthosewhohadan X-waiver,incomparisontothosewhodidnot,weremore likelytofeelpreparedtoadministerbuprenorphineinthe ED(P = 0.02).

Toenableustodescribeprescribingpractices,prescribers werealsoaskedwhethertheyhadorderednaloxonefor patientsintheEDinthepriorthreemonths;29said “ yes ” and13said “ no. ” Whenaskedwhethertheyhadordered buprenorphineforpatientsintheEDinthepriorthree months,18said “ yes ” and24said “ no. ” Wealsoobserved thatthosewhohadanX-waiverwerenotmorelikely tohavereportedorderingbuprenorphineornaloxone forpatientsintheEDwithinthepriorthreemonths (P = 0.17),(P = 0.51).

Sixty-sevenpercentofcliniciansagreedthattheyfelt preparedtoadministerbuprenorphineintheED,53.7% agreedthattheyfeltpreparedtoprescribebuprenorphineas abridgetooutpatienttreatment,and47.6%agreedthatthey feltpreparedtoprescribebuprenorphineforhomeinduction. Sixty-twopercentofallrespondentsagreedthattheyhadall

theresourcesneededtoinitiatebuprenorphineintheED. Barriersandfacilitatorstoinitiatingbuprenorphineinthe EDareidentiﬁedin Figure2 and Figure3,respectively. Toassesspossiblepersonalbarriersandfacilitatorsof buprenorphineprescribingthefollowingwasasked: “Have youhad,ordoyoucurrentlyhaveafamilymemberorclose friendwithSUD?” Responsesindicated43%said “ yes ” and 57%said “ no. ” Thosewhoreportedhavingafamilymember orclosefriendwithSUDwerenotmorelikelyto1)agreethat buprenorphineinitiationiswithintheemergencyclinician’ s scopeofpractice(P = 0.91);2)obtainanX-waiver (P = 0.58);or3)reportorderingbuprenorphineornaloxone forpatientsintheEDwithinthepriorthree months(P = 0.65),(P = 0.77).

IMPACTProjectQualitativeResults

Overthetwo-yearperiod,1,205patientswereseeninthe EDbyPRSSs,13%ofwhomwerediagnosedwithOUDor opioidwithdrawal.Atotalof377werereferredfor buprenorphinetreatmentbythePRSSswithintheED;168of thosepatientsreceivedbuprenorphinetreatment,and42 weregivenatake-homeprescription.Atthestartofthestudy therewerethreeX-waiveredphysicians;duringthecourseof theproject,12additionalcliniciansobtainedtheirX-waiver, foratotalof15.

DISCUSSION

Oursurveyaimedtoevaluateemergencyclinicians’ attitudestowardandpreparednesstoinitiatebuprenorphine intheEDaswellasidentifyperceivedfacilitatorsand barrierstoinitiatingbuprenorphinetreatmentafterthe implementationoftheIMPACTprojectanditsassociated resources.Ourresultsshowedthat78.6%ofcliniciansagreed thatprescribingbuprenorphineintheEDwaswithintheir scopeofpractice.Asshownin Figure1,thelevelof agreementthatbuprenorphineiswithintheemergency

Knowledge of available resources

Ability to ensure follow up

Concerned about misuse / diversion

Concerned about safety

Lack of pa ent interest in MOUD

Provides minimal beneﬁt to pa ents

Concerned prescribing buprenorphine is not in my scope of prac ce

Figure2. Clinician-perceivedbarrierstoinitiatingbuprenorphineintheemergencydepartment.Identiﬁedbarriersweregradedwitha3-point Likertscale:somewhatabarrier,moderatebarrier,signiﬁcantbarrier. MOUD,medicationforopioidusedisorder.

Pharmacist in the ED

inpa ent referral resources

Outpa ent referral resources

EHR alert re naloxone

EHR alert re buprenorphine

Availablility of PRSS / CM

Figure3. Clinician-perceivedfacilitatorstoinitiatingbuprenorphineintheemergencydepartment.Identi ﬁedfacilitatorsweregradedwitha 3-pointLikertscale:somewhatafacilitator,moderatefacilitator,signiﬁcantfacilitator. ED,emergencydepartment; EHR,electronichealthrecord; PRSS,peerrecoverysupportspecialist; CM,casemanager.

clinician’sscopeofpracticewasinverselycorrelatedtoyears inpractice.Anotherstudyfoundthatclinicianswithfewer yearsinpracticeweremorelikelytobelievethatOUDislike otherchronicdiseasesandweremorelikelytoapproveof ED-initiatedbuprenorphine.18 Otherstudieshaveidentiﬁed emergencymedicineresidentsasenthusiasticandeagerto incorporatecareforOUDintotheirpractice.17,19 Webelieve theseresultsareencouraginganddemonstratethatnewer generationsofcliniciansmayhavelesshesitancytoward initiatingMOUDtreatmentintheEDsetting.Thischange will,intime,likelyincreaseaccesstocareforthose withOUD.

Sixty-sevenpercentofallcliniciansagreedthattheyfelt preparedtoadministerbuprenorphineintheED.Wesuspect clinicians’ levelofpreparednesscouldbeimprovedwith continuingeducationlecturesandfeedback.Notably,the majorityofrespondentsreportedtheywouldbeinterestedin additionaleducationrelatedtomedicationandresourcesfor OUDtreatment.

WefoundthatthosewithanX-waiver,incomparisonto thosewhodidnothaveanX-waiver,weremorelikelytofeel preparedtoadministerbuprenorphineintheED.Other studieshavefoundthatX-waiveredcliniciansreported higherlevelsofreadinessorpreparednesstoinitiate buprenorphineintheEDincomparisontothosewhowere notX-waivered.14,17 Previously,aneight-hourtraining coursewasrequiredtoobtainanX-waiver;thistraining requirement,andthehassleofobtainingawaiver,was previouslyidentifiedasabarriertoinitiatingbuprenorphine intheED.14,17–18,20 However, findingthatX-waivered cliniciansfeltmorepreparedtoadministerbuprenorphinein theEDmayreflectthevaluethatwasassociatedwiththe previouslyrequirededucationcourse.Notably,wealso foundthatthosewhohadanX-waiverwerenotmorelikely tohavereportedorderingbuprenorphineornaloxonefor patientsintheEDwithinthepriorthreemonths.This finding

potentiallysupportstheideathatsimplyincreasingthe numberofX-waiveredcliniciansdoesnotsigniﬁcantly improveaccesstocareifX-waiveredcliniciansarenot activelyprescribingMOUDs.21,22 Notably,ourdatawas collectedpriortotherecenteliminationofthenational X-waiverrequirement.

Whenweaskedwhetherhavinghadafriendorfamily memberwithSUDwouldaffectclinicians’ attitudestoward buprenorphineintheED,wefoundthat42.8%ofclinicians reportedhavinghadafamilymemberorclosefriendwith SUD.Thispersonalrelationship,however,didnotmake cliniciansstatisticallymorelikelyto1)agreethatprescribing buprenorphinewaswithintheemergencyclinician’sscopeof practice;2)obtainanX-waiver;or3)reportordering buprenorphineornaloxoneforpatientsintheEDwithinthe priorthreemonths.Toourknowledge,aprescriber’ s personalrelationshipstoindividualswithSUDhasnotbeen evaluatedinpriorstudies.

Sixty-twopercentofcliniciansindicatedtheyhavethe resourcestheyneedtoinitiatebuprenorphineintheED. WiththeIMPACTproject,asdescribedabove,clinicians haveresourcessuchaspeerrecoverysupportspecialistsinthe ED,EHRprompts,andcloseoutpatientfollow-upavailable. Additionally,ouracademicEDisstaffedwithpharmacists andcasemanagers/socialworkers24/7.Giventhenumberof resourcesavailable,wewouldhaveexpectedthatmore clinicianswouldhavefelttheyhavetheresourcesnecessary toinitiatebuprenorphineintheED.Wesuspectitispossible thatmanycliniciansfelttheydidnothavetheresources necessarybecausetheyweresimplyunawareoftheavailable resources.Notably,lessthan75%ofrespondentswere familiarwiththeIMPACTproject.Allofthosewhowere unfamiliarwiththeIMPACTprojectwereresidents;this highlightsanopportunityforadditionaleducation.

Anumberofstudieshavebeenconductedlookingat facilitatorsandbarrierstobuprenorphineinitiationinthe

ED.14,17–18

Previouslyidentiﬁedbarrierstoinitiating buprenorphineintheEDincludethefollowing:lackof training/experience;concernsregardingmisuse/diversion/ harm;patientinterest;time/competingprioritiesintheED; concernsregardingfollow-up;concernsregardingincreased EDvolume;andfeelingasifprescribingbuprenorphinewas notwithintheirscopeofpractice.14,17–18

Notably,withtheimplementationoftheIMPACTproject anditsassociatedresources,severalsystemic/logistical barriershavebeeneliminatedasPRSSsareavailableinthe ED,outpatientfollow-upcanbeensured,andtheEHRis equippedwithpromptsandordersetsregardingboth buprenorphineandoutpatientreferrals.

Ourcliniciansidentifiedinabilitytoensurefollow-up, limitedknowledgeofavailableresources,andlackof education/preparednessasthetopthreebarrierstoinitiating buprenorphineintheED.AlthoughtheCOAT (comprehensiveopioidaddictiontreatment)clinichasa standingappointmentforEDreferrals,andPRSSsworkto facilitatetheseappointments,andevenaccompany patientstotheseappointments,concernregardingfollow-up wasstilltheprimarybarrieridentifiedbyclinicians. Arecentstudyvalidatedtheseconcernsasitfoundthat lessthan30%ofpatientswho fillbuprenorphine prescriptionsfromtheED fillsubsequentbuprenorphine prescriptions.23 Currentlywedonothavedataregarding EDfollow-upratesorratesofsubsequentbuprenorphine refills;however,thisisanareaofinterestforfuture investigationtobetterevaluatetheeffectivenessofour IMPACTprogram.

Previouslyidentifiedfacilitatorstobuprenorphine initiationintheEDincludeabilitytoensurefollow-up; supportstaff – PRSSs/socialwork/caremanagers;department protocols;EHRordersets;pharmacistconsultation;and feedbackonpatientexperiences.14,17–18 Ourclinicians identifiedavailabilityofpharmacistsandofbothinpatientand outpatientresources,andthepresenceofPRSSsand caremanagersasprimaryfacilitatorstobuprenorphine initiationintheED.Thefactthatcliniciansidentified pharmacistavailabilityasasignificantfacilitatorlikely highlightsunderlyingcliniciandiscomfortwiththe pharmacologyofbuprenorphineandagainhighlightsan opportunityforongoingeducationandexperience.Notably, timewasnotaprimarybarrieridentifiedbyourclinicians,and thismaybeduetothepresenceofadditionalsupport staffintheED.

LIMITATIONS

Ourstudyhasseverallimitations.Overallwehadasmall samplesize,andourrespondentsallworkatthesame academiccenter.Additionally,nearlyhalfofrespondents wereresidentswithfewerthanthreeyearsinclinicalpractice. Ourdatawascollectedpriortotheeliminationofthe X-waiverrequirement.Itispossiblethatthisnewlegislation

hassinceinﬂuencedprescribers’ attitudestoward buprenorphineaswellasprescribingpractices.Results relatedtofacilitatorsandbarriersmaynotbegeneralizable tocommunity-based,non-academicEDsthatdonothave similarresources.Additionally,ourresultsmaynotbe generalizabletoacademicEDsinurbanareas.

CONCLUSION

Theresultsofoursurveyidentifiedthefollowing: 1)agreementthatbuprenorphineiswithintheemergency clinician’sscopeofpracticewasinverselycorrelatedtoyears inpractice;2) >80%ofclinicianswereinterestedin additionaleducationregardingMOUDsandresourcesfor OUDtreatment;3)thosewithanX-waiverweremorelikely toreportfeelingmorepreparedtoadministerbuprenorphine intheEDincomparisontothosewhowerenotX-waivered; and4)clinicianswhoreportedhavinghadafamilymember orclosefriendwithSUDwerenotmorelikelytoagreethat buprenorphineinitiationiswithintheemergencyclinician’ s scopeofpractice,norweretheymorelikelytoobtainan X-waiverorreportorderingbuprenorphineornaloxonefor patientsintheEDwithinthepriorthreemonths.Wealso identifiedclinician-perceivedbarriersandfacilitatorsto initiatingbuprenorphineintheED.Ourcliniciansidentified inabilitytoensurefollow-upasaprimarybarriertoinitiating buprenorphineintheED.

Moreresearchisneededonretentionintreatmentfollowing EDreferraltoidentifywhatfactorsareassociatedwith successfultransitionsofcarefromED-initiatedMOUDto community-basedtreatment.Education/preparednesswas alsoidentifiedasasignificantbarrier.Weplantoaddressthis withadditionaldidacticsandprogramupdates.Timewasless ofabarrier,likelysecondarytotheavailabilityofpharmacists, supportstaff,andinpatientandoutpatientresources, whichwereidentifiedasfacilitators.Abetterunderstandingof facilitatorsandbarriersallowsforbetterresourceallocation.

ACKNOWLEDGMENTS

Ourresearchwassupportedbyagrant(G230766)from theSubstanceAbuseandMentalHealthServices AdministrationthroughasubcontractfromtheWest VirginiaDepartmentofHealthandHumanResources BureauforBehavioralHealth.

AddressforCorrespondence:LauraLander,MSW,WestVirginia University,DepartmentofBehavioralMedicineandPsychiatry,930 ChestnutRidgeRd.,Morgantown,WV26505.Email: llander@hsc. wvu.edu

ServicesAdministrationthroughasubcontractfromtheWest VirginiaDepartmentofHealthandHumanResourcesBureaufor BehavioralHealth.Therearenootherconﬂictsofinterestorsources offundingtodeclare.

REFERENCES

1.USCentersforDiseaseControlandPrevention.Opioiddataanalysis andresources.2022.Availableat: https://www.cdc.gov/opioids/data/ analysis-resources.html#anchor_data_sources AccessedSeptember19,2022.

2.USCentersforDiseaseControlandPrevention.Drugoverdosedeaths intheU.S.top100,000annually.2021.Availableat: https://www.cdc. gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm AccessedSeptember19,2022.

3.SoaresWE,MelnickER,NathB,etal.Emergencydepartmentvisitsfor nonfatalopioidoverdoseduringtheCOVID-19pandemicacrosssixUS HealthCareSystems. AnnEmergMed. 2022;79(2):158–67.

4.WeinerSG,BakerO,BernsonD,etal.One-yearmortalityofpatients afteremergencydepartmenttreatmentfornonfatalopioidoverdose. AnnEmergMed. 2020;75(1):13–7.

5.LarochelleMR,BernsonD,LandT,etal.Medicationforopioiduse disorderafternonfatalopioidoverdoseandassociationwithmortality:a cohortstudy. AnnInternMed. 2018;169(3):137–45.

6.NationalInstitutesofHealth.Initiatingbuprenorphinetreatmentinthe emergencydepartment.2022.Availableat: https://nida.nih.gov/ nidamed-medical-health-professionals/discipline-speciﬁc-resources/ emergency-physicians-ﬁrst-responders/initiating-buprenorphinetreatment-in-emergency-department.AccessedSeptember19,2022.

7.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence:a randomizedclinicaltrial. JAMA. 2015;313(16):1636–44.

8.HawkK,HoppeJ,KetchamE,etal.Consensusrecommendationson thetreatmentofopioidusedisorderintheemergencydepartment. Ann EmergMed. 2021;78(3):434–42.

9.U.S.DepartmentofHealthandHumanServices.Keysubstanceuse andmentalhealthindicatorsintheUnitedStates:R=resultsfromthe 2019nationalsurveyondruguseandhealth.2020.Availableat: https:// www.samhsa.gov/data/sites/default/ﬁles/reports/rpt29393/ 2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm AccessedSeptember19,2022.

10.vanBoekelLC,BrouwersEPM,vanWeeghelJ,etal.Stigmaamong healthprofessionalstowardpatientswithsubstanceusedisordersand

itsconsequencesforhealthcaredelivery:systematicreview. Drug AlcoholDepend. 2013;131(1–2):23–35.

11.RoomR.Stigma,socialinequalityandalcoholanddruguse. Drug AlcoholRev. 2005;24(2):143–55.

12.MendiolaCK,GalettoG,FingerhoodM.Anexplorationofemergency physicians’ attitudestowardpatientswithsubstanceusedisorder. J AddictMed. 2018;12(2):132–5.

13.BozinoffN,AndersonBJ,BaileyGL,etal.Correlatesofstigmaseverity amongpersonsseekingopioiddetoxiﬁcation. JAddictMed. 2018;12(1):19–23.

14.LowensteinM,KilaruA,PerroneJ,etal.Barriersandfacilitatorsfor emergencydepartmentinitiationofbuprenorphine:aphysiciansurvey. AmJEmergMed. 2019;37(9):1787–90.

15.MoranGE,SnyderCM,NoftsingerRF,etal.(2017). Implementing Medication-assistedTreatmentforOpioidUseDisorderinRuralPrimary Care:EnvironmentalScan.Rockville,MD:AgencyforHealthcare ResearchandQuality;2017.

16.Dickson-GomezJ,SpectorA,WeeksM,etal. “You’renotsupposedto beonitforever”:medicationstotreatopioidusedisorder(MOUD) relatedstigmaamongdrugtreatmentcliniciansandpeoplewhouse opioids. SubstAbuse. 2022;16:117822182211038.

17.HawkKF,D’OnofrioG,ChawarskiMC,etal.Barriersandfacilitatorsto clinicianreadinesstoprovideemergencydepartment-initiated buprenorphine. JAMANetworkOpen. 2020;3(5):e204561.

18.ImDD,CharyA,CondellaAL,etal.Emergencydepartmentclinicians’ attitudestowardopioidusedisorderandemergencydepartmentinitiatedbuprenorphinetreatment:amixed-methodsstudy. WestJ EmergMed. 2020;21(2):261–71.

19.WhitesideLK,D’OnofrioG,FiellinDA,etal.Modelsforimplementing emergencydepartment–initiatedbuprenorphinewithreferralfor ongoingmedicationtreatmentatemergencydepartmentdischargein diverseacademiccenters. AnnEmergMed. 2022;80(5):410–9.

20.MartinA,KunzlerN,NakagawaJ,etal.Getwaivered:aresident-driven campaigntoaddresstheopioidoverdosecrisis. AnnEmergMed. 2019;74(5):691–6.

21.DuncanA,AndermanJ,DeseranT,etal.Monthlypatientvolumesof buprenorphine-waiveredcliniciansintheUS. JAMANetwOpen. 2020;3(8):e2014045.

22.GordonAJ,KennyM,DunganM,etal.AreX-waivertrainingsenough? Facilitatorsandbarrierstobuprenorphineprescribingafterx-waiver trainings. AmJAddict. 2022;31(2):152–8.

23.SteinBD,SalonerB,KerberR,etal.Subsequentbuprenorphine treatmentfollowingemergencyphysicianbuprenorphineprescription ﬁlls:anationalassessment2019to2020. AnnEmergMed. 2022;79(5):441–50.

ORIGINAL RESEARCH

ANovelUseofthe “3-DayRule”:Post-dischargeMethadone DosingintheEmergencyDepartment

JennaK.Nikolaides,MD,MA*†

TranH.Tran,PharmD*‡

ElisabethRamsey,LCSW*

SophiaSalib,MSW,MPH*

HenrySwoboda,MD§

*RushUniversityMedicalCenter,SubstanceUseInterventionTeam, DepartmentofPsychiatryandBehavioralSciences,Chicago,Illinois

† RushUniversityMedicalCenter,DepartmentofEmergencyMedicine, Chicago,Illinois

‡ ChicagoCollegeofPharmacy,MidwesternUniversity,DownersGrove,Illinois § Queen’sUniversity,DepartmentofEmergencyMedicineandAddictions Medicine,Kingston,Canada

SectionEditor:PierreBorczuk,MD

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedFebruary9,2024;AcceptedFebruary16,2024

ElectronicallypublishedJune11,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18030

Introduction: Methadoneisamedicallynecessaryandlifesavingmedicationformanypatients withopioidusedisorder.Toadequatelyaddressthesepatients ’ needs,methadoneshouldbeoffered inthehospital,butbarriersexistthatlimititscontinuationupondischarge.Thecodeoffederal regulationsallowsformethadonedosingasaninpatientaswellasoutpatientdispensingfor uptothreedaystofacilitatelinkagetotreatment.Asaqualityinitiative,wecreatedanewwork ﬂ ow fordischargingpatientsonmethadonetoreturntotheemergencydepartment(ED)for uninterrupteddosing.

Methods: Ouraddictionmedicineteamchangedhospitalmethadonepolicytobetterallow hospitalizationasawindowofopportunitytostartmethadone.Thisnecessitatedthecreationofawarmhandoffprocesstolinkpatientstomethadoneclinicsifthatlinkagecouldnothappenimmediatelyon discharge.Thus,ourteamcreatedthe “EDBridge” process,whichusesthe “3-dayrule” todispense methadonefromtheEDposthospitaldischarge.Wethenfollowedeverypatientwedirectedthroughthis workﬂowasanobservationalcohortforoutcomesandtrends.

Results: OfthepatientsforwhomEDbridgedosingwasplanned,40.4%completedallbridgedosing andanadditional17.3%receivedatleastonebutnotallbridgedoses.Establishedmethadonepatients madeup38.1%ofsuccessfullinkages,and61.9%werepatientswhowerenewlystartedonmethadone inthehospital.

Conclusion: Improvingmethadoneasatreatmentoptionremainsanongoingissueforpolicymakers andadvocates.OurEDbridgeworkﬂowallowsustoexpandaccessandcontinuationofmethadonenow usingexistinglawsandregulations,andtobetterusehospitalsasapointofentryintomethadone treatment.[WestJEmergMed.2024;25(4)477–482.]

INTRODUCTION

Therearemanyregulatorybarrierstoinitiating medicationsforopioidusedisorder(MOUD)intraditional healthcaresettings.Sincetreatmentwithmethadone,an opioidagonist,orwithbuprenorphine,apartialopioid agonist,remainsthestandardofcareforpatientswithopioid

usedisorder(OUD),therehasbeenmuchfocusrecentlyon easingorcircumnavigatingbarrierstofacilitatelinkageto treatment.Whilethepassageofthe2023Consolidated AppropriationsActremovedtheX-waiverrequirementfor buprenorphineprescribing,1 methadonedispensingremains restrictedtoopioidtreatmentprograms(OTP).Giventhese

restrictionsonprescribingandotherlegalconsiderations, manyhospitalsareoftenhesitanttostartandtitrate methadoneforinpatientswithOUD.

Everyyeardrug-relateddeathscontinuetoincrease,and in2021over80,000peoplediedofanopioidoverdose.2 UnderuseofMOUDiscommonamongpatientsseeninthe hospitaldespiteevidencesupportingemergencydepartment (ED)andinpatientinitiationasbeneficialopportunitiesto starttreatment.3,4 Toaddressthisdeficit,ourtertiarymedical centercreatedtheSubstanceUseInterventionTeam(SUIT) in2018.5 TheSUITiscomprisedofemergencyphysicians whoaredual-ortriple-boardedinmedicaltoxicologyand/or addictionmedicine,psychiatricnursepractitioners,social workers,arecoverysupportspecialist,andapharmacist; SUITisavailableduringbusinesshours,Mondaythrough Friday.Theteamisacomprehensiveaddictionmedicine consultservice,workingtowardincreasingtherecognition, treatment,andlinkagetooutpatientcareforallsubstance usedisorders.TheSUIToffersallformsofMOUD, includingbuprenorphineandmethadone.Forpatientswho requestedorpreferredmethadone,thedosetitrationwas guidedbythe2019versionoftheCalifornia[CA]Bridge in-hospitalmethadonestartprotocol,6 tailoredtoeach patient,withthemostaggressivepossibletitrationbeing 40milligrams(mg)onday1,50mgonday2,and60mgon day3,atwhichpoint,thedosewasnotincreaseduntilevery fivedays.

Startingmorepatientsonmethadonenecessitatedthe craftingofnewpoliciesandproceduresatourcenterthat wouldallowawarmhandofftomethadoneOTPs.TheCode ofFederalRegulationsTitle21restrictsthedispensingof methadonetoOTPsandspeciﬁesthatmethadonemaybe administeredforthreedaysinahealthcaresettingforthe purposeofalleviatingwithdrawalwhilearrangementsare madetorefertotreatment.6 Itdoesnotlimittreatmentto threedays;however,ifthepatientisinthehospitalfor reasonsotherthanwithdrawal,MOUDcanbeused “to maintainordetoxifyapersonasanincidentaladjunctto medicalorsurgicaltreatmentofconditionsotherthan addiction.”7 Therefore,methadone,ifstartedwhilean inpatient,canbecontinuedfortheentiretyofthestay.Prior toSUIT’screation,ourtertiarymedicalhospitalhadan internalpolicythatifmethadonewasstartedforapatientnot previouslyenrolledinanOTP,thepatienthadtobeweaned priortodischargebecauseoftheprescribinglimitation. Becauseweaningwithoutfurthermaintenancetreatment onlyaddressesthephysicaldependenceintheshortterm whileneglectingthechronicdiseaseofOUD,itincreasesrisk ofrelapse,fataloverdose,andall-causemortality.8–11 This policy,althoughcompliantwiththelaw,wasnotevidencebasedbestpractice.

TheSUITcreatedanewpolicyandworkﬂowthatallowed thestartofaninpatienttitrationofmethadoneforpatients notpreviouslyenrolledinanOTP,arrangedlinkagetoOTPs

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

FederalregulationsallowEDstodispense methadoneforopioidusedisorder, andhospitalscanusethe3-dayruleto assistwithlinkagestomethadone maintenanceprograms.

Whatwastheresearchquestion?

WelookedatthefeasibilityofusingtheEDas apost-acutecarelandingsitetobridge patients ’ methadonetreatmentindischarging hospitalizedpatients.

Whatwasthemajor ﬁndingofthestudy?

Fortypercentofpatients(21/54)completed allbridgedosing,ofwhom62%werenewly initiatedonmethadoneinthehospital.

Howdoesthisimprovepopulationhealth?

Thiswork ﬂ owisanoveluseofthe3-dayrule toexpandaccesstomethadoneviatheED.

whilestillinpatient,andavoidedweaningpriortodischarge; ifpatientscouldnotimmediatelybetreatedatanOTPupon discharge(duetogapsintreatment,includingweekendor holidayclosures),theEDisusedasapost-dischargesetting forcontinueddosingunderthethree-dayruletocompletea warmhandoff.Thisworkﬂowwasreviewedbyourhospital’ s pharmacy,compliance,andlegaldepartments,allofwhich agreedthatitcompliedwithexistinglawsandhelpedusenact thechangeinhospitalpolicy.Oncethisprocesswasbuilt,our teamrealizedthatitwasalsohelpfulforthosepatientsin establishedOTPswhoweredischargedonweekendsor holidaysandcouldn’treturntotheirOTPfordosinguntilthe nextbusinessday.

HavingtheEDasapost-acutecarelandingsitefor methadonecontinuationhelpedavoiddisruptionof establishedMOUDaswellasnewlyinitiatedMOUD. Becausethenew-startmethadonetitrationwasmore aggressivethanatypicaloutpatientinitiationofmethadone, whenpatientsreturnedtotheED,thedoseadministeredwas theirdischargedoseandwasnottitratedintheEDtokeep thematsteady-stateandtoavoidaneedforobservationin theEDafterdosing.Duringthetimeframethisworkﬂowwas builtandused,theOTPsinourcityindependentlyunderwent changes.OneOTPinparticularagreedtohonorhospital titrationsonday1intheirclinicifthepatientbrought dischargepaperworkwiththem.Theprogrambecamea

preferredoptionforthisworkﬂow,althoughmanypatients eitheralreadyusedorrequestedotherOTPs.

Thisarticleservesasaproofofconceptandan observationalcohortofallpatientsthatSUITdirectedto returntotheEDformethadonedosing.

METHODS

Thesettingofthisstudywasourtertiaryurbanmedical center.Patientsidenti fi edasbeinginneedofan “ED bridge ” wereincludedinthisstudyiftheywereseenbythe SUITconsultservice;iftheywereidenti fi edaseither alreadyinamethadoneOTPornewlystartedon methadoneduringthehospitalizationandinneedof enrollmentinanOTP;andiftheprimaryteamdetermined thattheywouldbedischargedonadaywherethepatient wouldnotimmediatelybeabletogetoutpatientmethadone dosingbutwithaplaninplaceforlinkingtoanOTPwithin 72hoursofdischarge.Thisidenti fi cationusuallyhappened onaThursdayorFridayinanticipationofaweekend dischargeorfornewmethadonestartswhenanOTP appointmentcouldnotbemadeforthedayafterdischarge. SocialworkersontheSUITteammadeclearfollow-up plansbycontactingcooperatingOTPsaheadoftime. Patientswereexcludedfromthestudyiftheyendedupnot dischargingasplannedandtheEDbridgewasnolonger required,orifpatientsdeclinedtoreturn.Thesepatients weremanuallytrackedbychartreviewtodetermine whethertheyreturnedtotheEDfordosingovertheperiod fromJuly2019 –July2022.

The “EDbridge” processconsistedof1)instructingthe patienttoreturntotheEDeverydaystartingthemorning followingthedayofdischargeformethadoneadministration untilthedayofplannedOTPintakeorreturn(maximum threedays);2)writingacareplannoteinthechartnotifying theEDofthedosingplan,daysofdosing,andpolicy; 3)enteringanexpectedarrivalnotiﬁcationontheEDtrack board;and4)triagingthepatientonarrivaltoalow-acuity partoftheEDformethadonedosingandimmediate dischargeaslongastheydidnotappeartobeintoxicatedor haveanothercomplaint.

Atemplatednoteforthe “EDbridge” careplan (Appendix1)wasapprovedbythehospital’sPharmacyand TherapeuticsCommitteetoprovideconsistencyforthe process.Itincludedadotphraseforanotetemplatethatthe emergencycliniciancouldalsousewhenthepatientreturned. Theelectronichealthrecord(EHR)usedinourhospitalis Epic(EpicSystemsCorporation,VeronaWI).Ourhospital’ s methadonepolicywasamendedtoincludetheEDbridge pathwayandapprovedbyourhospital’scomplianceand legalofﬁces.Thepharmacydepartmentdisseminated hospital-widenotiﬁcationaboutthepolicyupdatesand providededucationaboutthenewprocesstoprescribers, pharmacists,nurses,andclinicalstaff.Thisstudyreceived institutionalreviewboardapproval.

Theprimaryoutcomemeasurementswerethepatient returnratetotheEDfordosingandthenumberofdoses completed.AnEDbridgewasconsideredsuccessfulifthe patientcamefordosingonallplanneddays;partially successfuliftheycamefordosingonsomeoftheplanned daysbutmisseddaysofdosing;andunsuccessfuliftheydid notcomeforanyoftheplanneddaysofdosing.Outcomes anddemographicdataareexpressedbydescriptivestatistics.

RESULTS

Therewere53plannedEDbridgessetupfor47unique patients.OneEDbridgewasexcludedafterthepatient stayedthroughtheweekendanddidn’trequireit.Several patientsusedtheEDbridgeworkﬂowmorethanoncedueto repeatedhospitalizations:threepatientsusedittwice,and onepatientuseditthreetimes.Demographiccharacteristics ofthe52plannedbridgesaresummarizedinthe Table. AllthepatientswithOUDwhousedthisworkﬂowwere usingheroin.

Ofthe52plannedEDbridges,21patientscompletedall necessarybridgedoses(40.4%).Ninepatients(17.3%) returnedtotheEDforatleastonedaybutdidn’tpresentfor allplanneddays.Theremainingplanswerenotsuccessful because22patients(42%)eitherdidnotreturntotheEDor lefttheEDbeforereceivingonedose.Intotal,94visitsfor methadonedosingintheEDwereplannedviatheEDbridge workﬂow,and40visitsactuallyoccurred.TheaverageED lengthofstay(LOS)fromtriagetodischargewas120 minutes,witharangeof36-682minutes.Sixofthe40visits requiredfullevaluationsforadditionalcomplaints. Excludingthesesixvisits,theaverageEDLOSwas89 minutes.Ofthe52plannedEDbridges,theaveragenumber ofdaysrequiredtocompletelinkagetotreatmentwas1.8 days.Forpatientswhosuccessfullycompletedallnecessary bridgedoses,theaveragenumberofdaysforlinkagewas 1.3days.

Patientswerelinkedtooneof10methadoneclinics,allof whichacceptedpatientswithMedicaid.Eightpatientswho werealreadyestablishedinamethadoneclinicaccountedfor 38.1%ofsuccessfullinkages.

DISCUSSION

Forthepurposesofthisstudy,apatientwasdeﬁnedasa “ new ” methadonepatientiftheywerenotenrolledinaclinic priortotheiradmissiontothehospitalandasan “established” patientiftheywere.Theterms “ new ” and “established” werenotdescriptorsofstabilityintreatment becauseoccasionallyevenestablishedpatientsneededtobe newlyrestartedonmethadoneduetomissingdosesattheir establishedOTP,andtheoutcomesofwhethertheycomplied withtheEDbridgeplanwereessentiallysimilarbetweenthe twogroups.Becauseourprojectlackedfollow-upwith patientsatalatertimepoint,wewereunabletodiscernthe reasonforpatientsnotreturningtotheED.

Table. Characteristicsofparticipantsintheemergencydepartmentbridgeprogramforpost-dischargemethadonedosing.

Characteristics(attimeofEDbridge)

Age

Average(years)44.647.945.140.5

Range(years)29 – 6929 – 6931 – 6129 – 64

Housingstatus

ED,emergencydepartment.

“Success” wasdeﬁnedasthepatientreturningforall planneddays.Theredidn’tappeartobeanydemographic factorthatcorrelatedwiththesuccessofthebridge,although thisstudywasnotpoweredtolookforanystatisticaltrends. Theclearestexplanationfromthedatawewereabletocollect isthatifabridgeplanwasshorter,itwasmorelikelytobe successful.Onaverage,patientsreturnedforapproximately oneday.Planslongerthanonedaywerelesslikelytobe successful.Nearlyhalfofthe10unsuccessfulbridgeplans occurredwithinarelativelyshortfour-monthtimespan (September–December2021).Emergencydepartmentwait timesandtheCOVID-19pandemicmayhavecontributedto thishighrateofunsuccessfulbridgedosesduringthattime.

PriortoinstitutingtheEDbridgeprocessinourcenter,we wouldroutinelyholdpatientscommittedtotreatmentinthe hospitaltoensurelinkagetoamethadoneclinicwithno misseddosestodecreasethepatients’ riskofrelapse,

overdose,anddeathupondischarge.TheEDbridgeprocess allowedgreater ﬂexibility:patientswhowerecommittedto treatmentbutwerereadyfordischargeotherwisecouldleave andcomebackfordosing;patientswhoweregettingplaced inpost-acutecaresettingsbutneededtotransportfor methadonecouldnowtransportbacktotheEDfordosing, therebyallowingweekenddischarges;andevenpatientswho wereleavingagainstmedicaladvicewereofferedthe opportunitytodoseintheEDtoreinforcethemessagethat MOUDisapriority.Whileitisdifﬁculttodeterminewhether everyEDbridgeplandecreasedLOS,thefactthat40visitsto ourEDformethadonedosingdidoccurviatheEDbridge processsuggeststhatwediddecreaseinpatienthospitaldays andthatthismitigatedtheincreaseduseofEDresourcesfor thesevisits.

InstitutingtheEDbridgeworkﬂowwasanadjustmentfor theEDstaff.Sincetherewasnopop-upintheEHR,the

triagenursesattimesneededtoberemindedtolookforan expectedarrivalnoteandtoberemindedthatthesepatients couldbetriagedtothelowacuitypartoftheED.Most clinicianswrotestandardEDnotesanddidnotusethepreformedtemplatednoteforamethadonevisit.Ittooksome timeforallstaffmemberstogetusedtothenewworkflow, whichlikelyexplainedtheaverageLOSbeingapproximately 1.5hourswhenafullevaluationwasnotrequired.TheLOS alsoaccountedfortimespentinthewaitingroomand cliniciansorderingmethadoneandprovidingdischarge instructions.Itwasnot1.5hoursofobservationafterthe dosewasgiven.Basedonourteam’sexperienceswith teachingtheworkflow,itappearedthattheEDstaffwas receptivetotheoverallidea,inpartbecauseourinstitution hadgottenusedtothecultureoftheemergencyphysician-led SUITteam.DuringtheCOVID-19pandemic,therewasalso turnoverintheEDnurseworkforcethatnecessitatedretrainingsontheworkflow,whichcouldhavealsocontributed tothewidevariationinLOS.

Thisstudytookplaceinalargeurbanenvironmentfrom 2019–2022,aperiodthatnotonlyencompassedtheCOVID19pandemicbutalsothecontinuedworseningoftheopioid epidemic.Duringthattime,thereweresignificantand evolvingchangestohowOTPsfunctionedduetoCOVID-19 emergencyconditionsandtothedesiretoreducebarriersto treatment.TheOTPschangedtheirintakeprocess, sometimesseveraltimesthroughoutthatperiod,at firsttobe morerestrictive12 andthenlatertoallow flexibility.Priorto thisperiod,atypicalOTPhadspecificdaysdesignatedfor intakeappointments.Intakescouldtakeapproximatelyone hour,andapatientmaynothaveactuallystarteddosing onthatday.Patientswereofteninstructedtoreturnafew dayslatertothenmeetwiththecliniciantostarttheir methadonetitration.

ThetypicalinitialdosingscheduleisdailydosingMonday throughSaturdaywithatake-homedosedispensedon SaturdayforuseonSundaywhentheOTPwasclosed. InitiallyourSUITprogramwasabletohelppatients completephoneintakeswhilehospitalized;however,this protocollaterevolvedtomatchthechangesinOTPs,which developedexpandeddaysforwalk-inintakes.SeveralOTPs alsochangedtheirworkflowsregardingdayofintakeand dayof firstdose,andsometimeswehadtouseourEDbridge protocoltokeepdosingpatientsduringthegapbetweenthe dayoftheirintakeandthedayoftheir firstdose.Duringthis period,OTPsalsopermittedmoretake-homemethadone doses,sometimesswitchingtoMonday-Wednesday-Friday dosingscheduleswitheveryotherdaytake-homedoses, weeklydosingscheduleswithsixdaysoftake-homedoses,or evenmonthlydosingwith27daysoftake-homedoses.This allowedpatientstonothavetogototheOTPasoften, facilitatingsocialdistancing,butitalsoledtogreateraccess todivertedmethadone.Thegoalofour “EDbridge” workflowwastodecreasedosedisruptionbyprovidingaway

forpatientstoobtainmethadonesafelywhilecomplyingwith dispensingrestrictions.Itispossiblepatientsobtained methadonethroughothermeansand,thus,didnotreturnfor theEDbridge.

OneOTPinoururbanareadecreasedthebarrierstoentry signiﬁcantlyoverthistimeperiod:theyexpandedintakesto MondaythroughFriday;alloweddosingevenbeforefull completionofintake;didnotrequirephotoIDaslongasthe patienthadidentifyingpaperwork(includinghospital dischargepapers);andacceptedallformsofgovernment insurance.ThisOTPendedupbecomingthedefaultoption thatwecouldrelyonwhensettingupourEDbridgeplans, eventhoughwestilldidusetheworkﬂowforlinkingtoother OTPsaswell.Inareasofthecountrywithmorelimitedand restrictiveaccesstomethadoneOTPs,ourthree-dayED bridgemodelmaynotbeasfeasible.

LIMITATIONS

Thisstudytookplaceinanurbanareawithfederaland statesupportforOTPs.WedidnotlookatpatientfollowthroughforOTPintakesorretentioninlong-termtreatment. AnotherlimitationisthatfeedbackfromEDstaffonthis newworkﬂowwasnotcollectedtofullyassessattitudes andbarriers.

CONCLUSION

Expandingaccesstomethadoneremainsanissuefor policymakersandadvocates.Ideassuchasmobileclinics, newguidelinessuggestinglimiteddispensing,andproposals toallowstandardcommercialpharmaciestodispense methadoneareallongoingconsiderations.13 OurEDbridge workﬂow,however,allowsustoexpandaccessand continuationofmethadoneusingexistinglawsand regulations,andtobetterusehospitalsasapointofentryinto methadonetreatment.

AddressforCorrespondence:JennaKNikolaides,MD,Rush UniversityMedicalCenter,SubstanceUseInterventionTeam, DepartmentofPsychiatryandBehavioralSciences,1611W Harrison,Suite106b,Chicago,IL60612.Email: Jenna_Nikolaides@ rush.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.TheSUITservicesweresupportedinpartbyacontracttoRushUniversityMedicalCenterfromtheIllinois DepartmentofHumanServices,DivisionofSubstanceUse PreventionandRecovery,aspartoftheIllinoisOpioid-State TargetedResponse(STR)Grant(TI-080231)andIllinoisState OpioidResponse(SOR)Grant(TI-081699)fromtheSubstance AbuseandMentalHealthservicesAdministration.Thecontentis solelytheresponsibilityoftheauthorsanddoesnotnecessarily

representtheofﬁcialviewsoftheNationalInstitutesofHealth, AgencyforHealthcareResearchandQuality,SubstanceAbuseand MentalHealthServicesAdministrationortheIllinoisDepartmentof HumanServices.Therearenootherconﬂictsofinterestorsources offundingtodeclare.

REFERENCES

1.SubstanceAbuseandMentalHealthServicesAdministration.Waiver elimination(MATAct).2023.Availableat: https://www.samhsa.gov/ medications-substance-use-disorders/removal-data-waiverrequirement.AccessedMarch30,2023.

2.AhmadFB,CisewskiJA,RossenLM,etal.Provisionaldrugoverdose deathcounts.2024.Availableat: https://www.cdc.gov/nchs/nvss/vsrr/ drug-overdose-data.htm.AccessedMarch30,2023.

3.RosenthalES,KarchmerAW,Theisen-ToupalJ,etal.Suboptimal addictioninterventionsforpatientshospitalizedwithinjectiondruguseassociatedinfectiveendocarditis. AmJMed. 2016;129(5):481–5.

4.D’OnofrioG,ChawarskiMC,O’ConnorPG,etal.Emergency department-initiatedbuprenorphineforopioiddependencewith continuationinprimarycare:outcomesduringandafterintervention. J GenInternMed. 2017;32(6):660–6.

5.TranTH,SwobodaH,PerticoneK,etal.Thesubstanceuseintervention team:ahospital-basedinterventionandoutpatientclinictoimprovecare forpatientswithsubstanceusedisorders. AmJHealthSystPharm. 2021;78(4):345–53.

6.CaliforniaBridgeProgram.Methadonehospitalquickstart.2019. Availableat: https://www.acep.org/siteassets/sites/acep/media/ equal-documents/ca-bridge protocol methadone-hospitalquick-start nov-2019.pdf.AccessedOctober12,2023.

7.DrugEnforcementAdministration,DepartmentofJustice.21CFR 1306.07:Administeringordispensingofnarcoticdrugs.Availableat: https://www.ecfr.gov/current/title-21/part-1306/section-1306.07 AccessedMarch23,2023.

8.BaileyGL,HermanDS,SteinMD.Perceivedrelapserisk anddesireformedicationassistedtreatmentamongpersons seekinginpatientopiatedetoxiﬁcation. JSubstAbuseTreat. 2013;45(3):302–5.

9.DavoliM,BargagliAM,PerucciCA,etal.Riskoffataloverdoseduring andafterspecialistdrugtreatment:theVEdeTTEstudy,anationalmultisiteprospectivecohortstudy. Addiction. 2007;102(12):1954–9.

10.CornishR,MacleodJ,StrangJ,etal.Riskofdeathduringandafter opiatesubstitutiontreatmentinprimarycare:prospectiveobservational studyinUKGeneralPracticeResearchDatabase. BMJ. 2010;341:c5475.

11.CousinsG,BolandF,CourtneyB,etal.Riskofmortalityonandoff methadonesubstitutiontreatmentinprimarycare:anationalcohort study. Addiction. 2016;111(1):73–82.

12.JoudreyPJ,AdamsZM,BachP,etal.Methadoneaccessforopioiduse disorderduringtheCOVID-19pandemicwithintheUnitedStatesand Canada. JAMANetwOpen. 2021;4(7):e2118223.

13.CongressionalResearchService.H.R.6279-OpioidTreatmentAccess Actof2022.Availableat: https://www.congress.gov/bill/117thcongress/house-bill/6279?s=1&r=64.AccessedMarch31,2023.

ORIGINAL RESEARCH

VariabilityinPracticeofBuprenorphineTreatmentbyEmergency DepartmentOperationalCharacteristics

GrantComstock,MD*

NataliaTruszczynski,PhD

†

SeanS.Michael,MD,MBA‡ JasonHoppe,DO

SectionEditor:GentryWilkerson,MD

*MedicalCollegeofWisconsin,DepartmentofEmergencyMedicine, DivisionofMedicalToxicology,Milwaukee,Wisconsin

† UniversityofColoradoSchoolofMedicine,Aurora,Colorado

‡ UniversityofColoradoSchoolofMedicine,DepartmentofEmergencyMedicine, Aurora,Colorado

§ UniversityofColoradoSchoolofMedicine,DepartmentofEmergencyMedicine, DivisionofMedicalToxicologyandPharmacology,Aurora,Colorado

Submissionhistory:SubmittedMarch30,2023;RevisionreceivedDecember27,2023;AcceptedFebruary28,2024

ElectronicallypublishedJune11,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18019

Introduction: Wesoughttodescribeemergencydepartment(ED)buprenorphinetreatmentvariability amongEDswithvaryingoperationalcharacteristics.

Methods: Weperformedaretrospectivecohortstudyofadultpatientswithopioidusedisorder dischargedfrom12hospital-basedEDswithinalargehealthcaresystemasasecondarydataanalysisof aqualityimprovementstudy.Primaryoutcomeofinterestwasbuprenorphinetreatmentrate.We describedtreatmentratesbetweenEDs,categorizedbytertileofoperationalcharacteristicsincluding annualcensus,hospitalandintensivecareunit(ICU)admissionrates,EDlengthofstay(LOS),and boardingtime.SecondaryoutcomeswereEDLOSand30-dayreturnrates.

Results: Therewere7,469uniqueEDencountersforpatientswithopioidusedisorderbetween January2020–May2021,ofwhom759(10.2%)weretreatedwithbuprenorphine.Buprenorphine treatmentrateswerehigherinlargerEDsandthosewithhigherhospitalandICUadmissionrates. EmergencydepartmentLOSand30-dayEDreturnratedidnothaveconsistentassociationswith buprenorphinetreatment.

Conclusion: RatesoftreatmentwithEDbuprenorphinevaryaccordingtotheoperationalcharacteristics ofdepartment.Wedidnotobserveaconsistentnegativerelationshipbetweenbuprenorphinetreatment andoperationalmetrics,asmanyfeared.Additionalfundingandtargetedresourceallocationshouldbe prioritizedbydepartmentalleaderstoimproveaccesstothisevidence-basedandlife-saving intervention.[WestJEmergMed.2024;25(4)483–489.]

INTRODUCTION

Theopioidcrisisisaworseningpublichealthemergency, withover80,000opioid-involvedoverdosedeathsintheUS in2021,anditisunlikelytoabateintheabsenceofeffectively implementedharmreductionandtreatmentstrategies.1 Buprenorphineisaneffective,evidence-basedtreatment resultinginincreasedabstinencefromillicitopioiduseand decreasedopioid-relatedmortality.2,3 Emergency department(ED)buprenorphinetreatmentisanevidencebasedpracticeandhasbeenassociatedwithincreasedfollowupandreducedillicitdruguseandmedicalcosts.4,5Although buprenorphineprescribingfromEDshasincreasedinrecent years,prescribingstilllagsfarbehindtheapparentneed,with disparitiesbypayerstatus,race,andethnicity.6,7

Improvedimplementationreliesonidentiﬁcationand removalofbarriers,providingresourcesforpatientsand clinicians,anddispellingstigmaandmisperceptions.8 Emergencydepartmentoperationalconsiderations,

includingperceptionsofinsuf ﬁcienttimeandincreasedED returnvisits,arecommonlycitedasperceivedbarriersto implementation. 9 However,thereal-worldinterplay betweenEDbuprenorphineinitiationandEDoperationsis notwelldescribed.UnderstandingtheimpactofED buprenorphinetreatmentonEDclinicaloperational outcomescaninformdecisionsonresourceallocationfor EDbuprenorphineprogramdevelopment.Conversely, barrierstoimplementationlikelyvarydependingonthe baselineoperationalperformanceofthedepartment. Identi ﬁ cationofoperationalcharacteristicsofEDswith lowerbuprenorphinetreatmentrateswouldallowfor targetedinterventions.

WesoughttodescribetheknowledgegapregardingED buprenorphinetreatmentvariabilityandoperational barrierstoimplementationby1)quantifyingtreatment ratesbetweenhospitalEDswithdifferentbaseline operationalcharacteristics,and2)measuringtheimpactof EDbuprenorphinetreatmentonoperationalmetrics.

METHODS

Weperformedaretrospectivecohortstudyofadult(age ≥18)EDpatientswithopioidusedisorder(OUD)discharged fromanyoftheacademic(one)orcommunity(11)hospitalbasedEDswithinalargehealthcaresystembetweenJanuary 2020–May2021.Thestudywasapprovedbyour institutionalreviewboardforsecondarydataanalysisofa completedqualityimprovementproject.

ToidentifyEDpatientswithOUDwhomaybenefitfrom buprenorphinetreatment,weappliedanelectronichealth record(EHR)computablephenotypepreviouslydevelopedand validatedbyChartashetal.10 Datawereextractedbyquerying anEDanalyticsdatamartpopulatedbyanightlyextractfrom theEpicClarity(EpicSystemsCorporation,Verona,WI) database.PatientswereidentifiedbysearchingfromphenotypespecificdiagnosiscodesandEDchiefcomplaints.Pertinent codesincludedInternationalClassificationofDiseases,10th Rev,ClinicalModification(ICD-10)diagnosticcodesrelating toopioiduse(T40.0*,T40.1*,T40.2*,T40.3*,T40.4*,T40.6*, andF11*)codedbyeitherthetreatingclinicianorsubsequently byamedicalcoder.Weadditionallyincludedpatientsnot identifiedbyICD-10diagnosticcodeEDchiefcomplaints relatingtoopioiduse.Chiefcomplaintdataisenteredintothe EHRattimeofEDencounterfromaprepopulatedlist,limiting ourselectionofsearchterms.Withinthelimitsofourdatabase, inclusionofencounterscontaining “opioid” or “naloxone” mostcloselyreflectedoriginalphenotypeterminology.Per phenotype,patientswiththeterms “benzodiazepine” or “alcohol” intheirEDdischargediagnosiswereexcludedto limitfalsepositiveinclusion.

Encounter-leveldataextractedincludedthefollowing: patientdemographics;chiefcomplaint;disposition;ED lengthofstay(LOS);dosesofmedicationsadministeredand prescribed;andfollow-upinformation,including30-dayED

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Understandingtheimpactofemergency department(ED)buprenorphineon operationscaninformresourceallocation decisionsforEDbuprenorphine programdevelopment.

Whatwastheresearchquestion?

HowdoesEDbuprenorphineimpact operations?HowdoEDoperational characteristicsimpacttreatmentrates?

Whatwasthemajor ﬁndingofthestudy?

Asmallnumberofpatientswithopioduse disorderwereprescribedbuprenorphine(2.5%in smallhospitals,11.6%inlargehospitals).ED lengthofstayand30-dayreturndidnotdiffer basedonbuprenorphinetreatment.

Howdoesthisimprovepopulationhealth? DepartmentalleadershipcanprioritizeED buprenorphineprogramdevelopmentwithout fearofnegativeoperationalimpactto increaseaccesstolifesavingtreatment.

returnrateandnumberofdaysuntilEDreturnwithinthe samehealthsystem.Alldatawasdeidentiﬁedforanalysisby theresearchteam.

TheprimaryoutcomeofinterestwasEDbuprenorphine treatment,deﬁnedaspercentageofpatientsadministered buprenorphineduringand/orprescribedbuprenorphineas partoftheEDvisitamongallpatientswithOUDidentiﬁedby theEHRphenotype.Afterconsultingwithkeyadministrative leadersandsystemstakeholders,wepartitionedEDsbasedon operationalcharacteristicsincludingannualEDcensus; hospitalandintensivecareunit(ICU)admissionrates;median EDLOS(timefromEDarrivaltoEDdeparture);andmedian boardingtime(timefromadmissionorderplacedtoED departure).Hospitalsweredividedintotertilesforeach characteristic.Asnopowerorsensitivityanalyseswere performed,andourgoalwasdescriptiveandhypothesisgenerating,wedidnotperformhypothesis-testing comparativeanalyses.Statisticalanalyseswereperformed usingRStudioversion4.0.5(RStudioPBC,Boston,MA)and IBMSPSS26(SPSS,Inc,Chicago,IL).

RESULTS

The2021annualcensusforthe12EDsrangedfrom8,934 to103,381patients.Among541,962totaluniqueED

Table1. Characteristicsofcohortofpatientswithopioidusedisorder.

EDbuprenorphinetreatment

YesNo

Totalencounters541,9627596,710

Gender

Male243,961(46.9)436(57.4)3,528(52.6)

Female286,504(52.9)323(42.6)3,182(47.4)

Notreporting1,497(0.3)00

Race

Black55,975(10.3)91(12)610(9.1)

White374,736(69.1)537(70.8)5,094(75.9)

Anotherrace111,251(20.5)131(17.3)1,006(15)

Insurancestatus

Self-pay62,124(11.5)3(0.4)22(0.3)

Medicare/Medicaid307,513(56.7)589(77.6)4,955(73.8)

Otherinsurer163,489(30.2)162(21.3)1,648(24.6)

VA8,836(1.6)5(0.7)85(1.3)

Averagebuprenorphinedose(mg)

AdministeredN/a76.28N/a PrescribedN/a103.42N/a

EncounterswithnaloxoneprescriptionN/a268(45.5)1,041(21)

*Percentagesnotedinparentheses

ED,emergencydepartment; VA,VeteransAdministration; mg,milligrams.

encountersacrosssitesfromJanuary1,2020–May31,2021, 7,469(1.4%)visitswerephenotypepositiveandconstituted ourstudypopulation,representing5,637uniquepatients, withameanof622visitsperEDsite(range51–2,547). Phenotype-positivepatientswerepredominantlyWhite (75.4%)andmale(53.1%)(Table1).Aminority(759,10.2%) weretreatedwithbuprenorphineduringtheEDencounter, 695ofwhom(91.6%)receivedbuprenorphineadministered intheED,301(40%)receivedabuprenorphineprescription, and237(31.2%)receivedboth.

BuprenorphinewasadministeredintheEDmore frequentlythanitwasprescribedatdischarge,irrespective ofoperationalcharacteristics.Largerhospitalsandthose withhigherhospitalandICUadmissionrateshadhigher buprenorphinetreatmentrates(Table2).EDsexperiencing longerboardingtimesalsotrendedtowardhigherrates oftreatment.

MedianEDLOSwassimilaramongpatientstreatedwith buprenorphineversusnottreated,althoughconﬁdence intervalswerewide(Table3).Loweradmissionrate,smaller EDsize,andsmallervolumewereassociatedwithlongerED LOSforpatientstreatedwithbuprenorphine.Proportionof patientsreturningtotheEDwithin30daysandtimetoED returndidnotdifferconsistentlybasedontreatment withbuprenorphine.

DISCUSSION

Withinthissinglehealthsystem,weobservedthatED buprenorphinetreatmentratesvariedaccordingtothe baselineoperationalcharacteristicsoftheED,whichmay beaproxyfortheprogressivenessorphilosophical approachofagivenED’ slocalchampionsandleadership team.Weobservedlowerratesofbuprenorphinetreatment inEDswithsmallerannualcensusandloweracuity(as measuredbyoverallandICUadmissionrates),whichare presumablypracticesettingswheretheremaybeless perceptionofinsuf ﬁ cienttime.However,smallerEDsare lesslikelytohavemultipleprescribingcliniciansworking simultaneously.Priorstudieshavesuggestedthatpractice variationportendslowerqualitycareandinequitiesin accesstoeffectivetreatmentforOUD. 11 ,12 Ourdata supportstheneedforinterventionsdesignedtopromote buprenorphinetreatmentinsmaller,loweracuityEDsto narrowthisvariation.

Buprenorphinetreatmentdidnotappeartohavea consistentassociationwithEDLOS,incontrastto commonlycitedbarriers.9 Thirty-dayreturnratesandtime toEDreturnweresimilarbetweenpatientswithOUD, regardlessoftheirtreatmentwithbuprenorphine,afarcry fromcitedfearsofEDsbecoming “ overrun ” bypatients seekingbuprenorphinereﬁlls.13

Table2. Buprenorphineadministrationandprescription,categorizedbyemergencydepartmentoperationalcharacteristics.

Average valueper quantile(SD) OUD visits (n = 7,469)

AnnualED censusvolume Patients

Small(n = 4)11,424 (±2,413)

Buprenorphine administered (n = ,%) Buprenorphine prescribed (n = ,%)

Administered and prescribed (n = ,%) Any buprenorphine (n = ,%) No buprenorphine (n = ,%)

2456(2.4%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)29,351.5 (±5,715) 1,24561(4.9%)2(0.2%)2(0.2%)61(4.9%)1,184(95.1%)

Large(n = 4)69,739 (±30,656)

EDnumberof beds Beds

5,979628(10.5%)298(5%)234(3.9%)692(11.6%)5,287(88.4%)

Small(n = 4)10.25(±2.5)2456(2.4%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)21(±4.34)1,24561(4.9%)2(0.2%)2(0.2%)61(4.9%)1,184(95.1%)

Large(n = 4)49.5(±17.23)5,979629(10.5%)298(5%)234(3.9%)692(11.6%)5,287(88.4%) Hospital admissionrate Rate

Low(n = 4)7.90% (±4.7%) 52726(4.9%)1(0.2%)1(0.2%)26(4.9%)501(95.1%)

Middle(n = 4)16.98% (±1.8)

High(n = 4)27.41% (±3.2%)

ICUadmission rate Rate

1,745115(6.6%)6(0.3%)4(0.2%)117(6.7%)1,628(93.3%)

5,197554(10.7%)294(5.7%)232(4.5%)616(11.9%)4,581(88.2%)

Low(n = 4)0.2%(±0.4%)2456(2.5%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)1.8%(±0.3%)2,027135(6.7%)6(0.3%)4(0.2%)137(6.8%)1,890(93.2%)

High(n = 4)3.1%(±0.6%)5,197554(10.7%)294(5.7%)232(4.5%)616(11.9%)4,581(88.2%) EDlengthofstayMinutes

Short(n = 4)106.3(±8.6)2456(2.5%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)149.8(±4.7)4,216587(13.9%)287(6.8%)225(5.3%)649(15.4%)3,567(84.6%)

Long(n = 4)160.5(±2.1)3,008102(3.4%)13(0.4%)11(0.4%)104(3.5%)2,904(96.5%) MedianED boardingtime Minutes

Short(n = 4)59.5(±10.2)2456(2.5%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)78.4(±4.6)1,43791(6.3%)2(0.1%)2(0.1%)91(6.3%)1,346(93.7%)

Long(n = 4)110.5(±24)5,787598(10.3%)298(5.2%)234(4%)662(11.4%)5,125(88.6%)

ED,emergencydepartment; ICU,intensivecareunit; OUD,opioidusedisorder.

Supportfromkeydepartmentalstakeholdersisa repeatedlyidentiﬁedfacilitatorforimplementingED buprenorphineprograms,andourobservationscorroborate this ﬁnding.13 IfLOSandEDreturnratearerelatively unaffectedbyEDbuprenorphinetreatment,thishas importantimplicationsthatmightallowdepartmental leaderstopromotegreaterresourcingandmitigatesomeof

theirapprehensionstofacilitatebuprenorphinetreatment withoutfearofnegativeoperationalimpacts.

LIMITATIONS

Ourstudyintentwasdescriptiveandshouldbeconsidered hypothesis-generating.Theuseofsecondarydatalimitedour abilitytopowerthestudy,and95%conﬁdenceintervalswere

Table3. EmergencydepartmentoperationaloutcomesbyEDoperationalcharacteristics.

EDOUDlengthofstay(minutes)30-DayEDOUDreturnvisitsDaysbeforeEDOUDreturn

Buprenorphine95%CI

AnnualEDcensusvolume

Small(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)250.4(211.8,289)263.7(251.1,276.3)14(1.8%)318(4.7%)8.7(4.7,12.8)11.2(10.2,12.2)

Large(n = 4)238(216.9,259.1)275.6(268.4,282.7)203(26.8%)1525(22.7%)11.5(10.2,12.67)11(10.6,11.5)

EDnumberofbeds

Small(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)250.4(211.8,289)263.7(251.1,276.3)14(1.8%)318(4.7%)8.7(4.7,12.8)11.2(10.2,12.2)

Large(n = 4)238(216.9,259.1)275.6(268.4,282.7)203(26.8%)1525(22.7%)11.5(10.2,12.7)11(10.6,11.5)

Hospitaladmissionrate

Low(n = 4)258(212.4,303.7)245.2(225.1,265.3)6(0.8%)156(2.3%)7.8(4.7,11)10.4(9.1,11.8)

Middle(n = 4)266(224.9,306.1)287(276.1,297.9)33(4.4%)461(6.9%)9.3(6.3,12.2)10.2(9.4,10.9)

High(n = 4)233.4(210.7,256.1)266.8(259.1,274.6)179(23.6%)1307(19.5%)11.7(10.4,13)11.3(10.8,11.7)

ICUadmissionrate

Low(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)264.1(228.8,299.5)289.2(278.9,299.6)38(5%)536(8%)9.1(6.5,11.7)10.5(9.8,11.2)

High(n = 4)233.4(210.7,256.1)266.8(259.1,274.6)179(23.6%)1307(19.5%)11.7(10.4,13)11.3(10.8,11.7)

EDlengthofstay

Short(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)225.8(205.2,246.3)279.7(271.6,287.9)187(24.6%)1059(15.8%)11.3(10.1,12.6)11.1(10.6,11.6)

Long(n = 4)321.7(261.8,381.6)265.5(255.8,275.3)30(4%)784(11.7%)11(7.9,14.1)11(10.4,11.6)

MedianEDboardingtime

Short(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)285.9(242.6,329.2)300.6(285.8,315.4)27(3.6%)370(5.5%)9(6,12)11.4(10.5,12.3)

Long(n = 4)232.6(211,254.1)266.2(259.3,273.1)190(25%)1473(22%)11.6(10.3,12.9)11(10.5,11.4)

ED ,emergencydepartment; ICU ,intensivecareunit; OUD ,opioidusedisorder.

oftenwide.Treatmentratesmaybefalselyloweredbythe presenceofpatientsalreadyontreatmentand,therefore,not offeredED-basedbuprenorphine,althoughthiswouldbe unlikelytoimpactcomparisonbetweensites.Ourdatasetis alsolimitedbysizeandconﬁnementtoasinglehealthsystem aswellaslackofpatientdiversity,whichmaylimit generalizability.Importantly,unmeasuredoperationaland culturalfactorsmaypromptanygivenED’sleadershipteam tosupportbuprenorphinetreatment,andmanyofthose samefactorslikelyinﬂuencethegeneraloperational characteristicsoftheED.

WhilethishealthsystemoperatesonacommonEHR, cliniciansareallemployedbythehealthsystem,and incentivesatallsitesaretiedtorelativevalueunits,thereisa strongelementoflocalcontrolovertheoperationsofeach localED,withlittleadmixingofstafforoperational processesbetweenthem.Nevertheless,cliniciansmayhave movedbetweensitesorworkedatmultiplesites.Theremay beunmeasuredtemporaltrendsduringthestudyperiod,and aminorityofmoreprogressiveEDs(includingonlyone academicED)mayhavecontributeddisproportionatelyto our ﬁndings.Finally,ourpartitioningofEDsby organizationalmetricswasbasedoninternalcomparisons speciﬁctoourhealthcaresystem.Attemptstousenational benchmarkingdatafromtheAcademyofAdministratorsin AcademicEmergencyMedicineorEmergencyDepartment BenchmarkingAlliancewereunsuccessful,asnationalmean andmedianmetricscreatedseverelyunevengroupsizes. Whileourapproachmaylimitgeneralizabilitytoother healthcaresystems,itstillmayhaveimplicationsforfuture hypothesis-testingresearch.

CONCLUSION

TheevidencesupportingthesocietalbeneﬁtofED initiationofbuprenorphineforpatientswithopioiduse disorderisclear,butEDoperationalleadershipand stakeholderbuy-iniskeytoincreasingimplementation. Basedonourstudyresults,wehypothesizethatED buprenorphinetreatmentratesvariedbasedonoperational characteristicsofEDs,withlowertreatmentratesatsmaller, loweracuityfacilities.Wedidnotobserveconsistent differencesinlengthofstayorreturnvisits.Futureresearch willallowdepartmentalleadershiptocontinueprioritizing theevidence-basedpracticeofEDbuprenorphinetreatment todecreasevariabilitywhileimprovingqualityofcareand accesstolife-savingtreatmentforpatientswithOUD.Thisis particularlyimportantgiventherecentremovalofthe X-waiverrequirement.

AddressforCorrespondence:GrantComstock,MD,Departmentof EmergencyMedicine,MedicalCollegeofWisconsinHubfor CollaborativeMedicine,8701WatertownPlankRd,Milwaukee,WI 53226.Email: gcomstock@mcw.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thedataforthisstudywereabstracted fromapreviouslycompletedqualityimprovementprojectfundedvia the2021EMF/NIDAMentor-FacilitatedTrainingAwardinSubstance UseDisordersScience.Therearenootherconflictsofinterestor sourcesoffundingtodeclare.

REFERENCES

1.AhmadFB,CisewskiJA,RossenLM,etal.Provisionaldrugoverdose deathcounts.2024.Availableat: https://www.cdc.gov/nchs/nvss/vsrr/ drug-overdose-data.htm.AccessedJanuary5,2024.

2.MattickRP,BreenC,KimberJ,etal.Buprenorphinemaintenance versusplaceboormethadonemaintenanceforopioiddependence. CochraneDatabaseSystRev. 2014;(2):CD002207.

3.LarochelleMR,BernsonD,LandT,etal.Medicationfor opioidusedisorderafternonfatalopioidoverdoseand associationwithmortality:acohortstudy. AnnInternMed. 2018;169(3):137–45.

4.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence:a randomizedclinicaltrial. JAMA. 2015;313(16):1636–44.

5.BuschSH,FiellinDA,ChawarskiMC,etal.Cost-effectivenessof emergencydepartment-initiatedtreatmentforopioiddependence. Addiction. 2017;112(11):2002–10.

6.StevensMA,TsaiJ,SavitzST,etal.Trendsanddisparitiesinaccessto buprenorphinetreatmentfollowinganopioid-relatedemergency departmentvisitamonganinsuredcohort,2014–2020. JAMANetwOpen. 2022;5(6):e2215287.

7.HollandWC,LiF,NathB,etal.Racialandethnicdisparitiesin emergencydepartment-initiatedbuprenorphineacross ﬁvehealthcare systems. AcadEmergMed. 2023;30(7):709–20.

8.WakemanSEandRichJD.Barrierstomedicationsfor addictiontreatment:howstigmakills. SubstUseMisuse. 2018;53(2):330–3.

9.ZuckermanM,KellyT,HeardK,etal.Physicianattitudeson buprenorphineinductionintheemergencydepartment:resultsfroma multistatesurvey. ClinToxicol(Phila). 2021;59(4):279–85.

10.ChartashD,PaekH,DziuraJD,etal.Identifyingopioidusedisorderin theemergencydepartment:multi-systemelectronichealthrecordbasedcomputablephenotypederivationandvalidationstudy. JMIR MedInform. 2019;7(4):e15794.

11.BrothersTD,MosselerK,KirklandS,etal.Unequalaccesstoopioid agonisttreatmentandsterileinjectingequipmentamonghospitalized patientswithinjectiondruguse-associatedinfectiveendocarditis. PLoSOne. 2022;17(1):e0263156.

12.AmiriS,McDonellMG,DenneyJT,etal.Disparitiesinaccesstoopioid treatmentprogramsandofﬁce-basedbuprenorphinetreatmentacross therural-urbanandareadeprivationcontinua:aUSnationwidesmall areaanalysis. ValueHealth. 2021;24(2):188–95.

13.RosenbergNK,HillAB,JohnskyL,etal.Barriersandfacilitators associatedwithestablishmentofemergencydepartment-initiated buprenorphineforopioidusedisorderinruralMaine. JRuralHealth. 2022;38(3):612–9.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

HarmReductionintheField:FirstResponders’ Perceptions ofOpioidOverdoseInterventions

CallanElswickFockele,MD,MS*

TessaFrohe,PhD†

OwenMcBride,MD*

DavidL.Perlmutter,MPH,MSW‡ BrendaGoh,BA‡ GroverWilliams§ CourteneyWettemann§ NathanHolland§ BradFinegood,MA∥

TheaOliphant-Wells,MSW∥ EmilyC.Williams,PhD,MPH‡¶ JennavanDraanen,PhD,MPH‡#

SectionEditor:GentryWilkerson,MD

*UniversityofWashington,DepartmentofEmergencyMedicine,Seattle,Washington

† UniversityofWashington,DepartmentofPsychiatryandBehavioralSciences, Seattle,Washington

‡ UniversityofWashington,DepartmentofHealthSystemsandPopulationHealth, Seattle,Washington

§ ResearchwithExpertAdvisorsonDrugUse,Seattle,Washington

∥ PublicHealth – Seattle&KingCounty,Seattle,Washington

¶ HealthServicesResearch&DevelopmentCenterofInnovationforVeteranCenteredandValue-DrivenCare,VeteransAffairsPugetSoundHealthCare System,Seattle,Washington

# UniversityofWashington,DepartmentofChild,Family,andPopulationHealth Nursing,Seattle,Washington

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedOctober24,2023;AcceptedFebruary9,2024

ElectronicallypublishedJune27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18033

Introduction: RecentpolicychangesinWashingtonStatepresentedauniqueopportunitytopair evidence-basedinterventionswith firstresponderservicestocombatincreasingopioidoverdoses. However,littleisknownabouthowtheseinterventionsshouldbeimplemented.Inpartnershipwiththe ResearchwithExpertAdvisorsonDrugUseteam,agroupofacademicallytrainedandcommunitytrainedresearcherswithlivedandlivingexperienceofsubstanceuse,weexaminedfacilitatorsand barrierstoadoptingleave-behindnaloxone, field-basedbuprenorphineinitiation,andHIVandhepatitisC virus(HCV)testingfor firstresponderprograms.

Methods: Ourteamcompletedsemi-structured,qualitativeinterviewswith32 ﬁrstresponders,mobile integratedhealthstaff,andemergencymedicalservices(EMS)leadersinKingCounty,Washington, fromFebruary–May2022.Semi-structuredinterviewswererecorded,transcribed,andcodedusingan integrateddeductiveandinductivethematicanalysisapproachgroundedincommunity-engaged researchprinciples.Wecollecteddatauntilsaturationwasachieved.Datacollectionandanalysiswere informedbytheConsolidatedFrameworkforImplementationResearch.Twoinvestigatorscoded independentlyuntil100%consensuswasreached.

Results: Ourthematicanalysisrevealedseveralperceivedfacilitators(ie,tensionforchange,relative advantage,andcompatibility)andbarriers(ie,limitedadaptability,lackofevidencestrengthandquality, andprohibitivecost)totheadoptionoftheseevidence-basedclinicalinterventionsfor firstresponder systems.Therewaswidespreadsupportforthedistributionofleave-behindnaloxone,althoughfunding wasidentifiedasabarrier.Manybelieved field-basedinitiationofbuprenorphinetreatmentcouldprovide amoreeffectiveresponsetooverdosemanagement,butthereweresignificantconcernsthatthis interventioncouldruncountertotherapidcaremodel.Lastly,participantsworriedthatHIVandHCV testingwasinappropriatefor firstresponderstoconductbutrecommendedthatthisservicebeprovided bymobileintegratedhealthstaff.

Conclusion: TheseresultshaveinformedlocalEMSstrategicplanning,whichwillinformrolloutof processimprovementsinKingCounty,Washington.Futureworkshouldevaluatetheimpactofthese interventionsonthehealthofoverdosesurvivors.[WestJEmergMed.2024;25(4)490–499.]

INTRODUCTION

Thepublichealthcrisisofopioidusedisorder(OUD)and opioidoverdosecontinuesunabated,withratescontinuingto rise.1–3 Survivorsofnon-fataloverdosehaveasigniﬁcantly greaterriskofrepeatoverdoseandoverdose-related mortalitywithinthefollowingyear,emphasizingthe importanceof ﬁrstresponderinterventions.4–7 Thesetrends aremirroredlocallyinKingCounty,Washington,wherethe annual9-1-1callvolumeofprobableoverdosesandother opioiduse-relatedincidentsincreasedbymorethan20% from2018–2021.8 Acriticalwindowforinterventionexists, asapproximately40%ofindividualswhodiedofanoverdose in2018hadatleastoneemergencymedicalservices(EMS) encounterduringtheprecedingyear.9

RecentlegislativechangesinWashingtonStatepresented auniqueopportunitytopairevidence-basedinterventions with firstresponderservicestoaddresstheriseinopioid overdoses.Specifically,inFebruary2021,theWashington StateSupremeCourtstruckdownthestatutethatmade possessionofcontrolledsubstancesaclassCfelony.Thestate governmentrespondedbypassingatemporarylawthat expandedtheroleof firstresponders(eg, firefighters, paramedics,andpoliceofficers)toconnectadultsfoundwith smallamountsofcontrolledsubstancestocasemanagement insteadofthecriminallegalsystem.10 In2023thelegislature rolledbacksomeofthesechangeswithapermanentbillthat increasedcriminalpenaltiesfordrugpossessionandpublic useandmadepre-trialdiversiontotreatmentprograms contingentontheprosecutor’sconsent.11

While firstrespondershavehistoricallyprovided importantreferralstocommunityresources,12 such programshavenothistoricallyofferedharm-reduction resourcesortreatmentinitiation.Specifically,therearethree medicalservicesthatareknowntoreduceoverdosedeath andincreaseaccesstocareforpeoplewhousedrugs:leavebehindnaloxone13,14; field-basedinitiationofbuprenorphine treatment14–19;andHIVandhepatitisCvirus(HCV) testing.20 Theseinterventionshavedocumentedefficacyin emergencydepartments13,15 andcommunityclinics14,20 whiledemonstratingpromisingresultsduringbrief encounterswithstreetmedicineteamsandparamedics.16–19 Inparticular,thedistributionofnaloxonekitsiscost effective21,22 andsignificantlyreducesopioid-related fatalities.23–25 BuprenorphinetreatmentforOUDmay decreaseall-causeandopioid-relatedmortalitybyupto 50%,26–29 andHIVandHCVtestingimprovesaccesstocare forpeoplewhousedrugs.30 However,thereisapaucityof literatureontheimplementationofthesethreeevidencebasedprogramsin firstrespondersystems. Groundedincommunityengagedresearch(CEnR) principles,31 ourteampartneredwiththeResearchwith ExpertAdvisorsonDrugUse(READU),agroupof academicallytrainedandcommunity-trainedresearchers withlivedandlivingexperienceofsubstanceuse,toaddress

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Firstrespondershavenothistoricallyoffered harmreductionservicesthatareknownto reduceoverdosedeathandincreaseaccessto careforpeoplewhousedrugs.

Whatwastheresearchquestion?

Whatarethefacilitatorsandbarriersfor ﬁ rst responderstoprovideharmreductionservices inthe ﬁ eld?

Whatwasthemajor ﬁndingofthestudy?

Perceivedfacilitatorsweretensionfor change,relativeadvantage,and compatibility,whilebarrierswerelimited adaptability,lackofevidence,and prohibitivecost.

Howdoesthisimprovepopulationhealth?

Participantsexperiencedatensionforchange andwereactivatedtoimplementleave-behind naloxone, ﬁ eld-basedbuprenorphine,and HIVandhepatitisCvirustesting.

thisgap.Theprimaryobjectivewastoexaminethe facilitatorsandbarrierstotheadoptionofleave-behind naloxone, ﬁeld-basedinitiationofbuprenorphinetreatment, andHIVandHCVtestingfor ﬁrstresponderprograms.The secondaryobjectivewastoinformlocalEMSoverdose responsepolicyandprogramming.

METHODS

StudyDesignandSetting

FromMarch–June2022,weconducted32semi-structured interviewswith ﬁrstresponders,mobilemedicalclinicians, andEMSleadersworkinginKingCounty,Washington.The studywasapprovedbytheUniversityofWashington InstitutionalReviewBoard.

TheoreticalFramework

ThisstudywasinformedbytheConsolidatedFramework forImplementationResearch(CFIR).32 Byprovidinga consistentlyappliedsetofanalyticalcategories,consistingof “constructs” situatedwithin “domains,” theCFIR32 simpliﬁesprocesses,highlightsbarriers,andidentiﬁes potentialareasofimprovement(Figure).Asdescribed below,thisframeworkprovidedthescaffoldingforthe interviewguides,deductivecoding,andthematicanalysis, whichhighlightedvariousconstructsasperceivedfacilitators

1.Intervention Characteristics

2.Outer

3.InnerSetting

EvidenceStrengthandQuality:Stakeholders’perceptionsofthequality andvalidityofevidencesupportingthebeliefthattheinterventionwillhave desiredoutcomes

RelativeAdvantage:Stakeholders’perceptionoftheadvantageof implementingtheinterventionversusanalternativesolution

Adaptability:Thedegreetowhichaninterventioncanbeadapted,tailored, refined,orreinventedtomeetlocalneeds

Cost:Costsoftheinterventionandcostsassociatedwithimplementingthe interventionincludinginvestment,supply,andopportunitycosts

TensionforChange:Thedegreetowhichstakeholdersperceivethecurrent situationasintolerableorneedingchange

Compatibility:Thedegreeoftangiblefitbetweenmeaningandvalues attachedtotheinterventionbyinvolvedindividuals,howthosealignwith individuals’ownnorms,values,andperceivedrisksandneeds,andhowthe interventionfitswithexistingworkflowsandsystems

Figure. AdaptedConsolidatedFrameworkforImplementationResearch(CFIR)withnumbereddomainsandselectedconstructs.

(ie,tensionforchange,relativeadvantage,compatibility) andbarriers(ie,adaptability,evidencestrengthandquality, andcost).

ReﬂexivityandPartnership

Ourstudyteamwascomposedofharmreductionists, includingbothacademicallytrainedresearcherswith advanceddegreesinpublichealth,psychology,and medicine,andcommunity-trainedresearcherswithlivedand livingexperienceofdruguseandEMSsysteminvolvement. Together,weembracedCEnRprinciples,31 practiced reﬂexivity,33 andcenteredtheperspectivesofpeoplewhouse drugsinthestudy’sdesign,execution,andanalyses.Priorto startingdatacollection,weengagedinbidirectionaltraining duringwhichcommunity-trainedREADUmembers educatedtheacademicallytrainedresearchersoneffective outreachstrategiesandexperienceswithpaststudies,while academicallytrainedresearcherssharedknowledgeabout qualitativestudydesignandanalysis.

ParticipantRecruitment

Participantswererecruitedthroughconvenienceand snowballsampling.Weemailedrecruitmentmaterialsto leadersandadministratorsatavarietyof firstresponder agenciesinKingCountytodisseminateinformationto potentialparticipants,includingparamedics, firefighters, policeofficers,mobileintegratedhealthstaff(ie,corespondingsocialworkersand firefightersengagedin communityparamedicine),andmobilemedicalclinicians (ie,socialworkers,nurses,physicianassistants,andnurse practitionersperformingstreetoutreach).Interested individualscontactedthestudyteamthroughourstudy phoneoremail,andtheywerescreenedforeligibility. Inclusioncriteriaincludedexperienceworkingasa first responder,amobilemedicalclinician,orinamanagement/ leadershippositionina firstresponderorganizationinKing County;beingover18yearsofage;andspeakingEnglish.

DataCollection

Demographicinformationcollectedfromparticipants includedage,gender,raceand/orethnicity,employment,and highestlevelofeducationalattainment.Separatebutrelated interviewguidesinformedbytheCFIR32 frameworkwere developedfor firstresponders,mobilemedicalclinicians,and EMSleaders.Topicscoveredintheinterviewsincluded participants’ perceivedrolewithintheopioidepidemic; perceptionsofservicesprovidedtopeoplewhousedrugs;and theperceivedfeasibility,acceptance,andappropriatenessof leave-behindnaloxone, field-initiatedbuprenorphine,and HIVandHCVtesting.Theinterviewguideswereiteratively refined,andthe finalguidesareincludedasanappendix.An academicallytrainedresearcherwithpriorexperiencein qualitativemethodswaspairedwithacommunitytrained READUmembertoconducteachinterview.

ThematicAnalysis

Weusedanintegrateddeductiveandinductivethematic approach34,35 toanalysis.Oncetheinitialinterviewswere completed,wefamiliarizedourselveswiththedata,reviewedthe transcriptsforaccuracy,andnotedinitialimpressionstogether. Wegroupedemergentobservationsintoinductivecodesand situatedtheminourpreliminarycodebookwiththepre-existing deductiveCFIRcodes.32 Weappliedthecodebooktoasingle interviewtranscript,engagedinline-by-linecodingasagroup, andreconciledanydisagreementsincodeapplicationsto ﬁnalizethecodebook.Individualteammembersthenprimarily appliedtherevisedcodebooktoeachtranscript,andanother conductedsecondarycoding,addressinganydifferences.

Subsequentsemi-structuredinterviewswereconducted untilthematicsaturationwasreached.Interviewswere recorded,transcribed,deidentiﬁed,uploadedtothe qualitativedatamanagementsoftwareDedoose (SocioCulturalResearchConsultants,LLC,Manhattan Beach,CA),andcodeddeductivelyusingexistingCFIR codes32 andinductivelyusingcodescreatedfromreviewinga 5.Process

sampleoftranscripts.36 Wesummarizedcodeddatato identifybarriersandfacilitatorstoadoptingleavebehind naloxone, ﬁeld-basedbuprenorphineinitiation,andHIVand HCVtestingfor ﬁrstresponderprograms,andweextracted prototypicalexamplesofeach.

RESULTS

ParticipantDemographics

Weinterviewed32 firstresponders,mobilemedical clinicians,andEMSleaderswhoworkedinsevendifferent citieslocatedinKingCounty,Washington(Table1). ParticipantsincludedBasicLifeSupportprofessionals (ie, firefighter/emergencymedicaltechnicians),Advanced LifeSupportprofessionals(ie,paramedics),policeofficers, nurses,andadvancedregisterednursepractitioners,social workers,andEMSleaders.Ofthe firstresponders interviewed,19(59%)hadbeenintheircurrentroleformore than10years.Participantswere31.3%femaleand12.5% racially/ethnicallydiverse,andmostwereabovetheageof36 withatleastsomecollegeeducation.

QualitativeResults

ThroughthelensoftheCFIRframework,32 ourthematic analysisrevealedseveralperceivedfacilitators(ie,tensionfor change,relativeadvantage,andcompatibility)andbarriers (ie,limitedadaptability,lackofevidencestrengthand quality,andprohibitivecost)totheadoptionofthree evidence-basedclinicalinterventionsfor ﬁrstresponder systems:1)leavebehindnaloxone;2) ﬁeld-basedinitiationof buprenorphinetreatment;and3)HIVandHCVtesting.

Leave-behindNaloxone

Therewaswidespreadsupportforthedistributionof leave-behindnaloxonewithmanyacknowledgingatension forchangeand ﬁndingtheinterventionrelatively advantageousandcompatiblewithinexistingsystems (Table2).Manyintervieweesrecognizedthatnaloxoneisa safe,easy-to-use,indispensablemedicationthatshouldbe accessibletopatients,theirlovedones,andothercommunity responders.Implementationofleave-behindnaloxonewas alsolargelythoughttobefeasiblewithseveralinterviewees explainingthatdistributioncouldbeeffortlesslyintegrated intocurrentworkﬂows.

Asmallergroupofindividualsexpressedconcernabout potentialbarriers,particularlylimitedadaptability,lackof evidencestrengthandquality,andprohibitivecost.Some policeofﬁcersthoughtthatnaloxonedistributionmay encourageunsafebehaviors(eg,usinglargeramountsor morepotentsubstances)andfeltthatitwasincongruouswith theirdepartments’ currentapproachtocontrollingdruguse throughlegalpenaltiesandincarceration.Otherservice professionalsworriedthatincreasedaccesstonaloxone wouldleadtocommunitymembers,ratherthan ﬁrst responders,managingmoreoverdoseresponsesand

Table1. Interviewees’ demographicinformation.

Agen(%)

20–252(6.3%)

26–355(15.6%)

36–4511(34.4%)

46–556(18.8%)

56–658(25%)

Gendern(%)

Male20(62.5%)

Female10(31.3%)

Trans,non-binary,orgendernon-conforming2(6.3%)

Raceand/orethnicityn(%)

White28(87.5%)

AsianorPaciﬁcIslander2(6.3%)

Hispanic1(3.1%)

Mixedrace1(3.1%)

Employmentn(%)

BasicLifeSupportprofessionals (ie, ﬁreﬁghter/emergencymedical technicians) 8(25%)

AdvancedLifeSupportprofessionals (ie,paramedics) 6(18.8%)

Policeofﬁcers5(15.6%)

Nursesandadvancedregistered nursepractitioners 3(9.4%)

Socialworkers5(15.6%)

Emergencymedicalservicesleaders5(15.6%)

Numberofyearsincurrentrolen(%) <12(6.3%)

1–48(25%)

5–93(9.4%)

10–198(25%) >2011(34.4%)

Highestlevelofeducationalattainmentn(%)

Associate’sdegree8(25%)

Bachelor’sdegree8(25%)

Master’sdegree10(31.3%)

Doctoraldegree2(6.3%)

Unspeciﬁed4(12.5%)

consequentlydecreasingthelikelihoodofconnectingpeople totreatmentandotherresources.Lastly,severalinterviewees inleadershipormanagementroleswereskepticalaboutthe relativebeneﬁtofnaloxone,explainingthattheybelieved thereoughttobemoreevidenceontheefﬁcacyofleavebehindnaloxoneprograms.Theyalsoworriedaboutthe resourcesandtrainingrequiredforimplementation.

Table2. Interviewees’ perceivedfacilitatorsandbarrierstoimplementingaleave-behindnaloxoneprogram.

Facilitators

Tensionforchange “AndIthink,yes,certainlythe ﬁredepartmentshouldplayaroleinhavingaccesstothatandbeing abletohanditoutandprovidingeducationonhowtouseitandwhentouseit.” Paramedic(ID#25)

Relativeadvantage “Ithinkthatnaloxonesare[a]lifesavingintervention,andit’srelativelyeasyforpeopletoadministerto theirfriendsorbystanderscanadministertopeopletheydon’tknow.So,Idothinknaloxoneisvery importantanditshouldbeoutthereandthereshouldbeaccesstoit.Andusleavingitbehindwith people,Ithinkisagoodidea.” Paramedic(ID#7)

Compatibility “Ithinkthat’sprobablytheeasiestone WecouldabsolutelygettheNarcan Firstresponders deﬁnitelycanprovide[those]asanintervention.” Mobileintegratedhealthsocialworker(ID#20)

Barriers

Limitedadaptability “Ifeellikeit’dbeapsychologicalthingforofficers,especiallyofficerswho’vebeenaroundfor10plus years,whereweusedtoarrestdrugdealersandputtheminjail.Andnowwe’reignoringthecrimes they’recommittingandwe’regivingthemnaloxonesothattheycanfurtherjustcontinuetousedrugs. So,Icanseesomeonewhoismaybenotlookingatthefullpictureorjusthastheirpersonalbeliefs.” Policeofficer(ID#1)

Lackofevidencestrength andquality “Iworrythatwe’rejustput[ting]morepeopleinwithdrawalandsortofmiss[ing]theopportunitiestodo somethingaboutit.” Intervieweeinleadershipormanagementrole(ID#28)

Prohibitivecost “ButIalsohavesomeskepticismthatsortofjustthrowingoutnaloxonekitsisgonnamakeabig difference.I’mnotopposedtoit,butitdoesrequiremoreeffortandtimeandenergy,andthere’sacost toit.Andquitefrankly,wehave[a]limitedbudget,andso,who’sgoingtopayforthosethings?Idon’t know.SoI’mmeasuredinmysupportforthatprogram,butifthere’sevidencethatitsaveslives,then wewillworktowardsthat.” Intervieweeinleadershipormanagementrole(ID#27)

Field-basedInitiationofBuprenorphineTreatment

Despitehavinglessfamiliaritywiththemedication comparedtonaloxone,mostintervieweesrecognizeda tensionforchangeandapprovedoftheimplementationof field-basedinitiationofbuprenorphinetreatment, consideringitevidence-based,appropriate,andrelatively advantageousfortheirsettings(Table3).Manyfelt unpreparedtoaddresswithdrawal,particularlywhena patient’soverdosemayhavebeenfullyreversedwith bystandernaloxone,butbuprenorphinewasseenasa “destigmatizing” toolthatrelievessymptoms,demonstrates compassion,andbuildstrustbetweenpatientsand first responders.Additionally,participantsdescribedhowthe recentuptickinoverdoseresponses,occasionallywiththe sameindividuals,ledtoburnoutandadesiretoaddressthe upstreamcausesofsubstanceuse.Severalhighlightedhow field-basedinitiationofbuprenorphinetreatmentcould bridgevulnerableindividualstoongoingtreatment, potentiallypreventingfutureoverdoses,decreasingoverall callvolumes,andsavinglives.

Thoseopposedwerelargelyconcernedwiththis intervention’slimited adaptability totherapidservice deliverymodelofemergencyservices,emphasizingthatthe timeneededfortheinterventionmayoverburdenanalready overwhelmedsystem.However,otherssuggestedthatthe deploymentofspecializedteams(eg,mobileintegrated healthormobilemedicalclinicteams)dedicatedtotreating thispatientpopulationmaybeawaytooffsetthesedemands. Finally,somepoliceofﬁcersworriedaboutthe evidence

strengthandquality ofbuprenorphine,speculatingthatit couldbedivertedfornon-prescribeduseandcould encourageongoingriskybehaviorsbycurbing withdrawalsymptoms.

HIVandHepatitisCVirusTesting

Intervieweesobservedthetensionforchangeintheir organizationsandgenerallysupportedincreasingaccessto HIVandHCVtesting(Table4).Somefeltthat ﬁrst responderencounterscouldserveasrelativelyadvantageous opportunitiestoengageindividualswhomaynotfeel comfortableseekingcareinmoretraditionalsettings. ProvidingHIVandHCVtestinginatrauma-informed mannerwasseentoincreaseeducationaroundprevention andimprovelinkagetocare.

Many,however,wereconcernedabouttheadaptability, appropriateness,andfeasibilityofHIVandHCVtesting duringanEMSresponse.Someworriedthatitwouldbe inconsistentwiththerapidservicedeliverymodelof emergencyservicessincepoint-of-caretestingtakesatleast 20minutestocomplete.37,38 Othersvoicedthattestingmay feelcompulsoryandcoerciveifcompletedimmediatelyafter anunnervingoverdoseevent.Like field-based buprenorphinestarts,someintervieweesalternatively proposedhaving firstrespondershandoffthesepatientstoa specializedteamthatwouldhavemoretimetoconductthe tests,providetheappropriatecounseling,andarrange follow-upasneededforconfirmatorydiagnosis andtreatment.

Table3. Interviewees’ perceivedfacilitatorsandbarriersto ﬁeld-basedinitiationofbuprenorphinetreatment.

Facilitators

Tensionforchange “Ithinktheopioidissuethatwehaveinourkindofcityrightnow,it’sbigandittakesabigtollon people.AndIthinkthatifthereisevidencethatshowsthatSuboxoneorbuprenorphinecanhelp,and ::: especiallyifwe’refollowinginthefootstepsofanotheragencyoragenciesthathaveuseditand havesomedataonwhatworksandwhatdoesn’t,thenIwouldbeallforit.” Mobilemedical nurse(ID#15)

“Suboxoneisgoodstuff.Ifwe’retrulytryingtohelppeopletransitionoutofaddiction,it’sagreattoolto helpmanagewithdrawals.Asfarasinthe ﬁeld,Ithinkifwecouldprovidethemaccesstoit, absolutely,Iwouldbe100%behindthat.” Fireﬁghter(ID#4)

“IthinkEMSisoftenthe ﬁrstinteractionofaprettytraumaticchainofeventsleadingtotheED.Andso, Ithinkifthatengagementwerepositive,there’dbelesshesitationtocall911,numberone,for overdose.Andthennumbertwo,everychancewecangivesomeonetodecreaseorstoptheiropioid useiswellworthit.Itfeelsalittlemorelikewe’remakingadifferencethangivingthenaloxone,the Narcan,'causehereit’slike, ‘Thisisgoingtohelpyouweanyourbodyoffthisstuff.’" Mobile medicalsocialworker(ID#11)

Relativeadvantage

“Iwouldsay,absolutelyanywaythatwecanexpandourreachtoourcommunityandgetthemmore support,andforaddictionsandforrecovery,Iwouldthinkwouldbeoptimal.AndIthinkthatthe ﬁre serviceisagreatwaytoallowthattohappen ::: I’minfullsupport.Ithinkthatwouldbeadvantageous inourcommunity.” Paramedic(ID#25)

“Anditseemsfarmoreofaviableoptiontomethantheleaveathome[naloxone].Sothe[leave behindnaloxone]wasjustgonnasolvetheproblemintheminute.Butitdoesnottakeawaythenext problem,whichisIneedmore,whereasbuprenorphinedoesaddressthat Butthebetteroption [is]tohowtogetthatmedicinetopeople.” Intervieweeinleadershipormanagementrole(ID#28) Barriers

Limitedadaptability “Thatwouldbepotentiallygood ::: [But]we’re[a]busyunit ::: howmuchoutofservicetimewould thataddtotheunittodothat?” Paramedic(ID#22)

Lackofevidencestrength andquality

“We’vemadelifeeasierforallthese[peoplewhousedrugs]outinSeattle,andithasn’tmadethings better.It’sactuallymadethingsworse.Imean,we’relookingatlike270deathssofarjustinthis ﬁrst quarter.Thatisfourtimesmorethanthreeorfouryearsago.So,Idon’tknowifgivingsuboxoneis actuallyhelpful.” Policeofﬁcer(ID#1)

EMS,emergencymedicalservices; ED,emergencydepartment.

Table4. Interviewees’ perceivedfacilitatorsandbarrierstoHIVandhepatitsCvirustesting.

Facilitators

Tensionforchange

“Thisisoneofthosethingsthatisinourrealmof responsibility.Ourprimarygoalistohelppeoplewith what’shappeningrightnow,butifwecanalsohelpthemoutwithlike, ‘Well,whatisthenextstepfor you?’” Mobileintegratedhealthsocialworker(ID#17)

Relativeadvantage “Hundredpercentliketheideaofbeingabletohaveanagencythathasacontractthatthisiswhatthey do.Yougoout,andyouprovidesomebodyanHIVtest.Wehavepeoplethatarespeciallytrainedtodeal withalltheramificationsofsomebodywho findsouttheyhaveHIV,'causethat’sgonnabeahorrible feeling.” Firefighter(ID#4)

Barriers

Limitedadaptability “Thatwouldn’tbesomethingusefulfor firstrespondersbecauseourpriorityisnotnecessarilytestingand tryingtodiagnosewhetherindividualshave[a]specificdisease.” Firefighter(ID#2) “Ijustthinkthat’dbehorribletodotosomebody LikeHIVorhepatitisC,likethosearehugethings.So, youjustdon’twanttojustdropabombonsomebodyontopofthembeing Duringadrugoverdose, forexample.” Paramedic(ID#25)

DISCUSSION

Workingonthefrontlinesoftheopioidepidemic, ﬁrst responders,mobilemedicalclinicians,andEMSleadersare confrontedwithskyrocketingoverdoseresponses.Many

wanttoimprovethecareofpatientswhousedrugs,beyond acuteoverdosereversal,butfeeluncertainabouthowto proceed.Peoplewhousedrugshavealsoexpressedaneedfor improvedcarewithmanyrefusingEMStransportfollowing

overdoseduetolawenforcement’spresenceatoverdose scenes, 39 unmanagedwithdrawalsymptoms,andanticipated stigmatizingtreatmentbyEMSandemergencyclinicians.40 OurthematicanalysisinformedbytheCFIRframework32 identifiedseveralperceivedfacilitators(ie,tensionfor change,relativeadvantage,andcompatibility)andbarriers (ie,limitedadaptability,lackofevidencestrengthand quality,andprohibitivecost)totheadoptionofthree evidence-basedclinicalinterventionsfor firstresponder systems:1)leave-behindnaloxone;2) field-basedinitiationof buprenorphinetreatment;and3)HIVandHCVtesting. However,therearefewexamplesofimplementingthese evidence-basedinterventionsin firstrespondersystemswith onenarrativereview findingonly27programsoutofnearly 22,000EMSagenciesnationallydescribedintheliterature, withmanyprovidingnaloxonedistributionandcommunity referralswhilefewfacilitatedlinkagetomedications forOUD.41

Manyrecognizedthetensionforchangeintheir communityandtherelativeadvantageofdistributing naloxonekitsandtreatingOUDwithbuprenorphineinthe ﬁeld.Leave-behindnaloxoneisacost-effective,21,22 widely accepted42–44 toolthatreducesopioidoverdose-related mortality45,46 anddoesnotincreaseriskydruguse behavior.47 ExistingEMSprogramsdistributingnaloxone kitsdemonstratedfeasibility48 andincreasedconnectionto otherresources.49 Mostintervieweesbelievedleave-behind naloxonewascompatiblewithandcouldbeeasilyintegrated intotheirworkﬂows,yetseveralhighlightedtheimportance ofsecuringsustainablefundingtoaddresscostsandreceiving additionaltrainingtoaddresstheperceivedlackofevidence strengthandqualitybeforeimplementation.Participants weresimilarlyenthusiasticabouttheprospectoftreating opioidwithdrawalandOUDwithbuprenorphine.In additiontoaninitialcaseseriesdescribingtreating withdrawalfromnaloxoneadministrationwith buprenorphine,18 apilotstudyexaminingprehospital buprenorphinetreatmentforOUDshowed50%retentionin treatmentatsevendaysand36%in30days.19

Notably,participantsworkinginlawenforcementwere moreskepticalofharmreductionthanthoseemployedin healthcareandsocialservices.Someexpressedfrustration withrecentlegislationthatcurtailedcriminalpenaltiesfor drugpossessionandpublicuse.Otherlawenforcement officersexpressedsentimentssimilartothoseofhealthcare andsocialservicesworkersbutquestionedwhattheirrolein addressingtheopioidepidemiccouldbeunderthenewlaws. Importantly,policeofficersstillregularlyrespondtomedical emergenciesinvolvingdruguse,includingoverdoses, highlightingtheurgentneedfortargetededucationonhowto usetheseevidence-basedinterventionseffectively inthe field.

Lastly,themostdiscussedbarriertoallthree interventions,particularly ﬁeld-basedinitiationof

buprenorphineandHIVandHCVtesting,wasafeelingfrom frontlineprofessionalsthatimplementationhadlimited adaptabilitytotherapidservicedeliverymodelofemergency services.However,othersrecommendedeitherdeployinga specializedteamtothesceneortransportingthepatienttoa diversionfacilitythatcouldprovidewraparoundservices. Localmobilemedicalclinicteamshavesuccessfully integratedharmreductionservicesintotheircareofthose experiencinghomelessness,50 andthecreationofmobile integratedhealthresponseunitshaveexpandedcase managementandreferralsthroughmultidisciplinary collaborationsin ﬁredepartments.51 Withlonger dispatchtimeandtheabilitytodolongitudinalfollow-up, theseteamsmaybewellsuitedtoprovide post-overdosecare.

ThePhiladelphiaFireDepartmenthasanalternative responseunit(“AR-2”)equippedwithAdvancedLife Supportcapabilities,whichislocatedinanareaheavily impactedbyopioidoverdoses.Itrespondstothose resuscitatedwithnaloxonebutwhorefusetransportationto thehospital,andearlydatademonstratesthat84%of patientsacceptedservices,includingtreatmentfacility placement,resources,and/ornaloxonekits.52 Diversion facilitiesofferinglow-barrieraccesstotreatmentandother servicescouldalsooperateasanalternativetoaprolonged EMSresponseoremergencydepartmentvisits;infact,a formerhospitalfacilityinColumbus,Ohio,nowequipped with60bedsdedicatedtoaddictionstabilizationserves astheprimarypost-overdosereceivingcenterfor individualsseekingtreatmentanddeemedmedically stablebyEMS.53

LIMITATIONS

Ourobjectiveinthisstudywastoexaminethefacilitators andbarrierstotheadoptionofleave-behindnaloxone, fieldbasedinitiationofbuprenorphinetreatment,andHIVand HCVtestingfor firstresponderprograms.However,the resultsmayonlybeapplicabletothegeographiclocationof theinterviewees,whichincluded firstresponders,mobile medicalclinicians,andEMSleadersworkinginKing County,Washington.Racialandethnicminoritieswere notablypoorlyrepresentedinourstudy.Becausethereisno publiclyavailabledataonthedemographicinformationof EMSprofessionalslocally,wewereunabletoassesswhether oursamplewasrepresentative.Ourconvenienceand snowballsamplingmayhavealsointroducedbias.Most participantsdescribedbeingintheircurrentroleformore than10years,whichislikelymuchhigherthanthegeneral firstresponderpopulation.Finally,wedidnottrackthe decline-to-beinterviewedrate.

CONCLUSION

Withoutthetoolstoaddresstheuptickinopioid overdoses, ﬁrstresponders,mobilemedicalclinicians,and

EMSleadersinKingCountyexperiencedatensionfor changeandarenowactivatedtoimplementleave-behind naloxone, ﬁeld-basedinitiationofbuprenorphinetreatment, andHIVandHCVtestingthroughnewEMSprotocols, post-overdoseresponseteams,anddiversionfacilities.Inthis studywetookateam-basedapproachandcenteredthe perspectivesofpeoplewithlivedandlivingexperienceof drugusetoensurethatthisresearchledtoaction.Members ofREADUhighlightedourwork’srelevancetothe communityandframedthese ﬁndingstoinformpolicy, particularlywiththerecentchangesinWashington Statelegislation.Futureworksshouldevaluatethe impactoftheseinterventionsonthehealthof overdosesurvivors.

AddressforCorrespondence:CallanElswickFockele,MD,MS, UniversityofWashington,DepartmentofEmergencyMedicine,325 9th Ave.,Box359702,Seattle,WA98109.Email: cfockele@uw.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisstudywassupportedbya UniversityofWashingtonImplementationScienceProgramPilot Grant(PIvanDraanen).Therearenootherconflictsofinterestor sourcesoffundingtodeclare.

REFERENCES

1.KingCountyMedicalExaminer.Overdosedeaths.2022.Availableat: https://kingcounty.gov/depts/health/examiner/services/reports-data/ overdose.aspx.AccessedFebruary23,2023.

2.AdministrationforStrategicPreparedness&Response.Renewalof determinationthatapublichealthemergencyexists.2022.Availableat: https://aspr.hhs.gov/legal/PHE/Pages/Opioids-29Sept22.aspx AccessedonFebruary23,2023.

3.CentersforDiseaseControlandPrevention:NationalCenterforHealth Statistics.DrugoverdosedeathsintheU.S.top100,000annually.2021. Availableat: https://www.cdc.gov/nchs/pressroom/nchs_press_ releases/2021/20211117.htm.AccessedFebruary23,2023.

4.BarefootEH,CyrJM,BriceJH,etal.Opportunitiesforemergency medicalservicesinterventiontopreventopioidoverdosemortality. PrehospEmergCare. 2021;25(2):182–90.

5.OlfsonM,WallM,WangS,etal.Risksoffatalopioidoverdoseduringthe ﬁrstyearfollowingnonfataloverdose. DrugAlcoholDepend. 2018;190:112–9.

6.StoovéMA,DietzePM,JolleyD.Overdosedeathsfollowingprevious non-fatalheroinoverdose:recordlinkageofambulanceattendanceand deathregistrydata. DrugAlcoholRev. 2009;28(4):347–52.

7.WeinerSG,BakerO,BernsonD,etal.One-yearmortalityofpatients afteremergencydepartmenttreatmentfornonfatalopioidoverdose. AnnEmergMed. 2020;75(1):13–7.

8.PublicHealth Seattle&KingCounty.Non-fataloverdose.2022. Availableat: https://kingcounty.gov/depts/health/overdose-prevention/ non-fatal.aspx.AccessedFebruary23,2023.

9.CarhartE.Abstractsforthe2020NAEMSPScientiﬁcAssembly. PrehospEmergCare. 2019;24(1):100–56.

10.WashingtonStateLegislature.SB5476–2021-22:addressingtheState v.Blakedecision.2021.Availableat: https://app.leg.wa.gov/ billsummary?BillNumber=5476&Initiative=false&Year=2021 AccessedonFebruary23,2023.

11.WashingtonStateLegislature.SB5536–2023-24:Concerning controlledsubstances,counterfeitsubstances,andlegenddrug possessionandtreatment.2023.Availableat: https://app.leg.wa.gov/ billsummary?BillNumber=5536&Year=2023&Initiative=False AccessedonOctober3,2023.

12.MarrenR.REACH/EMSpilotstudydesign:vulnerablepopulations strategicinitiative(VPSI)ofKingCountyEmergencyMedicalServicesin partnershipwithREACHandPugetSoundandRentonRegionalFire Authorities.2018.Availableat:~https://kingcounty.gov/depts/health/ emergency-medical-services/vulnerable-populations/~/media/depts/ health/emergency-medical-services/documents/vulnerablepopulations/reach-ems-pilot-study.ashx AccessedonFebruary23,2023.

13.SamuelsEA,DwyerK,MelloMJ,etal.Emergencydepartment-based opioidharmreduction:movingphysiciansfromwillingtodoing. AcadEmergMed. 2016;23(4):455–65.

14.WinhusenT,WalleyA,FanucchiLC,etal.TheOpioid-overdose ReductionContinuumofCareApproach(ORCCA):evidence-based practicesintheHEALingCommunitiesStudy. DrugAlcoholDepend. 2020;217:108325.

15.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence: arandomizedclinicaltrial. JAMA. 2015;313(16):1636–44.

16.CarrollGG,WassermanDD,ShahAA,etal.Buprenorphine ﬁeld initiationofrescuetreatmentbyemergencyservices (BupeFIRSTEMS):acaseseries. PrehospEmergCare. 2021;25(2):289–93.

17.CarterJ,ZevinB,LumPJ.Lowbarrierbuprenorphinetreatmentfor personsexperiencinghomelessnessandinjectingheroininSan Francisco. AddictSciClinPract. 2019;14(1):20.

18.HernHG,GoldsteinD,KalminM,etal.Prehospitalinitiationof buprenorphinetreatmentforopioidusedisorderbyparamedics. PrehospEmergCare. 2022;26(6):811–7.

19.HernHG,LaraV,GoldsteinD,etal.Prehospitalbuprenorphine treatmentforopioidusedisorderbyparamedics: ﬁrstyear resultsoftheEMSbuprenorphineusepilot. PrehospEmergCare. 2023;27(3):334–42.

20.CalinR,MassariV,PialouxG,etal.Acceptabilityofon-siterapidHIV/ HBV/HCVtestingandHBVvaccinationamongthreeat-riskpopulations

indistinctcommunity-healthcareoutreachcentres:theANRS-SHS154 CUBEstudy. BMCInfectDis. 2020;20(1):851.

21.CofﬁnPOandSullivanSD.Cost-effectivenessofdistributing naloxonetoheroinusersforlayoverdosereversal. AnnInternMed. 2013;158(1):1–9.

22.UyeiJ,FiellinDA,BuchelliM,etal.Effectsofnaloxonedistributionalone orincombinationwithaddictiontreatmentwithorwithoutpre-exposure prophylaxisforHIVpreventioninpeoplewhoinjectdrugs: acost-effectivenessmodellingstudy. LancetPublicHealth. 2017;2(3):e133–40.

23.BirdSMandMcAuleyA.Scotland’sNationalNaloxoneProgramme. Lancet. 2019;393(10169):316–8.

24.BirdSM,McAuleyA,PerryS,etal.EffectivenessofScotland’sNational NaloxoneProgrammeforreducingopioid-relateddeaths:abefore (2006-10)versusafter(2011-13)comparison. Addiction. 2016;111(5):883–91.

25.WalleyAY,XuanZ,HackmanHH,etal.Opioidoverdoseratesand implementationofoverdoseeducationandnasalnaloxone distributioninMassachusetts:interruptedtimeseriesanalysis. BMJ. 2013;346:f174.

26.LarochelleMR,BernsonD,LandT,etal.Medicationforopioiduse disorderafternonfatalopioidoverdoseandassociationwithmortality:a cohortstudy. AnnInternMed. 2018;169(3):137–45.

27.PearceLA,MinJE,PiskeM,etal.Opioidagonisttreatment andriskofmortalityduringopioidoverdosepublichealthemergency: populationbasedretrospectivecohortstudy. BMJ. 2020;368:m772.

28.SordoL,BarrioG,BravoMJ,etal.Mortalityriskduringandafteropioid substitutiontreatment:systematicreviewandmeta-analysisofcohort studies. BMJ. 2017;357:j1550.

29.WakemanSE,LarochelleMR,AmeliO,etal.Comparativeeffectiveness ofdifferenttreatmentpathwaysforopioidusedisorder. JAMANetw Open. 2020;3(2):e1920622.

30.SimeoneCA,SealSM,SavageC.ImplementingHIVtestingin substanceusetreatmentprograms:asystematicreview. JAssoc NursesAIDSCare. 2017;28(2):199–215.

31.KeyKD,Furr-HoldenD,LewisEY,etal.Thecontinuumof communityengagementinresearch:aroadmapforunderstandingand assessingprogress. ProgCommunityHealthPartnersh. 2019;13(4):427–34.

32.DamschroderLJ,AronDC,KeithRE,etal.Fosteringimplementationof healthservicesresearch ﬁndingsintopractice:aconsolidated frameworkforadvancingimplementationscience. ImplementSci. 2009;4:50.

33.JonesRG.Puttingprivilegeintopracticethrough “intersectional reﬂexivity:” ruminations,interventions,andpossibilities. Reﬂections: NarrativesofProfessionalHelping. 2010;16(1):122–5.

34.BraunVandClarkeV.Usingthematicanalysisinpsychology. QualRes Psychol. 2006;3(2):77–101.

35.BraunVandClarkeV.Thematicanalysis. JPositPsychol. 2017;12(3):297–8.

36.LyonAR,MunsonSA,RennBN,etal.Useofhuman-centered designtoimproveimplementationofevidence-based psychotherapiesinlow-resourcecommunities:protocolfor studiesapplyingaframeworktoassessusability. JMIRResProtoc. 2019;8(10):e14990.

37.AroraDR,MaheshwariM,AroraB.Rapidpoint-of-caretestingfor detectionofHIVandclinicalmonitoring. ISRNAIDS. 2013;2013:287269.

38.SmooklerD,VanderhoffA,BiondiMJ,etal.Reducingreadtime ofpoint-of-caretestdoesnotaffectdetectionofhepatitisCvirusand reducesneedforreﬂexRNA. ClinGastroenterolHepatol. 2021;19(7):1451–8.e4.

39.WagnerKD,HardingRW,KelleyR,etal.Post-overdoseinterventions triggeredbycalling911:centeringtheperspectivesofpeoplewhouse drugs(PWUDs). PLoSOne. 2019;14(10):e0223823.

40.BergsteinRS,KingK,Melendez-TorresGJ,etal.Refusaltoaccept emergencymedicaltransportfollowingopioidoverdose,andconditions thatmaypromoteconnectionstocare. IntJDrugPolicy. 2021;97:103296.

41.Champagne-LangabeerT,Bakos-BlockC,YatscoA,etal.Emergency medicalservicestargetingopioiduserdisorder:anexplorationofcurrent out-of-hospitalpost-overdoseinterventions. JAmCollEmerg PhysiciansOpen. 2020;1(6):1230–9.

42.MistlerCB,ChandraDK,CopenhaverMM,etal.Engagement inharmreductionstrategiesaftersuspectedfentanylcontamination amongopioid-dependentindividuals. JCommunityHealth. 2021;46(2):349–57.

43.SealKH,DowningM,KralAH,etal.Attitudesaboutprescribing take-homenaloxonetoinjectiondrugusersforthemanagement ofheroinoverdose:asurveyofstreet-recruitedinjectors intheSanFranciscoBayArea. JUrbanHealth. 2003;80(2):291–301.

44.StrangJ,PowisB,BestD,etal.Preventingopiateoverdosefatalities withtake-homenaloxone:pre-launchstudyofpossibleimpactand acceptability. Addiction. 1999;94(2):199–204.

45.McDonaldRandStrangJ.Aretake-homenaloxoneprogrammes effective?SystematicreviewutilizingapplicationoftheBradfordHill criteria. Addiction. 2016;111(7):1177–87.

46.StrangJ,McDonaldR,CampbellG,etal.Take-homenaloxone fortheemergencyinterimmanagementofopioidoverdose:thepublic healthapplicationofanemergencymedicine. Drugs. 2019;79(13):1395–418.

47.JonesJD,CampbellA,MetzVE,etal.Noevidenceofcompensatory druguseriskbehavioramongheroinusersafterreceivingtake-home naloxone. AddictBehav. 2017;71:104–6.

48.LeSaintKT,MontoyJCC,SilvermanEC,etal.Implementationofa leave-behindnaloxoneprograminSanFrancisco:aone-year experience. WestJEmergMed. 2022;23(6):952–7.

49.ScharfBM,SabatDJ,BrothersJM,etal.Bestpracticesforanovel EMS-basednaloxoneleavebehindprogram. PrehospEmergCare. 2021;25(3):418–26.

50.PublicHealth Seattle&KingCounty.Streetmedicineforpeopleliving unsheltered.2021.Availableat: https://kingcounty.gov/depts/health/ locations/homeless-health/mobile-medical-care/street-medicine.aspx AccessedonFebruary23,2023.

51.ChoiBY,BlumbergC,WilliamsK.Mobileintegratedhealthcareand communityparamedicine:anemergingemergencymedicalservices concept. AnnEmergMed. 2016;67(3):361–6.

52.MechemCC,YatesCA,RushMS,etal.Deploymentofalternative responseunitsinahigh-volume,urbanEMSsystem. PrehospEmerg Care. 2020;24(3):378–84.

53.BurtonWandMartinA.Opioidoverdoseandaddictiontreatment: acollaborativemodelofcompassion,patience,andrespect. JNursScholarsh. 2020;52(4):344–51.

REVIEW:SUBSTANCE USE DISORDER

BystandersSavingLiveswithNaloxone:AScopingReviewon MethodstoEstimateOverdoseReversals

AndrewT.Kinoshita,MPH* SoheilSaadat,MD,PhD,MPH† BharathChakravarthy,MD,MPH†

SectionEditor:GentryWilkerson,MD

*UniversityofCaliforniaIrvine,SchoolofMedicine,Irvine,California † UniversityofCaliforniaIrvine,SchoolofMedicine,DepartmentofEmergency Medicine,Irvine,California

Submissionhistory:SubmittedApril1,2023;RevisionreceivedJanuary26,2024;AcceptedFebruary12,2024

ElectronicallypublishedMay21,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18037

Introduction: Peoplewhousedrugsincommunitysettingsareatriskofafataloverdose,whichcanbe mitigatedbynaloxoneadministeredviabystanders.Inthisstudywesoughttoinvestigatemethodsof estimatingandtrackingopioidoverdosereversalsbycommunitymemberswithtake-homenaloxone (THN)tocoalescepossiblewaysofcharacterizingTHNreachwithametricthatisusefulforguidingboth distributionofnaloxoneandadvocacyofitsbeneﬁts.

Methods: WeconductedascopingreviewofpublishedliteratureonPubMedonAugust15,2022,using PRISMA-ScRprotocol,forarticlesdiscussingmethodstoestimateTHNreversalsinthecommunity.The followingsearchtermswereused: naloxoneAND(“takehome” ORkitOR “communitydistribution” OR “naloxonedistribution”).Weusedbackwardscitationsearchingtopotentially ﬁndadditionalstudies. Overdoseeducationandnaloxonedistributionprogram-basedstudiesthatanalyzedonlysingle programswereexcluded.

Results: Thedatabasesearchcaptured614studies,ofwhich14studieswererelevant.Backwards citationsearchingof765referencesdidnotrevealadditionalrelevantstudies.Ofthe14relevantstudies, 11weremathematicalmodels.TenusedMarkovmodels,andoneusedasystemdynamicsmodel.Of theremainingthreearticles,onewasameta-analysis,andtwousedspatialanalysis.Studiesrangedin yearofpublicationfrom2013–2022withmathematicalmodelingincreasinginuseovertime.Onlyspatial analysiswasusedwithafocusoncharacterizinglocalnaloxoneuseatthelevelofaspeciﬁccity.

Conclusion: OfexistingmethodstoestimatebystanderadministrationofTHN,mathematicalmodels aremostcommon,particularlyMarkovmodels.Systemdynamicsmodeling,meta-analysis,andspatial analysishavealsobeenused.Allmethodsareheavilydependentuponoverdoseeducationand naloxonedistributionprogramdatapublishedintheliteratureoravailableasongoingsurveillancedata. Overall,thereisapaucityofliteraturedescribingmethodsofestimationandevenfewerwithmethods appliedtoalocalfocusthatwouldallowformoretargeteddistributionofnaloxone.[WestJEmergMed. 2024;25(4)500–506.]

INTRODUCTION

Peoplewhousedrugsincommunitysettingshavetherisk ofafataloverdose,whichcanbemitigatedbynaloxone administeredviabystandersduringoverdoseincidents. Currently,thereissomepublichealthinfrastructureinplace totracknaloxonedistribution.InCalifornia,the DepartmentofHealthCareServices(DHCS)actsasahub

fordisseminationofnaloxonetocommunity-based organizations.1 Theseorganizationsare,inturn,charged withmaintainingdistributionandusedata.However,the DHCSisnottheonlydistributorofnaloxone,nordo programsthatdistributenaloxonehaveanywaytorequire individualstoreportuse.Further,naloxoneinNarcannasal sprayformhasrecentlybeenapproved(inMarch2023)by

theUSFoodandDrugAdministrationforover-the-counter (OTC)distribution.Duetothismultitudeoffactors,itisnot knownhowfrequentlycommunity-distributednaloxoneis administeredtotreatoverdose.

Whilenaloxonedistributionisaneffective,evidencebasedintervention,andOTCformulationsareapproved, thereisstillpushbackagainsthighlyvisibleandavailable naloxonedistributionpointsfrompolicymakersand communitymembersduetothestigmaassociatedwithdrug useand,byextension,thelegallandscape.2,3 Inthisstudywe soughttoinvestigatemethodsofestimatingandtracking opioidoverdosereversalsbycommunitymemberswithtakehomenaloxone(THN)tocoalescepossiblewaysof characterizingTHNreachwithametricthatisusefulfor guidingbothdistributionofnaloxoneandadvocacy ofitsbeneﬁts.

METHODS

WithPRISMA-ScRprotocolusingthePubMed database,4 weconductedascopingreviewonmethodsto estimateopioidoverdosereversalsbycommunitymembers usingTHN,beforeanypotentialinterventionby ﬁrst respondersorclinicians.Thedatabasesearchwasfollowed bybackwardscitationsearchingtoidentifyrelevantarticles omittedinthedatabasesearch.PubMed,adatabase providedbytheNationalCenterforBiotechnology InformationattheUSNationalLibraryofMedicine,was usedforthescopingreviewduetoitscoverageof 35millioncitationscontainedwithintheliterature compilationsofMEDLINE,PubMedCentral, andBookshelf.5

SearchStrategy

WeperformedasearchonAugust15,2022,using PubMedto ﬁndarticlesthatdiscussedsurveillanceor estimationofTHNadministration.Thesearchwasrestricted toarticlespublishedintheEnglishlanguage,butitwasnot restrictedbyyearofpublication.Thetermsusedforthe searchstrategywereselectedtoensurethatrelevantstudies foundinpilotsearcheswereallincluded.Sincetherehasbeen anevolvinglexiconsurrounding “take-home” naloxone, alternativetermshadtobeincludedinthesearch,even thoughthisdilutedtheproportionofrelevantstudiesinthe ﬁnalsearch.Weusedthefollowingsearchterms: naloxone AND( “ takehome ” ORkitOR “ communitydistribution ” OR “ naloxonedistribution ” ) . ArticlesfromthePubMedsearchthatdiscussedTHNand werepossiblyrelatedtosurveillanceorestimationwere sortedintomethodologybucketsforpossiblefurtherreview basedontitleandabstract,orreviewoffullarticleswhere uncertaintyexisted.Thesemethodologybucketsincludedthe following:1)mathematicalmodels;2)meta-analysis; 3)spatialanalysis;4)otherpossiblyrelevantarticles; 5)opioidoverdoseeducationandnaloxonedistribution

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Administrationofnaloxonemitigatestherisk ofafataloverdoseincommunitysettings; however,surveillanceofcommunitynaloxone anditsadministrationisweak.

Whatwastheresearchquestion?

Whatmethodsexistfortrackingorestimating opioidoverdosereversalsbycommunity memberswithnaloxone?

Whatwasthemajor ﬁndingofthestudy?

Thescopingreviewyielded14studies:11 mathematicalmodels,onemeta-analysis,and twospatialanalyses.

Howdoesthisimprovepopulationhealth?

Fewmethodshavebeenpublishedtoestimate communitynaloxoneadministration; methodsmustbeadaptedforlocalusebefore informingpolicyoradvocacy.

(OEND)program-basedstudies;and6)otherarticles deemednotrelevant.

Thearticlessortedintothe firstfourbuckets mathematicalmodels;meta-analysis;spatialanalysis;and otherpossiblyrelevantarticles werereadinfullfor confirmationof finalinclusion.Weexcludedfromfurther reviewbucket5(OENDprogram-basedstudies)because thesestudieshavestraightforwardmethodologyandare alreadyawell-knownmethodoftrackingTHN administration,whichisevidencedbythenumberofOEND program-basedstudies(59studiescapturedwithour databasesearchstrategy).TheseOENDprogram-based studiesarediscussedfurtherinthe Discussion section.After selectionofPubMedarticlesfor finalinclusion,we performedbackwardscitationsearchingonthesearticles usingtitles,withabstractsasneeded.Thefulltextofpossibly relevantarticleswasreviewedfor finalinclusion.

DataExtractionandSynthesis

Weextractedthefollowingdatausingastandardized table:method(bucket);modeltype;datasources;location (country,location – community);andfundingsources. Methodcorrespondedtothebucketcategoriesdiscussed above.Modeltypewasrelevantforstudiesinbucket1 (mathematicalmodels),andtherecordedmodeltypewas basedonhowauthorsself-describedtheirstudies.Theseself-

descriptionsformathematicalmodelsincludedMarkov modelingandsystemdynamicsmodeling.Datawas synthesizedthroughconceptmapping.

RESULTS

Thedatabasesearchresultedinthecaptureof614studies. Ofthese,108studiesweremarkedaspossiblyrelevantbased ontitlesorabstractsdiscussingTHNprograms,surveillance, orestimation.Usingfullarticlesasneeded,39studieswere categorizedintobucketsofinterest(1–4).Following categorization,fullarticlereviewresultedin14articlesfor finalinclusion.Backwardscitationsearchingofthe765 referencescontainedwithinthe14articlesresultedinthree articlesforfullreview.Allthreewereexcludedfrom final analysisleaving14articlesfor finalinclusion.These14 articleswerefrombuckets1–3. Figure1 presentsa flowchart ofthecapturesandthereviewofliterature.

StudyCharacteristics

Theincludedstudiesvariedintheirobjectives.Developing awaytoidentifyhowmuchnaloxonewasadministeredby bystanderswasoftenacontributortotheoverallgoalsofthe studiesinsteadoftheprimaryobjective.Thissectionpresents asynthesisofstudyobjectivesandthemethodsemployedto surveilorestimatecommunitynaloxoneuse.The Table presentsanoverviewofthestudiesbymethod.

MathematicalModels

Ofthe14studies,11employedmathematicalmodels.Of these,10usedMarkovmodelsandwerepublishedbetween 2012–2022.Markovmodelsdeﬁneseveralnon-overlapping statuses(ie,chronicopioiduse,cessationofopioiduse, overdosing,dead)andrepresenteachindividualwithina simulatedpopulationasamemberofoneofthestatuses.6

Studies identified through database searching. (n = 614)

Abstracts screened. (n = 614)

Abstracts possibly relevant. Categorized into buckets using full text as needed. (n = 108)

Studiescategorized into relevant buckets. Full text reviewed. (n = 39)

Studies included in qualitative synthesis. (n = 14)

Individualstransitionfromonestatetoanother,not necessarilylinearly,basedonprobabilityparametersthat representchangeinindividualstatusesovertime.Thismeans thatmodeloutputofanypriororsubsequentpopulation distributionwithinthesystemcanbederivedfromanygiven populationdistribution.Theoneremainingmathematical modelingstudyusedasystemdynamicsmodelandwas publishedin2022.Systemdynamicsmodelingrepresents differentvariables(ie,population,treatmentavailability, overdosedeaths)withinasystemandtherelationships betweenthem,factoringintemporaldelayasappropriate.7 Thismeansthatthemodeloutputofanysubsequent populationdistributionwithinthesystemmaybebasedon boththegivenpopulationdistributionandthechanges precedingthegivenpopulationdistribution.

Studiesemployingmathematicalmodelsvariedintheir primaryobjectives.FiveofthestudiesemployingMarkov modelsweredesignedtoevaluatethecosteffectivenessof naloxonedistribution.Fourofthesecost-effectiveness studiesusevariationsofthesameMarkovmodel,whichwas originallydevelopedin2013byCofﬁnandSullivan,who authoredtwoofthefourarticles.8–11 Theoneremainingcosteffectivenessstudy,byUyeietal,wasuniqueinthatitalso investigatednaloxonedistributioninconjunctionwithother interventions,includingpre-exposureprophylaxisfor HIVprevention.12

Oftheremaining fiveMarkovmodelstudies,allmodeled theeffectsofnaloxonedistributiononopioidoverdosedeath rates.Coffinetal(2022)modeledtheUSpopulationusing theMarkovmodeldevelopedpreviouslybyCoffinand Sullivanin2013.13 Irvineetal(2018)andIrvineetal(2019) modeledthepopulationofBritishColumbiausingamodel developedbyIrvineetalin2018.14,15 Irvineetal(2022) modeledtheUSpopulation,andLinasetal(2021)modeled

Titles screened from backwards citation searching using abstracts as needed. (n = 765)

Studies excluded;abstracts not relevant. (n = 506)

Study excluded; bucket not relevant. (n = 69)

Studies excluded; full text not relevant. (n = 25)

Abstract relevant and not duplicate study. Full text reviewed. (n = 3)

Studies included in qualitative synthesis. (n = 0)

Studies excluded; title/abstract not relevant or duplicate study. (n = 762)

Studies excluded; full text not relevant. (n = 3)

TOTAL studies included in qualitative synthesis. (n = 14)

Figure1. PRISMA ﬂowchart.

Table. Studycharacteristicsbymethod.

Method (bucket)

Model type First authorYearDatasources

Mathematical models Markov model Acharya M2020Literature, Surveillancedata, Assumption

CofﬁnPO2022Literature, Assumption

CofﬁnPO2013Literature, Expertinput, Assumption

CofﬁnPO2013Literature, Assumption

IrvineMA2018Surveillancedata, Literature, Expertinput, Assumption

IrvineMA2019Surveillancedata, Literature, Expertinput, Assumption

Location country Location communityFundingsources

USUS Notreported

USUSNationalInstitutesofHealth

USUSNationalInstituteofAllergyand InfectiousDiseases(National InstitutesofHealth)

RussiaRussiaOpenSocietyFoundation

CanadaBritish Columbia CanadianInstitutesofHealth Research,NaturalScienceand EngineeringResearchCouncil ofCanada

CanadaBritish Columbia BritishColumbiaGovernment, CanadianInstitutesofHealth Research,NaturalScienceand EngineeringResearchCouncil ofCanada,MichaelSmith FoundationforHealth Research,NationalInstitutes ofHealth

IrvineMA2022Literature, Modiﬁed-Delphi panel USUSNationalInstituteonDrug Abuse(NationalInstitutes ofHealth)

LanghamS2018Literature, Assumption UKUKMundipharmaInternationalLtd.

LinasBP2021Surveillancedata, Literature, Assumption USRural,urban Massachusetts NationalInstituteonDrug Abuse(NationalInstitutes ofHealth)

UyeiJ2017Surveillancedata, Literature, Assumption USConnecticutConnecticutDepartmentof PublicHealth,NationalInstitute ofMentalHealth(National InstitutesofHealth)

System dynamics model Stringfellow EJ

2022Surveillancedata, Literature, Expertinput, Assumption USUS USFoodandDrug Administration

Meta-analysis McAuleyA2015OENDprogram studies Canada, UK,US n/a NationalHealthService Scotland

Spatialanalysis RoweC2016SurveillancedataUSSanFranciscoNationalInstituteonDrug Abuse(NationalInstitutes ofHealth)

YiG2022SurveillancedataUSBaltimore Notreported

urbanandruralMassachusettspopulationsalsousingthe 2018Irvineetalmodel.16,17

Theonestudyusingasystemdynamicsmodelwas conductedbyStringfellowetalin2022andinvestigatedthe effectsofdifferentinterventions,includingnaloxone distribution,onopioidoverdosedeathrates.18

Mathematicalmodelsemployedvariousdatasourcesto informtheparametersused.Thesesourcesincluded parametersfrompublishedliteratureandsurveillancedata (ie,publichealthdepartmentrecords,coronerreports, insuranceclaims).Whensourcesofdatawerenotavailable, authorsusedtheirownassumptionsorexpertinput,

includingamodiﬁed-Delphipanelinthe2022Irvineetal study.16 Thestudiesdonotapplythemathematicalmodelsto anyspeciﬁccitiesorsmallercommunities,althoughthe2021 Linasetalstudymodelsageneralizedruralcityanda generalizedurbancityinMassachusetts.17 Adoptingthe mathematicalmodelsemployedinthesestudiestoestimate bystandernaloxoneadministrationinaparticular communityofinterestwouldrequiretheinputoflocal parameters,whichcouldbeanintensiveeffortifsurveillance infrastructureisnotestablished.

Meta-analysis

OnestudybyMcAuleyetal,publishedin2015,consisted ofameta-analysisofnineOENDprogramstudies, synthesizingtheiroutcomesandaccountingforparticipants losttofollow-uptoreporttheproportionofnaloxonekits thatarelikelytobeusedinthe ﬁrstthreemonthsafter distribution.19 Thestudiesthatcomprisedthemeta-analysis werefromCanada,theUnitedKingdom,andtheUS. Adoptingameta-analysismethodologytoestimate bystandernaloxoneadministrationinaparticular communityofinterestwouldinvolvesynthesizingdatafrom OENDprogramsinthecommunity.

SpatialAnalysis

Twostudies,byRoweetal(2016)andYietal(2022),used geographicsysteminformation(GSI)mappingtechnologyto conductspatialanalysisofnaloxoneoverdoseincidents.The studiesdeterminedtherelationshipbetweenproximityofthe censustractinwhichnaloxonewasadministeredandthe nearestnaloxonedistributionsite.20,21 Roweetalconducted ananalysisofSanFrancisco,California,andYietal conductedananalysisofBaltimore,Maryland.Surveillance datawasusedtoestablishthisrelationship.TheGSI mappingandspatialanalysismethodologyusedinthese studiescouldbeadoptedinotherjurisdictionstoestimate bystandernaloxoneadministrationinaparticular neighborhoodofinterestbasedinpartondistancefrom naloxonedistributionpoints.

DISCUSSION

LimitedMethodstoEstimateTake-homeNaloxoneUse

Thelimitednumberofstudiescapturedinthisscoping reviewevidencesthelackofsurveillanceandestimation methodsfortheadministrationofTHN,outsideofOEND programrecordsbasedonself-reports.Ofthemethodsused, mathematicalmodelingandmeta-analysisprovideddirect estimationsoftheproportionofdistributednaloxone administered;however,bothmethodswereappliedonlyover largegeographicareas(entirecountries,statesorprovinces, amalgamatingdifferentcitiesaroundtheglobe)or theoreticalcitiesrepresentingalargegeographicarea (“urbancityofMassachusetts”).

Mathematicalmodelingwasthemostpopularformof estimatingadministrationofnaloxonebycommunity members.Further,thepopularityofmodelingincreased relativetotheothermethods.Whilemakingup79%ofstudy methodologiesfoundoverall,itcomprises89%ofstudiesin the ﬁveyearsfrom2018–2022,asshownin Figure2.Reasons forthepopularityofmathematicalmodelsmaybe convenience,includingtheuseofexpertinputand assumptionsforunknownparameters,andtheabilityto tailormodelstodifferentgeographicareasbyadjusting parameters.Nineofthe11modelingstudiesusedoneoftwo modelbases,CofﬁnandSullivan(2013)and Irvineetal(2018).9,14

Therelativedisuseofmeta-analysismaybeexplainedby thelowerpracticalvalueofnaloxoneadministrationdata averagedovermultiplelocations,asopposedtoapplying localdatatoinformprogramgrowthandgaugeimpact. Meta-analysisofnaloxoneuseinothercommunitiesmaybe informativeinjurisdictionslackingtheirownsurveillance data,butcaremustbeexercisedinselectingwhich communitiesandprogramstouseasreferences.Thespread ofOENDprograms,however,mayprovideanopportunity formoreapplicablecomparisons.Further,largeproportions offollow-uplossareevidencedinsomeOENDprograms, addinguncertaintytometa-analysisresults;threeofthenine OENDprogramsthatMcAuleyetal(2015)usedintheir analysishadthree-monthfollow-upratesoflessthan70% (eg,34%,30%,23%).19

Spatialanalysisyieldedarelationshipbetweennaloxone administrationanddistancefromnaloxonedistribution point.Bothstudiesincludedinthisscopingreview(Rowe etal2016,andYietal2022)werereliantuponself-reported datafromOENDprograms.Thisdata,whichisneededto constructaGSImap,maybeusefulforidentifying geographicareasforinterventionbutmaybelessusefulfor extrapolationtounreportedTHNuse.Further,onlythe studybyYietal(2022)characterizedtherelationship betweenprobabilityofbystandernaloxoneadministrationat

Figure2. Methodsusedovertime.

anoverdoseanddistancefromdistributionpoint.21 Rowe etal(2016)insteadreportedtotalnumberofadministration eventsasafunctionofdistance,furtherlimitingexternal validityoftheresults.20

OpioidEducationandNaloxoneDistributionPrograms

WhileweexcludedindividualOENDprogram-based studiesfromthisscopingreview,theyareimportantfor discussionandcomprised59ofthecapturedarticlesinthe systematicsearch.Datafromtheseprograms,whetherornot publishedinpeer-reviewedjournals,isthefoundationforthe parametersinmathematicalmodels,thecomponentstudies ofmeta-analysis,andthelocationdataforspatialanalysis. Theaccuracyofallmethodstoestimatenaloxone administrationbybystanderswrapsbackaroundtothe qualityofself-reporteddatafromOENDprograms.When estimationsofTHNuseareputforwardtoinformpolicy,the methodsbehindtheestimatemustbejustiﬁablybetterthan localOENDdata,ifavailable.Amalgamateddataprovided bygovernmentinstitutionsandnationalcoalitionsmayalso beavailablebutwilllacklocalspeciﬁcity.22,23

LIMITATIONS

Therearelimitationstothisscopingreviewandits applicability.Inourstudywedidnotattempttoinclude methodspublishedinthegrayliteratureinourinitialsearch strategy.Thislimitationwasaddressedinpartthrough informalpreliminarysearches,correspondencewithpublic healthpersonnelattheCaliforniaDepartmentofPublic HealthandtheCABridgeprogram,andcitationsearching. Further,itwasnotexpectedthatmethodsforestimationof bystandernaloxoneusewouldexistwithoutbeingpublished inpeer-reviewedjournals.

Arelatedlimitationofthisstudyisthattheinitialsearch forrelevantarticleswaslimitedtothePubMeddatabase. ThisdecisionwasbasedonthePubMedsearchterms comprehensivelycapturingallstudiesidentiﬁedbyprevious informalpreliminarysearchesandcorrespondencewith publichealthpersonnel.Additionally,thesearchstrategy attemptedtocaptureanypotentiallymissedliterature throughbackwardscitationsearching,andtheabsenceof anynewrelevantarticlessupportedtheparametersofthe initialsearch.

Anotherlimitationtothisscopingreviewisthatitdidnot attempttoascertainthecomparativevalueofmethodsused inestimatingbystandernaloxoneuse.Itispossiblethat preferredmethodsfordeterminingbystandernaloxoneuse willbedependentuponintendeduseoftheanalysisand preferenceforrisk.MethodshighlyinﬂuencedbyOEND programdatawillinherentlyprovideunderestimation, whileothersmaycauseoverestimation.Finally,the environmentsurroundingharmreductionisconstantly changing.TherecentapprovalofOTCnaloxoneisanew

policythatthestudiescapturedinourreview donotaddress.

CONCLUSION

Thepresentscopingreviewdescribestheavailable methodsforestimatingbystanderadministrationof naloxone.Mathematicalmodels,particularlyMarkov models,aremostcommon.Systemdynamicsmodeling, meta-analysis,andspatialanalysishavealsobeenused.All methodsareheavilydependentuponOENDprogramdata publishedintheliteratureoravailableasongoing surveillancedata.Overall,thereisapaucityofliterature describingmethodsofestimation,andofthesefewhavebeen appliedwithalocalfocus.Thisisofconcernasharm reductionisstillregardedwithstigma.Further,evenas naloxonedistributionbecomesmorenormalized,both politicallyandsocially,effectivedistributionwillremain importantinalandscapeoffundingandresourcescarcity withcomplementaryinterventionsandcompeting policypriorities.

AddressforCorrespondence:BharathChakravarthy,MD,MPH, UniversityofCaliforniaIrvine,SchoolofMedicine,Departmentof EmergencyMedicine,3800WChapmanAve.,Suite3200,Orange, CA92868.Email: bchakrav@hs.uci.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thepresentscopingreviewwas researcherfunded.Therearenoconflictsofinterestorsourcesof fundingtodeclare.

REFERENCES

1.CaliforniaDepartmentofHealthCareServices.Naloxone distributionproject.2023.Availableat: https://www.dhcs.ca.gov/ individuals/Pages/Naloxone_Distribution_Project.aspx AccessedMarch22,2023.

2.MartignettiLandSunW.Perspectivesofstakeholdersofequitable accesstocommunitynaloxoneprograms:aliteraturereview. Cureus. 2022;14(1):e21461.

3.CarrollJJ,GreenTC,NoonanRK.Evidence-basedstrategiesfor preventingopioidoverdose:what’sworkingintheUnitedStates. CDC 2018.Availableat: http://www.cdc.gov/drugoverdose/pdf/pubs/ 2018-evidence-based-strategies.pdf.AccessedMarch22,2023.

4.TriccoAC,LillieE,ZarinW,etal.PRISMAextensionforscoping reviews(PRISMA-ScR):checklistandexplanation. AnnInternMed. 2018;169(7):467–73.

5.NationalLibraryofMedicine.PubMedoverview.Availableat: https:// pubmed.ncbi.nlm.nih.gov/about/.AccessedMarch29,2023.

6.SonnenbergFAandBeckJR.Markovmodelsinmedicaldecision making:apracticalguide. MedDecisMaking. 1993;13(4):322–38.

7.WangY,HuB,ZhangY,etal.Applicationsofsystemdynamicsmodels inchronicdiseaseprevention:asystematicreview. PrevChronicDis. 2021;18:E103.

8.AcharyaM,ChopraD,HayesCJ,etal.Cost-effectivenessofintranasal naloxonedistributiontohigh-riskprescriptionopioidusers. Value Health. 2020;23(4):451–60.

9.CofﬁnPOandSullivanSD.Cost-effectivenessofdistributingnaloxone toheroinusersforlayoverdosereversal. AnnInternMed. 2013;158(1):1–9.

10.CofﬁnPOandSullivanSD.Cost-effectivenessofdistributingnaloxone toheroinusersforlayoverdosereversalinRussiancities. JMedEcon. 2013;16(8):1051–60.

11.LanghamS,WrightA,KenworthyJ,etal.Cost-effectiveness oftake-homenaloxoneforthepreventionofoverdosefatalities amongheroinusersintheUnitedKingdom. ValueHealth. 2018;21(4):407–15.

12.UyeiJ,FiellinDA,BuchelliM,etal.Effectsofnaloxonedistributionalone orincombinationwithaddictiontreatmentwithorwithoutpre-exposure prophylaxisforHIVpreventioninpeoplewhoinjectdrugs: acost-effectivenessmodellingstudy. LancetPublicHealth. 2017;2(3):e133–40.

13.CofﬁnPO,MayaS,KahnJG.Modelingofoverdoseandnaloxone distributioninthesettingoffentanylcomparedtoheroin. DrugAlcohol Depend. 2022;236:109478.

14.IrvineMA,BuxtonJA,OtterstatterM,etal.Distributionoftake-home opioidantagonistkitsduringasyntheticopioidepidemicinBritish

Columbia,Canada:amodellingstudy. LancetPublicHealth. 2018;3(5):e218–25.

15.IrvineMA,KuoM,BuxtonJA,etal.Modellingthecombinedimpactof interventionsinavertingdeathsduringasynthetic-opioidoverdose epidemic. Addiction. 2019;114(9):1602–13.

16.IrvineMA,OllerD,BoggisJ,etal.EstimatingnaloxoneneedintheUSA acrossfentanyl,heroin,andprescriptionopioidepidemics:amodelling study. LancetPublicHealth. 2022;7(3):e210–8.

17.LinasBP,SavinkinaA,MadushaniRWMA,etal.Projectedestimatesof opioidmortalityaftercommunity-levelinterventions. JAMANetwOpen. 2021;4(2):e2037259.

18.StringfellowEJ,LimTY,HumphreysK,etal.Reducingopioiduse disorderandoverdosedeathsintheUnitedStates:adynamicmodeling analysis. SciAdv. 2022;8(25):eabm8147.

19.McAuleyA,AucottL,MathesonC.Exploringthelife-savingpotentialof naloxone:asystematicreviewanddescriptivemeta-analysisoftake homenaloxone(THN)programmesforopioidusers. IntJDrugPolicy. 2015;26(12):1183–8.

20.RoweC,SantosGM,VittinghoffE,etal.Neighborhood-levelandspatial characteristicsassociatedwithlaynaloxonereversaleventsandopioid overdosedeaths. JUrbanHealth. 2016;93(1):117–30.

21.YiG,DaytonL,UzziM,etal.Spatialandneighborhood-levelcorrelates oflaynaloxonereversaleventsandserviceavailability. IntJDrugPolicy. 2022;106:103739.

22. WheelerE,DavidsonPJ,JonesTS,etal.Community-basedopioid overdosepreventionprogramsprovidingnaloxone UnitedStates, 2010. MMWRMorbMortalWklyRep. 2012;61(6):101–5.

23.WheelerE,JonesTS,GilbertMK,etal.Opioidoverdoseprevention programsprovidingnaloxonetolaypersons UnitedStates,2014. MorbMortalWklyRep. 2015;64(23):631–5.

CoXuanDao,MD,PhD*†‡ ChinhQuocLuong,MD,PhD†‡§

ToshieManabe,PhD,MPH∥¶ MyHaNguyen,MD,MSc# DungThiPham,MD,PhD** TraThanhTon,MD,PhD†† QuocTrongAiHoang,MD,PhD‡‡ TuanAnhNguyen,MD,PhD†§ AnhDatNguyen,MD,PhD†§ BryanFrancisMcNally,MD,MPH§§∥∥ MarcusEngHockOng,MBBS,MPH¶¶## SonNgocDo,MD,PhD*†‡ TheLocalPAROSInvestigatorsGroup***

SectionEditor:MuhammadWaseem,MD

ORIGINAL RESEARCH

*BachMaiHospital,CenterforCriticalCareMedicine,Hanoi,Vietnam † HanoiMedicalUniversity,DepartmentofEmergencyandCriticalCare Medicine,Hanoi,Vietnam

‡ VietnamNationalUniversity,UniversityofMedicineandPharmacy, DepartmentofEmergencyandCriticalCareMedicine,Hanoi,Vietnam

§ BachMaiHospital,CenterforEmergencyMedicine,Hanoi,Vietnam

∥ NagoyaCityUniversityGraduateSchoolofMedicine,Departmentof MedicalInnovation,Nagoya,Aichi,Japan

¶ NagoyaCityUniversityWestMedicalCenter,CenterforClinicalResearch, Nagoya,Aichi,Japan

# ThaiBinhUniversityofMedicineandPharmacy,DepartmentofHealth OrganizationandManagement,ThaiBinh,Vietnam

Af ﬁliationscontinuedatendofpaper

Submissionhistory:SubmittedSeptember8,2023;RevisionreceivedMarch6,2024;AcceptedMarch18,2024

ElectronicallypublishedJune14,2024

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

DOI: 10.5811/westjem.18413

Introduction: Patientsexperiencinganout-of-hospitalcardiacarrest(OHCA)frequentlydonotreceive bystandercardiopulmonaryresuscitation(CPR),especiallyinlow-andmiddle-incomecountries(LMIC). InthisstudywesoughttodeterminetheprevalenceofOHCApatientsinVietnamwhoreceived bystanderCPRanditseffectsonsurvivaloutcomes.

Methods: Weperformedamulticenter,retrospectiveobservationalstudyofpatients(≥18years) presentingwithOHCAatthreemajorhospitalsinanLMICfromFebruary2014–December2018.We collecteddataonthehospitalandpatientcharacteristics,thecardiacarrestevents,theemergency medicalservices(EMS)system,thetherapymethods,andtheoutcomesandcomparedthesedata, beforeandafterpairwise1:1propensityscorematching,betweenpatientswhoreceivedbystanderCPR andthosewhodidnot.Uponadmission,weassessedfactorsassociatedwithgoodneurologicalsurvival athospitaldischargeinunivariableandmultivariablelogisticmodels.

Results: Of521patients,388(74.5%)weremen,andthemeanagewas56.7years(SD17.3).Although mostcardiacarrests(68.7%,358/521)occurredathomeand78.8%(410/520)werewitnessed,alow proportion(22.1%,115/521)ofthesepatientsreceivedbystanderCPR.Onlyhalfofthepatientswere broughtbyEMS(8.1%,42/521)orprivateambulance(42.8%,223/521),50.8%(133/262)ofwhomhad resuscitationattempts.Beforematching,therewasasigniﬁcantdifferenceingood neurologicalsurvival betweenpatientswhoreceivedbystanderCPR(12.2%,14/115)andpatientswhodidnot(4.7%,19/406; P < .001).Aftermatching,goodneurologicalsurvivalwasabsentinallOHCApatientswhodidnotreceive CPRfromabystander.ThemultivariableanalysisshowedthatbystanderCPR(adjustedoddsratio:3.624; 95%conﬁdenceinterval1.629–8.063)wasanindependentpredictorofgoodneurologicalsurvival.

Conclusion: Inourstudy,only22.1%oftotalOHCApatientsreceivedbystanderCPR,whichcontributed signiﬁcantlytoalowrateofgoodneurologicalsurvivalinVietnam.Toimprovethechancesofsurvival withgoodneurologicalfunctionsofOHCApatients,morepeopleshouldbetrainedtoperformbystander CPRandteachothersaswell.Astandardprogramforemergency ﬁrst-aidtrainingisnecessaryforthis purpose.[WestJEmergMed.2024;25(4)507–520.]

INTRODUCTION

Out-of-hospitalcardiacarrest(OHCA)isaprominent causeofdeathanddisabilityworldwide,1–4 accountingforup to10%ofoverallmortalityinlow-andmiddle-income countries(LMIC).5–7 Itisdeﬁnedasthelossoffunctional cardiacmechanicalactivityinassociationwithanabsence ofsystemiccirculation,occurringoutsideahospital setting.8,9 TheexactburdenofOHCAonpublichealth globallyisunknownsincemanycasesarenotattended byemergencymedicalservices(EMS),andthereareoften widevariationsamongdifferentregions,countries, andcontinentsinboththeirreportingsystemsand survivaloutcomes.5,10–13

InAsia-Paciﬁccountries,EMSsystemsareoften underdevelopedandvaryconsiderably.Survivaloutcomes forOHCAinPan-Asiadifferconsiderably,andthese variationsmayberelatedtodifferencesinpatientsandthe EMSsystem.12 Thesedifferencessuggestthatsurvival outcomesforOHCAcanbeimprovedbyinterventionsto enhanceEMSsystems,14 suchasincreasingbystander cardiopulmonaryresuscitation(CPR)throughcommunitybasedCPRtrainingprograms,15 increasingavailabilityof publicaccessdeﬁbrillators,16 andimprovingpostresuscitationcare.17 TheOHCApatientsinLMICsare considerablylesslikelytoreceivebystanderCPRthanthose inhigh-incomecountries(HIC).12 Furthermore,inareas withunderdevelopedEMSinfrastructures,extremelyillor injuredpatientsarefrequentlytransportedtohospitalsby non-EMSvehicles.18–21

VietnamisanLMICwithapopulationof96.462million people,ranking15th intheworldandthirdinSoutheastAsia, anditstillstruggleswithalackofdevelopmentinprehospital services.18,19,22,23 TheVietnamesegovernmentimplemented acountrywidestrategyfortheEMSsystemin2008; nonetheless,onlyafewlocalities,suchasurbanareas,havea workingEMSsystem.Inaddition,theavailabilityof ambulances,qualiﬁedandauthorizedmedicalpersonnel, andlife-savingequipmentisrestricted.Medicalcontroland frequentmonitoringofqualityindicatorsarealso uncommon. 22 Prehospitaltreatmentistypicallyleftto bystanders,andtheinjuredorsickindividualisusuallytaken immediatelytothenextvehiclelargeenoughtohandlehim orher;bystanderCPRisalsofrequentlynotperformed.18–20 Asaresult,theseissuespreventtheintegrationofprehospital andhospitaltreatmentprotocolsandclinicaldatacollection forsurveillance,qualityimprovement,andresearch-related activities,andpatientswithlife-threateningdiseasesor injuriesarefrequentlynotofferedBasicLifeSupport(BLS) andAdvancedLifeSupport(ALS)servicesuntiltheyarrive atthehospital.18–20,24

UnderstandingthepresentstateofbystanderCPRand howitaffectstheoutcomesofOHCApatientslocallyis criticalforincreasingsurvivalinVietnamandothercountries whereclinicalpracticeishamperedbyinadequate

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Globalsurvivalratesforout-of-hospital cardiacarrest(OHCA)varyconsiderably duetodifferencesinpatientsand EMSsystems.

Whatwastheresearchquestion?

Howdoesthecurrentstateofbystander cardiopulmonaryresuscitation(CPR) impactoutcomesofOHCAinVietnam?

Whatwasthemajor ﬁndingofthestudy?

AlowrateofbystanderCPR(22.1%) contributedtolowsurvival.However, bystanderCPRwasassociatedwithgood neurologicalsurvival(adjustedOR3.624; 95%CI1.629 – 8.063).

Howdoesthisimprovepopulationhealth?

TrainingmorepeopletoperformCPRand encouragingthemtoteachotherscanimprove thechancesofOHCApatientssurvivingwith goodneurologicaloutcomes.

medicalresources.Inthisstudyweaimedtoinvestigate thesurvivalratesfromOHCAandtocomparethesurvival ratesofnon-matchedandmatchedOHCAcohortswho receivedbystanderCPRandwhodidnotreceive bystanderCPR.

METHODS StudyDesignandSetting

Thismulticenter,retrospectiveobservationalstudyispart ofthePan-AsianResuscitationOutcomesStudy(PAROS) ClinicalResearchNetwork,whichcollectsdataonOHCA patientsadmittedtohospitalemergencydepartments(ED)in countriesacrossAsia.18,19,25,26 Inthisstudy,weretrieved datafromVietnaminthePAROSdatabase.Thehospitalsin VietnamparticipatinginthePAROSstudyarethreepublicsector,tertiaryhospitalsinthethreelargestcitiesofthe country:Hanoi(northernVietnam)whichservesan estimated10millionpeople;Hue(centralVietnam)which serves1.154millionpeople;andHoChiMinhCity(southern Vietnam)whichserves13millionpeople.Thehospitals receivepatientsfromallpartsofeachcity.Thereasonsfor selectingtheseinstitutionswereasfollows:1)theyare academichospitals,responsibleforeducatinghospitalstaff, treatingpatientswhoneedproceduressuchascardiac catheterizationthatcannotbeperformedinlocalhospital

settings,andreceivingmostofthecasesattendedbythe EMS;and2)thesethreehospitalsserveadiversepopulation ofvaryingsocioeconomicstatusandethnicity.Thishospitalbasedsamplerepresentsthegeneralurbanpopulation inVietnam.

SeveralambulanceservicesareavailableinVietnam,but onlyoneemergencyservicehasanemergencynumber (telephonenumber115),trainedandaccreditedmedical staff,life-savingequipment,medicaloversight,andquality indicatorsthatareregularlymonitored.22,27 Severalother privateorganizationsalsoprovideemergencyserviceswith theabilitytodeliverCPR,life-savingdrugs,and deﬁbrillation,oratleasthaveahealthprofessionaltrainedto dealwithemergencies.28 However,theambulance dispatchedbytheseorganizationsisnotcoordinatedbyan EMSdispatchcenter.29 Forthisstudy,wecategorizedthe typeofprehospitaltransportationintotwogroups:EMS, whichreferstoambulancesdispatchedbyanEMSdispatch center;andnon-EMS,whichreferstoprivateambulances, privatetransport,orpublictransport.Wedeﬁnedaprivate ambulanceasanambulancethatwasnotdispatchedbyan EMSdispatchcenter.Privatetransportincludestransportin vehiclesbyfamilymembers,relatives,neighbors,or passersby.Publictransportincludestaxis,buses,orother typesofpublictransport.

Participants

Thisstudyincludedallpatients >18yearspresentingwith OHCAtotheemergencydepartments(ED)ofthethree hospitals.WeexcludedOHCApatientswhohadsuffered traumaticinjury.WedeﬁnedacaseofOHCAasaperson whowasunresponsive,notbreathing,andwithoutapulse outsidethehospitalsetting.30–32 ThediagnosisofOHCAor thereturnofspontaneouscirculation(ROSC)wasconﬁrmed byEMSpersonnelonthescene/enroute,orbyaphysicianin theED.Weexcludedpatientsforwhomresuscitationwas notattemptedbyEMSorprivateambulancepersonnelatthe scene/enrouteandwhowereimmediatelypronounceddead (becauseofrigormortis,lividity,or “donotresuscitate” orders)attheED.However,weincludedpatientsonwhom resuscitationwasattemptedbutwhowerelaterpronounced deadbeforetheyreachedthehospital.

DataCollection

Weusedastandardizedclassificationandcaserecord formtocollectdataoncommonvariables.Thedata dictionaryofthePAROSstudyisavailableasanonline supplementtopreviouslypublishedpapers.12,18 Thedatawas extractedfromemergencydispatchrecords,ambulance patientcasenotes,andEDandin-hospitalrecordsand enteredintothePAROSstudydatabaseusinganelectronic datacapturesystem.Patientidentifierswerenotenteredin thedatabasetoprotectpatientconfidentiality.Wethen extracteddatafromVietnamandmergedthedatasetsforthe

threehospitals.Eachhospitalcontributed ﬁveyearsofdata fromFebruary2014–December2018.

Variables

WeincludedvariablesbasedonUtstein recommendations,33,34 suchasinformationonthefollowing: 1)bystanderCPR;2)availabilityofpublicaccess deﬁbrillators;3)responsetimes;4)provisionofALS(eg, intravenousdrugs,advancedairwaymanagementincluding endotrachealintubationoralternativeairwaydevices);5) causeofthearrest(acardiacarrestwaspresumedunlessit wasknownorlikelythatthearresthadanon-cardiaccause (eg,asthma,terminalillness,cerebrovascularaccident,drug overdose,suicide,drowning,ortrauma);and6)provisionof specializedpost-resuscitationcare(hypothermiaor extracorporealmembraneoxygenation[ECMO]).Wealso collecteddataonthelocationoftheOHCA(eg,home,public area).Wecollecteddataonsystemvariables;thelistof variablesisavailableasanonlinesupplementtopreviously publishedpapers.12,18

Outcomes

Theprimaryoutcomeofthepresentstudywasgood neurologicalsurvivalonhospitaldischargeoratday30postarrest.WeusedtheCerebralPerformanceCategory(CPC) scoretoevaluatetheneurologicalfunctionoftheOHCA patients.35,36 TheCPCscorewascalculatedbasedondata collectedfromclinicalrecords,andtelephoneandface-tofaceinterviews.Inthisstudywedeﬁnedgoodneurological functionasaCPCscoreof1or2,12 whichindicatessurvival withmildormoderatedisability.Wealsoexamined secondaryoutcomesthatincludedthefollowing:the proportionsofpatientsinwhomspontaneouscirculation returnedatthescene/enroute;patientswhosurvivedto hospitaladmission;andpatientswhoweredischargedfrom thehospital.

StatisticalAnalyses

DescriptionandComparisonofCohorts

Wereportdataasnumbersandpercentages(%)for categoricalvariablesandmediansandinterquartileranges (IQR25–75%)ormeansandSDsforcontinuousvariables. WecomparedOHCApatientswhoreceivedbystanderCPR withthosewhodidnotreceivebystanderCPRforeach variable.Weusedthechi-squaredtestorFisherexacttestfor categoricalvariablesandtheindependentsamples t -test, Mann-WhitneyUtest,orone-wayanalysisofvariancefor continuousvariablesincomparisonsofthesevariables.

MatchingMethod

Wecarriedoutpairwise1:1propensityscorematching (SupplementaryFigure),usingthenearestneighbor matchingmethodtoreducetheeffectofbiasbyunbalanced covariatesandpotentialconfounding.37,38 Thepropensity

scorewasestimatedusingmultiplelogisticregression analysisthatincludedtheindependentvariablesofage (either <60yearsor ≥60years),gender(eithermaleor female),pastmedicalhistory(none,heartdiseasesonly, otherdiseases,suchasdiabetes,cancer,hypertension,renal disease,respiratorydisease,hyperlipidemia,stroke,HIV, andothers,orbothheartdiseasesandotherdiseases),and etiologyofOHCA(eitherpresumedcardiacornon-cardiac, suchasrespiratory,drowning,electrocution,andothers) withbystanderCPRandwithoutbystanderCPR.

AssessingFactorsAssociatedwithSurvivability

Uponadmission,weassessedfactorsassociatedwithgood neurologicalsurvivalonhospitaldischargeusinglogistic regressionanalysis.Toreducethenumberofpredictors, multicollinearityandoverﬁtting,weuseddifferentwaysto selectvariables.First,westartedvariableselectionwitha univariablelogisticregressionanalysisofeachvariablethat includedindependentvariablesrelatedtoparticipating hospitals,patient-relatedfactors,cardiacarrestevent-related factors,EMSsystem-andtherapy-relatedfactors.We includedvariablesforconsiderationinthemultivariable logisticregressionanalysisifthe P -valuewas <0.05inthe univariablelogisticregressionanalysis,aswellasfactorsthat wereclinicallyimportant(includingage,pastmedical history,presenceofawitness,etiologyofOHCA,typeof prehospitaltransportationandbystanderCPR).Second,we usedastepwisebackwardeliminationmethodtoselect variablesformultivariablelogisticregressionanalysis.

Similarly,weusedthesemethodsofvariableselectionand analysistoassessfactorsassociatedwithsurvivaltohospital admissionandsurvivaltohospitaldischarge.Wepresent oddsratios(OR)and95%conﬁdenceintervals(CI).

WeusedSPSSStatistics25.0(SPSS,Inc,Chicago,IL) fordataanalysis.Forallstatisticalanalyses,signiﬁcance levelsweretwo-tailed,andweconsidered P < 0.05as statisticallysigniﬁcant.

RESULTS

Duringthestudyperiod,779OHCApatientshadtheir datasubmittedtothePAROSdatabase.Weremovedfrom thestudy31individuals <18yearsoldand109withtraumatic injuries.Weadditionallyremoved30patients(4.69%; 30/639)duetoaprolongedprehospitalstay(ie,morethan oneday),whichmighthaveindicatedinputmistakesor enrollmentofpatientstransferredfromthereferring hospitals.Moreover,weexcluded88patients(13.77%; 88/639)fromouranalysisduetotheabsenceofmost variables.Intotalweincluded521eligiblepatientsinour analyses(Figure).

ThePrimaryandSecondaryOutcomes

Ofthe521OHCApatients,98(18.8%)hadaROSCatthe scene/enroute,andfor113(21.7%)patients,spontaneous circulationreturnedintheED(Table1).Overall,18.4% (96/521)ofpatientssurvivedonhospitaladmission,and9.4% (49/521)survivedtohospitaldischarge;6.3%(33/521) survivedwithgoodneurologicalfunction(aCPCscore

Figure. Flowchartoftypeofbystandercardiopulmonaryresuscitation,transportationtothehospital,andoutcomeofpatientswithout-ofhospitalcardiacarrestincludedinthestudy,Vietnam,February2014–December2018. CPR,cardiopulmonaryresuscitation; EMS,emergencymedicalservices.

Table1. Outcomesofnon-matchedandmatchedcohortsofpatientswithout-of-hospitalcardiacarrestaccordingtothetypeofbystander cardiopulmonaryresuscitation,Vietnam,February2014–December2018.

BeforematchingAftermatching

Variables

ROSC,no.(%)

ROSCatscene/ enroute

ROSCatED113(21.7)81(20.0032(27.8)0.0749(23.1)18(17.0)31(29.2)0.03

Outcomeofpatientat ED,no.(%)

DiedinED425(81.6)338(83.3)87(75.7)185(87.3)106(100.0)79(74.5)

Admitted96(18.4)68(16.7)28(24.3)27(12.7)0(0.0)27(12.7)

Patientstatus,no.(%)0.14 <0.001

Diedinthehospital41(7.9)31(7.6)10(8.7)10(4.7)0(0.0)10(9.4)

Remainsinhospital atday30postarrest 6(1.2)5(1.2)1(0.9)0(0.0)0(0.0)0(0.0)

Dischargedalive49(9.4)32(7.9017(14.8)17(8.0)0(0.0)17(16.0)

PostarrestCPC1or 2,n(%) 33(6.3)19(4.7)14(12.2) <.00114(6.6)0(0.0)14(13.2) <0.001

aThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthenon-matchedcohort. bThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthematchedcohort. CPC,cerebralperformancecategory; CPR,cardiopulmonaryresuscitation; ED,emergencydepartment; ROSC,returnof spontaneouscirculation.

of1or2)onhospitaldischargeorat30th-day post-arrest(Table1).

ClinicalCharacteristicsandPre-Hospitaland In-HospitalManagement

AmongthetotalnumberofOHCApatients,74.5%(388/ 521)weremenandthemeanagewas56.7years(SD17.3). Lessthana ﬁfthofthepatients(18.1%;85/470)hadapast medicalhistoryofheartdisease(Table2).MostOHCAs occurredathome(68.7%;358/521)andduringtheday (56.6%;181/320)(Table3).ThewitnessedOHCAs accountedfor78.8%(410/520)ofpatients(Table3),mostof whichwerebystander-witnessedcardiacarrests,including layperson(4.2%;22/520),familymembers(13.8%;72/520), andhealthcareprofessionals(49.8%;259/520).Acardiac conditionwasthepresumedcauseofcardiacarrestin44.9% (234/521)ofpatients(Table3).Ofthe521OHCApatients, 49.1%(256/521)weretakentohospitalbyprivateorpublic transport,42.8%(223/521)weretakenbyprivateambulance, andonly8.1%(42/521)weretakenbyEMS(Table4 and SupplementaryTable1).

Only31.9%(43/135)ofOHCApatientsreceived prehospitaldeﬁbrillation(Table5).Only22.1%(115/521)of thepatientsreceivedbystanderCPR,and5.3%(14/262) receivedabystanderautomatedexternaldeﬁbrillator(AED)

(Table5).Epinephrinewasgivento23.4%(122/521)of patientswithcardiacarrestatthescene/enroute,and20.7% (108/521)receivedprehospitaladvancedairway management(Table5).Hypothermiatherapywasgivento 15.0%(78/521)ofOHCApatients,butonly1.3%(7/519) weregivenECMOtherapy(Table5).Thecharacteristics, management,andcomplicationsofthestudycohortare shownin Tables2, 3, 4,and 5.

ImpactofBystanderCPRontheOutcomes

Innon-matchedandmatchedcohorts, Tables1, 2, 3, 4, and 5 comparethegeneralcharacteristics,prehospitalandinhospitaltreatment,andoutcomesofOHCApatientswhodid notreceivebystanderCPRtothosewhodid.

InNon-MatchedCohort

Therewasasigniﬁcantdifferenceinresuscitation attemptedbyEMSorprivateambulancebetweenpatients whoreceivedbystanderCPR(61.7%;58/94)andpatients whodidnotreceivebystanderCPR(44.6%;75/168; P = 0.01)(Table4).Theproportionofpatientsinwhom spontaneouscirculationreturnedatthescene/enroutewas signiﬁcantlyhigherinpatientswhoreceivedbystanderCPR (35.7%;41/115)comparedtopatientswhodidnotreceive bystanderCPR(14.0%;57/406; P < 0.001)(Table1).

Table2. Patient-relatedcharacteristicsofnon-matchedandmatchedcohortsofpatientswithout-of-hospitalcardiacarrestaccordingtothe typeofbystandercardiopulmonaryresuscitation,Vietnam,February2014–December2018.

Variables

Hospitalparticipated

Allcases (n = 521)

= 406) Bystander

BachMai,no.(%)396(76.0)306(75.4)90(78.3)176(83.0)91(85.8)85(80.2)

Hue,no.(%)24(4.6)24(5.9)0(0.0)2(0.9)2(1.9)0(0.0)

ChoRay,no.(%)101(19.4)76(18.7)25(21.7)34(16.0)13(12.3)21(19.8)

Patient-related

Age(year), mean(SD)

56.7(17.3)57.6(17.2)53.7(17.6)0.0456,6(17.5)60.0(16.6)53.1(17.8) <.001

Gender(male), no.(%) 388(74.5)305(75.1083(72.2)0.52154(72.6)78(73.6)76(71.7)0.76

Pastmedicalhistory, no.(%),n1 = 470c

Heartdisease85(18.1)60(16.5)25(23.6)0.1038(17.9)13(12.3)25(23.6)0.03

Diabetes64(13.6)46(12.6)18(17.000.3030(14.2)12(11.3)18(17.0)0.24

Cancer38(8.1)34(9.3)4(3.8)0.0611(5.2)7(6.6)4(3.8)0.35

Hypertension111(23.6)85(23.4)26(24.5)0.8047(22.2)21(19.8)26(24.5)0.41

Renaldisease38(8.1)27(7.4)11(10.4)0.3315(7.1)4(3.8)11(10.4)0.06

Respiratorydisease75(16.0)53(14.6)22(20.8)0.1337(17.5)15(14.2)22(20.8)0.21

Hyperlipidemia4(0.9)4(1.1)0(0.0)0.580(0.0)0(0.0)0(0.0)NA

Stroke16(3.4)15(4.1)1(0.9)0.146(2.8)5(4.7)1(0.9)0.21

HIV1(0.2)1(0.3)0(0.0) > 0.990(0.0)0(0.0)0(0.0)NA

However,therewasnosigniﬁcantdifferenceinsurvival tohospitaladmissionbetweenpatientswhoreceived bystanderCPR(24.3%;28/115)andpatientswhodidnot (16.7%;68/406; P = 0.06)andsurvivaltohospitaldischarge betweenpatientswhoreceivedbystanderCPR(14.8%; 17/115)andpatientswhodidnot(7.9%;32/406; P = 0.14) (Table1).Incontrast,therateofgoodneurologicalsurvival onhospitaldischargeoratday30post-arrestinpatientswho receivedbystanderCPR(12.2%,14/115)wassigniﬁcantly higherthanthatinpatientswhodidnotreceivebystander CPR(4.7%,19/406; P < .001)(Table1).

InMatchedCohort

Weusedpropensityscorematchingtoobtain106pairsof patientswithsimilarcharacteristics(Tables1, 2, 3, 4,and 5). AmongOHCApatientswhodidnotreceivebystanderCPR, nonereceivedresuscitationattemptedbyEMSorprivate

ambulance(Table4)orhadROSCatthescene/enroute (Table1).Asaresult,noneoftheOHCApatientssurvived onhospitaladmissionorobviouslysurvivedtohospital discharge(Table1).

AssociationofBystanderCPRwithSurvivability

IncontrasttotheassociationbetweenbystanderCPRand survivaltohospitaladmission(SupplementaryTable2), SupplementaryTables3and4 showbystanderCPRwas identiﬁedintheunivariablelogisticregressiontobe signiﬁcantlyassociatedwithincreasedchanceofsurvivalto hospitaldischarge(OR2.027;95%CI1.081–3.802)andgood neurologicalsurvivalonhospitaldischargeoratday30postarrest(OR2.823;95%CI1.368–5.825).However,the multivariablelogisticregressionshowedthatbystanderCPR wasindependentlyassociatedwithonlyanincreasedchance ofgoodneurologicalsurvivalonhospitaldischargeoratday

Table3. Event-relatedcharacteristicsofnon-matchedandmatchedcohortsofpatientswithout-of-hospitalcardiacarrestaccordingtothe typeofbystandercardiopulmonaryresuscitation,Vietnam,February2014–December2018.

BeforematchingAftermatching

Variables

Locationtype,n(%)

InEMS/private ambulance

63(12.1)46(11.3)17(14.8)40(18.9)24(22.6)16(15.1)

Healthcarefacility50(9.6)14(3.4)36(31.3)40(18.9)8(7.5)32(30.2)

Homeresidence358(68.7)304(74.9)54(47.0)109(51.4)59(55.7)50(47.2)

Publicarea50(9.642(10.38(7.023(10.8)15(14.2)8(7.5)

Timeoftheday,no.(%), n1 = 320d,n2 = 105d

181(56.6)125(53.0)56(66.7)0.0364(61.0)13(44.8)51(67.1)0.04

Witnessedarrest, n1 = 520d 410(78.8)297(73.30113(98.3) <0.001128(60.4)24(22.6)104(98.1) <0.001

Arrestwitnessedby, no.(%),n1 = 520d

Notwitnessed110(21.2)108(26.7)2(1.7)84(39.6)82(77.4)2(1.9)

Bystander(layperson)22(4.2)16(4.0)6(5.2)11(5.2)6(5.7)5(4.7)

Bystander(family)72(13.8)19(4.7)53(46.1)65(30.7)16(15.1)49(46.2)

Bystander(healthcare worker)

259(49.8)229(56.5)30(26.1)31(14.6)2(1.9)29(27.4)

EMS/private ambulance 57(11.0)33(8.1)24(20.9)21(9.9)0(0.0)21(19.8)

Presumedcardiac etiologyofOHCA

234(44.9)184(45.3)50(43.5)0.7382(38.7)36(34.0)46(43.4)0.16

Shockable ﬁrstarrest rhythmsc,n1 = 135d, n2 = 56d 93(68.9)51(67.1)42(71.2)0.6139(69.6)NA39(69.6)NA

aThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthenon-matchedcohort. bThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthematchedcohort. cShockable firstarrestrhythmsincludedventriculartachycardia,ventricular fibrillation,orunknownshockablerhythms. dn1andn2weredefinedasthetotalnumberofpatientsrecordedifavariablewasgivenornotinthenon-matchedandmatchedcohorts. CPR,cardiopulmonaryresuscitation; EMS,emergencymedicalservices; NA,notavailable; OHCA, out-of-hospitalcardiacarrest.

30post-arrest(adjustedOR3.624;95%CI1.629–8.063) (Table6).Otherfactorswereassociatedwithsurvivability,as shownin Table6 and SupplementaryTables2,3,and 4.

DISCUSSION

Of521OHCApatientsincludedinouranalysis,justover one-ﬁfth(22.1%)receivedbystanderCPR.Asaresult,less thanone-ﬁfth(18.4%)ofthesepatientssurvivedtohospital admission,onlyone-tenth(9.4%)weredischargedfromthe hospital,andjustoverone-twentieth(6.3%)weredischarged fromthehospitalwithgoodneurologicalfunction(Table1). OurstudyfoundthatthesurvivalrateofmedicalOHCA patientsonadmissionalignswiththerate(20.4%;8,341/ 40,878)reportedbytheFrenchnationalregistry.39 This couldbeduetotheFranco-GermanEMSmodel,where physiciansoftenaccompanypatientsinambulances.40 However,ourresultssurpassapreviousstudyinHanoi, Vietnam,whichreportedlowerratesofbystanderCPR (8.4%;20/239),survivalatdischarge(3.8%;9/239),andgood neurologicalsurvival(0.4%;1/239).20

Thedifferencescouldbeduetothedistinctinclusion criteriabetweenthestudies.Forinstance,ourstudyincluded OHCApatientswhoreceivedresuscitationattemptsby EMS/privateambulancepersonnelatthescene/enrouteand excludedthosewithtraumaticinjuries.Despitehavinga lowerrateofbystanderCPR,ourstudyhasahigherrateof survivaltodischargethantheratereportedinaretrospective cohortstudyinThailand(3.4%;42/1240),41 andevenhasa higherrateofsurvivaltodischargethantheratesreportedin studiesinJapan(5.2%;2,677/51,377),Korea(8.5%;681/

Table4. System-relatedcharacteristicsofnon-matchedandmatchedcohortsofpatientswithout-of-hospitalcardiacarrestaccordingtothe typeofbystandercardiopulmonaryresuscitation,Vietnam,February2014–December2018.

BeforematchingAftermatching

Variables

Prehospitaltransport, no.(%)

= 521)

EMS42(8.1)26(6.4)16(13.9)16(7.5)1(0.9)15(14.2)

Privateambulance223(42.8)142(35.0)81(70.4)111(52.4)37(34.9)74(69.8)

Privateorpublictransport256(49.1)238(58.6)18(15.7)85(40.1)68(64.2)17(16.0)

Resuscitationattempted byEMS/private ambulance,no.(%), n1 = 262c,n2 = 125c

TimetoinitiationofCPR (min),mean(SD),n1 = 87c

133(50.8)75(44.6)58(61.7)0.0155(44.0)0(0.0)55(63.2)

Timetodeﬁbrillationat scene(min),mean(SD), n2 = 36c 9.0(6.2)9.7(5.1)7.7(7.9)0.138.5(8.4)NA8.5(8.4)NA

aThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthenon-matchedcohort. bThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthematchedcohort. cn1andn2werede ﬁnedasthetotalnumberofpatientsrecordedifavariablewasgivenornotinthenon-matchedandmatchedcohorts. CPR,cardiopulmonaryresuscitation; EMS,emergencymedicalservices; NA,notavailable.

7,990),andSingapore(2.5%;76/3,023).12 Ourrateforgood neurologicalsurvivaltohospitaldischargeisalsohigherthan theratesreportedinthesecountries:Thailand(1.6%;9/573); Japan(2.8%;1,436/51,377);Korea(3.0%;236/7,990);and Singapore(1.7%;50/3,023).12

Werecognizethatourcohortislikelytobeahighly selectedpopulation,asmanyOHCApatientsinVietnamare notbroughttothehospitalanddieoutsidethehospital setting.42–44 These findingscouldbeduetoaselectionbiasin ourstudy,asweonlyhaddataonpatientsbroughttothe threehighestlevelpublicsectorhospitalsinVietnam. Furthermore,weincludedOHCApatientsbroughttothe hospitalbyEMS/privateambulances.Amongthesepatients, therewerenocasesforwhomresuscitationwasnot attemptedbyEMS/privateambulancepersonnelatthe scene/enrouteandthenwereimmediatelypronounceddead attheED.Thesemightinflatethesurvivalrate.Therefore, thesecasesmaynotreflectallOHCAsinthecountry.

Apivotalcomponentinsuccessfulresuscitationfrom OHCAisthechainofsurvival.45,46 Rapidpublic-access deﬁbrillation(PAD)withAEDsandbystanderCPR improvesurvivalrates.6,47–50 However,ourstudyfoundthat asmallnumberofOHCAsreceivingbystanderCPRstill considerablyinﬂuencedtheloweroverallsurvivalrates (Table1).MostpatientsnotreceivingbystanderCPRwere takentothehospitalbyprivateorpublictransport(Table4),

usuallywithout ﬁrst-aid.24,42,43,51 Insuchsituations, bystander ﬁrst-aidisvitalforOHCAoutcomes.52 However, bystanderCPRisrarelyperformedinVietnam,24 which couldbeduetothelackofknowledge,absenceofdispatcherassistedCPR(T-CPR)programs,fearofharmorinfection, andlegalconcerns53 thatmaypreventbystandersfromusing suchtechniques(eg,CPR,PAD)andusingthem effectively.54 MostCPR-willingnessstudieshavebeen conductedinHICs,53,55 withfewinLMICs.

AstudyinLebanondiscoveredanegativecorrelation betweenthelackofprevioustrainingandconfidencein performingCPRandthewillingnesstodoCPRinOHCA patients.54 ItisclearthattimelyCPRanddefibrillation, regardlessofwhodoesthem,arecrucialforimproving survivalratesfromOHCAs.56 WhileenhancingEMS responsetimesischallengingandpotentiallycostly, simplifiedtrainingprogramscanengagethepublic effectively.Forinstance,afocusoncompression-onlyCPR hasincreasedbystanderCPRratesandsurvivalrates.57 The aimshouldnotbetodilutethequalityofCPRtrainingbutto extendoutreachtomoreindividualsinthecommunityto buildapyramidof firstresponders.14 Toimprovebystander first-aidinVietnam,morelaypeopleshouldbetrained througharecognizedemergency first-aidprogram.58 Plans forthefutureshouldincludededicatedtrainingandquality improvementactivitiesforT-CPRatdispatchcenters.

Table5. Therapy-relatedcharacteristicsofnon-matchedandmatchedcohortsofpatientswithout-of-hospitalcardiacarrestaccordingtothe typeofbystandercardiopulmonaryresuscitation,Vietnam,February2014–December2018.

BeforematchingAftermatching

Bystander

Variables

Pharmacotherapy, no.(%)

Allcases (n = 521) Nobystander CPR(n = 406)

(n = 115)

Epinephrine(atscene)122(23.4)67(16.5)55(47.8)

Epinephrine(atED)480(92.1)374(92.1)106(92.2) >0.99196(92.5)99(93.4)97(91.5)0.60

Prehospitalintervention, no.(%)

Prehospital deﬁbrillation,n1 = 135c, n2 = 56c

BystanderAEDapplied, n1 = 262c,n2 = 125c

EDdeﬁbrillation performed,no.(%)

43(31.9)29(38.2)14(23.7)0.0712(21.4)NA12(21.4)NA

14(5.3)7(4.2)7(7.4)0.267(5.6)0(0.0)7(8.0)0.10

68(13.1)48(11.8)20(17.4)0.1224(11.3)6(5.7)18(17.0)0.01

Prehospitaladvanced airway,no.(%) 108(20.7)62(15.3)46(40.0) <0.00143(20.3)0(0.0)43(40.6) <0.001

Advancedairwayused atED,no.(%)

Admissioncoronary angiography,no.(%)

Post-resuscitationcare, no.(%)

ECMOtherapyinitiated, n1 = 519c 7(1.30)5(1.2)2(1.7)0.652(0.9)1(0.9)1(0.9)

Hypothermiatherapy initiated

aThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthenon-matchedcohort. bThecomparisonbetweenpatientswhodidnotreceivebystanderCPRandwhoreceivedbystanderCPRinthematchedcohort. cn1andn2werede ﬁnedasthetotalnumberofpatientsrecordedifavariablewasgivenornotinthenon-matchedandmatchedcohorts. AED,automatedexternaldeﬁbrillation; CABG,coronaryarterybypassgrafting; CPR,cardiopulmonaryresuscitation; ECMO,extracorporeal membraneoxygenationtherapy; ED,emergencydepartment; NA,notavailable; PCI,percutaneouscoronaryintervention.

Inourstudy,EMSattendedtoandtransportedasmall numberofOHCApatientstothehospital(Table4).This ﬁndingmightbeattributedtoalackofresources,knowledge, andinfrastructureforemergencymedicaltreatment,suchas EMSdispatchcenters.22,27 Despiteeconomicandpolitical changesthathaveresultedinstrongeconomicgrowthin Vietnam,59 ambulances,qualiﬁedandaccreditedmedical personnel,andlife-savingequipmentareinshortsupply. Medicalsupervisionandfrequentmonitoringofquality indicatorsarealsorare.22,27 Atthesametime,recruitingnew EMSworkersorhealthcarepractitionersisfraughtwith

difficulties.27 Forexample,followinggraduation,alldoctors andnursesmustcompletean18-monthclinicaltraining programininpatientsettingstoobtaintheircompleteclinical license.28 However,EMSisnotrecognizedasaclinical trainingfacility,whichmakesobtainingpostgraduate certificationdifficult.Asaresult,ambulancemedicalstaffare understaffed,overworked,andunderequipped;andEMS centersareoverburdened.27 Moreover,callcenterstaffdo nothavetheabilitytoidentifyapossiblepersonincardiac arrestandprovideCPRinstructionstocallers.22 Public bystandersarealsoreluctanttocallEMS,andthismay

Table6. Factorsrelatedtosurvivaloutcomesinanon-matchedcohortofpatientswithout-of-hospitalcardiacarrestinVietnam,February 2014–December2018:multivariablelogisticregressionanalyses.

Factors

Patient-related

Pastmedicalhistory

–0.955)0.030.329(0.155–0.698) <0.0010.273(0.106–0.702)0.01

HeartdiseasesNANA0.073(0.015–0.356) <

Cancer0.167(0.038–0.740)0.02NANANANA

Renaldisease0.059(0.008–0.453)0.01NANANANA

Respiratorydisease2.490(1.320–4.697)0.014.310(1.869–9.941) <0.0018.386(2.834–24.812) <0.001

Event-related

Locationtype

InEMS/privateambulanceReference <0.001NANANANA

Healthcarefacility3.175(0.679–14.848)0.14NANANANA

Homeresidence7.827(2.294–26.708) <0.001NANANANA

Publicarea10.330(2.384–44.757) <0.001NANANANA

Witnessedarrest3.657(1.471–9.091)0.013.625(1.057–12.431)0.04NANA

PresumedcardiacetiologyNANA3.337(1.570–7.094) <0.0017.236(2.611–20.053) <0.001

System-related

Prehospitaltransportation

Privateorpublictransport0.204(0.106–0.392) <0.001NANANANA

Therapy-related

BystanderCPRNANA1.962(0.980–3.929)0.063.624(1.629–8.063) <0.001

Constant0.024 <0.0010.023 <0.0010.022 <0.001

aIndicatethepatientreceivedhospitaladmission.

bIndicatewhetherthepatientwasdischargedaliveorremainedinthehospitalontheday30post-arrest. cIndicatethepatient’sneurologicaloutcomeatthetimeofdischargeorthe30th dayafterthecardiacarrest.

AOR, adjustedoddsratio; CI,conﬁdenceinterval; CPR,cardiopulmonaryresuscitation; EMS,EmergencyMedicalServices; NA,notavailable; OHCA,out-of-hospitalcardiacarrest.

explainwhyinourstudywefoundthataverylowproportion ofOHCApatientsreceivedbystanderCPRorweretakento thehospitalbyEMS.

In2011,theMinistryofHealthbeganissuinglicensesfor privateambulancestoprovide first-aidorpatient transportation.28 Theseservicesareequippedtoperform CPR,administerlife-savingdrugs,usedefibrillators,and generallyhaveamedicalprofessionalonboardtrainedto handleemergencies.However,ourstudyfoundthatonly abouttwo-fifthsofOHCApatientsweretransportedbythese services.Asignificantnumberofthesepatientsdidnot receiveCPRfrombystanders(Table4).Moreover,for OHCApatientswhodidnotreceiveCPRfrombystanders, resuscitationattemptswereoftennotperformedbyEMS/ privateambulancepersonnel(Table4).These findingscould beduetolimitedmedicalinterventionsprovidedbysome privateorganizationsandhealthcareworkers’ difficultyin recognizingcardiacarrests.29 Bystandersmightalsobe

unwillingtocallprivateambulanceservices;theinjuredor sickpersonorOHCApatientisoftencarriedquickly bythenearestprivatevehiclelargeenoughtoaccommodate themandbroughttothehospitalbyfriends andrelatives.24,29,42

Inthisstudy,univariablelogisticregressionidentifi ed twofactorsassigni fi cantlyloweringthelikelihoodofgood neurologicalsurvivalathospitaldischarge:patientswho weretransportedtothehospitalbyprivateorpublic transportation,andpatientswhodidnotreceivebystander CPR(SupplementaryTable4).Comparatively,thosewho receivedbystanderCPRwerefoundinmultivariable logisticregressiontobeindependentlyrelatedtoahigh probabilityofsurvivinguntilhospitaldischargewithgood neurologicalfunction( Table6).These fi ndingshighlightthe mostimportantfactorthatstronglypredictedgood neurologicalsurvivalathospitaldischargewasbystander CPR,whichoverwhelmedotherfactorsincludedin

ourmultivariablelogisticregression( Table6).These ﬁ ndingsalsomeanthatbystanderCPRplaysthe ﬁ rstcrucial roleinthechainofsurvival,regardlessofthetypeof prehospitaltransport.14,45,46 ,57, 60

LIMITATIONS

Thereareseverallimitationstothisstudy.Firstly,our studywaslimitedbyitsretrospectivedesign.Asaresult,our datawasmissingmanyvariables.Forinstance,weonlyhad informationonwhetherresuscitationattemptsweremadeby EMS/privateambulancepersonnelfor262patients. Moreover,mosttime-stampeddatawasabsentforvarious events(eg,responsetimes),andweexcluded88patientsfrom ouranalysisduetotheabsenceofmostvariables.These limitationshaveresultedinanimplicitselectionbias, hinderedourabilitytocalculateahigherpropensityscore, andlimitedanypotentialdeﬁnitiveconclusions.Secondly ,it isnotfeasibletoascertainwhetherbystanderCPRadhered totheAmericanHeartAssociationorRedCrossprotocol. Consequently,bystanderCPRmayvarysigniﬁcantlyand notalignwithstandardrecommendations.

Thirdly,ourstudywasconductedinthreeofthehighest levelpublicsectorhospitalsinVietnamandfocusedona highlyselectedpopulationofcases.However,thestudydid notincludepatientsbroughttothehospitalbyEMS/private ambulanceswhowerepronounceddeadinthe field.Asa result,thenumberofpersonssufferingfromOHCAis expectedtobemuchlargerthanwhatwasreportedinthis hospital-basedstudy.Additionally,wefoundthatmany OHCApatientsarrivedatthehospitalbyprivate transportationratherthanEMS/privateambulances.Some oftheseindividualsmayhavebeenseenbyprimarycare doctors,mayhavediedathome,ormaynothavebeen transportedtothehospitalatall.Moreover,thenumberof OHCApatientsvariedsignificantlyacrosshospitals.This differenceisbecausetheHueCentralGeneralandtheCho RayHospitalshadonlyasmallnumberofpatientsenrolled in2017and2018.Thus,thesefactorshavealsoresultedinan implicitselectionbiasorincompleteenrolmentandinclusion ofpatientsintheOHCAdatabase.Differencesin figures foundbetweenVietnamandothercountriesmightbe accountedforbythesefactors.Finally,thesamplesizewas relativelysmall,whichmighthaveledtooverfittinginthe multivariablepredictionmodels.Therefore,wedidnot includemorevariablesatthemedicalinstitutionsin thesemodels.

CONCLUSION

OurstudyshowedthatthelowproportionofOHCA patientswhoreceivedbystanderCPRcontributed signiﬁcantlytoalowrateofgoodneurologicalsurvivalin Vietnam.Uponadmission,bystanderCPRwasan independentpredictorofgoodneurologicalsurvivalat hospitaldischarge.Toimprovethechancesofgood

neurologicalsurvivalofOHCApatients,morepeopleshould betrainedtoperformbystanderCPRandteachothersas well.Astandardprogramforemergency ﬁrst-aidtrainingis necessaryforthispurpose.

AFFILIATIONSCONTINUED

** ThaiBinhUniversityofMedicineandPharmacy, DepartmentofNutritionandFoodSafety,ThaiBinh,Vietnam ††ChoRayHospital,EmergencyDepartment,HoChiMinh City,Vietnam

‡‡HueCentralGeneralHospital,EmergencyDepartment, HueCity,ThuaThienHue,Vietnam

§§EmoryUniversitySchoolofMedicine,Departmentof EmergencyMedicine,Atlanta,Georgia

∥∥EmoryUniversityRollinsSchoolofPublicHealth,Atlanta, Georgia

¶¶SingaporeGeneralHospital,DepartmentofEmergency Medicine,Singapore,Singapore

##Duke-NUSMedicalSchool,HealthServicesandSystems Research,Singapore,Singapore

*** Namesandafﬁliationslistedinsupplemental ﬁ le

AddressforCorrespondence:SonNgocDo,MD,PhD,Centerfor CriticalCareMedicine,BachMaiHospital,78GiaiPhongRd.,Dong DaDistrict,Hanoi,100000,Vietnam.

Email: sondongoc.ump@vnu.edu.vn

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

REFERENCES

1.SassonC,RogersMA,DahlJ,etal.Predictorsofsurvivalfromout-ofhospitalcardiacarrest:asystematicreviewandmeta-analysis. Circ CardiovascQualOutcomes. 2010;3(1):63–81.

2.BerdowskiJ,BergRA,TijssenJG,etal.Globalincidences ofout-of-hospitalcardiacarrestandsurvivalrates:systematic reviewof67prospectivestudies. Resuscitation. 2010;81(11):1479–87.

3.MerchantRM,TopjianAA,PanchalAR,etal.Part1:Executive summary:2020AmericanHeartAssociationguidelinesfor cardiopulmonaryresuscitationandemergencycardiovascularcare. Circulation. 2020;142(16_suppl_2):S337–57.

4.HsuA,SassonC,KudenchukPJ,etal.2021interimguidancetohealth careprovidersforBasicandAdvancedCardiacLifeSupportinadults,

children,andneonateswithsuspectedorconﬁrmedCOVID-19. Circ CardiovascQualOutcomes. 2021;14(10):e008396.

5.NicholG,ThomasE,CallawayCW,etal.Regionalvariationinout-ofhospitalcardiacarrestincidenceandoutcome. JAMA. 2008;300(12):1423–31.

6.IwamiT,NicholG,HiraideA,etal.Continuousimprovementsin “chainof survival” increasedsurvivalafterout-of-hospitalcardiacarrests:alargescalepopulation-basedstudy. Circulation. 2009;119(5):728–34.

7.RaoBH,SastryBK,ChughSS,etal.Contributionofsuddencardiac deathtototalmortalityinIndia:apopulationbasedstudy. IntJCardiol. 2012;154(2):163–7.

8.RogerVL,GoAS,Lloyd-JonesDM,etal.Heartdiseaseandstroke statistics–2011update:areportfromtheAmericanHeartAssociation. Circulation. 2011;123(4):e18–209.

9.JacobsI,NadkarniV,BahrJ,etal.Cardiacarrestandcardiopulmonary resuscitationoutcomereports:updateandsimpliﬁcationoftheUtstein templatesforresuscitationregistries:astatementforhealthcare professionalsfromataskforceoftheInternationalLiaisonCommitteeon Resuscitation(AmericanHeartAssociation,EuropeanResuscitation Council,AustralianResuscitationCouncil,NewZealandResuscitation Council,HeartandStrokeFoundationofCanada,InterAmericanHeart Foundation,ResuscitationCouncilsofSouthernAfrica). Circulation. 2004;110(21):3385–97.

10.ZiveD,KoprowiczK,SchmidtT,etal.Variationinout-of-hospitalcardiac arrestresuscitationandtransportpracticesintheResuscitation OutcomesConsortium:ROCEpistry-CardiacArrest. Resuscitation. 2011;82(3):277–84.

11.GirotraS,vanDiepenS,NallamothuBK,etal.Regionalvariationinoutof-hospitalcardiacarrestsurvivalintheUnitedStates. Circulation. 2016;133(22):2159–68.

12.OngME,ShinSD,DeSouzaNN,etal.Outcomesforout-of-hospital cardiacarrestsacross7countriesinAsia:thePanAsianResuscitation OutcomesStudy(PAROS). Resuscitation. 2015;96:100–8.

13.McNallyB,RobbR,MehtaM,etal.Out-of-hospitalcardiacarrest surveillance CardiacArrestRegistrytoEnhanceSurvival(CARES), UnitedStates,October1,2005–December31,2010. MMWRSurveill Summ. 2011;60(8):1–19.

14.OngMEH,PerkinsGD,CariouA.Out-of-hospitalcardiacarrest: prehospitalmanagement. Lancet. 2018;391(10124):980–8.

15.YuY,MengQ,MunotS,etal.Assessmentofcommunityinterventions forbystandercardiopulmonaryresuscitationinout-of-hospitalcardiac arrest:asystematicreviewandmeta-analysis. JAMANetwOpen. 2020;3(7):e209256.

16.NakashimaT,NoguchiT,TaharaY,etal.Public-accessdeﬁbrillation andneurologicaloutcomesinpatientswithout-of-hospitalcardiacarrest inJapan:apopulation-basedcohortstudy. Lancet. 2019;394(10216):2255–62.

17.GirotraS,ChanPS,BradleySM.Post-resuscitationcarefollowing out-of-hospitalandin-hospitalcardiacarrest. Heart. 2015;101(24):1943–9.

18.DoSN,LuongCQ,PhamDT,etal.Survivalafterout-of-hospitalcardiac arrest,VietNam:multicentreprospectivecohortstudy. BullWorldHealth Organ. 2021;99(1):50–61.

19.DoSN,LuongCQ,PhamDT,etal.Survivalaftertraumaticout-ofhospitalcardiacarrestinVietnam:amulticenterprospectivecohort study. BMCEmergMed. 2021;21(1):148.

20.HoangBH,DoNS,VuDH,etal.Outcomesforout-of-hospitalcardiac arresttransportedtoemergencydepartmentsinHanoi,Vietnam:amulticentreobservationalstudy. EmergMedAustralas. 2021;33(3):541–6.

21.MawaniM,KadirMM,AzamI,etal.Epidemiologyandoutcomesofoutof-hospitalcardiacarrestinadevelopingcountry:amulticentercohort study. BMCEmergMed. 2016;16(1):28.

22.LeeSCL,MaoDR,NgYY,etal.Emergencymedicaldispatchservices acrossPan-Asiancountries:aweb-basedsurvey. BMCEmergMed. 2020;20(1):1.

23.WorldBank.Worlddevelopmentindicators.2019.Availableat: https://databank.worldbank.org/data/download/POP.pdf AccessedJune4,2023.

24.HoangBH,DaoXD,NakaharaS.Theneedforimprovingaccessto emergencycarethroughcommunityinvolvementinlow-andmiddleincomecountries:acasestudyofcardiacarrestinHanoi,Vietnam. EmergMedAustralas. 2018;30(6):867–9.

25.SingaporeClinicalResearchInstitute.Pan-AsianResuscitation OutcomesStudy(PAROS)ClinicalResearchNetwork(CRN) Committee.2010.Availableat: https://www.scri.edu.sg/ national-coordinating-body/clinical-research-network/paros/ AccessedJanuary9,2022.

26.DoctorNE,AhmadNS,PekPP,etal.ThePan-AsianResuscitation OutcomesStudy(PAROS)clinicalresearchnetwork:what,where,why andhow. SingaporeMedJ. 2017;58(7):456–8.

27.HoangBH,MaiTH,DinhTS,etal.Unmetneedforemergencymedical servicesinHanoi,Vietnam. JMAJ. 2021;4(3):277–80.

28.VietnamMinistryofHealth.Conditionsforgrantofoperationlicensesfor ﬁrst-aidorpatienttransportationservicefacilities.InCircular No.41/2011/TT-BYTdatedonNovember14,2011: Guidanceon IssuanceofPracticeCertiﬁcatesforMedicalPractitionersandOperation LicensesforMedicalExaminationandTreatmentFacilities.Hanoi, Vietnam:LabourPublishingHouse;2011.

29.NielsenK,MockC,JoshipuraM,etal.Assessmentofthestatusof prehospitalcarein13low-andmiddle-incomecountries. Prehosp EmergCare. 2012;16(3):381–9.

30.BergRA,HemphillR,AbellaBS,etal.Part5:adultbasiclifesupport: 2010AmericanHeartAssociationguidelinesforcardiopulmonary resuscitationandemergencycardiovascularcare. Circulation. 2010;122(18Suppl3):S685–705.

31.VaillancourtC,CharetteML,BohmK,etal.Inout-of-hospitalcardiac arrestpatients,doesthedescriptionofanyspeciﬁcsymptomstothe emergencymedicaldispatcherimprovetheaccuracyofthediagnosisof cardiacarrest:asystematicreviewoftheliterature. Resuscitation. 2011;82(12):1483–9.

32.LernerEB,ReaTD,BobrowBJ,etal.Emergencymedicalservice dispatchcardiopulmonaryresuscitationprearrivalinstructionsto improvesurvivalfromout-of-hospitalcardiacarrest:ascientiﬁc statementfromtheAmericanHeartAssociation. Circulation. 2012;125(4):648–55.

33.PerkinsGD,JacobsIG,NadkarniVM,etal.Cardiacarrestand cardiopulmonaryresuscitationoutcomereports:updateoftheUtstein ResuscitationRegistryTemplatesforout-of-hospitalcardiacarrest:a statementforhealthcareprofessionalsfromataskforceofthe InternationalLiaisonCommitteeonResuscitation(American HeartAssociation,EuropeanResuscitationCouncil,Australian andNewZealandCouncilonResuscitation,HeartandStroke FoundationofCanada,InterAmericanHeartFoundation, ResuscitationCouncilofSouthernAfrica,ResuscitationCouncilof Asia);andtheAmericanHeartAssociationEmergency CardiovascularCareCommitteeandtheCouncilon Cardiopulmonary,CriticalCare,PerioperativeandResuscitation. Circulation. 2015;132(13):1286 – 300.

34.CumminsRO,ChamberlainDA,AbramsonNS,etal.Recommended guidelinesforuniformreportingofdatafromout-of-hospital cardiacarrest:theUtsteinStyle.Astatementforhealthprofessionals fromataskforceoftheAmericanHeartAssociation,the EuropeanResuscitationCouncil,theHeartandStrokeFoundationof Canada,andtheAustralianResuscitationCouncil. Circulation. 1991;84(2):960–75.

35.SafarPJ.Cerebralresuscitationaftercardiacarrest:summariesand suggestions. AmJEmergMed. 1983;1(2):198–214.

36.AjamK,GoldLS,BeckSS,etal.Reliabilityofthecerebralperformance categorytoclassifyneurologicalstatusamongsurvivorsofventricular ﬁbrillationarrest:acohortstudy. ScandJTraumaResuscEmergMed. 2011;19:38.

37.AustinPC.Anintroductiontopropensityscoremethodsforreducingthe effectsofconfoundinginobservationalstudies. MultivariateBehavRes. 2011;46(3):399–424.

38.RezaeianS,PoorolajalJ,MoghimbegiA,etal.Riskfactorsofcongenital hypothyroidismusingpropensityscore:amatchedcase-controlstudy. J ResHealthSci. 2013;13(2):151–6.

39.EscutnaireJ,GeninM,BabykinaE,etal.Traumaticcardiac arrestisassociatedwithlowersurvivalratevs.medicalcardiacarrest: resultsfromtheFrenchnationalregistry. Resuscitation. 2018;131:48–54.

40.DickWF.Anglo-Americanvs.Franco-Germanemergencymedical servicessystem. PrehospDisasterMed. 2003;18(1):29–35; discussion35–27.

41.SirikulW,PiankusolC,WittayachamnankulB,etal.Aretrospective multi-centrecohortstudy:pre-hospitalsurvivalfactorsofout-of-hospital cardiacarrest(OHCA)patientsinThailand. ResuscPlus. 2022;9:100196.

42.NguyenTL,NguyenTH,MoritaS,etal.Injuryandpre-hospitaltrauma careinHanoi,Vietnam. Injury. 2008;39(9):1026–33.

43.NagataT,TakamoriA,KimuraY,etal.Traumacenteraccessibilityfor roadtrafﬁcinjuriesinHanoi,Vietnam. JTraumaManagOutcomes. 2011;5:11.

44.WaltonM,HarrisonR,ChevalierA,etal.Improvinghospitaldeath certiﬁcationinVietNam:resultsofapilotstudyimplementinganadapted WHOhospitaldeathreportformintwonationalhospitals. BMJGlob Health. 2016;1(1):e000014.

45.KronickSL,KurzMC,LinS,etal.Part4:systemsofcareandcontinuous qualityimprovement:2015AmericanHeartAssociationguidelines updateforcardiopulmonaryresuscitationandemergency cardiovascularcare. Circulation. 2015;132(18Suppl2):S397–413.

46.MonsieursKG,NolanJP,BossaertLL,etal.EuropeanResuscitation Councilguidelinesforresuscitation2015:Section1.Executive summary. Resuscitation. 2015;95:1–80.

47.DeakinCD.Thechainofsurvival:notalllinksareequal. Resuscitation. 2018;126:80–2.

48.MaltaHansenC,KragholmK,PearsonDA,etal.Associationof bystanderand ﬁrst-responderinterventionwithsurvivalafter out-of-hospitalcardiacarrestinNorthCarolina,2010–2013. JAMA. 2015;314(3):255–64.

49.NakaharaS,TomioJ,IchikawaM,etal.Associationofbystander interventionswithneurologicallyintactsurvivalamongpatientswith bystander-witnessedout-of-hospitalcardiacarrestinJapan. JAMA. 2015;314(3):247–54.

50.KitamuraT,KiyoharaK,SakaiT,etal.Public-accessdeﬁbrillation andout-of-hospitalcardiacarrestinJapan. NEnglJMed. 2016;375(17):1649–59.

51.SonNT.VietNam:Improvementsintraumacarecapabilitiesinthe networkofhealthfacilitiesinHanoi.InMockCharles,JuillardCatherine, JoshipuraManjul,GoosenJacques(Eds.), StrengtheningCareforthe Injured:SuccessStoriesandLessonsLearnedfromAroundtheWorld Geneva,Switzerland:WorldHealthOrganization;2010.

52.PerkinsGD,TraversAH,BergRA,etal.Part3:adultbasiclifesupportand automatedexternaldeﬁbrillation:2015internationalconsensuson cardiopulmonaryresuscitationandemergencycardiovascularcare sciencewithtreatmentrecommendations. Resuscitation. 2015;95:e43–69.

53.BhanjiF,ManciniME,SinzE,etal.Part16:Education,implementation, andteams:2010AmericanHeartAssociationguidelinesfor cardiopulmonaryresuscitationandemergencycardiovascularcare. Circulation. 2010;122(18Suppl3):S920–33.

54.ShamsA,RaadM,ChamsN,etal.Communityinvolvementinoutof hospitalcardiacarrest:across-sectionalstudyassessing cardiopulmonaryresuscitationawarenessandbarriersamongthe Lebaneseyouth. Medicine. 2016;95(43):e5091.

55.MaltaHansenC,RosenkranzSM,FolkeF,etal.Laybystanders’ perspectivesonwhatfacilitatescardiopulmonaryresuscitationanduse ofautomatedexternaldeﬁbrillatorsinrealcardiacarrests. JAmHeart Assoc. 2017;6(3):e004572.

56.KitamuraT,IwamiT,KawamuraT,etal.Nationwidepublic-access deﬁbrillationinJapan. NEnglJMed. 2010;362(11):994–1004.

57.BobrowBJ,SpaiteDW,BergRA,etal.Chestcompression-onlyCPRby layrescuersandsurvivalfromout-of-hospitalcardiacarrest. JAMA. 2010;304(13):1447–54.

58.KangS,SeoH,HoBD,etal.Implementationofasustainable trainingsystemforemergencyinVietnam. FrontPublicHealth. 2018;6:4.

59.TheWorldBank.TheWorldBankinVietnam.2020.Availableat: https:// www.worldbank.org/en/country/vietnam/overview.Published2020. AccessedJune4,2023.

60.ChocronR,JobeJ,GuanS,etal.Bystandercardiopulmonary resuscitationquality:potentialforimprovementsincardiacarrest resuscitation. JAmHeartAssoc. 2021;10(6):e017930.

End-tidalCarbonDioxideTrajectory-basedPrognosticationof Out-of-hospitalCardiacArrest

Chih-HungWang,MD,PhD*†

Tsung-ChienLu,MD,PhD*†

JoyceTay,MD†

Cheng-YiWu,MD†

Meng-CheWu,MD†

Chun-YenHuang,MD,MSc‡ Chu-LinTsai,MD,ScD*†

Chien-HuaHuang,MD,PhD*†

MatthewHuei-MingMa,MD,PhD*†§

Wen-JoneChen,MD,PhD*†

SectionEditor:EricMelnychuk,MD

*NationalTaiwanUniversity,CollegeofMedicine,DepartmentofEmergency Medicine,Taipei,Taiwan

† NationalTaiwanUniversityHospital,DepartmentofEmergencyMedicine, Taipei,Taiwan

‡ FarEasternMemorialHospital,DepartmentofEmergencyMedicine, NewTaipeiCity,Taiwan

§ NationalTaiwanUniversityHospitalYunlinBranch,Departmentof EmergencyMedicine,YunlinCounty,Taiwan

Submissionhistory:SubmittedJuly18,2023;RevisionreceivedOctober25,2023;AcceptedJanuary19,2024

ElectronicallypublishedJune11,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.61563

Background: Duringcardiopulmonaryresuscitation(CPR),end-tidalcarbondioxide(EtCO2)isprimarily determinedbypulmonaryblood flow,therebyreflectingtheblood flowgeneratedbyCPR.Weaimedto developanEtCO2 trajectory-basedpredictionmodelforprognosticationatspecifictimepointsduring CPRinpatientswithout-of-hospitalcardiacarrest(OHCA).

Methods: WescreenedpatientsreceivingCPRbetween2015–2021fromaprospectivelycollected databaseofatertiary-caremedicalcenter.Theprimaryoutcomewassurvivaltohospitaldischarge.We usedgroup-basedtrajectorymodelingtoidentifytheEtCO2 trajectories.Multivariablelogisticregression analysiswasusedformodeldevelopmentandinternallyvalidatedusingbootstrapping.Weassessed performanceofthemodelusingtheareaunderthereceiveroperatingcharacteristiccurve(AUC).

Results: Theprimaryanalysisincluded542patientswithamedianageof68.0years.Threedistinct EtCO2 trajectorieswereidentifiedinpatientsresuscitatedfor20minutes(min):low(averageEtCO2 10.0 millimetersofmercury[mmHg];intermediate(averageEtCO2 26.5mmHg);andhigh(averageEtCO2: 51.5mmHg).Twenty-minEtCO2 trajectorywas fittedasanordinalvariable(low,intermediate,andhigh) andpositivelyassociatedwithsurvival(oddsratio2.25,95%confidenceinterval[CI]1.07–4.74).When the20-minEtCO2 trajectorywascombinedwithothervariables,includingarrestlocationandarrest rhythms,theAUCofthe20-minpredictionmodelforsurvivalwas0.89(95%CI0.86–0.92).Allpredictors inthe20-minmodelremainedstatisticallysignificantafterbootstrapping.

Conclusion: Time-speciﬁcEtCO2 trajectorywasasigniﬁcantpredictorofOHCAoutcomes,whichcould becombinedwithotherbaselinevariablesforintra-arrestprognostication.Forthispurpose,the20-min survivalmodelachievedexcellentdiscriminativeperformanceinpredictingsurvivaltohospital discharge.[WestJEmergMed.2024;25(4)521–532.]

Keywords: Cardiopulmonaryresuscitation;end-tidalcarbondioxide;group-basedtrajectorymodeling; out-of-hospitalcardiacarrest;survival;trajectory.

INTRODUCTION

Theannualincidenceofout-of-hospitalcardiacarrest (OHCA)isestimatedtobe28–44casesper100,000 populationworldwide.1 Theestimatedproportionofsurvival todischargeinOHCAwas7.6%inEurope,6.8%inNorth America,3.0%inAsia,and9.7%inAustralia.1 High-quality cardiopulmonaryresuscitation(CPR)iscriticalinimproving OHCAoutcomes.2,3 Capnographyisrecommendedto monitorCPRqualityinrealtimeandadjustchest compressionqualityaccordingly.2,3 DuringCPR,end-tidal carbondioxide(EtCO2)isprimarilydeterminedby pulmonaryblood flow,therebyreflectingtheblood flow generatedbyCPR.4,5

The2020InternationalLiaisonCommitteeon Resuscitation(ILCOR)consensus6,7 recommendedthat EtCO2 ≥20millimetersofmercury(mmHg)measuredafter 20minutes(min)ofCPRmaypredictsurvivalto discharge.Nonetheless,thisweakrecommendationwas supportedbyonlymoderate-qualityevidence.A2018 ILCORsystematicreviewnoticedthatthemeasurementtime pointsofEtCO2 wereveryheterogeneousacross differentstudies.8 Accordingly,ILCOR6,7 suggestedthat insteadofsingleEtCO2 values,theEtCO2 trend shouldbefurtherexploredinfuturestudiesforits prognosticperformance.

ThepreviousstudynotedthatEtCO2 trajectoryduring CPRwasassociatedwithOHCAoutcomes.9 However,the predictiveabilityofEtCO2 trajectoryataspeciﬁctimingwas notexploredinthepreviousstudy.9 WhetherEtCO2 canbe combinedwithothermetricsforintra-arrestprognostication wasconsideredacriticalknowledgegapbythe2020 AmericanHeartAssociation(AHA)guidelines.2 Inour recentstudy,10 weincorporatedtheminimumEtCO2 value intothereturnofspontaneouscirculationaftercardiacarrest (RACA)scoreandimprovedtheperformanceofRACA scoreinpredictingROSC,suggestingthatEtCO2 could potentiallyhelpintra-arrestprognostication.

Inthecurrentstudy,wefurtherdevelopedmodelsthat couldpredictsurvivalathospitaldischarge.Insteadofasingle EtCO2 value,10 weattemptedtocombineEtCO2 trajectory andotherpredictorsinderivingpredictionmodels.Moreover, thesemodelsweredevelopedusingtime-speciﬁcwindowsto prognosticatepatientoutcomesduringresuscitation, including10-and20min6,7 afterinitiationofCPR.

MATERIALSANDMETHODS

Thisobservationalstudywasasecondaryanalysisofa prospectivelycollectedOHCAdatabaseregisteredinthe emergencydepartment(ED)ofNationalTaiwanUniversity Hospital(NTUH).Theinstitutionalreviewboardapproved thisstudy(referencenumber:201906082RINB)andwaived therequirementforinformedconsent.Thestudywas performedaccordingtotherecommendationsfromWorster etal11 regardinghealthrecordreviewstudiesinemergency

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Theend-tidalcarbondioxide(EtCO 2 )level duringcardiopulmonaryresuscitation(CPR) isassociatedwithoutcomesfollowingout-ofhospitalcardiacarrest(OHCA).

Whatwastheresearchquestion?

CouldEtCO 2 trajectoriesduringCPRbe combinedwithbaselinevariablestopredict outcomesofOHCA?

Whatwasthemajor ﬁndingofthestudy?

TheareaunderthecurveoftheEtCO 2 -based modelforsurvivalwas0.89(95%con ﬁ dence interval0.86 – 0.92).

Howdoesthisimprovepopulationhealth?

AnEtCO 2 trajectory-basedpredictionmodel mayhelpemergencymedicalservicesto predictOHCAoutcomesandfacilitate allocationofmedicalresources.

medicineresearchwithallelementsfollowed.Theresultsare reportedaccordingtothetransparentreportingofa multivariablepredictionmodelforindividualprognosisor diagnosis(TRIPOD)statement.12

StudySetting

TheNTUHisatertiary-caremedicalcenterwith2,600 beds,including220bedsinintensivecareunits. Approximately100,000patientsvisitNTUHEDannually. PatientswithOHCAaretransporteddirectlytothe resuscitationbayofthecriticalcareareaintheEDforCPR, whichisdeliveredaccordingtoresuscitationguidelines.2,3 Also,since2013EDstaffhavebeentrainedwiththeA-C-L-S (airway-circulation-leadership-support)teamwork model9,13,14 tostreamlinetheresuscitationprocessviaboth strengthenedtechnicalandnon-technicalskills.15,16 Any intervention,suchastrachealintubationperformedduring CPR,aretimestampedbynurseswithaspeciallydesigned mobileapplication.TheEtCO2 isrecordedeverytwomin rightbeforepulsecheck.TheEtCO2 ismonitoredwith devicesattachedtotheadvancedairways,including supraglotticairwaysandendotrachealtubes.Forpatients withOHCAwhoneverachievereturnofspontaneous circulation(ROSC),CPRisusuallyperformedforatleast 30minintheED,exceptforthosewithadocumented do-not-resuscitate(DNR)order.

StudyPopulation

PatientswithOHCAsenttotheNTUHEDbetween January1,2015–December31,2021werescreened.The inclusioncriteriaforthestudywereasfollows:1)nontraumaticarrest;2)absenceofROSCbeforeEDarrival; (3)absenceofdocumentedDNRorderbeforeCPR;4)age ≥18years;and5)insertionofadvancedairwaysduringCPR. BasedontheCPRduration,theincludedpatientswouldbe furtherselectedforprimaryandsecondaryanalyses.Ifthe includedpatientsreceivedCPR ≥20minandhadEtCO2 measurements ≥3timeswithin20minofCPR,theywouldbe selectedintothe20-mingroupfortheprimaryanalysis. Similarly,iftheincludedpatientsreceivedCPR ≥10min andhadEtCO2 measurements ≥3timeswithin10minof CPR,theywouldbeselectedintothe10-mingroupfor secondaryanalysis.

DataCollection,VariableDe

ﬁnitions,and OutcomeMeasures

IntheNTUHdatabase,OHCAeventswererecorded basedontheUtsteintemplate.17 Datarequestedforanalysis includedage,gender,variablesderivedfromtheUtstein template,advancedairwayinsertiontiming,EtCO2 values withmeasurementtiming,andoutcomes.ForED resuscitation,thetimepointoftheinitialchestcompression deliveredintheEDwassetastimezeroforreference.Timeto advancedairwayusewasdeﬁnedastheintervalbetweentime zeroandtimeforcompletingadvancedairwayinsertion.If advancedairwaydeviceswereinsertedbeforeEDarrival,the

timetoadvancedairwaywasrecordedaszero.Durationof CPRintheEDreferredtothetimeintervalbetweentime zeroandtheendofresuscitation,eitherduetoROSCor death.Time-specificEtCO2 referredtotheEtCO2 level measuredafterthespecifictimeelapsingfollowingtimezero. Theprimaryoutcomewassurvivalstatusatthetimeof hospitaldischarge.ThesecondaryoutcomewasROSC, definedasapalpablepulsefor20seconds.18 Dataabstraction forthecurrentanalysiswasperformedbytrainedresearchers whowereblindedtothestudyhypothesis.

StatisticalAnalysis

Intheprimaryanalysis,weusedthe20-mingrouptobuild modelsforpredictingsurvival(20-minsurvivalmodel)and ROSC(20-minROSCmodel).Inthesecondaryanalysis, similarprocedureswereappliedtodevelopthe10-min survivalmodeland10-minROSCmodel.We ﬁrstperformed group-basedtrajectorymodeling(GBTM)toidentify trajectorygroupsbasedontheEtCO2 level.TheGBTMisan explanatorymodelingtechniquetoidentifyhiddengroupsof individualswithsimilartrajectoriesforaparticularvariable ofinterest.19 TheGBTMperformsbetterwhenlongitudinal dataismeasuredatleastthreetimes.

Fordescriptivestatistics,categoricalvariablesare presentedasproportions,andcontinuousvariablesare presentedasmedianswithinterquartileranges.Weexamined categoricalvariablesusingthechi-squaredtest,whereas continuousvariableswerecomparedusingtheKruskalWallistestorMann-Whitneytest,asappropriate.Weused

Figure1. Patientinclusion ﬂowchart. CPR,cardiopulmonaryresuscitation; DNR,do-not-resuscitate; ED,emergencydepartment; NTUH,NationalTaiwanUniversityHospital; OHCA,out-of-hospitalcardiacarrest; ROSC,returnofspontaneouscirculation.

multivariablelogisticregressionanalysestodevelopthe predictionmodels.Allavailablevariables,includingbasic demographics,peri-CPRevents,andEtCO2 trajectorywere accountedforintheregressionmodelviaastepwise, variableselectionprocedure.TheEtCO2 trajectorywouldbe testedasordinalorcategoricalvariablesinthemodelbuildingprocess.Weusedgeneralizedadditivemodels (GAM)20 toidentifytheappropriatecutoffpoint(s)for dichotomization.Thediscriminativeperformanceand calibrationofthepredictionmodelwereassessedbyarea underthereceiveroperatingcharacteristiccurve(AUC)and theHosmer-Lemeshowgoodness-of-ﬁttest,respectively.We internallyvalidatedthepredictionmodelusingthe bootstrappingprocedurewith1,000repetitionstoexamine therobustnessoftheeffectestimateofeachvariableinthe predictionmodel.

WeperformedGBTMandbootstrappingusingthetraj packageandbootstrapprocedureofStatasoftware (StataCorpLLC,CollegeStation,TX),respectively.We usedtheR4.1.1software(RFoundationforStatistical Computing,Vienna,Austria)forotheranalyses.Atwotailed P -value <0.05wasconsideredstatisticallysigniﬁcant.

RESULTS

Thepatientselectionprocedureresultedin542and532 patientsinthe20-minand10-mingroups,respectively (Figure1).Thetwogroupswerenotmutuallyexclusive. Becausenotallpatientsinthe20-mingrouphadEtCO2 measurements ≥3timeswithin10mins,the20-mingroup patientsmaynothavebeennecessarilyincludedinthe 10-mingroup.Also,becausesomeofthepatientsinthe 10-mingroupwouldachieveROSCwithin20minofCPR, the10-mingrouppatientswouldnotnecessarilyhavebeen includedinthe20-mingroup.Therefore,therewasan overlapof385patientsbetweenthe20-minand10-min groupswhomettheselectioncriteriaforbothgroups.

Intheprimaryanalysis,weidentifiedandnamedthree EtCO2 trajectoriesaslow,intermediate,andhightrajectories accordingtotheirrespectiveaverageEtCO2 levels(Figure2). Thecharacteristicsofthe20-mingroupandcomparisons betweentheseEtCO2 trajectoriesarepresentedin Table1. ThemedianCPRdurationintheEDwas31.0minutes,and themediannumberofEtCO2 measurementswaseight.A totalof25(4.6%)patientssurvivedathospitaldischarge. Thereseemstobeanincreasingtrendofsurvivalfromlowto highEtCO2 trajectory.Thecomparisonsbetweenpatients stratifiedbysurvivalareshownin SupplementalTable1 Duringthemodeldevelopment,the20-minEtCO2 trajectory was fittedasanordinalvariablebythelogisticregression analysisandpositivelyassociatedwithsurvival(oddsratio [OR]2.25,95%confidenceinterval[CI]1.07–4.74)and ROSC(OR2.46,95%CI1.78–3.41)(Table2).Inother words,comparedwiththelowEtCO2 trajectory,the intermediatetrajectoryhad2.25timeshigheroddsof

Figure2. Theend-tidalcarbondioxidetrajectory.

TheEtCO2 trajectorygroupsidentiﬁedbygroup-basedtrajectory modelinginthe(A)primary(20minute)and(B)secondary (10minute)analysis.Dottedlinesindicate95% conﬁdenceintervals.

CPR,cardiopulmonaryresuscitation; EtCO2,end-tidal carbondioxide.

survivaltohospitaldischarge.Similarly,compared withtheintermediatetrajectory,thehighEtCO2 trajectory alsohad2.25timeshigheroddsofsurvival.Whenthe 20-minEtCO2 trajectorywascombinedwithothervariables, theAUCsofthe20-minsurvivalandROSCmodels were0.89(95%CI0.86–0.92)and0.78(95%CI 0.74–0.81),respectively.

Similarly,inthesecondaryanalysisweidentifiedthree EtCO2 trajectories(Figure2 and Table3).ThemedianCPR durationintheEDwas30.0min,andthemediannumberof EtCO2 measurementswasfour.Atotalof34(6.4%)patients survivedathospitaldischarge.Significantsurvival differenceswerenotedamongthethreeEtCO2 trajectories; nonetheless,thesurvivalofintermediateandhighEtCO2 trajectorieswassimilar.Thesurvival-stratifiedcomparisons areshownin SupplementalTable2.Duringthemodel-fitting process,the10-minEtCO2 trajectorywas fittedasa categoricalvariable.Asshownin Table4,comparedwiththe 10-minlowEtCO2 trajectory,the10-minintermediateor highEtCO2 trajectorywassignificantlyassociatedwith

Table1. Characteristicsofpatientsincludedinthetwenty-minutegroupstratiﬁedbyend-tidalcarbondioxidetrajectorygroup.

Variables

Basicdemographics

Age,year68.0(57.0

Male,n354(65.3)111(56.6)199(71.1)44(66.7)0.005

Peri-CPRevents

TransportedbyEMS,n507(93.5)179(91.3)263(93.9)65(98.5)0.11

Arrestathome,n296(54.6)113(57.6)149(53.2)34(51.5)0.55

Witnessbybystander,n193(35.6)56(28.5)112(40.0)25(37.9)0.03

WitnessbyEMS,n28(5.2)11(5.6)12(4.3)5(7.6)0.52

Witnessbybystander orEMS,n 212(39.1)61(31.1)121(43.2)30(45.4)0.02

BystanderCPR,n269(49.6)93(47.4)140(50.0)36(54.5)0.60

Prehospitaldeﬁbrillation byEMS,n 117(21.5)17(8.6)82(29.2)18(27.2) <0.001

Initialshockablerhythmsat EDarrival,n 37(6.8)8(4.1)25(8.9)4(6.1)0.43

DurationofprehospitalCPR performedbyEMS,min

ProceduresduringCPR SGAuse,n376(69.4)134(68.4)196(70.0)46(69.7)0.93

TimetoSGAuse,min0(0–0)(n = 376)0(0–0)(n = 134)0(0–0)(n = 196)0(0–0)(n = 46)0.12 ETTuse,n531(98.0)189(96.4)277(98.9)65(98.5)0.12 TimetoETTuse,min3.0(2.0–5.0) (n = 531) 3.0(2.0–6.0) (n = 189)

Time-speciﬁcEtCO2 levels,mmHg 0-minEtCO2 29.0(20.3–36.0) (n = 39) 15.0(12.5–20.5) (n = 8)

1-minEtCO2 24.5(15.0–38.5) (n = 56) 14.5(10.5–19.0) (n = 20)

2-minEtCO2

3-minEtCO2

4-minEtCO2

5-minEtCO2

6-minEtCO2

7-minEtCO2

8-minEtCO2

9-minEtCO2

24.0(5.8–33.0) (n = 113) 14.0(9.0–23.3) (n = 37)

–

(n = 277)

–

(n = 27)

–38.3) (n = 25)

–33.0) (n = 62)

22.0(13.5–36.0) (n = 120) 11.5(6.0–20.0) (n = 46) 30.0(21.0–39.5) (n = 60)

22.0(12.0–33.0) (n = 231) 11.5(7.0–18.0) (n = 78) 24.0(18.0–34.8) (n = 123)

22.0(12.0–33.0) (n = 121) 10.0(3.0–14.8) (n = 43) 27.0(21.0–35.0) (n = 62)

21.0(12.0–31.0) (n = 245) 8.0(3.0–12.0) (n = 75)

–

(n = 65)

(n = 4)

–68.3) (n = 11) <

–54.0) (n = 14) <

–43.0) (n = 14) <0.001

–52.0) (n = 30) <0.001

–60.0) (n = 16) <0.001

24.0(18.0–31.0) (n = 141) 47.0(37.8–60.8) (n = 29) <0.001

18.5(10.0–32.0) (n = 142) 9.0(4.0–13.5) (n = 61) 27.0(18.0–34.0) (n = 62)

22.0(11.0–34.0) (n = 282) 9.0(3.0–12.0) (n = 94)

20.0(10.0–34.0) (n = 147) 8.5(3.0–12.0) (n = 58)

–62.3) (n = 19) <0.001

27.0(19.0–35.3) (n = 157) 56.0(45.0–60.8) (n = 31) <0.001

27.0(19.0–36.0) (n = 70) 58.0(45.0–72.8) (n = 19) <0.001

(Continuedonnextpage)

Table1. Continued.

Variables Twenty-min

10-minEtCO2

(n = 542) Twenty-minlow

21.0(12.0–33.0) (n = 296) 9.0(3.3–13.0) (n = 103) 27.0(20.0–34.8) (n = 163)

11-minEtCO2 21.0(11.0–36.5) (n = 144) 11.0(5.0–15.0) (n = 58) 28.0(21.0–36.0) (n = 63)

12-minEtCO2

13-minEtCO2

14-minEtCO2

15-minEtCO2

16-minEtCO2

21.0(12.0–31.8) (n = 331) 10.0(5.0–14.0) (n = 122)

21.0(12.0–33.8) (n = 123) 9.5(7.5–13.5) (n = 48)

–33.0) (n = 176)

–33.0) (n = 57)

21.0(12.0–33.0) (n = 324) 10.0(5.0–15.0) (n = 117) 26.0(21.0–34.0) (n = 173)

21.0(11.0–32.0) (n = 143) 9.5(4.0–14.0) (n = 58) 27.0(21.0–35.0) (n = 65)

22.0(12.0–33.0) (n = 329) 9.0(6.0–14.0) (n = 114) 26.5(21.0–33.0) (n = 180)

17-minEtCO2wp 21.0(12.0–36.0) (n = 139) 9.0(5.0–13.5) (n = 52)

–33.8) (n = 63)

18-minEtCO2 21.0(10.8–32.0) (n = 333) 9.0(3.0–14.0) (n = 125) 26.0(20.0–33.0) (n = 173)

19-minEtCO2

21.0(10.0–34.0) (n = 137) 8.5(3.0–13.0) (n = 50) 23.0(20.0–34.0) (n = 68)

trajectory (n = 66)

–68.0) (n = 30)

–65.8) (n = 23) <0.001

–71.3) (n = 33)

–65.0) (n = 18)

–

(n = 34)

–58.5) (n = 20)

–68.8) (n = 35) <0.001

–66.5) (n = 24) <0.001

–69.0) (n = 35) <0.001

–62.0) (n = 19) <0.001

20-minEtCO2 21.0(11.0–33.3) (n = 329) 9.0(4.5–14.0) (n = 123) 26.0(20.0–34.0) (n = 171) 56.0(50.0–64.5) (n = 35) <0.001

Availablemeasurementsof EtCO2 levels,times 8.0(6.0–9.0)8.0(7.0–9.0)8.0(6.0–9.0)8.0(7.0–9.0)0.64

EtCO2 summaryparameters,mmHg

Initial23.0(14.0–36.0)14.0(7.0–20.5)29.0(20.0–

Maximum36.0(22.0–50.0)18.0(12.0–24.0)41.0(34.0–

Minimum13.0(5.0–21.0)3.5(2.0–9.0)16.0(12.0–

–

Final21.0(11.0–35.0)9.0(4.0–14.0)26.0(20.0–34.5)56.0(46.0–65.0) <0.001

Average23.0(14.0–33.0)10.0(6.5–14.0)26.5(22.0–

Outcome,n

ROSC184(33.9)32(16.3)118(42.1)34(51.5) <0.001 Survivaltohospital discharge 25(4.6)3(1.5)16(5.7)6(9.1)0.02

Dataarepresentedasmedian(interquartilerange)orcounts(proportion).

CPR,cardiopulmonaryresuscitation; ED,emergencydepartment; EMS,emergencymedicalservices; mmHg,millimetersofmercury; ETT,endotrachealtube; ROSC,returnofspontaneouscirculation; SGA,supraglotticairway;min,minute.

survival(OR2.53,95%CI1.10–5.81).Inaddition,compared withthe10-minlowEtCO2 trajectory,10-minintermediate (OR3.36,95%CI2.25–5.04)andhigh(OR6.59,95%CI 3.42–12.69)EtCO2 trajectoriesweresigniﬁcantlyassociated withROSC,respectively.Whenthe10-minEtCO2 trajectory wascombinedwithothervariables,theAUCofthe10-min

survivalandROSCmodelswere0.76(95%CI0.72–0.79)and 0.75(95%CI0.71–0.79),respectively.

Forthe20-and10-minmodels,allthepredictors remainedsigniﬁcantlyassociatedwithoutcomesafterthe bootstrappingprocedure,indicatingtherobustnessofthese models(SupplementalTable3).

Table2. Multivariablelogisticregressionanalysisfortwenty-minutegrouptobuildend-tidalcarbondioxidetrajectory-based predictionmodels.

VariablesOddsratio(95%con

Twenty-minsurvivalmodel

Twenty-minEtCO2 trajectory2.25(1.07–4.74)0.03

Arrestathome0.28(0.10–0.77)0.01

PrehospitaldeﬁbrillationbyEMS3.42(1.34–8.77)0.01

InitialshockablerhythmsatEDarrival8.36(3.13–22.31) <0.001

Twenty-minROSCmodel

Twenty-minEtCO2 trajectory2.46(1.78–3.41) <0.001

Arrestathome0.54(0.34–0.85)0.008

WitnessbybystanderorEMS1.72(1.13–2.63)0.01

PrehospitaldeﬁbrillationbyEMS2.72(1.64–4.53) <0.001

InitialshockablerhythmsatEDarrival4.97(2.07–11.90)

DurationofprehospitalCPRperformedbyEMS0.96(0.93–0.99)0.003

Twenty-minsurvivalmodel:goodness-of-fitassessment:n = 542,adjustedgeneralized R2 = 0.32,estimatedareaunderthereceiver operatingcharacteristiccurve = 0.89(95%confidenceinterval:0.86–0.92),andHosmerandLemeshowgoodness-of-fitChi-Squared test p = 0.64;Twenty-minROSCmodel:goodness-of-fitassessment:n = 542,adjustedgeneralized R2 = 0.30,estimatedareaunderthe receiveroperatingcharacteristiccurve = 0.78(95%confidenceinterval:0.74–0.81),andHosmerandLemeshowgoodness-of-fit Chi-Squaredtest p = 0.19.

CPR,cardiopulmonaryresuscitation; ED,emergencydepartment; EMS,emergencymedicalservices; ROSC,returnofspontaneous circulation; min,minute.

DISCUSSION

MainFindings

Byusingaprospectivelycollecteddatabase,weidentified thatthetime-specificEtCO2 trajectorywasasignificant intra-arrestoutcomepredictor.Time-specificEtCO2 trajectorycouldbecombinedwithotherpredictorstoassist inintra-arrestprognosticationatdifferenttimepointsduring CPR.Amongallthepredictionmodels,the20-minEtCO2 trajectory-basedsurvivalmodelachievedthehighest discriminativeperformance(AUC0.89).

ComparisonwithPreviousStudies

ForoutcomepredictioninOHCA,mostmodelswere developedforpatientswhohadalreadyachievedROSC.21 Therewerefew,ifany,modelsavailableforpatientswhowere stillundergoingCPR.ForpredictingROSCbeforeCPRwas performed,theRACAscore18 wasoneofthemostwellvalidatedmodels,demonstratingAUCrangingfrom0.71to 0.76.22–24 AllthepredictorsincludedintheRACAscorewere baselinevariables,suchasarrestlocationandarrestrhythms, whichdidnotconsiderthetreatmenteffectsofCPR. Nonetheless,itwaspossiblethateventhoughtheRACA score-predictedROSCprobabilitiesweresimilar,theactual outcomesmaydifferbecauseofdifferentCPRqualitiesand durationsdeliveredbyrescuers.Tomakeindividualizedintraarrestprognostication,variablesspeciﬁctothepatientand resuscitationprocess,suchasEtCO2,maybenecessary,. The2018ILCORsystematicreview8 indicatedthatEtCO2 wasassociatedwithROSCprobability.Nonetheless,the

optimalparameterofEtCO2 forprognosticationisstill debated.8 Forexample,despiteitsconvenienceinstatistical analysis,averageEtCO2 couldnotdifferentiatebetween differentEtCO2 trajectories.Ascendinganddescending EtCO2 trajectoriesmayhavesimilaraverageEtCO2,but theirprognosesmaybeverydifferent.25,26 Moreover,the term “initial” EtCO2 maynotaccuratelyreflecttheEtCO2 levelduringtheearlyphaseofCPR,astheendotrachealtube couldpotentiallybeintroducedlaterduringtheresuscitation. ItwasreportedthatthespecificityofEtCO2 inpredicting ROSCwouldincreaseprogressivelyfrom50%at0minto 60%,98%,and100%at10,15,and20min,respectively.27 Therefore,forEtCO2 tobeavalidpredictor,thetimingof prognosticationshouldbespecified,anditstrendduring CPR,insteadofasinglevalue,shouldbeadopted.

InterpretationofCurrentAnalysis

The2020ILCORconsensus6,7 recommendsthatEtCO2 measuredafter20minofCPRmaybeapredictorofsurvival todischarge.Rosmanetal28 indicatedthatwhenhigher EtCO2 levelswerereachedbeyond20minofCPRtheymay notleadtoROSC.Progressivelyworseningischemiamay causerefractorinesstoCPRduringthemetabolicphaseof cardiacarrest,29 andEtCO2 trajectoriesbeyond20minmay notbeprognosticofoutcomes.Therefore,CPRfor20min wasusedtoselectthe20-mincohortandidentifythe20-min EtCO2 trajectory.TheadvantageofemployingGBTMwas thatitofferedanefﬁcientmethodtounravelthehidden trajectoriesthatmaynotbereadilyrecognizablefromthe

Table3. Characteristicsofpatientsincludedintheten-mingroupstratiﬁedbyend-tidalcarbondioxidetrajectorygroup.

Variables

Basicdemographics

(n = 532)

Age,year71.0(59.5–82.0)73.0(60.0–

Male,n346(65.0)143(61.1)167(69.6)36(62.1)0.14

Peri-CPRevents

TransportedbyEMS,n500(94.0)215(91.9)227(94.6)58(100)0.11

Arrestathome,n308(57.9)144(61.5)134(55.8)34(51.7)0.27

Witnessbybystander,n192(36.1)78(33.3)89(37.1)25(43.1)0.35

WitnessbyEMS,n26(4.9)7(3.0)16(6.7)3(5.2)0.18

WitnessbybystanderorEMS,n207(38.9)79(33.8)101(42.1)27(46.6)0.08

BystanderCPR,n276(51.9)115(49.1)126(52.5)35(60.3)0.30

PrehospitaldeﬁbrillationbyEMS,n101(19.0)24(10.2)60(25.0)17(29.3) <0.001

InitialshockablerhythmsatEDarrival,n30(5.6)11(4.7)16(6.7)3(5.2)0.64

DurationofprehospitalCPRperformed byEMS,min

ProceduresduringCPR

SGAuse,n380(71.4)166(70.9)172(71.7)42(72.4)0.97

TimetoSGAuse,min0(0–0)(n = 380)0(0–0)(n = 166)0(0–0)(n = 172)0(0

ETTuse,n508(95.5)219(93.6)234(97.5)55(94.8)0.12

TimetoETTuse,min3.0(2.0–4.0) (n = 508) 3.0(2.0–4.0) (n = 219)

Time-speciﬁcEtCO2 levels,mmHg

–4.0) (n = 234)

0-minEtCO2 26.0(18.0–36.0) (n = 48) 18.0(14.5–20.5) (n = 16) 31.0(25.3–38.3) (n = 27)

1-minEtCO2

2-minEtCO2

3-minEtCO2

4-minEtCO2

5-minEtCO2

6-minEtCO2

7-minEtCO2

8-minEtCO2

9-minEtCO2

10-minEtCO2

24.0(12.0–38.3) (n = 73) 12.0(7.0–17.0) (n = 30)

25.5(17.0–37.5) (n = 148) 17.0(11.0–23.0) (n = 62)

–41.0) (n = 34)

–42.0) (n = 70)

24.0(14.0–36.0) (n = 158) 13.5(9.0–21.0) (n = 70) 34.0(25.3–43.8) (n = 71)

23.0(13.3–35.8) (n = 299) 13.0(9.0–19.8) (n = 131)

23.0(12.0–34.0) (n = 153) 12.0(3.5–17.0) (n = 63)

–38.0) (n = 132)

–36.0) (n = 74)

22.0(13.0–34.0) (n = 326) 12.0(7.0–18.0) (n = 142) 28.0(21.3–38.0) (n = 147)

23.0(10.0–36.0) (n = 154) 10.0(5.5–15.5) (n = 68) 30.0(24.8–37.0) (n = 69)

25.0(13.0–38.0) (n = 343) 12.0(7.8–17.3) (n = 149) 33.0(26.0–40.0) (n = 159)

23.0(11.0–37.0) (n = 142) 10.0(4.0–15.8) (n = 63) 30.0(23.0–37.0) (n = 60)

–4.0) (n = 55)

–

(n = 5)

–69.3) (n = 9) <

–61.5) (n = 16)

–54.0) (n = 17)

–62.5) (n = 36) <0.001

–66.5) (n = 16) <0.001

–63.3) (n = 37) <0.001

–64.8) (n = 17) <0.001

–72.5) (n = 35) <0.001

–78.0) (n = 19) <0.001

23.0(14.0–39.8) (n = 339) 13.0(6.0–18.0) (n = 150) 32.0(24.0–43.0) (n = 154) 68.0(58.0–79.5) (n = 35) <0.001

(Continuedonnextpage)

Table3. Continued. Variables

Ten-mingroup (n = 532)

Ten-minlow EtCO2 trajectory (n = 234)

Ten-min intermediate EtCO2 trajectory (n = 240)

Ten-minhigh EtCO2 trajectory (n = 58) P value

AvailablemeasurementsofEtCO2 levels,times4.0(3.0–5.0)4.0(3.0–5.0)4.0(3.0–5.0)4.0(4.0–5.0)0.41

EtCO2 summaryparameters,mmHg

Initial25.0(15.0–40.0)15.0(10.0–22.0)34.0(25.0–43.5)55.5(45.0–65.0) <0.001

Maximum34.0(22.0–50.0)20.0(13.0–26.0)44.0(36.0–51.0)71.5(63.0–89.0) <0.001

Minimum16.0(9.0–24.5)8.0(3.0–12.0)21.5(17.0–

Final23.0(13.0–39.0)12.0(6.0–18.0)33.0(24.0–

Average25.0(15.0–36.0)13.0(8.0–19.0)32.0(26.0–

–

DurationofCPRperformedinED,min30.0(18.0–32.0)30.0(22.0–32.0)30.0(17.0–33.0)20.0(13.0–

Outcome,n

ROSC239(44.9)64(27.4)135(56.3)40(69.0) <0.001

Survivaltohospitaldischarge34(6.4)8(3.4)21(8.8)5(8.6)0.05

Dataarepresentedasmedian(interquartilerange)orcounts(proportion).

CPR,cardiopulmonaryresuscitation; ED,emergencydepartment; EMS,emergencymedicalservice; mmHG,millimetersofmercury; ETT,endotrachealtube; ROSC,returnofspontaneouscirculation; SGA,supraglotticairway.

Table4. Multivariablelogisticregressionanalysisforten-minutegrouptobuildend-tidalcarbondioxidetrajectory-basedpredictionmodels.

VariablesOddsratio(95%conﬁdenceinterval) P value

Ten-minsurvivalmodel

Ten-minintermediateorhighEtCO2 trajectory2.53(1.10–5.81)0.03

Witnessbybystander3.00(1.42–6.33)0.004

InitialshockablerhythmsatEDarrival5.21(2.03–13.33) <

Ten-minROSCmodel

Ten-minintermediateEtCO2 trajectory3.36(2.25–5.04) <0.001

Ten-minhighEtCO2 trajectory6.59(3.42–12.69) <0.001

Agebetween37and69(year)1.49(1.02–2.20)0.04

WitnessbybystanderorEMS1.92(1.31–2.84)0.001

InitialshockablerhythmsatEDarrival5.29(2.04–13.71) <0.001

DurationofprehospitalCPRperformedbyEMS(min)0.96(0.93–0.98) <0.001

Ten-minsurvivalmodel:goodness-of-fitassessment:n = 532,adjustedgeneralized R2 = 0.14,estimatedareaunderthereceiveroperating characteristiccurve = 0.76(95%confidenceinterval:0.72–0.79),andHosmerandLemeshowgoodness-of-fitchi-squaredtest P = 0.79; ten-minROSCmodel:goodness-of-fitassessment:n = 532,adjustedgeneralized R2 = 0.25,estimatedareaunderthereceiveroperating characteristiccurve = 0.75(95%confidenceinterval:0.71–0.79),andHosmerandLemeshowgoodness-of-fitchi-squaredtest P = 0.65. CPR,cardiopulmonaryresuscitation; ED,emergencydepartment; EMS,emergencymedicalservice; ROSC,returnof spontaneouscirculation.

baselinecharacteristicsorinitialEtCO2 values.The significantlydifferentEtCO2 levelsamongEtCO2 trajectoriesindicatedthesuccessofGBTMindistinguishing thesehiddenclusters(Table1).Also,inanunbiasedmanner, GBTMidentifiesthehiddenEtCO2 trajectoriesonlyby examiningtherepeatedlymeasuredEtCO2 without consideringbaselinevariablesoroutcomes.Whetherthe identifiedtrajectorieswereassociatedwithoutcomesshould

befurtherinvestigated.Forexample,comparedwithpatients withlow20-minEtCO2 trajectory,thosewithintermediate orhigh20-minEtCO2 trajectoryhadhigherproportionsof bystander-witnessedarrest(Table1),whichmayalsoexplain betteroutcomesinthelatter.

Inthe20-minsurvivalmodel,themultivariablelogistical regressionanalysisindicatedthatthe20-minEtCO2 trajectory waspositivelyassociatedwithsurvival,demonstratingthetrend

ofahigherEtCO2 trajectorywithincreasedsurvival.Studies revealedthatforevery10mmincreaseinchestcompression depth,EtCO2 wouldincreaseby1.4mmHg30 or4.0%.31

HigherEtCO2 trajectorymaysuggestbetterCPRquality, whichmayexplainthepositiveassociationbetweenEtCO2 trajectoryandchancesofsurvival.Incontrast,arrestetiology mayalsobeaconfoundingfactorinexplainingtheassociations betweenfavorableoutcomesandintermediateorhighEtCO2 trajectory.Studieshaveshownthatpatientswithasphyxial arrest32 orsuspectedrespiratoryetiology33 mayhavehigher EtCO2 levelsthanthosewithinitialshockablerhythms 32 or suspectedcardiacetiology,33 respectively.Nonetheless,inour cohort,patientsofintermediateorhighEtCO2 trajectoryhad higherproportionsofprehospitaldeﬁbrillationbyemergency medicalservices(EMS)(Table1).Therefore,insteadofthe arrestetiology,theCPRqualitymayaccountfor thepositiveassociationbetween20-minEtCO2 trajectory andsurvival.

WhetherEtCO2,alongwithotherfactors,canbeusedfor intra-arrestprognosticationwaslistedbyAHAguidelines2 asanimportantknowledgegap.Inthe20-minsurvival model,besidesEtCO2 trajectory,otherbaselinevariables, includingarrestathome,prehospitaldefibrillationbyEMS, andinitialshockablerhythmsonEDarrival,werealso selectedassignificantpredictors.Thesebaselinevariables hadbeenwell-validatedfortheirpredictiveperformancein previousstudies.18 The20-minsurvivalmodelachieved excellentdiscriminativeperformanceandmay firstanswer thequestionpresentedbytheAHA.2 Moreover,wefurther testedwhetherthe20-minEtCO2 trajectorycouldfacilitate predictingROSC.However,theAUCofthe20-minROSC modelwas0.78,lowerthanthatofthe20-minsurvival model.Inourstudy,ROSCwasdefinedasapalpablepulse for20seconds,asusedbyRACAscore.18 Theswiftnatureof thissecondaryoutcomemayrenderitdifficulttobe predicted,eventhoughthe20-minROSCmodel includedmorevariablesthanthe20-min survivalmodel.

Finally,wedevelopedthe10-minpredictionmodelsto explorewhetheroutcomescouldbepredictedatanearlier timepointduringCPR.Nevertheless,theAUCsofboth 10-minmodelswererespectivelylowerthantheir counterpartsof20-minmodels.Asshownin Figure2,the 10-minEtCO2 trajectorywasslightlydifferentfromthe 20-minEtCO2 trajectoryinthetrendpattern.Forexample, thehighEtCO2 trajectorycontinuedtorisewithin10min;it wasonlyevidentlaterinthe20-minwindowthatthe trajectoryhadplateaued.Takentogether,thesetime-speciﬁc modelsvariedovertimeintermsoftrajectoryshapesand modelperformance.Earliertrajectoriesmaystillbeevolving withmoderatemodelperformance,whilelatetrajectories mayhaveimprovedmodelperformanceatthecostofmore medicalrecoursesconsumed.Ourdatasuggestedthat20min afterCPRmaybetheearliestpointintimewithexcellent

modelperformancetopredictdistant,clinicallyimportant outcomes,suchassurvivaltohospitaldischarge.

FutureApplications

ForOHCApatientstransportedtotheEDfor continuousCPR,emergencycliniciansarefacedwiththe problemofbalancingtheprobabilityofafavorable outcomewiththeutilizationofcurrentandfutureresources whenmakingimportantdecisions,suchasterminationof resuscitationorimplementationofinvasiveextracorporeal CPR. 34 Mostoftheseadvancedinterventionsarereserved forpatientsreceivingCPRwithinacertainduration. 34 DespitethefactthatCPRdurationisknowntobeinversely associatedwithfavorableoutcomes, 35 itmaynotbethesole prognosticfactor.QualityCPRmayfacilitatemaintaining patients’ potentialforfavorableoutcomesandlengthenthe timewindowforadvancedinterventionstobeimplemented. Ourpredictionmodelsdemonstratedthattime-speci fi c EtCO2 trajectory,takingintoaccountboththeCPR durationandquality,couldbeasigni fi cantintra-arrest prognosticfactor.Inthefuture,time-speci fi cEtCO2 maybe transmittedinstantaneouslyfromEtCO 2 monitorsto mobiledeviceswiththeassistanceofadvancedinformation andcommunicationtechnology.Thepredictedoutcomes couldbeupdatedinstantaneouslyminutebyminutefor eachindividualpatientandmaynotberestrictedtoa certaintimepointduringCPR,suchas20minor10min,as usedinourstudy.

LIMITATIONS

First,whilewehadinternallyvalidatedtheprediction modelsbyusingthebootstrapmethod,furtherexternal validationinotherdatasetsshouldbeperformed.Second,the analyzedEtCO2 datasetwasderivedfromaprospectively collecteddatabaseofasingleEDwithaspecializedtraining modelforCPR.Furtherstudiesareneededtoinvestigate whetherthesemodelscouldbegeneralizedtootherEDsor prehospitalresuscitation.

CONCLUSION

Time-speciﬁcEtCO2 trajectorywasasigniﬁcantpredictor ofOHCAoutcomes,whichcouldbecombinedwithother baselinevariablesforintra-arrestprognostication.Forthis purpose,the20-minsurvivalmodelachievedthehighest discriminativeperformanceinpredictingsurvivalto hospitaldischarge.

AddressforCorrespondence:Chun-YenHuang,MD,MSc,Far EasternMemorialHospital,DepartmentofEmergencyMedicine,No. 21,Sec.2,NanyaS.Rd.,BanqiaoDist.,NewTaipeiCity220, Taiwan.Email: meureka@gmail.com.Chu-LinTsai,MD,ScD, NationalTaiwanUniversity,CollegeofMedicine,Departmentof EmergencyMedicine,No.7,ZhongshanS.Rd.,ZhongzhengDist., TaipeiCity100,Taiwan.Email: chulintsai@ntu.edu.tw

ConflictsofInterest: Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Chih-HungWangreceivedagrant (111-FTN0003)fromtheFarEasternMemorialHospitalandNational TaiwanUniversityHospitalJointResearchProgram.Chun-Yen Huangreceivedagrant(111-FTN0003)fromtheFarEastern MemorialHospitalandNationalTaiwanUniversityHospitalJoint ResearchProgram.BothFarEasternMemorialHospitaland NationalTaiwanUniversityHospitalhadnoinvolvementindesigning thestudy,collecting,analysingorinterpretingthedata,writingthe manuscript,ordecidingwhethertosubmitthemanuscriptfor publication.Therearenootherconflictsofinterestorsourcesof fundingtodeclare.

REFERENCES

1.BerdowskiJ,BergRA,TijssenJG,etal.Globalincidencesofout-ofhospitalcardiacarrestandsurvivalrates:systematicreviewof67 prospectivestudies. Resuscitation. 2010;81(11):1479–87.

2.PanchalAR,BartosJA,CabanasJG,etal.Part3:adultbasicand advancedlifesupport:2020AmericanHeartAssociationguidelinesfor cardiopulmonaryresuscitationandemergencycardiovascularcare. Circulation. 2020;142(16_suppl_2):S366–468.

3.SoarJ,BöttigerBW,CarliP,etal.EuropeanResuscitationCouncil guidelines2021:adultadvancedlifesupport. Resuscitation. 2021;161:115–51.

4.GarnettAR,OrnatoJP,GonzalezER,etal.End-tidalcarbondioxide monitoringduringcardiopulmonaryresuscitation. JAMA. 1987;257(4):512–5.

5.SandroniC,DeSantisP,D’ArrigoS.Capnographyduringcardiac arrest. Resuscitation. 2018;132:73–7.

6.SoarJ,BergKM,AndersenLW,etal.AdultAdvancedLifeSupport: 2020InternationalConsensusonCardiopulmonaryResuscitationand EmergencyCardiovascularCareSciencewithTreatment Recommendations. Resuscitation. 2020;156:A80–119.

7.BergKM,SoarJ,AndersenLW,etal.Adultadvancedlifesupport:2020 internationalconsensusoncardiopulmonaryresuscitationand emergencycardiovascularcaresciencewithtreatment recommendations. Circulation. 2020;142(16_suppl_1):S92–139.

8.PaivaEF,PaxtonJH,O’NeilBJ.Theuseofend-tidalcarbondioxide (ETCO(2))measurementtoguidemanagementofcardiacarrest:a systematicreview. Resuscitation. 2018;123:1–7.

9.WangCH,LuTC,TayJ,etal.Associationbetweentrajectoriesofendtidalcarbondioxideandreturnofspontaneouscirculationamong emergencydepartmentpatientswithout-of-hospitalcardiacarrest. Resuscitation. 2022;177:28–37.

10.WuCY,LuTC,SuPI,etal.End-tidalcarbondioxide + returnof spontaneouscirculationaftercardiacarrest(RACA)scoretopredict

outcomesafterout-of-hospitalcardiacarrest. WestJEmergMed. 2023;24(3):605–14.

11.WorsterA,BledsoeRD,CleveP,etal.Reassessingthemethodsof medicalrecordreviewstudiesinemergencymedicineresearch. AnnEmergMed. 2005;45(4):448–51.

12.CollinsGS,ReitsmaJB,AltmanDG,etal.Transparentreporting ofamultivariablepredictionmodelforIndividualprognosisor diagnosis(TRIPOD):theTRIPODstatement. AnnEmergMed. 2015;162(1):55–63.

13.ChongKM,WuC-H,LinJ-J,etal.Advancedcardiaclifesupport(ACLS) isallaboutairway-circulation-leadership-support(A-C-L-S):anovel cardiopulmonaryresuscitation(CPR)teamworkmodel. Resuscitation. 2016;106:e11–2.

14.LinCH,LinHY,TsengWP,etal.Resuscitationteamworkduringthe COVID-19pandemicintheemergencydepartment:challengesand solutions. Resuscitation. 2021;160:18–9.

15.SoarJ,MonsieursKG,BallanceJH,etal.EuropeanResuscitation Councilguidelinesforresuscitation2010section9.Principlesof educationinresuscitation. Resuscitation. 2010;81(10):1434–44.

16.BhanjiF,ManciniME,SinzE,etal.Part16:education,implementation, andteams:2010AmericanHeartAssociationguidelinesfor cardiopulmonaryresuscitationandemergencycardiovascularcare. Circulation. 2010;122(18Suppl3):S920–33.

17.PerkinsGD,JacobsIG,NadkarniVM,etal.Cardiacarrestand cardiopulmonaryresuscitationoutcomereports:updateoftheutstein resuscitationregistrytemplatesforout-of-hospitalcardiacarrest:a statementforhealthcareprofessionalsfromataskforceofthe InternationalLiaisonCommitteeonResuscitation(AmericanHeart Association,EuropeanResuscitationCouncil,AustralianandNew ZealandCouncilonResuscitation,HeartandStrokeFoundationof Canada,InterAmericanHeartFoundation,ResuscitationCouncilof SouthernAfrica,ResuscitationCouncilofAsia);andtheAmericanHeart AssociationEmergencyCardiovascularCareCommitteeandthe CouncilonCardiopulmonary,CriticalCare,Perioperativeand Resuscitation. Resuscitation. 2015;96:328–40.

18.GräsnerJ-T,MeybohmP,LeferingR,etal.ROSCaftercardiacarrest theRACAscoretopredictoutcomeafterout-of-hospitalcardiacarrest. EurHeartJ. 2011;32(13):1649–56.

19.MoriM,KrumholzHM,AlloreHG.Usinglatentclassanalysistoidentify hiddenclinicalphenotypes. JAMA. 2020;324(7):700–1.

20.HastieTJandTibshiraniRJ. GeneralizedAdditiveModels.BocaRaton, FL:Chapman&Hall,1990.

21.GueYX,AdatiaK,KanjiR,etal.Out-of-hospitalcardiacarrest:a systematicreviewofcurrentriskscorestopredictsurvival. AmHeartJ. 2021;234:31–41.

22.KupariP,SkrifvarsM,KuismaM.ExternalvalidationoftheROSCafter cardiacarrest(RACA)scoreinaphysicianstaffedemergencymedical servicesystem. ScandJTraumaResuscEmergMed. 2017;25(1):34.

23.LiuN,OngMEH,HoAFW,etal.ValidationoftheROSCaftercardiac arrest(RACA)scoreinPan-Asianout-of-hospitalcardiacarrestpatients. Resuscitation. 2020;149:53–9.

24.CaputoML,BaldiE,SavastanoS,etal.Validationofthereturnof spontaneouscirculationaftercardiacarrest(RACA)scoreintwo differentnationalterritories. Resuscitation. 2019;134:62–8.

25.LevineRL,WayneMA,MillerCC.End-tidalcarbondioxideandoutcome ofout-of-hospitalcardiacarrest. NEnglJMed. 1997;337(5):301–6.

26.Grmec Š andKlemenP.Doestheend-tidalcarbondioxide(EtCO2) concentrationhaveprognosticvalueduringout-of-hospitalcardiac arrest? EurJEmergMed. 2001;8(4):263–9.

27.KolarM,Križmari´cM,KlemenP,etal.Partialpressureofend-tidal carbondioxidesuccessfulpredictscardiopulmonaryresuscitationinthe ﬁeld:aprospectiveobservationalstudy. CritCare. 2008;12(5):1–13.

28.RosmanM,QiY,O’NeillC,etal.TheutilityofendtidalCO2 (EtCO2) monitoringduringin-hospitalcardiacarresttopredictreturnof spontaneouscirculation. Chest. 2018;154(4):68A.

29.WeisfeldtMLandBeckerLB.Resuscitationaftercardiacarrest: a3-phasetime-sensitivemodel. JAMA. 2002;288(23):3035–8.

30.SheakKR,WiebeDJ,LearyM,etal.Quantitativerelationshipbetween end-tidalcarbondioxideandCPRqualityduringbothin-hospitaland out-of-hospitalcardiacarrest. Resuscitation. 2015;89:149–54.

31.MurphyRA,BobrowBJ,SpaiteDW,etal.Associationbetween prehospitalCPRqualityandend-tidalcarbondioxidelevelsinout-ofhospitalcardiacarrest. PrehospEmergCare. 2016;20(3):369–77.

32.Grmec Š,LahK,Tušek-BuncK.Differenceinend-tidalCO2 betweenasphyxiacardiacarrestandventricular ﬁbrillation/pulseless ventriculartachycardiacardiacarrestintheprehospitalsetting. Crit Care. 2003;7(6):R139–44.

33.JavaudinF,HerS,LeBastardQ,etal.Maximumvalueofend-tidal carbondioxideconcentrationsduringresuscitationasanindicatorof returnofspontaneouscirculationinout-of-hospitalcardiacarrest. PrehospEmergCare. 2020;24(4):478–84.

34.YannopoulosD,BartosJ,RaveendranG,etal.Advancedreperfusion strategiesforpatientswithout-of-hospitalcardiacarrestandrefractory ventricular ﬁbrillation(ARREST):aphase2,singlecentre,open-label, randomisedcontrolledtrial. Lancet. 2020;396(10265):1807–16.

35.WangCH,HuangCH,ChangWT,etal.Monitoringofserumlactatelevel duringcardiopulmonaryresuscitationinadultin-hospitalcardiacarrest. CritCare. 2015;19(1):344.

ORIGINAL RESEARCH

PulmonaryEmbolism:ProspectiveStudy

AnthonyJ.Weekes,MD,MSc*

ParkerHambright,MD*

ArianaTrautmann,MD*

ShaneAli,MD*

AngelaPikus,MD*

NicoleWellinsky,BS*

SanjeevShah,MD†

NathanielO’Connell,PhD‡

SectionEditor:RobertEhrman,MD

*AtriumHealth’sCarolinasMedicalCenter,DepartmentofEmergencyMedicine, Charlotte,NorthCarolina

† AtriumHealthSangerHeartandVascularInstitute,Charlotte,NorthCarolina ‡ WakeForestUniversitySchoolofMedicine,DepartmentofBiostatisticsandData Science,Winston-Salem,NorthCarolina

Submissionhistory:SubmittedAugust18,2023;RevisionreceivedFebruary23,2024;AcceptedMarch6,2024

ElectronicallypublishedJune14,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18434

Introduction: Prognosisandmanagementofpatientswithintermediate-riskpulmonaryembolism(PE) ischallenging.Weinvestigatedwhetherstrokevolumemaybeusedtoidentifythesubsetofthis populationatincreasedriskofclinicaldeteriorationorPE-relateddeath.Oursecondaryobjectivewasto compareechocardiographicmeasurementsofpatientswhoreceivedescalatedinterventionsvs anticoagulationmonotherapy.

Methods: Weselectedpatientswithintermediate-riskPE,whohadcomprehensiveechocardiography within18hoursofPEdiagnosisandbeforeanyescalatedinterventions,fromaPEregistrypopulatedby 11emergencydepartments.Echocardiographersmeasuredrightventricle(RV)size,tricuspidannular planesystolicexcursion(TAPSE),andstrokevolume(SV)usingvelocitytimeintegral(VTI)byleft ventricular(LV)outﬂowtractDopplerortwo-dimensionalmethodofdiscs(MOD).Theprimaryoutcome wasacompositeofPE-relateddeath,cardiacarrest,catecholamineadministrationforsustained hypotension,oremergencyrespiratoryinterventionduringtheindexhospitalization.Secondaryoutcome wasescalatedinterventionwithreperfusionorextracorporealmembraneoxygenationtherapy.

Results: Of370intermediate-riskPEpatients(meanage64.0 ± 15.5years,38.1%male),39(10.5%) hadtheprimaryoutcome.These39patientshadlowermeanSVregardlessofmeasurementmethod thanthosewithouttheprimaryoutcome:SVMOD36.2vs49.9milliliters(mL), P < 0.001;SVDoppler 41.7vs57.2mL, P = 0.003;VTI13.6vs17.9centimeters[cm], P = 0.003.Patientswithprimaryoutcome alsohadlowermeanTAPSEthanthosewithout(1.54vs1.81cm, P = 0.003).Multivariablemodels, selectingSVaspredictor,hadareaunderthereceiveroperatingcurveof0.8andBrierscore0.08. ThebestechocardiographicpredictorofourprimaryoutcomewasSVMOD(oddsratio0.72[0.53,0.94], P = 0.02).PatientswhoreceivedescalatedinterventionshadsigniﬁcantlylowerSVorsurrogate measurements,greaterRVdilatation,andlowerRVsystolicfunctionthanpatientswhoreceived anticoagulationmonotherapy.

Conclusion: LowstrokevolumewasapredictorofclinicaldeteriorationandPE-relateddeath.LowSV maybeusedtoidentifyasubsetofintermediate-riskPEpatients,whoarehigherrisk(intermediate-high risk),andforwhomescalatedinterventionsshouldbeconsidered.[WestJEmergMed.2024;25(4) 533–547.]

INTRODUCTION

Pulmonaryembolism(PE)riskstratificationtoolsfocus onpresenceorabsenceofrightventricle(RV)dysfunction andhemodynamicstability.1–5 PatientswithPEwhohave RVdysfunctionandarehemodynamicallystableare classifiedasintermediaterisk(submassive)bytheEuropean SocietyofCardiology(ESC)andCHESTguidelines.1,5–8 However,thereisaspectrumofdiseaseseveritywithinthis classification.Whilemostintermediate-riskpatientsimprove withanticoagulationonly,somemayneedmoreintensive inpatientmonitoringandescalatedinterventionsdueto acuteclinicaldeterioration.Thechallengeistoidentifywhich intermediate-riskpatientsareatthehigherendofthe riskspectrum.

Thosewhoareatgreaterriskforhemodynamicinstability orclinicaldeteriorationareclassifiedas intermediate-high risk (severesubmassive)bytheESCandCHEST.Thissubset isdefinedbytroponinelevationwithESCguidelines; however,thisstrategyhaslowpositivepredictive value.1,5,9,10 WhilesomePEresponseteams(PERT)useESC guidelines,othersuseclinicalsignsofhypoxia,episodic hypotension,orelevatedshockindextoidentify intermediate-highriskPE.Howintermediate-highriskis classifiedmattersbecausephysiciandecisionsregarding escalatedtreatmentsarebasedonthepredictedriskofacute clinicaldeterioration.

ExpertresearchersarguethatqualitativeRVdilatationis insufficienttoidentifypatientssufferingfromalow-flow stateandlikelytoexperienceclinicaldeterioration.8,9,11 Itis physiologicallyplausiblethatinadequateleftventricle(LV) fillingwithreducedstrokevolume(SV)maysignalmore severePEwithintheintermediate-riskgroupthanRV dilatationorelevatedlaboratorymeasurementsof myocardialinjury.12 ReducedSV,ahemodynamic parameter,mayidentifythoseatincreasedriskforacute clinicaldeterioration(definedhereinascardiac arrest,catecholamineadministrationforsustained hypotension,oremergencyrespiratoryinterventionduring theindexhospitalization)orPE-relateddeath.The PEliterature,however,rarelyreportsonSV forriskstratificationorprognosisofacute clinicaldeterioration.6,7,11–14

Ourprimaryobjectivewastocompareprognostic performanceofSVmeasurementsincomparisontoRV measurementstocharacterizetherelationshipbetween echocardiographichemodynamicparameters,includingSV, andacuteclinicaldeteriorationinemergencydepartment (ED)patientsclassiﬁedasintermediate-riskPE.We hypothesizedthatthosewhoexperiencedclinical deteriorationwouldhavelowerSVatpresentationthan thosewhodidnot.Oursecondaryobjectivewastocompare initialechocardiographicmeasurementsofpatientswho receivedescalatedinterventionswiththosewhoreceived anticoagulationmonotherapy.WehypothesizedinitialSV

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Rightventricledysfunctionidenti ﬁ es intermediate-riskpulmonaryembolism(PE) butmaynotpredictincreasedlikelihoodof hemodynamicinstability.

Whatwastheresearchquestion?

Dohemodynamicparameterssuchasstroke volume(SV)predictclinicaldeteriorationin intermediate-riskPE?

Whatwasthemajor ﬁndingofthestudy?

Apredictivemodelforclinicaldeterioration inPEpatientsincludingstrokevolumehad AUC0.81(95%CI0.69,0.92)andBrier score0.08(0.06,0.10).

Howdoesthisimprovepopulationhealth?

Lowstrokevolumemayidentify intermediate-highriskPE,ie,thoseatgreater riskforclinicaldeteriorationanddeath.

measurementswouldbesigniﬁcantlydifferentbetween treatmentgroups.

METHODS

StudyDesignandSettings

Weidentifiedpatientsfromourprospective,observational ClinicalOutcomesinPulmonaryEmbolismResearch Registry(COPERR).TheCOPERRwaspopulatedwith patientsdiagnosedwithintermediate-orhigh-riskPEinanyof ourhealthsystem’s11EDsbetweenJune2018–August2022. AllCOPERRpatientshadconfirmedacutePEwithRVtoLV basaldiameterratio(RV:LV) ≥ 1.0bycomputedtomography (CT)orpoint-of-careechocardiography,orcardiacbiomarker elevation(brainnatriureticpeptide[BNP],troponin,orhigh sensitivitytroponin).Weusedthe2019ESCPEguidelinesto classifyCOPERRpatientsashighriskandintermediate-low riskPE5;however,weusedaninstitution-specificdefinitionfor intermediate-highrisk(whichwasinformedbythe2019ESC guidelines).5 Weclassifiedpatientsasintermediate-highriskif theyhadRVdilatationandoneormoreofthefollowingsigns: episodichypotension(systolicbloodpressure[SBP]90 millimetersofmercury[mmHg] <15minutes);sustained shockindex >1.0;orpulseoximetryreading <92%onroom airwithrespiratorydistress.Fortheregistry,board-certified radiologistsreviewedCTimagesandreportedRVdilatation, andsonographersperformedcomprehensivetransthoracic echocardiography(TTE).

TheAtriumHealthInstitutionalReviewBoardapproved COPERRandplannedanalyses(includingthisstudy)witha waiverofinformedconsent.Clinicianswereblindtostudy designandhypothesisandmanagedpatientswithout guidanceorrecommendations.

Subjects

WeincludedCOPERRpatientsclassifiedasintermediate riskatEDpresentation,whohadTTEwithin18hoursofPE ordersetbeingplacedandbeforeanyescalatedinterventions. AtriumHealthhasamultidisciplinaryPERTequippedwith anintermediate-andhigh-riskPEordersetwithinthe electronichealthrecord(EHR).TheTTEcanbeordered separatelyoraspartofthePEorderset.Mostpatientswith PERTactivationshadTTEpre-orderedaspartofthePE orderset.Weexcludedpatientsifanyofthefollowingcriteria werepresent:1)PEwasincidental findingonimaging;2)PE wasnottheprimarydiagnosiscontributingtopatient’ s clinicalpresentationtotheED;3)PEdiagnosissecured >2 hoursafteradmissionfromtheED;4)non-acutePEwith similar fillingdefects(unchangedorresolving)ifpreviousCT available;5)hemodynamicinstabilityattributabletoPE, includingsustainedhypotension(SBPbelow90mmHg >15 minutes)orunstablecardiacrhythmsorobstructiveshockor cardiacarrest(classificationashighrisk)5;6)TTEwasnot completedorwaswithoutRVorSVmeasurements;and7) escalatedinterventionperformedbeforeTTE.

DataCollection

Dataextractorsweretrainedintheexplanationofall variablesandidentificationofEHRsourcedocuments. Thosewhocompletedsuccessfultrialsofdataextractionon testcaseswerequalifiedtomonitortheEHRforstudydata entryintoResearchElectronicDataCapture(REDCap, hostedatAtriumHealth’sCarolinasMedicalCenter)case reportforms,whichhaddetailed fieldnotestoenhance reliability.15 Extractorswhoretrievedechocardiography measurementswereblindtopatientoutcomes.Aproject managermonitoreddataaccuracy andcompleteness.

Measurements

CardiacBiomarkers

Samplesandmeasurementswereobtainedwhilepatients wereintheED.Weusedani-STATcardiactroponintest cartridge(AbbottLaboratories,AbbottPark,IL),measured innanogramspermilliliter(ng/mL)fortroponinIorhighsensitivitytroponinassays.NormalvaluesfortroponinI were < 0.07ng/mL.Normalvaluesforhigh-sensitivity troponinwere <12forfemalesand <20formales.Weused thei-STATBNPtestcartridge(Abbott)measuredin picograms(pg)/mL.Normalpoint-of-careBNP measurementswere90ng/mL.

TransthoracicEchocardiography

Trainedsonographers(blindtoresearchstudyandpatient outcomes)performedTTEmeasurementsfollowingthe AmericanSocietyofEchocardiographyguidelines16,17 atan echocardiographyfacilityaccreditedbytheIntersocietal CommissionfortheAccreditationofEchocardiography Laboratories.TTEwascompletedandrecordedbeforethe primaryoutcomeoranyescalatedinterventionsoccurred. Measurementsincludedchamberdimensionsandsystolic functionforleftandrightventriclesandleftventricularSV. Digitalimagesandvideoweremappedfrom echocardiographymachinesandstoredinMergeCardio (MerativeLP,AnnArbor,MI),animagingarchiving platform.Thecardiologist-investigator(blindtopatient presentationandoutcomes)reviewedventricularandSV measurementsorperformeddenovotwo-dimensional(2D) measurementsontheimagingplatform.

VentricularChamberSize

Weusedapical4-chamberorRVfocusedapicalviewto measureend-diastolicinternalmeasurementsoftheRVin shortaxis(midandbasallevels)andlongaxis(length).We usedparasternallongaxisviewtomeasureLVbasal diameter.WecalculatedtheRV:LVbasaldiameterratio.

RightVentricleSystolicFunction

Intheapicalview,weusedMmodetomeasuretricuspid annularplanesystolicexcursion(TAPSE)oftheRVfreewall tricuspidannulus.WeusedtissueDopplertomeasurepeak systolicvelocityofthebasalRVfreewallsegmentand continuouswaveDopplertomeasurepeaktricuspid regurgitationvelocityduringsystoleandtoestimateright atrialpressure.Traceorunmeasurableregurgitation velocitieswerecategorizedasadiscreteresponseratherthan consideredmissing.

CardiacOutput

Wecalculatedcardiacoutput(CO)asSVmultipliedby heartrate.(TheSVisoftenusedasasurrogateofCO.18,19) WecalculatedSVfromtheLVby2Dmethodofdiscs (MOD)orpulsedwaveDoppler.19 Inpatientswhohad pulsedwaveDopplertracingsrecorded,wecalculatedSVby usingleftventricularoutﬂowtract(LVOT)diametertakenin theparasternallongaxisandmultiplyingLVOTareaby velocitytimeintegral(VTI)ofLVOTusingtheapical5chamberview.TheVTImaybeusedasasurrogateof SV.20,21 Whenavailable,abiplaneMODwasalsousedfor apical-4andapical-2chamberviewstocalculatedifferences betweenend-diastolicandend-systolicvolume.Whenonly anapical-4chamberviewwasavailable,weusedMOD. Whenbothviewswereavailable,theaverageofapical-4and -2SVmeasurementswasused.

Because2Dmethodsdonotaccountformitralregurgitant ﬂow,wereportedabsenceorpresenceofmitralregurgitation

(MR).Ifpresent,MRwasgradedasmild,moderate,or severe.Bodysurfacearea(BSA)wasavailableforindexing ofmeasurements.

Outcomes

TheprimaryoutcomewasacompositeofPE-related deathorclinicaldeterioration,deﬁnedascardiacarrest, catecholamineadministrationforsustainedhypotension,or emergencyrespiratoryinterventionduringtheindex hospitalization.Thesecondaryoutcomewasuseofoneor moreescalatedinterventions,includingreperfusion interventions(systemicthrombolysis[fullorreduceddose]), catheter-directedinterventions,advancedendovascular interventions,surgicalthrombectomy,andextracorporeal membraneoxygenation[ECMO]).

StatisticalAnalyses

Studysamplewasdeterminedbythenumberofregistry patientseligibleforinclusion.Analysesspeciﬁctoeach objectivefollow.WeusedRsoftware(RProjectfor StatisticalComputing,Vienna,Austria)forallanalyses.

PrimaryObjective

ForTTEvariables,wereportedthenumberof observations,meanswithstandarddeviations,or frequencies.Wecompareddifferencesinmeansbetween primaryoutcomegroupsusingunpaired t -testsfor continuousvariablesandchi-squaretestsforcategorical variables.Wereportedthepercentageofmissing observationsforeachvariableandusedimputationfor multivariableanalyses.Weperformedbivariableand multivariablelogisticregressiontoassessassociationsof echocardiographicmeasurementswiththeprimaryoutcome. ForpatientswithSVmeasuredbybothDopplerandMOD methods,wedeterminedtwo-sided95%confidenceintervals (CI)forthePearsoncorrelationcoefficientbetweenSV measurements.BecauseSVandCOareinherently correlated,includingbothwithinthesamemultivariable modelwouldleadtomulticollinearityandvarianceinflation. Therefore,we fittwoseparatemodelsforeachoutcome,one withDoppler-derivedSVorCOasapredictor,andasecond onewithMOD-derivedSVorCOasapredictor.Eachmodel containedthesameotherpredictors.

We fitmultivariablelogisticregressionmodelsforour primaryoutcome,includingTTEandnon-TTE measurementsindependentlyassociatedwiththeprimary outcomeintheunivariablemodels(P < 0.10).We fita multivariablelogisticregressionmodelforourprimary compositeoutcome.Toselectthebest fittingmodelwhile controllingforkeysourcesofconfoundingandissueswith multicollinearitybetweenclinicalpredictorsofinterest,we usedleastabsoluteshrinkageandselectionoperator (LASSO)regressionwith10-foldcrossvalidationtoselect our finallogisticregressionmodel.TheSVMOD,SVLVOT,

COMOD,andCOLVOTallinducedvarianceinﬂationdue tocollinearitywhenincludedinthesamemodel.From univariablebivariablelogisticmodels,wedetermined optimalthresholdsforpredictingourprimaryoutcomefor eachTTEmetricusingYouden’sJ-statistic.22,23 Wereported performancemetricsofthesethresholdsassensitivity, speciﬁcity,positivepredictivevalue(PPV),negative predictivevalue(NPV),andoddsratios(OR)with95%CIs forpredictingclinicaldeterioration.

Weusedthefulldatasetto fitarandomforest(RF)model. Wegeneratedavariableimportanceplotbasedonmean decreaseinaccuracytoassessimportanceofpredictorsand comparethemwiththesignificanceofunivariablebivariable associationsbasedon t -tests.Wereportedprognostic performanceofLASSOandRFwithAUC,Brierscore, scaledBrierscore,calibrationintercept,slope,andplot. Finally,toaddresspotentialinaccuraciesofpredicted probabilitieswithunbalanceddataortranslationinto clinicalutility,wereportedonnetbenefitbasedondecision curveanalysis.27,28

SecondaryObjective

Wecomparedechocardiographicmeasurementsbetween groupsthatreceivedanticoagulationmonotherapyvs escalatedinterventionswiththeunpaired t -test.

RESULTS

Of370patientswhometinclusioncriteria,363(98.1%) wereseenJuly2020–August2022;fourpatientswerefrom 2018;andthreepatientsfrom2019(Figure).Therewereno signiﬁcantdifferencesindemographicsbetweenoutcome groups(Table1).Patientswithprimaryoutcomehadhigher respiratoryandheartratesatpresentationandlowerSBP andoxygensaturationthanthosewithout.Initialhighsensitivitytroponinelevationwasnotsigniﬁcantlydifferent betweenprimaryoutcomegroups.

Asshownin Figure,39of370patients(10.5%)hadthe primaryoutcome.Of21(5.7%)patientswhodied,only17 (4.6%)PE-relateddeathswerecountedashavingtheprimary outcome.TheSVmeasurementwasbyLVOTDoppler methodin301(81.4%)patientsandbyMODin359(97.0%). In290patients,bothSVmeasurementmethodswereused, withacorrelationcoefﬁcientof0.69(0.63,0.75).TheCOhad correlationcoefﬁcientof0.66(0.59,0.72).Escalated interventionsoccurredin56(15.1%)patients,with39 receivingsystemicthrombolysis,15receivingcatheterdirectedintervention(CDI),tworeceivingECMO,andone receivingsurgicalembolectomy.Onepatienthadboth systemicthrombolysisandCDI.Of15patientsreceiving CDIs,12hadcatheter-directedthrombolysis(10ultrasoundassistedandtwonon-ultrasoundassisted),andfourhad aspirationthrombectomy(datanotshown).

Table2 showsthatbothDoppler-andMOD-derived outputmeasurementswerelowerforthosewiththanwithout

Screened out: 120patients due to limited or no RV measurements within 18 hours

504registry patientswith intermediate-risk PE identified. June2018–August2022

Figure 1: Screening and Patient Flow Diagram

Met inclusion criteria: TTEperformed within 18hours of PE diagnosis, n= 384

14post-exclusions: 14 echocardiography scheduled but images not completedor not available for analysis.

TTE with one or more stroke volumemetrics for analysis, n=370 By left ventricular outflow tract pulsed wave Doppler, n=301 By method of discs, n= 359

Primary Outcome

YES (N= 39) *

All cause death, n = 21

PE related death, n =17 Cardiac arrest, n=22

Respiratory failure, n =23 Vasopressor support, n =28

NO (N= 331)

Secondary Outcome

EscalatedPE intervention

N= 56

Anticoagulation monotherapy

N= 314

Figure. Screeningandpatient ﬂowdiagram. PE,pulmonaryembolism; RV,rightventricle; TTE,transthoracicechocardiography. *Componentsoftheprimarycompositeoutcomearenotmutuallyexclusive.

theprimaryoutcome.Incontrast,forRVsystolicfunction, meanTAPSEwaslower(worse)inthosewiththanwithout theprimaryoutcome.Mostvalueswerelowerthanmean valuesforahealthycohort(Table2 footnote).Therewereno signiﬁcantdifferencesinTTEmetricsforRVsize,withonly RV:LVratioapproachingstatisticalsigniﬁcance.BothPE cohortshadhigherSVmeasurementsbyDopplerthanSVby MOD(withorwithoutindexingbyBSA).MeanSV measurements,irrespectiveofmeasurementapproach,were statisticallyreducedinpatientswhoexperiencedclinical deteriorationvsthosewhodidnot.

Table3 showsresultsfromtheLASSOmodelthatstarted withallSVandCOmeasuresconsidered.Itendedwith selectingonlySVbyMOD,amongotherpatientandclinical characteristicsthatwerealsopredictive.Forimputedvalues, thebestpredictorwasSVbyMODwithOR0.72(CI0.53, 0.94; P = 0.02).AsSVincreased,theprobabilityofprimary outcomedecreased.Recenthospitalizationandmetastatic solidtumorwereotherindependentpredictors.SVDoppler, TAPSE,andRVbasalwidthhadnon-signiﬁcantORs.The SVbyMODwasmorestronglyassociatedwiththeprimary outcomethanSVDoppler.TheORof0.72forSVMOD

Table1. Patientcharacteristicsandclinicalpresentationbyprimaryoutcome.

Patientcharacteristics

Age,years

Mean(SD)66.4(13.5)62.3(16.0)62.7(15.8)0.12

Missing0(0%)1(0.3%)1(0.3%)

Race

African-American16(41.0%)123(37.4%)139(37.6%)0.36 Other3(7.7%)13(4.0%)16(4.3%)

White20(51.3%)193(58.7%)215(58.1%)

Ethnicity

Hispanic2(5.1%)14(4.3%)16(4.3%)0.77 Non-Hispanic37(94.9%)312(94.8%)351(94.9%)

Unknown0(0%)3(0.9%)3(0.8%)

Gender

Female17(43.6%)173(52.6%)192(51.9%)0.31 Male22(56.4%)156(47.4%)178(48.1%)

Lowestsystolicbloodpressurewithin3hoursofpresentation(mmHg)

Mean(SD)97.8(30.7)122(23.8)120(25.7) <

Highestheartratewithin3hoursofpresentation(beatsperminute)

Mean(SD)122(21.1)107(22.1)108(22.5) <

Lowestoxygensaturationonroomairwithin3hoursofpresentation(%)

Mean(SD)86.6(15.5)93.6(5.34)92.8(7.40) <

Highestrespiratoryratewithin3hoursofpresentation(breathsperminute)

Mean(SD)32.5(13.0)25.2(9.17)26.0(9.88) <

Bodysurfacearea,m2

Mean(SD)1.94(0.25)2.08(0.31)2.07(0.31)0.01

Missing4(10.3%)24(7.3%)29(7.8%)

Dementia

No34(87.2%)314(94.9%)348(94.1%)0.06

Yes5(12.8%)16(4.9%)21(5.7%)

Missing0(0%)1(0.3%)1(0.3%)

Chronicobstructivepulmonarydisease

No34(87.2%)288(87.0%)322(87.0%)0.99

Yes5(12.8%)42(12.7%)47(12.7%)

Missing0(0%)1(0.3%)1(0.3%)

Metastaticsolidtumor

No30(76.9%)310(93.6%)340(91.9%)0.001

Yes9(23.1%)20(6.1%)29(7.8%)

Missing0(0%)1(0.3%)1(0.3%)

Anymalignancy

No33(84.6%)285(86.1%)318(85.9%)0.80

Yes6(15.4%)45(13.6%)51(13.8%)

Missing0(0%)1(0.3%)1(0.3%)

(Continuedonnextpage)

Table1. Continued.

Priordiagnosisofpulmonaryembolism

No32(82.1%)248(74.9%)280(75.7%)0.43

Yes7(17.9%)82(24.9%)89(24.1%)

Missing0(0%)1(0.3%)1(0.3%)

Recenthospitalization

No26(66.7%)290(87.6%)316(85.4%)0.001

Yes13(33.3%)40(12.1%)53(14.3%)

Missing0(0%)1(0.3%)1(0.3%)

Currentprescribedanticoagulation

No36(92.3%)295(89.1%)331(89.5%)0.78

Yes3(7.7%)35(10.6%)38(10.3%)

Missing0(0%)1(0.3%)1(0.3%)

Recenttrauma

No39.0(100%)315(95.2%)354(95.7%)0.39

Yes0(0%)15(4.5%)15(4.1%)

Missing0(0%)1(0.3%)1(0.3%)

Familyhistoryofvenousthromboembolism

No39(100%)308(93.1%)347(93.8%)0.24

Yes0(0%)18(5.4%)18(4.9%)

Missing0(0%)5(1.5%)5(1.4%)

Hormonalreplacementtherapy

No38(97.4%)315(95.2%)353(95.4%)1.00

Yes1(2.6%)15(4.5%)16(4.3%)

Missing0(0%)1(0.3%)1(0.3%)

Tobaccouse

Current9(23.1%)65(19.6%)74(20.0%)0.16

Exsmoker(smoked >100cigarettesintheirlifetimebuthas notsmokedinthelast28daysbutlessthan12months) 4(10.3%)11(3.3%)15(4.1%)

Exsmokerfor >12months4(10.3%)56(16.9%)60(16.2%)

Never22(56.4%)197(59.5%)219(59.2%)

Missing0(0%)2(0.6%)2(0.5%)

Severerenaldisease

No35(89.7%)293(88.5%)328(88.6%)1.00 Yes4(10.3%)37(11.2%)41(11.1%)

Missing0(0%)1(0.3%)1(0.3%)

Congestiveheartfailure

No33(84.6%)297(89.7%)330(89.2%)0.27 Yes6(15.4%)33(10%)39(10.5%)

Missing0(0%)1(0.3%)1(0.3%)

Hemi-orparaplegia

No38(97.4%)323(97.6%)361(97.6%)0.60

Yes1(2.6%)7(2.1%)8(2.2%)

Missing0(0%)1(0.3%)1(0.3%)

Table2. Bivariableanalysisofechocardiographicmeasurementscomparedbyprimaryoutcome.*

Echocardiographicmeasurements

InternaldiameterofLVOT(cm)

Primaryoutcome = YES (N = 39)

Primaryoutcome = NO (N = 331)

Overall (N = 370) P-value

Mean(SD)2.1(0.2)2.1(0.2)2.1(0.3)0.63

VelocitytimeintegralatLVOT(cm)

Mean(SD)13.6(8.0)17.9(6.0)17.5(6.3)0.003

StrokevolumeasdeterminedatLVOT(mL)

Mean(SD)41.7(28.0)57.2(27.0)55.7(27.4)0.004 Missing10(25.6%)57(17.3%)69(18.6%)

StrokeVolumeIndexatLVOT(mL/m2)

Mean(SD)21.2(13.4)27.5(12.2)26.9(12.4)0.001

CardiacoutputasdeterminedatLVOT(mL/min)

Mean(SD)3860(2290)4890(2150)4790(2180)0.02 Missing10(25.6%)57(17.3%)69(18.6%)

CardiacoutputindexasdeterminedatLVOT(mL/min/m2)

Mean(SD)1970(1100)2340(953)2300(972)0.05

Strokevolume,byMOD(mL)

Mean(SD)36.2(15.8)49.9(20.1)48.4(20.1) < .001 Missing0(0%)11(3.3%)11(3.0%)

StrokeVolumeindexbyMOD,(mL/m2)

Mean(SD)18.8(8.7)24.0(8.9)23.4(9.0)0.001

Cardiacoutput,byMOD(mL/min)

Mean(SD)3460(1310)4320(1760)4230(1740)0.003

Missing0(0%)11(3.3%)11(3.0%)

CardiacOutputIndexbyMOD(mL/min/m2)

Mean(SD)1760(734)2070(741)2040(746)0.02

Severityofmitralregurgitation,ifpresent

None20(51.3%)170(52%)192(51.9%)0.36

Mild14(35.9%)123(37.2%)137(37.0%)

Moderate1(2.6%)10(3.0%)11(3.0%)

Severe1(2.6%)1(0.3%)2(0.5%)

Missing3(7.7%)25(7.6%)28(7.6%)

LVbasalwidth(cm)

Mean(SD)4.0(0.9)4.2(0.8)4.2(0.8)0.07

Missing0(0%)6(1.8%)6(1.6%)

LVejectionfraction,estimated(%)

Mean(SD)53.9(14.7)54.7(10.9)54.6(11.4)0.66 Missing0(0%)2(0.6%)2(0.5%)

RVbasalwidth(cm)

Mean(SD)4.3(0.9)4.2(0.8)4.3(0.8)0.87 Missing2(5.1%)13(4.0%)15(4.1%)

RV:LVbasalwidthratio

Mean(SD)1.1(0.3)1.1(0.3)1.1(0.3)0.09 Missing2(5.1%)18(5.4%)20(5.4%)

(Continuedonnextpage)

Table2. Continued.

Echocardiographicmeasurements

RVmidwidth(cm)

Primaryoutcome = YES (N = 39)

Primaryoutcome = NO (N = 331) Overall (N = 370) P-value

Mean(SD)3.6(0.9)3.7(2.6)3.7(2.5)0.80 Missing4(10.3%)22(6.6%)26(7.0%)

RVmajorlength(cm)

Mean(SD)7.0(0.9)7.2(3.7)7.2(3.5)0.68 Missing5(12.8%)31(9.4%)36(9.7%)

Peaktricuspidregurgitantjetvelocity(m/s)

Mean(SD)2.9(0.6)2.9(0.7)2.9(0.7)0.15 Missing15(38.5%)92(28.0%)107(28.9%)

TAPSE(cm)

Mean(SD)1.5(0.5)1.8(0.5)1.8(0.5)0.003 Missing8(20.5%)52(15.7%)60(16.2%)

RVannuluspeaksystolicvelocityS'(cm/s)

Mean(SD)10.7(5.2)11.5(4.4)11.4(4.5)0.37 Missing10(25.6%)68(20.5%)78(21.1%)

Initialhigh-sensitivitytroponin(ng/L)

Mean(SD)237(332)175(378)182(374)0.34 Missing2(5.1%)4(1.2%)6(1.6%)

InitialBNPlevel(pg/mL)

Mean(SD)435(661)290(387)304(424)0.05 Missing3(7.7%)14(4.2%)17(4.6%)

*NormalValuesareprovidedforcomparison:TheWorldAllianceofSocietiesofEchocardiographyStudy19 publishednormalvaluesfortwo echocardiographicassessments(DopplerandMOD)forvariablesinthecalculationofcardiacoutputforadultsubjectswithoutdiseases.By Doppler,normalvaluesarevelocitytimeintegral20.2 ± 3.6mm,strokevolume68.7 ± 17.0ml,SVindexedbybodysurfacearea38.7 ± 8.1 ml/m2,cardiacoutput4.58 ± 1.12L/min/m2,andcardiacindex2.6 ± 0.58L/min/m2.Bytwo-dimensionalechocardiography,normalvalues are:SV58.4 ± 15.4ml,SVindexed32.7 ± 6.8ml/m2,cardiacoutput3.88 ± 1.00L/min,andcardiacindex2.18 ± 0.48L/min/m2

TheAmericanSocietyofEchocardiography16 reportsthefollowingvaluesasabnormal:RVbasaldiameter > 4.2cm,TAPSE < 1.6cm,pulse Dopplerpeakvelocity,S’ < 10cm/s.

LVOT,leftventricularoutﬂowtract; MOD,methodofdiscs; LV,leftventricle; RV,rightventricle; TAPSE,tricuspidannularplanarsystolic excursion; BNP,brainnatriureticpeptide.

impliesthatforevery10mLincreaseinSV,therewas28% decreasedoddsoftheprimaryoutcome.Thatis,person AwithSVof60mLhad0.72timestheoddsofthe outcomerelativetopersonBwithanSVof50mL (ie,1.0 – 0.72 = 0.28).

Table4 showsYouden’sindexoftheoptimalcut-off valuesforTTEindicestomaximizesensitivityand specificity.ThemostsignificantpredictorswereSVMOD, VTI,andSVDoppler,withbestpredictiveperformancefor acuteclinicaldeteriorationintermsofbalancebetween sensitivityandspecificity.ForcommonmetricsofRVsize andsystolicfunction,highestAUCwastheTAPSEcut-off.

TheRFmodeldeterminedindependentpredictorsofour primaryoutcomeandgeneratedavariableimportanceplot (SupplementalFigure).TheSVbyMOD,VTI,andCOby

MODwerethehighestrankingTTEpredictorsforthe primaryoutcome.PerformancemetricsforLASSOandRF modelsincludedAUC0.8andBrierscore0.08(Table5). Calibrationanddecision-curveanalysisplotsareincludedin the Appendix.

Table6 showspatientswhoreceivedescalated interventionshadsigniﬁcantlylowerSVorsurrogate measurements,greaterRVdilatation,andlower(worse) RVsystolicfunctionthanpatientswhoreceived anticoagulationmonotherapy.

DISCUSSION

Inourcohortof370intermediate-riskpatientsidentiﬁed intheED,bothearlyTTEmetricsforSVwerestrongly associatedwithacuteclinicaldeterioration.Byboth

Table3. Leastabsoluteshrinkageandselectionoperator(LASSO)regressionresultsusingimputedvalues. Predictors

LVOT,leftventricularoutﬂowtract; MOD,methodofdiscs; RV,rightventricle; TAPSE,tricuspidannularplanarsystolicexcursion.

bivariableandmultivariableanalyses,TTEmetricsforSV indicesandRVsystolicfunctionwerebetterpredictorsofthe primaryoutcomethanRVsizeortroponinlevels.Thetwo methodsofmeasuringSVwerecorrelatedbutnot interchangeable.Echocardiographicparameters(SVby MOD,VTI,CObyMOD,andSVLVOT)wereidentified amongthe20highestrankingpredictorsofallcandidate variablesfortheprimaryoutcome.Intermediate-risk patientssubsequentlytreatedwithescalatedinterventions hadsignificantlylargerbasalRVsize,lowerRVsystolic function(TAPSEandS’wave),andlowerSVparameters (VTI,SVMOD,andSVDoppler)thanthosetreatedwith anticoagulationmonotherapy.Evenwithtradeoffsand limitationsofdeterminingoptimalcut-offvalueson combinedsensitivityandspecificity(Table4),SV,VTI,and COpredictorshadthebestpredictiveability.Optimalcutoffsshownin Table4 maydiscriminatebetweenpatientsat riskofsubsequentdeteriorationvsthoseatlowrisk.High NPVsamongthesemetricswouldsuggestlow-riskpatients werecorrectlyidentified.

OurcohorthadlowermeanSVthannormalvalues forhealthyadults.TheWorldAllianceofSocietiesof EchocardiographyidentiﬁednormalmeanSVin adultsasVTI20.2 ± 3.6centimeters(cm),SVDoppler 68.7 ± 17.0mL,andSVMOD58.4 ± 15.4mL.19 Means forourcohortwere:VTI17.5 ± 6.3cm,SVDoppler 55.7 ± 27.4mL,andSVMOD48.4 ± 20.1mL.MeanSVwas evenlowerforourpatientswhohadprimaryoutcome (VTI13.6,SVDoppler41.7,SVMOD36.2mL).

Thestrengthofthisstudyisidentiﬁcationofapossible predictorwithaplausiblephysiologicalmechanismforacute clinicaldeteriorationthathasbeenminimallyreportedinthe PEmedicalliterature.AbruptarterialocclusiononPEmay leadtoincreasedRVafterload.WorseningPE-provoked

physiologyinvolveskeystepsofdecreasedRVsystolic function,reducedRVoutput,LVunderfilling,reducedLV CO,decreasedbloodpressure,andreducedRVperfusion andoxygendeliverybeforeobstructiveshockanddeath.5,29 AlthoughitisprematuretodeterminecausalityofsingleSV metrics,reducedLVCOanditssurrogates(SVandVTI) representanadvancedstageonthepathwaytoward hemodynamicinstabilityordeathfromacutePE.5,29 InpatientswithRVdilatation,lowSVmightsuggest subclinicalshock,inadequateLV fillingandoutput, andsuggestthispatientbetreatedas intermediate-high risk .Thus,SVmayidentifyasubgroupofintermediateriskpatientswithamorefavorableriskprofilefor 11escalatedinterventions.30

Althoughbivariableandmultivariableanalysesshowed meanvitalsignswereassociatedwiththeoutcome-positive group(eg,lowestSBP,highestheartrate,andhighest respiratoryrate),themeanvaluesthemselvesdidnotleadto reassignmentfromintermediaterisktohighrisk;theymerely disqualifiedpatientsfrombeingconsideredlowriskbyPE severityindex(PESI)/simplifiedPESI(sPESI).31,32 At presentation,ourpatientswerewithoutcardiacarrest, obstructiveshock,orpersistenthypotensionandthuswere notclassifiedashighriskbyESCcriteriadespitehaving higherheartratesandlowerSBP(<100mmHgbut >90mm Hg).5 InnormotensivePEpatients,webelievelowerSV measurementsprovidemoreinformationaboutsubclinical orimpendingshockinmoreseverecasesthanRV dilatationalone.

ExistingPEstudiesthatreportSVusevarioustechniques, outcomes,andtimepoints.FewreportSVbeingpredictiveof clinicaldeteriorationwhenintermediateriskisdeﬁnedby presenceofRVabnormalities.SomestudiedCOsurrogates usingRVoutﬂowtractorLVCO,orcombinedRVpressure

Table4. Prognosticperformanceofoptimalechocardiographycut-offpointsfortheprimaryoutcome.

cityPPVNPVAUCOddsratio

VariableCut-offpoint P -valueSensitivitySpeci

InternaldiameterofLVOT2.00.6384(68,100)23(17,29)10(5,14)94(87,100)0.54(0.4,0.7)1.6(0.5,5.7)

RVmajorlength(cm)6.30.6985(73,97)26(21,31)12(8,16)94(89,99)0.52(0.4,0.6)2.1(0.8,5.5)

RVbasalwidth(cm)4.90.8824(1,38)85(81,89)16(6,26)91(87,94)0.51(0.4,0.6)1.8(0.8,4.2)

RVmidwidth(cm)4.50.8043(26,59)65(60,70)12(6,18)91(87,95)0.49(0.4,0.6)1.4(0.7,2.9)

LVbasalwidth(cm)5.40.0751(36,67)74(69,78)19(12,27)93(89,96)0.63(0.5,0.7)3.0(1.5,5.8)

RV:LVbasalwidthratio1.00.0865(49,80)55(50,61)15(9,20)93(89,97)0.58(0.5,0.7)2.3(1.1,4.7)

3.20.6367(48,86)45(38,51)11(6,16)93(88,98)0.53(0.4,0.7)1.6(0.7,3.9)

Peaktricuspidregurgitantjet velocity(m/s)

LVejectionfraction,estimated(%)55.00.6621(8,33)87(84,91)16(6,26)90(87,93)0.48(0.4,0.6)1.8(0.8,4.1)

TAPSE(cm)1.80.0081(67,95)47(41,53)15(9,20)96(92,99)0.67(0.6,0.8)3.7(1.5,9.4)

16.100.3534(17,52)88(84,92)24(11,38)92(89,96)0.59(0.5,0.7)3.9(1.7,9.2)

RVannuluspeaksystolicvelocity S ’ (cm/s)

Strokevolume,byMOD(mL)54.30.0069(55,84)66(61,71)20(13,27)95(92,98)0.72(0.6,0.8)4.3(2.1,8.9)

27.20.0257(36,77)75(7,80)14(7,22)96(93,98)0.65(0.5,0.8)3.9(1.6,9.2)

StrokevolumeindexedbyBSA,by MOD(mL/m 2 )

Cardiacoutput,byMOD(mL/min)5,9160.0036(21,51)86(83,90)25(13,36)92(89,95)0.64(0.6,0.7)3.6(1.7,7.4)

2,820.70.1939(19,59)86(82,90)17(7,28)95(92,98)0.58(0.4,0.7)4.0(1.6,9.7)

CardiacoutputindexedbyMOD, mL/min/m 2

VelocitytimeintegralatLVOT,cm19.00.0076(58,94)67(60,74)21(12,30)96(93,99)0.72(0.6,0.8)6.7(2.3,18.8)

13.10.2833(7,60)90(86,95)19(2,36)95(92,98)0.60(0.4,0.8)4.6(1.2,16.7)

73.00.0072(56,89)67(61,73)19(12,26)96(93,99)0.70(0.6,0.8)5.3(2.3,12.5)

37.40.0647(25,70)86(82,90)19(8,30)96(94,98)0.64(0.5,0.8)5.6(2.1,14.6)

4,2840.0279(65,94)47(41,53)14(9,19)96(92,99)0.66(0.6,0.8)3.5(1.4,8.8)

Velocitytimeintegral,indexedby BSA,cm/m 2

Strokevolumeasdeterminedat LVOT(mL)

Strokevolumeindexed,atLVOT, ml/m 2

Cardiacoutputasdeterminedat LVOT(mL/min)

CardiacoutputindexedatLVOT (mL/min/m 2 )

3,0220.2347(25,70)81(76,85)14(6,23)96(93,98)0.59(0.4,0.8)3.78(1.5,9.8) PPV ,positivepredictivevalue; NPV ,negativepredictivevalue; AUC ,areaunderthecurve; LV ,leftventricle; RV ,rightventricle; MOD ,methodofdiscs; LVOT ,leftventricular out ﬂ owtract; TAPSE ,tricuspidannularplanarsystolicexcursion.

Table5. Performanceandcalibrationofpredictionmodels.* ModelDiscriminationCalibration

Sensitivityvs1-speciﬁcityplot AUC(95%CI) BrierscoreScaledBrierCalibrationinterceptCalibrationslope

Logisticmodel**0.81(0.69,0.92)0.08(0.06,0.10)0.17(0,0.36)0.02( 0.54,0.51)0.83(0.37,1.59)

Randomforest† 0.79(0.71,0.85)0.080.15 0.08( 0.44,0.27)1.12(0.73,1.51)

*Usingascaleof0to1,indicatorsofbetterperformancemetricsare:AUC(closerto1),Brierscore(lower),scaledBrier(closertozero), calibrationintercept(closertozero),calibrationslope(closerto1).26

**Duetoissuesofcollinearity,LASSOregressionwasforvariableselectionbasedon10-foldcrossvalidationandselectingvariablesbased onthelambdaminimum.FortheLASSOselectedvariables,weusedMonteCarlocrossvalidationacross500iterationswitha70/30split betweentrainingandtestdatato ﬁtrepeatedlogisticmodelsfortheprimaryoutcome.Toassessdiscrimination,performance,andcalibration, wereportedtheaveragesacrossiterationsand95%coverageintervals(ie,the2.5thand97.5thquantilefromthe500iterations).

†Forcomparisontotherandomforest(RF) ﬁttedmodel,weestimatedthesamemetricsbasedonout-of-bagsamplesfromtheRF ﬁtted model,andcalibrationplotbasedonout-of-bagpredictedprobabilityestimates.

AUC,areaunderthereceiveroperatingcurve; CI,conﬁdenceinterval.

assessmentswithLVSVassessments.18,20,21,33,34 For example,Kamranetalstudied343PEpatientsevaluatedby aPERT,whohadpulmonaryarterysystolicpressure(PASP) andLVoutﬂowtractSVmeasurements.34 APASP/SVratio ≥1.0mmHg/mLwasassociatedwithanincreasedrisk oftheirprimaryoutcome(death,cardiacarrest,and escalatedinterventions).

WeandotherresearchersarguethatRVdilatationis insufficienttodistinguishwhichintermediate-riskPEpatient issufferingfromalow-flowstateandlikelytoexperience clinicaldeterioration.8,9,11 Whileameta-analysisconcluded RVparameterswereassociatedwithpoorclinicaloutcomes, theauthorscautionedofmethodologicalissueswithlowqualityevidenceformostincludedstudies.12 Also,RV dysfunctiondefinitionsvary,andTTEmeasurement thresholdsarenotcommonlyincorporatedintodecisionmakingforintermediate-riskPEpatients.8,12 Inthisstudy, SVhadgreaterprognosticvaluethanRVsizeortroponinin distinguishingthetransitiontohemodynamicor clinicalinstability.

Aretrospectivestudyofintermediate-riskPEpatientsby Prosperi-PortaetalreportedsuperiorperformanceofSV indexoverRVmeasurementsforanticipatingPE-related adverseevents(similartoourprimaryoutcome).18 Unlike ourstudy,theyincludedpatientswithoutRVabnormalities becausetheydeﬁnedintermediateriskassPESI >zero.Their cohorthadloweracuityoverallthanours.Incontrast,our deﬁnitionofintermediateriskincludedabnormalRVbyCT orelevatedcardiacbiomarkers.Givenourcohorthadhigher severity,ourchallengewastoidentifyuniquepredictors amongpatientswithPE-associatedcardiacdysfunction.Our outcomeeventrate(10.5%)wasmorethantwicethat reportedbyProsperi-Portaetal.

YuriditskyetalusedVTImeasuredattheLVOTasanSV surrogateanddeﬁnedlowVTIas <15cm.20 Patientswho diedorhadcardiacarresthadlowermeanVTIthanpatients

whodidnot(13.4[3.9]and18.3[5.0]cm,respectively). Patientswhoexperiencedshockorneededreperfusion hadlowermeanVTIthanthosewhodidnot(12.8[3.2] and18.6[4.8]cm,respectively).Babesetalstudied normotensivepatientswithPEandRV:LVof ≥1and showedVTI <15cmhadPPVandNPVof75%and 95%,respectively,forclinicaldeterioration.35 Wehad similar ﬁndings.

Inourstudy,patientswiththeprimaryoutcomehadlower meanVTIthanthosewhodidnot(13.6[8.0]and17.9[6.0] cm,respectively).Patientswhoreceivedescalated interventionshadlowermeanVTIthanthosewhodidnot (13.96[7.4]and17.9[6.0]cm,respectively).Inourstudy, intermediate-riskpatientswhoreceivedescalated interventionshadlowerVTI,SV,andRVsystolicfunction andlargerRVchambersthanadultswithoutdisease.16,19,36 Patientswhoconcernedcliniciansenoughtoreceive escalatedinterventionshadsigniﬁcantlylowerSVand VTI,greaterRVdilation,andlower(worse)RVsystolic functionthanpatientstreatedwithanticoagulation monotherapy.Webelievethesedifferencesidentifythe subgroupofpatientswithcurrentorimpending subclinicalshock.

Theclinicalrelevanceofourstudy ﬁndingsisthatSV measurementsmaybeusedto1)identifyasubgroupof intermediate-riskpatientsatincreasedriskforclinical deterioration,and2)determinecandidacyforescalated interventions.TheSVcanbeeasilymeasured,incorporated intoclinicalpractice,andusedtoinformprompttreatment withescalatedinterventionsforintermediate-highriskPE patientsintheED.Ultrasounduseisintegraltotrainingand practiceofemergencymedicine(EM)andisarequired skillsetofphysicianscertiﬁedbytheAmericanBoardof EmergencyMedicine.Thenearfutureinvolvesmore emergencycliniciansacquiringandusingclinicallyindicated ultrasound.37 Inaddition,automatedVTI,SV,andCO

Table6. Bivariableanalysisofechocardiographicmeasurementscomparedbytreatmentgroup.* Echocardiographicmeasurements

Immediateor delayed escalatedPE interventions (N = 56)

Anticoagulation monotherapy watchandwait (N = 314)

VelocitytimeintegralLVOTindexedbyBSA,cm/m2

StrokevolumeasdeterminedatLVOT(mL)

StrokevolumeasdeterminedatLVOTindexed byBSA,mL/m2

Strokevolume,byMOD(mL)

Strokevolume,byMODindexedbyBSA,mL/m2

RVannuluspeaksystolicvelocityS’ (cm/s)

*Normalvaluesareprovidedforcomparison:TheWorldAllianceofSocietiesofEchocardiographyStudy19 publishednormalvaluesfortwo echocardiographicassessments(DopplerandMOD)forvariablesinthecalculationofcardiacoutputforadultsubjectswithoutdiseases.By Doppler,normalvaluesarevelocitytimeintegral20.2 ± 3.6mm,strokevolume68.7 ± 17.0ml,SVindexedbybodysurfacearea38.7 ± 8.1 ml/m2,cardiacoutput4.58 ± 1.12)L/min/m2 andcardiacindex2.6 ± 0.58L/min/m2.Bytwo-dimensionalechocardiography,normalvalues are:SV58.4 ± 15.4ml,SVindexed32.7 ± 6.8ml/m2,cardiacoutput3.88 ± 1.00L/minandcardiacindex2.18 ± 0.48L/min/m2

TheAmericanSocietyofEchocardiography16 reportsthefollowingvaluesasabnormal:RVbasaldiameter >4.2cm,TAPSE <1.6cm,pulse Dopplerpeakvelocity,S’ <10cm/s.

PE,pulmonaryembolism; BSA,bodysurfacearea; LVOT,leftventricularoutﬂowtract; MOD,methodofdiscs; LV,leftventricle; RV,right ventricle; TAPSE,tricuspidannularplanarsystolicexcursion.

measurementsareemerginginpoint-of-carecardiac ultrasoundapplicationsbyvendorsandbecomingavailable toclinicianswithbasic/intermediateadvancedcardiac ultrasoundskills.38

GiventheknowledgegapinRVfailureresearch,this studysupportsfurtherinvestigationintotheimpactofSVon clinicaloutcomesanddecision-making.11,30 Futurestudies maybedesignedtoincludeSVasapredictororinclude

changesinSVasanefﬁcacyoutcomeofPEinterventions. Suchreportsmayprovideevidencetosupportorrefutethe useofSVmetricstoindicatecandidacyforescalated interventionsorinformdecision-makinginEDs,including theneedtoprovideintensivecareortransfertoahealthcare facilitywithaPERT.TheendresultmaybeinclusionofSV inriskstratiﬁcationtoolsusedbyPERTs.

LIMITATIONS

First,wedidnotreportonaorticinsufficiencyasa confounderofLVOTVTIandSVDopplermeasurements. TheSVDopplerassessmentswillbelimitedbyoutflowtract obstructionandmeasurementsaffectedbyconditionssuchas hypertrophiccardiomyopathyandhypovolemia.Accuracy ofSVassessmentmaybeaffectedbydysrhythmiasand underestimationofforward flowbyaorticandmitral valvularinsufficiency.Second,treatmentteamswerenot blindedtoTTEresults.However,mostwereagnostictothe hypothesizedclinicalsignificanceofthemeasurements.Itis unlikelytreatingphysiciansincorporatemetricsonRVsize, systolicfunction,pressure,andSVintheirclinicaldecisionmaking.TherearenoestablishedthresholdsforTTEmetrics orrecommendationstotriggerearlyuseofescalated interventions.Third,wedidnotperforminter-rater reliabilitymeasures.Finally,althoughdiscriminationand calibrationmetricsshowSVasapredictorofclinical deterioration,therewasnoexternalvalidationtofurther addressusefulnessandimpact.

CONCLUSION

Echocardiographichemodynamicparameterswere amongthebestpredictorsofclinicaldeterioration.Low strokevolumeprecededandpredictedclinicaldeterioration. LowerSVwasfoundinpatientstreatedwithescalated interventionthaninthosewithout.Werecommendfurther inquiryintoincorporatingSVintopulmonaryembolismrisk stratiﬁcation,prognosis,anddecisionsonpatientdisposition andclinicalmanagement.

AddressforCorrespondence:AnthonyJ.WeekesMD,MSc,1000 BlytheBlvd.,MedicalEducationBuilding,3rdFloor,Charlotte,NC 28203.Email: anthony.weekes@atriumhealth.org

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

REFERENCES

1.KearonC,AklEA,OrnelasJ,etal.AntithrombotictherapyforVTE disease:CHESTguidelineandexpertpanelreport. Chest. 2016;149(2):315–52.

2.DesaiH,NattB,BimeC,etal.Pulmonaryembolismwithrightventricular dysfunction:Whoshouldreceivethrombolyticagents? AmJMed. 2017;130(1):93.e29–93.e32.

3.OrtelTL,NeumannI,AgenoW,etal.AmericanSocietyofHematology 2020guidelinesformanagementofvenousthromboembolism: treatmentofdeepveinthrombosisandpulmonaryembolism. BloodAdv. 2020;4(19):4693–738.

4.ChenYL,WrightC,PietropaoliAP,etal.Rightventriculardysfunctionis superiorandsufﬁcientforriskstratiﬁcationbyapulmonaryembolism responseteam. JThrombThrombolysis. 2020;49(1):34–41.

5.KonstantinidesSV,MeyerG,BecattiniC,etal.2019ESCguidelinesfor thediagnosisandmanagementofacutepulmonaryembolism developedincollaborationwiththeEuropeanRespiratorySociety (ERS). EurHeartJ. 2020;41(4):543–603.

6.ChoJH,KuttiSridharanG,KimSH,etal.Rightventriculardysfunction asanechocardiographicprognosticfactorinhemodynamically stablepatientswithacutepulmonaryembolism:ameta-analysis. BMCCardiovascDisord. 2014;14:64.

7.CoutanceG,CauderlierE,EhtishamJ,etal.Theprognosticvalueof markersofrightventriculardysfunctioninpulmonaryembolism:ametaanalysis. CritCare. 2011;15(2):R103.

8.HuangSJ,NalosM,SmithL,etal.Theuseofechocardiographicindices indeﬁningandassessingrightventricularsystolicfunctionincriticalcare research. IntensiveCareMed. 2018;44(6):868–83.

9.LeidiA,BexS,RighiniM,etal.Riskstratiﬁcationinpatientswithacute pulmonaryembolism:currentevidenceandperspectives. JClinMed Res. 2022;11(9):2533.

10.StevensSM,WollerSC,BaumannKreuzigerL,etal.Executive summary:antithrombotictherapyforVTEdisease:Second updateoftheCHESTguidelineandexpertpanelreport. Chest. 2021;160(6):2247–59.

11.LahmT,DouglasIS,ArcherSL,etal.Assessmentofrightventricular functionintheresearchsetting:knowledgegapsandpathwaysforward. AnofﬁcialAmericanThoracicSocietyresearchstatement. AmJRespir CritCareMed. 2018;198(4):e15–43.

12.Prosperi-PortaG,RonksleyP,KiamaneshO,etal.Prognosticvalueof echocardiography-derivedrightventriculardysfunctionin haemodynamicallystablepulmonaryembolism:asystematicreview andmeta-analysis. EurRespirRev. 2022;31(166):220120.

13.SanchezO,TrinquartL,ColombetI,etal.Prognosticvalueofright ventriculardysfunctioninpatientswithhaemodynamically stablepulmonaryembolism:asystematicreview. EurHeartJ. 2008;29(12):1569–77.

14.KahnSRanddeWitK.Pulmonaryembolism. NEnglJMed. 2022;387(1):45–57.

15.HarrisPA,TaylorR,ThielkeR,etal.Researchelectronicdatacapture (REDCap)–Ametadata-drivenmethodologyandworkﬂowprocessfor

providingtranslationalresearchinformaticssupport. JBiomedInform. 2009;42(2):377–81.

16.RudskiLG,LaiWW,AﬁlaloJ,etal.Guidelinesfortheechocardiographic assessmentoftherightheartinadults:areportfromtheAmerican SocietyofEchocardiographyendorsedbytheEuropeanAssociationof Echocardiography,aregisteredbranchoftheEuropeanSocietyof Cardiology,andtheCanadianSocietyofEchocardiography. JAmSoc Echocardiogr. 2010;23(7):685–713;quiz786–8.

17.LangRM,BadanoLP,Mor-AviV,etal.Recommendationsforcardiac chamberquantiﬁcationbyechocardiographyinadults:anupdatefrom theAmericanSocietyofEchocardiographyandtheEuropean AssociationofCardiovascularImaging. EurHeartJCardiovasc Imaging. 2015;16(3):233–70.

18.Prosperi-PortaG,SolversonK,FineN,etal.Echocardiography-derived strokevolumeindexisassociatedwithadversein-hospitaloutcomesin intermediate-riskacutepulmonaryembolism:aretrospectivecohort study. Chest. 2020;158(3):1132–42.

19.PatelHN,MiyoshiT,AddetiaK,etal.Normalvaluesofcardiacoutput andstrokevolumeaccordingtomeasurementtechnique,age,sex,and ethnicity:resultsoftheWorldAllianceofSocietiesofEchocardiography Study. JAmSocEchocardiogr. 2021;34(10):1077–85.

20.YuriditskyE,MitchellOJ,SibleyRA,etal.Lowleftventricularoutﬂow tractvelocitytimeintegralisassociatedwithpooroutcomesinacute pulmonaryembolism. VascMed. 2020;25(2):133–40.

21.BrailovskyY,LakhterV,WeinbergI,etal.Rightventricularoutﬂow Dopplerpredictslowcardiacindexinintermediateriskpulmonary embolism. ClinApplThrombHemost. 2019;25:1076029619886062.

22.FlussR,FaraggiD,ReiserB.EstimationoftheYoudenindexandits associatedcutoffpoint. BiomJ. 2005;47(4):458–72.

23.YoudenWJ.Indexforratingdiagnostictests. Cancer. 1950;3(1):32–5.

24.SteyerbergEW,VickersAJ,CookNR,etal.Assessingtheperformance ofpredictionmodels:aframeworkfortraditionalandnovelmeasures. Epidemiology. 2010;21(1):128–38.

25.VickersAJElkinEB.Decisioncurveanalysis:anovelmethod forevaluatingpredictionmodels. MedDecisMaking. 2006;26(6):565–74.

26.HuangC,LiS-X,CaraballoC,etal.Performancemetricsforthe comparativeanalysisofclinicalriskpredictionmodels employingmachinelearning. CircCardiovascQualOutcomes. 2021;14(10):e007526.

27.WoodKE.Majorpulmonaryembolism:reviewofapathophysiologic approachtothegoldenhourofhemodynamicallysigniﬁcantpulmonary embolism. Chest. 2002;121(3):877–905.

28.ZuinM,BecattiniC,PiazzaG.Earlypredictorsofclinicaldeteriorationin intermediate-high-riskpulmonaryembolism:clinicalneeds,research imperatives,andpathwaysforward. EurHeartJAcuteCardiovascCare. 2024;13(3):297–303.

29.JimenezD,AujeskyD,MooresL,etal.SimpliﬁcationofthePulmonary EmbolismSeverityIndexforprognosticationinpatientswith acutesymptomaticpulmonaryembolism. ArchInternMed. 2010;170(15):1383–9.

30.AujeskyD,PerrierA,RoyPM,etal.Validationofaclinicalprognostic modeltoidentifylow-riskpatientswithpulmonaryembolism. JIntern Med. 2007;261(6):597–604.

31.FalsettiL,MarraAM,ZacconeV,etal.Echocardiographicpredictorsof mortalityinintermediate-riskpulmonaryembolism. InternEmergMed. 2022;17(5):1287–99.

32.KamranH,HaririEH,IskandarJ-P,etal.Simultaneouspulmonaryartery pressureandleftventriclestrokevolumeassessmentpredicts adverseeventsinpatientswithpulmonaryembolism. JAmHeartAssoc. 2021;10(18):e019849.

33.BabesEE,StoicescuM,BungauSG,etal.Leftventricleoutﬂowtract velocity-timeindexandrightventricletoleftventricleratioaspredictors forinhospitaloutcomeinintermediate-riskpulmonaryembolism. Diagnostics. 2022;12(5):1226.

34.AddetiaK,MiyoshiT,CitroR,etal.Two-dimensionalechocardiographic rightventricularsizeandsystolicfunctionmeasurementsstratiﬁedby sex,age,andethnicity:resultsoftheWorldAllianceof SocietiesofEchocardiographyStudy. JAmSocEchocardiogr. 2021;34(11):1148–57.

35.AdhikariS,LeoM,LiuR,etal.The2023corecontentofadvanced emergencymedicineultrasonography. JAmCollEmergPhysicians Open. 2023;4(4):e13015.

36.O’DonnellC,SanchezPA,CelestinB,etal.Theechocardiographic evaluationoftherightheart:currentandfutureadvances. CurrCardiol Rep. 2023;25(12):1883–96.

37.VickersAJ,vanCalsterB,SteyerbergEW.Asimple,step-by-step guidetointerpretingdecisioncurveanalysis. DiagnPrognRes. 2019;3:18.

ORIGINAL RESEARCH

StrokeCenter:OperationsforMechanicalThrombectomy

DuringthePandemic

QuincyK.Tran,MD,PhD*†‡

RobinsonOkolo,BS‡

WilliamGum,BS§

ManalFaisal,BS‡

VainaviGambhir‡

AditiSingh,BS‡

ZoeGasparotti,BSN§

ChadSchrier,MSN,RN,SCRN¶

GauravJindal,MD¶#

WilliamTeeter,MD*†

JessicaDowning,MD‡§

DanielJ.Haase,MD*†

SectionEditor:JosephR.Shiber,MD

*UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, Baltimore,Maryland

† UniversityofMarylandSchoolofMedicine,RAdamsCowleyShockTrauma Center,PrograminTrauma,Baltimore,Maryland

‡ UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, ResearchAssociatePrograminEmergency&CriticalCare,Baltimore,Maryland

§ UniversityofMarylandMedicalCenter,CriticalCareResuscitationUnit, Baltimore,Maryland

∥ UniversityofMaryland,SchoolofMedicine,Baltimore,Maryland

¶ UniversityofMarylandMedicalCenter,DepartmentofNeurology,Baltimore,Maryland

# UniversityofMarylandSchoolofMedicine,DepartmentofNeuroradiology, Baltimore,Maryland

Submissionhistory:SubmittedMay31,2023;RevisionreceivedMarch7,2024;AcceptedMarch21,2024

ElectronicallypublishedJune20,2024

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

DOI: 10.5811/westjem.18335

Introduction: Standardofcareforpatientswithacuteischemicstrokefromlargevesselocclusion(AISLVO)includespromptevaluationforurgentmechanicalthrombectomy(MT)atacomprehensivestroke center(CSC).Duringthestartofthecoronavirus2019pandemic(COVID-19),therewerereportsabout disruptiontoemergencydepartment(ED)operationsanddelaysinmanagementofpatientswithAIS-LVO. InthisstudyweinvestigatetheoutcomeandoperationsforpatientswhoweretransferredfromdifferentEDs toanacademicCSC’scriticalcareresuscitationunit(CCRU),whichspecializesinexpeditioustransferof time-sensitivedisease.

Methods: Thiswasapre-postretrospectivestudyusingprospectivelycollectedclinicaldatafromourCSC’s strokeregistry.AdultpatientswhoweretransferredfromanyEDtotheCCRUandunderwentMTwereeligible. Wecomparedtimeintervalsinthepre-pandemic(PP)periodbetweenJanuary2018– February2020,suchas EDin-outandCCRUarrival-angiography,tothoseduringthepandemic(DP)betweenMarch2020–May31, 2021.Weusedclassiﬁcationandregressiontree(CART)analysistoidentifywhichtimeintervals,besides clinicalfactors,wereassociatedwithgoodneurologicaloutcome(90-daymodiﬁedRankinscale0–2).

Results: Weanalyzed203patients:135(66.5%)inthePPgroupand68(33.5%)intheDPgroup.Timefrom EDtriagetocomputedtomography(difference7minutes,95%conﬁdenceinterval[CI] 12to 1, P < 0.01)fortheDPgroupwasstatisticallylonger,butEDin-outwassimilarforbothgroups.Timefrom CCRUarrivaltoangiography(difference9minutes,95%CI4–13, P < 0.01)fortheDPgroupwasshorter. Forty-ninepercentoftheDPgroupachievedmRS ≤ 2vs32%forthePPgroup(difference 17%,95%CI 0.32to 0.03, P < 0.01).TheCARTidentiﬁedinitialNationalInstitutesofHealthStrokeScale,age,EDinand-outtime,andCCRUarrival-to-angiographytimeasimportantpredictorsofgoodoutcome.

Conclusion: Overall,thecareprocessinEDsandatthissingleCSCforpatientsrequiringMTwerenot heavilyaffectedbythepandemic,ascertaintimemetricsduringthepandemicwerestatisticallyshorterthan pre-pandemicintervals.TimeintervalssuchasEDin-and-outandCCRUarrival-to-angiographywere importantfactorsinachievinggoodneurologicoutcomes.Furtherstudyisnecessarytoconﬁrmour observationandimproveoperationalefﬁciencyinthefuture.[WestJEmergMed.2024;25(4)548–556.]

INTRODUCTION

Priorresearchhasshownthatpatientswhosustainacute ischemicstrokefromlargevesselocclusion(AIS-LVO)face highratesofmortalityandmorbidity1 iftheydonotreceive timelyreperfusiontherapy.Multiplestudieshave demonstratedthatmechanicalthrombectomy(MT)can improveneurologicoutcomesforpatientswithAIS-LVO,2–4 andsince2015MThasbecomethestandardofcare. ThroughouttheUS,however,thetechnologyandexpertise requiredtoperformMTareonlyavailableatapproximately 216comprehensivestrokecenters(CSC),5 whichalso managethesecriticallyillpatientsinaspecialized neurocriticalcareunit(NCCU).Therefore,patientswith AIS-LVOwhoinitiallypresenttoahospitalwithoutMT capabilityrequiretransfertoaCSC.Giventhewidely acceptedassociationoftimetoreperfusionwithneurologic outcomes(theadage “timeisbrain” verymuchapplies), itisessentialthatbothinterhospitaltransferandtransfer totheinterventionalsuitefollowingarrivalattheCSC areexpeditious.6

TheUniversityofMarylandMedicalCenter(UMMC)in Baltimore,MD,isaCSCofferingMTtopatientswithAISLVOthroughoutthestate.ToincreaseaccesstoMTand avoidunnecessarydelayoftransferduetobedunavailability attheNCCU,patientswithAIS-LVOaretransferreddirectly totheUMMCCriticalCareResuscitationUnit(CCRU),a six-bedresuscitationunitcreatedtoexpeditetransferof patientswithcriticalillnessortime-sensitivediseasessuchas AIS-LVO.7,8 Wehavepreviouslydemonstratedthatthe CCRUisabletodirectlyadmitamajorityofpatientswith AIS-LVOforMTwhentheNCCUatUMMCdoesnothave availablebeds,whileprovidinginitialresuscitationand outcomessimilartopatientswhoweretransferreddirectlyto theNCCU.Priortothecoronavirus2019(COVID-19) pandemic,upto68%ofpatientstransferredtoUMMCfor AIS-LVOwereadmitted ﬁrsttotheCCRU,while32%were admitteddirectlytotheNCCU.9

TheonsetoftheCOVID-19pandemicaffectedtheUS healthcaresysteminmanyways.Duringtheearlyphaseofthe pandemic,staffshortages,personalprotectiveequipment (PPE)requirements,andthelackofCOVID-19testing resultedindelaysintheprocessofcareforpatients.Patients’ lengthofstayintheemergencydepartment(ED)waslonger thaninthepre-pandemicperiod.10,11AccordingtoaKorean study,theessentialtimeintervalfromEDtriageto neuroimagingstudiesforpatientswithischemicstrokewas delayedwhencomparedtothepre-pandemicperiod.10 This delayintheEDprocessofcareislikelytohaveaffectedthe outcomeofpatientstransferredtoCSCsforMT.Itisnot knownwhethertheprocessofcareforthesepatientswith AIS-LVOtransferredthroughtheCCRU,whichis specializedtoexpeditethetransferandtreatmentofpatients withtime-sensitivediseases,wasalsodelayedduring thepandemic.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Duringthepandemic(DP),theprocessesof careforpatientsinEDsweresigni ﬁ cantly delayed,comparedtothepre-pandemic (PP)time.

Whatwastheresearchquestion?

Wesoughttodeterminewhethertheprocess ofcareforpatientswithacuteischemicstroke fromlargevesselocclusionintheEDandthe criticalcareresuscitationunit(CCRU)was affectedduringthepandemic.

Whatwasthemajor ﬁndingofthestudy?

TotaltimeinEDwassimilarat157minutes bothPPandDP(p=0.74),whileDPtimein theCCRUwas9minutesshorterthanPP.

Howdoesthisimprovepopulationhealth?

In-outEDtimewasoneofthetoppredictors foroutcome.Cliniciansshouldexpedite transferofpatientstothrombectomy.

Inthispre-postpandemicstudy,wesoughttocomparethe processofcareforpatientswithAIS-LVOforboththeED andtheCSCs,fromEDtriagetotheCCRU,and subsequentlytotheMTsuite.Acknowledgingthatthe timeintervalfrompatients’ last-known-wellperiodtothe timeofreperfusion(recanalization)isessential,12 wealso investigatedwhichtimeintervalsfollowingarrivalto theEDweremostimportantindeterminingpatients’ neurologicaloutcomes.

METHODS

PatientSelection

Thiswasaretrospectivestudyamongadultpatients transferredfromanyEDtotheCCRUbetweenJanuary1, 2018–May31,2021forMT.Dataforthesepatientswith AIS-LVOwascollectedprospectivelyforourinstitutional strokeregistry.Wecomparedpatientstransferredbetween January1,2018–February29,2020(pre-pandemic)with thosewhoweretransferredbetweenMarch1,2020–May31,2021(duringthepandemic).Thestudywas exemptedfromformalconsentbytheUMMCInstitutional ReviewBoard.

StudySettings

TheCCRUisasix-bed,intensivecareunit(ICU)-based resuscitationunitthatwascreatedinJuly2013toexpedite

thetransferofpatientswithtime-sensitiveconditions13 to UMMC,aquaternaryacademicmedicalcenterofferinga varietyoftime-sensitiveinterventionsforcriticalpatients, includingMT,emergencycardiacandaorticsurgery, extracorporealmembraneoxygenation,andneurosurgery. TheCCRUhasfacilitatedthetransferofover1,500 patientsperyear,orupto20%oftotaltransfers,toour institution.8 Priorresearchhasdemonstratedthattransfer throughtheCCRUwasassociatedwithmorerapidtransfer, deﬁnedasshorterintervalsfromtransferrequesttoarrivalat UMMC,thandirecttransfertotraditionalinpatientcritical careunits.

Theunitisstaffedatalltimesbyanonsiteattending physicianwhoisboardcertiﬁedinbothemergencymedicine (EM)andcriticalcaremedicineandanadvancedpractice practitioner(APP)withpostgraduatetrainingorexperience incriticalcare.Fellowandresidentphysiciansoftenrotate throughtheCCRUandworkunderthedirectsupervisionof theCCRUattending.Thenursingstaffiscomposed ofonechargenurseandfourbedsidenurseswithatleast twoyearsofICUexperience;thechargenurseoften participatesinpatients’ initialresuscitationandclinicalcare inadditiontoservinganadministrativerole.Duringthe pandemic,therewasnochangeinthebasicstafﬁngmodelof theCCRU.

SincetheopeningoftheCCRU,patientswithAIS-LVO whoareconsideredcandidatesforMTbytheStroke NeurologyteamatUMMCaretransferredtotheNCCUor theCCRU(ifthereisnoNCCUbedavailable,staffed,and readyatthetimeoftransfer).Anyregionalemergency physicianwhohasdiagnosedapatientwithanAIS-LVO anddoesnothavein-houseMTcapabilitiescandirectly connecttoamultidisciplinaryteamresponsiblefor determiningeligibilityforMTandcoordinating appropriatecarebefore,during,andaftertheprocedure throughtheMarylandAccessCenter(MAC),which handlesalltransfersfromotherhospitalstotheUMMC. Thisteamincludestheon-callattendingphysiciansforthe strokeneurologyteam,theNCCU,neuroradiology,and theCCRU.

Duringthisdiscussion,eligibilityforMTisdetermined, recommendationsforinitialcarepriortothrombectomy (bothatthesendingfacilityanduponarrivalatUMMC)are discussed,and foreligiblepatients arrangementsfor urgentthrombectomyandpost-thrombectomycare (including “activation” ofon-callbutoffsiteteamsduringoff hours)areinitiated.Foreligiblepatients,arrangementsare madeforpromptbedassignmentineithertheNCCUorthe CCRU,dependingonNCCUbedavailability,andtransport isarrangedinconjunctionwiththereferringfacility,often coordinatedbytheMAC.

OnCCRUarrival,patientsareassessedimmediatelyby theCCRUandstrokeneurologyteams.TheCCRUteam assesseshemodynamicstabilityandtheneedforairway

protection,establishesadequateintravascular(andattimes arterial)access,andinitiatestreatmentofhypertensionfor patientswhoreceivedthrombolyticspriortotransfer. ThestrokeneurologyteamperformsaninitialNational InstitutesofHealthStrokeScale(NIHSS)assessmentand conﬁrmseligibilityforMT.Ifeligibilityisconﬁrmedthe patient,oncestabilized,istransferredtotheneuroradiology angiographysuiteforMT.Followingthrombectomy, thepatientistransferredeithertotheNCCUorthe CCRUforfurtherintensivestrokecare.Thepatientis ultimatelytransferredtotheNCCUwhenanappropriate bedisavailable.

Thisprocess,aswellasthestafﬁngandprotocolsofeach involvedmedicalteam,hadbeenmaintainedsincebeforethe pandemicandcontinuedthroughouttheCOVID-19 pandemic.Duringthepandemic,allpatientstransferredto theCCRUwiththromboticdisease(suchasischemicstroke) weretreatedasapatientunderinvestigation(PUI)for COVID-19andremainedsountilresultsofapolymerase chainreaction(PCR)testbecameavailable.However, patientswerestilltakentotheangiographysuiteimmediately asindicated.WhencaringforanyPUI,clinicianswere requiredtousefullPPE,includinggowns,poweredairpurifyingrespirators,andsupplied-airhoods.Followinga negativePCR,PPErequirementsrelaxedtorequireonly gownsandN95masks.

Outcome

Theprimaryoutcomewasthetimeintervalbetween CCRUarrivalandtransfertotheangiographysuite.This wasselectedaprioriasamodifiableriskfactorthatreflects theprocessandefficiencyofcarewithintheCCRU.Our secondaryoutcomewasthepercentageofpatientswho achievedgoodneurologicrecovery,definedas90-day modifiedRankinscale(mRS)score ≤2.The90-daymRS scorewascollectedprospectivelybyourstrokeneurology teamaspartofrequiredclinicalstrokecareforaCSC.For ourintention-to-treatanalysis,wecategorizedanypatients whowerelosttofollow-up,suchaspatientsinskillednursing facilities,asmRS >3.

DataCollection

Patientdemographicdata(age,gender,pastmedical history)wasextractedfromourelectronichealthrecords. ClinicaldataduringtheinitialEDstayatthesendingfacility, suchasinitialvitalsigns,EDtriagetime,andtimefrom triagetocomputedtomography(CT),wasextractedusing thepaperrecordsaccompanyingpatientsaspartofthe transferprocess.Priortodataextraction,juniorinvestigators whowerenotblindedtothestudyhypothesisweretrainedto collectdatainsetsof10patients’ chartsuntilinter-rater agreementreached90%.Datadisagreementwasadjudicated byaseniorinvestigator.Datawasextractedandenteredinto

astandardizedExcelspreadsheet(MicrosoftCorporation, Redmond,WA).

DataAnalysis

Weuseddescriptiveanalysistoexpresspatientdataas mean(±SD),median(interquartile[IQR]),orpercentage. Priortoanalysis,weassessedandanalyzedhistogramsof continuousdatadistributionpatternswiththeStudent t -test orMann-WhitneyUtestasappropriate.Categoricaldata wasanalyzedviathePearsonchi-squaretest.

Weperformedtimeseriesanalysestoexaminethe correlationofcertaintimeintervalswithneworcumulative casesofCOVID-19.DataforglobalcasesofCOVID-19was obtainedfromthewebsiteStatista.comonSeptember1, 2022.14 Weperformedanalysesofdifferentmediantime intervalstoassesstrendsofdifferenttimeintervalsduringthe pandemic.Thetrendwiththesmallestvaluesofmean absolutepercentageerror,meanabsolutedeviation,and meansquareddeviationamongfourdifferentalgorithms (linear,quadratic,exponentialgrowth,S-curve)was consideredashavingthebest ﬁtforthetimeseries.Tofurther assesstheimpactofthepandemiconoperationsofeachstage ofthepatient’scare(fromEDarrivaltotheangiography suite),wecreatedadummyvariable, “presentingduring pandemic,” forpatientspresentingbetweenMarch1, 2020–May31,2021.

Weusedtheclassificationandregressiontree(CART) methodtoidentifypredictorsassociatedwithpatients’ neurologicaloutcomes.ThevariablesfortheCART (Appendix1)wereidentifiedaprioriasknownclinically importantfactorsforpatientoutcome,accordingto literatureandclinicalconsensus.TheCARTisasupervised, machine-learningtechniquethatusesrepetitivepartitioning toidentifyaseriesofdichotomoussplits(eg,90-daymRS ≤2 vs90-mRS ≥3)untilthealgorithmachieves “purity” where nofurthersplitispossible.TheCARTgeneratedatreeof decisionfromtheinteractionsbetweenalltheindependent variablesthatwedefinedapriori.Thealgorithmassignsthe mostinfluentialindependentvariablearelativevariable importance(RVI)of100%.Otherimportantvariablesare assignedsubsequentRVIsaspercentagesofthemost importantfactor.

WeassessedthediscriminatorycapabilityoftheCART modelusingtheareaunderthereceiveroperatingcurve (AUROC)analysis.AnAUROCof1.0wouldhaveperfect discriminatorycapabilityofpredictingthedichotomous outcome.OurCARTalgorithmwasperformedwith 10-foldcross-validation,aminimumofthreecountsper terminalnode,andamaximumdepthof30layersand 30terminalnodes.Theoptimaltreewasselectedaccording toabalancebetweennumberofnodesandlowest miscalculationcost.

Additionally,weperformedsensitivityanalysistoassess whetherthetimeintervalswereimportantfactorswhen

analyzedwithdifferentgroupsofvariables.Inthissensitivity analysis,insteadofusingseparatesegmentsoftimeintervals, suchasCCRU-to-angiogramsuite,angiogramsuite-togroinpuncture,andgroinpuncture-to-recanalization,we dividedtheoveralltimeintervalintoEDin-and-out (coveringthetimefromEDtriagetotransfer)andCCRU arrival-to-recanalization(Appendix2).

Weperformedalldescriptiveanalyses,timeseriesand CARTanalysesviaMinitabversion20(MinitabLLC,State College,PA).All P -values < 0.05wereconsidered statisticallysigniﬁcant.

RESULTS

Thestudyidentified225patientsduringthestudyperiod; 22patientsdidnotmeetinclusioncriteria,and203were includedinthe finalanalysis(Figure1).Onehundredthirtyfive(66.5%)patientswithAIS-LVOweretransferredfroman EDtotheCCRUbetweenJanuary2018–February2020prepandemic,while68(33.5%)weretransferredbetweenMarch 2020–May2021duringthepandemic.Themeanagewas67 (±15)years(Table1).Patients’ medianNIHSSatCCRU arrivalinthepre-pandemicperiodwassimilartothatof patientsduringthepandemicperiod(Table1).Patients duringthepandemicperiodhadahigherpercentageof occlusionfrommiddlecerebralartery(59/68,87%), comparedtopatientsinthepre-pandemicperiod(97/143, 72%,difference15%,95%CI 0.26to 0.04).Ahigher percentageofpatientsinthepandemicperiodachievedgood 90-dayneurologicalrecovery(33/68,49%)comparedto patientsinthepre-pandemicgroup(41/143,32%,difference 17%,95%CI 0.32to 0.03).

Figure1. Patientselectiondiagram.

Table1. Patients’ demographics.

VariablesAllpatients

Pre-pandemic (1/2018–2/2020)

Pandemic (3/2020–5/2021)

Differencebetween groups P-value

N = 203N = 135N = 68N95%CI

Age,mean(SD)67(15.15)66(14.94)68(15.57) 1.89( 6.42,2.63)0.41

Gender

Female,N(%)111(55)72(53)39(57) 0.04( 0.18,0.10)0.66

Male,N(%)92(45)63(47)29(43)0.04( 0.10,0.18)0.66

IVthrombolysis,N(%)89(44)63(47)26(38)0.08( 0.06,0.23)0.3

NIHSSinED,median[IQR]17[12–21]17[12–21]16[10–21]1( 1,3)0.35

NIHSSonCCRUarrival,median[IQR]17.5[12–21.25]18[14–21]16[11–23]0( 2,2)0.71

Occludedvessels,N(%)

Internalcarotidarteryonly19(9)16(12)3(4)0.07(0,0.15)0.12

Middlecerebralarteryonly156(77)97(72)59(87) 0.15( 0.26, 0.04)0.02

Multiplevessels28(14)22(16)6(9)0.07( 0.02,0.17)0.2 Laboratoryvalues,mean(SD)

Sodium(mEq/L)138(3.29)138(3.16)137(3.36)1.35(0.38,2.32)0.007

Creatinine(mg/dL)0.96(0.81)0.91(0.34)1.04(1.32) 0.13( 0.46,0.19)0.41

Internationalnormalizedratio1.14(0.25)1.15(0.25)1.11(0.25)0.03( 0.04,0.11)0.37

Outcomes

TICI2c/3,N(%)132(65)85(63)47(69) 0.06( 0.2,0.08)0.44 90-daymRS0–2,N(%)74(38)41(32)33(49) 0.17( 0.32, 0.03)0.02

Mortality,N(%)46(24)30(23)16(24)0( 0.13,0.12)0.99

CI, confidenceinterval; CCRU,criticalcareresuscitationunit; ED,emergencydepartment; IV,intravenous; mEq/L,milliequivalentperliter; mg/dL,milligramsperdeciliter; mRS,modifiedRankinscale; NIHSS,NationalInstituteofHealthStrokeScale; TICI,thrombolysisin cerebralinfarction; TICI2c:nearcompleteperfusionexceptforslow flow; TICI3:completeantegradereperfusionofthepreviously occludedtargetartery.

TimeIntervals

Overall,medianinterval(minutes)fromlastknownwell timetorecanalizationwassimilarforbothgroups(462 [326–986]vs557[371–984],difference40,95%CI 119to 32),althoughlastknownwelltimetoCCRUarrival (327[221–682]vs472[279–869],difference80,95%CI 20–157, P = 0.001)andgroinpuncture(370[270–752]vs512 [332–911],difference80,95%CI20–154, P = 0.01)were signiﬁcantlylongerinthepandemicgroup.

Patientsinthepandemicgrouphadastatisticallylonger timefromEDtriagetoCT(difference7minutes,95%CI 12 to 1)(Table2).However,EDin-and-outtimesweresimilar inbothgroups(Table2).Duringthepandemic,patients hadstatisticallyshortertime(minutes)betweenarrival attheCCRUandleavingtheCCRUfortheangiography suite(difference9,95%CI4–13).Similarly,median interval(inminutes)fromgroinpuncturetorecanalization wasstatisticallyshorterduringthepandemic(difference9, 95%CI2–17).

Weplottedmedianvaluesofdifferenttimeintervalswith thenumberoftotalglobalcasesofCOVID-19(Figure2A)or totalnumberofglobalnewcases(Figure2B).Thistimeseries

suggestedthattheEDin-and-outtimewasmostparallelwith thenumberofnewcases(Figure2B,line1andline2).

Figures2C–2F displaydifferenttrendanalysesfordifferent timeintervalsbetweenJanuary2020–May2021.Overall,a downwardtrendofalltimeintervalstowardMay2021 wasobserved.

ClassiﬁcationandRegressionTree(CART)Analysis

TheCARTanalysisidentifiedthatpatients’ NIHSSat arrivalattheCCRUwasthemostimportantpredictorfor poorneurologicalrecoveryat90days,asNIHSSwas assignedaRVIof100%(Figure3A).TheEDin-and-out timeandCCRUarrival-to-angiographytimewereidentified bytheCARTanalysisasthethirdandsixthmostimportant factorsforgoodneurologicoutcome,withreportedRVIof 25%and16.5%,respectively(Figure3A).Patient’sNIHSSat CCRUarrivalwasresponsibleforthe firstsplitinthe decisiontree(Node1, Figure3B).Ifapatient’ sagewas greaterthan69.5years(Node2),thepatientwasmorelikely tohavepoorneurologicrecovery(Terminalnode3, Figure3B).Theonlymodifiableriskfactorsidentifiedas “important” weremedianEDin-and-outandCCRU

Table2. Comparisonofvarioustimeintervalsforpatientswithcerebrovascularaccidentduetolargevesselocclusionpresentingfor mechanicalthrombectomypriortoorduringtheCOVID-19pandemic.

VariablesAllpatients Pre-pandemic (1/2018–2/2020)

Differencebetween groups P-value N = 203N = 135N = 68N95%CI

(3/2020–5/2021)

IntervalsfromLKW

LKWtoCCRUarrival361[243–724]327[221–682]472[279–869] 80( 157, 20)0.001

LKWtogroinpuncture403[294–784]370[270–752]512[332–911] 80( 154, 20)0.01

LKWtorecanalization483[340–986]462[326–986]557[371–984] 40( 119,32)0.25

EDtimeintervals(minutes), median[IQR]

TriagetoCTscanresults25[14–40]21[13–37]30.5[18.3–47] 7( 12, 1)0.02

TriagetoneurologyconsultatUMMC65[40–110]68[46–119]57.5[36–91.5]11( 1,24)0.09

TriagetoIVthrombolysis(N = 91)48[31–72]48[29–70.5]51[33.5–74] 1( 13,12)0.79

TriagetoleavingED(EDin-out)157[125–211]157[119–221]157[131.3–202.8] 3( 20,16)0.74

TransferrequesttoCCRUarrival111[92–139]106[86–131]121.5[100–149] 14( 24, 3)0.01

TimeintervalsafterarrivalatCCRU (minutes),median[IQR]

CCRUarrivaltothrombectomysuite28[18–40]32[21–44]20.5[14–33.8]9(4,13)0.01

Thrombectomysuitetogroinpuncture (minutes),median[IQR] 14[11–19]13[10–17]18.5[13.25–22.75] 5( 7, 3)0.01

Groinpuncturetorecanalization (minutes),median[IQR] 40[23–70]44[27–73]37[19.25–55]9(2,17)0.01

CCRU,criticalcareresuscitationunit; CT,computertomography; ED,emergencydepartment; IQR,interquartilerange; IV,intravenous; LKW,lastknownwell; UMMC,UniversityofMarylandMedicalCenter.

arrival-to-angiographytimes.TheAUROCfortheCART’ s trainingdatasetwasgood(0.72),aswastheAUROCforthe testdataset(0.58);misclassiﬁcationcostwas0.63.

DISCUSSION

Our findingssuggestthatdespitepreviouslynotedimpacts oftheCOVID-19pandemiconmultipleaspectsof emergencyandcriticalcare,thecareprocessesusedto facilitatetreatmentwithMTforpatientswithAIS-LVOwere relativelyunaffected,aswerepatientoutcomes.Giventhe spoke-and-hubmodelofcomprehensivestrokecare frequentlyemployedthroughouttheUS,includingatour center,treatmentwithMTrequiresrapidcoordinationof multipleteamsandresources,oftenacrossmultiple resources.Wefoundthattheonlytimeintervalduringwhich patientsexperiencedstatisticallysignificantdelayswasthat fromEDtriagetoCTscanner(althoughwithamean differenceofonly7minutes,itisunclearwhetherthisdelay conferredclinicalsignificance).Thissuggeststhatoncean LVOwasidentified,thecarecoordinationsystemspreviously developedtofacilitaterapidtransferandtreatmentof thesepatientswereabletooperateefficientlydespitethe ongoingpandemic.

Thephilosophythat “timeisbrain” continuestobethe primeconsiderationinthetreatmentofpatientswithAIS-

LVO,andhasledtoanationwideemphasisonefficiency, organization,andprotocolizationofstrokeidentificationand treatmentateachstageofcare:inthecommunity(via educationinitiativespromotingstrokerecognition);among emergencymedicalservices(EMS)professionals;inthe ED;andinin-hospitalsettingsacrossthecountry.The importanceofthesesystemsandorganizedcarehavebeen emphasizedinclinicalstudiesandnationalguidelines.15,16 The findingspresentedinthisstudysupportthisemphasisas well:ourCARTanalysisidentifiedthetimeinterval betweenCCRUarrivalandarrivalintheangiography suiteandthatbetweenEDtriageanddeparturefortransferas themostimportantmodifiableriskfactorsinpatients’ neurologicoutcomes.

Althoughour ﬁndingisconsistentwithcurrent consensus, 6 itwasincontrasttoapreviousstudyabouttime intervalmetricsintheED.5 Schevingetal5 suggestedthat timeintervalsintheEDwerenotassociatedwithpatients’ 90-dayoutcome.However,thestudybySchevingetalwas restrictedbyasmallernumberofEDpatientsundergoing MTandretrospectivecalculationofmRS.Ourinstitution usesahighlycoordinatedandprotocolizedapproachto facilitatepromptidentiﬁcation,transfer,andtreatmentof patientspresentingtosurroundingprimarystrokecenters whoarecandidatesforMT.Theexpeditioustransferof

Figure2. Timeseriesanalysisofdifferenttimeintervalsforpatientswithcerebrovascularaccidentduetolargevesselocclusion(LVO) presentingformechanicalthrombectomyduringtheCOVID-19pandemic.Figure2A.Timeseriesanalysiscomparingdifferenttimeintervals fortreatmentofcerebrovascularaccidentduetoLVOandglobalprevalenceofCOVID-19cases.Figure2B.Timeseriesanalysisof prevalenceofnewCOVID-19casesanddifferenttimeintervalsfortreatmentofcerebrovascularaccidentduetoLVO.Figure2C.Trend analysisoftimeintervalofEDin-and-outtimeforpatientswithcerebrovascularaccidentduetoLVOoverthecourseoftheCOVID-19 pandemic.Figure2D.TrendanalysisoftimeintervalbetweenCCRUarrivalandarrivalintheangiographysuiteforpatientswith cerebrovascularaccidentduetoLVOpresentingduringtheCOVID-19pandemic.Figure2E.Trendanalysisoftimeintervalfromarrivalatthe angiographysuitetogroinpunctureforpatientswithcerebrovascularaccidentduetoLVOocclusionpresentingduringtheCOVID-19 pandemic.Figure2F.Trendanalysisoftimeintervalfromgroinpuncturetorecanalizationforpatientswithcerebrovascularaccidentdueto LVOpresentingduringtheCOVID-19pandemic.

CCRU,criticalcareresuscitationunit; COVID-19,coronavirusdisease2019; ED,emergencydepartment; MAPE,meanabsolutepercentage error; MAD,meanabsolutedeviation; MSD,meansquareddeviation; IR,interventionalradiology.

Figure3. Relativevariableimportance(RVI)valuesandthetreediagramfromtheclassificationandregressiontree(CART)analysis.Figure 3A.RVIfromtheCARTanalysis.TheCARTwasusedtoassessimportantclinicalfactorsandpatients’ neurologicaloutcome,definedas 90-daymodifiedRankinscale(mRS)0–2.Figure3B.ThetreediagramfromtheCARTanalysis.TheCARTwasusedtoassessimportant clinicalfactorsandpatients’ neurologicaloutcome,definedas90-daymRS0–2.

patientswithtime-sensitiveillnessisaprimarymissionofthe CCRU,13 andourgrouphaspreviouslydemonstratedthat theCCRUmodelisassociatedwithshortertransfertimesfor patientswithAIS-LVOtoourinstitution.9

Our ﬁndingsnotonlysupportpreviousrecommendations thatprotocolizedandorganizedcaresystemsshouldbe prioritizedgivenanassociationwithimprovedoutcomesbut highlightthatsuchsystemscanpromotestandardizedand

efficientcareeveninthesettingoflarge-scaledisruptionsand disasters,suchastheCOVID-19pandemic.Patientstransferred toourfacilityduringthepandemicdidnotexperienceworse outcomesthanthosepresentingpre-pandemicand apart fromtimefromEDtriagetoCTimaging,asnotedabove did notexperiencesignificantdelaysintheircarefollowingED arrival.Ourtime-seriesanalysisfoundthat,exceptforaninitial slowdowninEDin-and-outtimeattheverybeginningofthe pandemic,whichwebelieveisconsistentwithhealthcareaccess issuesexperiencedbypatientsduringthisearlyperiodandthe outsizedoperationalimpactoftheoutbreak,10,11 eachstepof careforpatientswithAIS-LVOproceededatarelatively constant(toslightlyimproving)ratefollowingEDarrival, regardlessofprevalenceoftotalornewCOVID-19cases.While thesetrendswerelikely,atleastinpart,duetotherelatively smallnumberofAIS-LVOpatientspresentingtoEDsduring theearlyCOVID-19period,webelievetheyalsoreflectthe resilienceofstrokecareprotocolsacrossmultiple caresettings.

Withincertainareasofthehospital,theCOVID-19 pandemicpromptedtheintroductionofnewcareand coordinationprocessestomeetthedemandsofanincreasing volumeofcriticallyillpatientsandensurethesafetyofcareteam memberswhencaringforpatientswithahighlycommunicable disease.Theseprocessesmayhaveimprovedcarecoordination forpatientswithoutCOVID-19aswell.Forexample,during theheightoftheCOVID-19pandemic,alltransportclinicians wererequiredtonotifytheCCRUteamoftheirestimatedtime ofarrival,togiveteammemberstimetodontheirPPEin preparationtoreceivethepatients.Forpatientstransferredfor AIS-LVO,thestrokeneurologyandneuro-interventionalteams receivedthesameadvancednotice,whichallowedthemtobe presentatthebedsidewhenthepatientarrived.Afteraquick assessment,eligiblepatientswerethenquicklymovedfromthe CCRUtotheangiographysuitebytheneuro-interventional team.Ourstudydemonstratedrelativereductionsinthemedian timesfromCCRUarrivaltoangiographysuite,andfrom CCRUarrivaltorecanalizationoverall,whichmayinpart reﬂecttheimpactofthesenewprotocols.

WhilewefoundthatstrokeprocessesofcareintheEDand withinthehospitalwererelativelyunaffectedbythe pandemic,wedidobserveasignificantincreaseintimefrom lastknownwellnesstoarrivalattheCSCduringCOVID-19, highlightingthebreakdowninthe firststepofthestroke “chainofsurvival” activationofEMS.Thisisunsurprising giventheemphasisonsocialdistancingandresultant isolationduringthepandemic.Althoughthisriskfactoris modifiablethroughimprovedpubliceducationand outreach,itisnotatimeintervalthatcanbemeaningfully impactedbyhospitalandEDprocesses,andthuswasnot includedinourCARTanalysis.Multiplepriorstudieshave demonstrateddelaysinpresentationforstrokeduringthe COVID-19pandemicacrosstheglobe,thoughttoberelated

todelaysinrecognitionofstrokesymptomsorcallingfor helpduetosocialisolationaswellasfearofcontracting COVID-19inahealthcaresetting.17–20 Weanticipatethat thisbreakdownmayhavehadanevengreaterimpactoutside thescopeofthisstudybyreducingthepercentageofAISLVOpatientspresentingwithinthe “window” forMT. Becauseourstudypopulationincludedonlypatients transferredforthrombectomy,thosepatientswould notbecapturedhere.

LIMITATIONS

GiventheuniquemodeloftheCCRUasawell-resourced resuscitationunitdedicatedto facilitatingrapidtransferand criticalcareforpatientswithtime-sensitiveconditions,our resultsmaynotbegeneralizable.Thepre-thrombectomycare providedinourCCRUpopulationwouldbelikelytooccurin theEDatotherfacilitiesthatdonothavesimilarmodels, whichmaybemoresubjecttotheconstraintsimposedby COVID-19(althoughour ﬁndingsdonotsuggestthis). However,ourpopulationwasderivedfrommorethan50 referringEDswithintheregions;therefore,thetimemetrics fromtheEDtoarrivaltorecanalizationshouldstillbe applicabletootherinstitutions.Sincealmostallourpatients weretransferredfromotherhospitals,alargepercentageofthe patientsdidnothaveAlbertaStrokeProgramEarlyCT (ASPECT)scores;therefore,wedecidednottoreportthe ASPECTscoreoruseitinouranalysis.Thenumberof patientsbeingtransferredtotheCCRUduringthestudy periodwasrelativelysmallerthaninthepre-pandemicperiod, whichloweredtheAUROCof ourCARTalgorithmduring thetestingphase.NeitherdidweassesstheCOVID-19 vaccinationstatusamongpatientsandstaff,which mighthaveaffectedtheCCRUstaff’spreparednesswhen receivingpatients.

CONCLUSION

Thisstudyshowedthattheoutcomesandinitialcareof patientswithacuteischemicstrokefromlargevessel occlusiontreatedwithmechanicalthrombectomywerenot affectedbytheCOVID-19pandemicatourcomprehensive strokecenter.ThisinitialcarespannedfromEDarrival throughidentificationofLVO,coordinationoftransfertoa CSC,andfacilitationofrapidmechanicalthrombectomy. Besidesthepatients’ intrinsicfactors(NIHSSatarrival,age), thetimeintervalsfromEDarrivaltotransfer,andfrom CCRUarrivaltoarrivalintheangiographysuite,were identifiedasimportant,independentriskfactorsassociated with90-daymodifiedRankinscale.Thishighlightsthe importanceofstreamlinedandprotocolizedcareforpatients withAIS-LVOeligibleformechanicalthrombectomyand illustratestheroleofacriticalcareresuscitationunitin promotingthesecaresystems.

AddressforCorrespondence:QuincyKTran,MD,PhD,Universityof Maryland,SchoolofMedicine,DepartmentofEmergencyMedicine, 22SouthGreeneSt.,SuiteT3N45,Baltimore,MD21043.

Email: qtran@som.umaryland.edu

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

REFERENCES

1.LimaFO,FurieKL,SilvaGS,etal.Prognosisofuntreatedstrokes duetoanteriorcirculationproximalintracranialarterialocclusions detectedbyuseofcomputedtomographyangiography. JAMANeurol. 2014;71(2):151–7.

2.BerkhemerOA,FransenPSS,BeumerD,etal.Arandomizedtrialof intraarterialtreatmentforacuteischemicstroke. NEnglJMed. 2015;372(1):11–20.

3.GoyalM,DemchukAM,MenonBK,etal.Randomizedassessmentof rapidendovasculartreatmentofischemicstroke. NEnglJMed. 2015;372(11):1019–30.

4.JovinTG,ChamorroA,CoboE,etal.Thrombectomywithin8hours aftersymptomonsetinischemicstroke. NEnglJMed. 2015;372(24):2296–306.

5.SchevingWL,FroehlerM,HartK,etal.Inter-facilitytransferforpatients withacutelargevesselocclusionstrokereceivingmechanical thrombectomy. AmJEmergMed. 2021;39:132–6.

6.KamalN,ShengS,XianY,etal.Delaysindoor-to-needletimesandtheir impactontreatmenttimeandoutcomesingetwiththeguidelines-stroke. Stroke. 2017;48(4):946–54.

7.TranQK,O’ConnorJ,VesselinovR,etal.Thecriticalcareresuscitation unittransfersmorepatientsfromemergencydepartmentsfasterandis associatedwithimprovedoutcomes. JEmergMed. 2020;58(2):280–9.

8.PowellE,SahadzicI,NajafaliD,etal.Isthecriticalcareresuscitation unitsustainable:a5-yearexperienceofabeneﬁcialandnovelmodel. CritCareResPract. 2022;2022:6171598.

9.TranQK,YarbroughKL,CapobiancoP,etal.Comparisonof outcomesaftertreatmentoflargevesselocclusioninacriticalcare resuscitationunitoraneurocriticalcareunit. NeurocritCare. 2020;32(3):725–33.

10.ChangH,YuJY,YoonSY,etal.ImpactofCOVID-19pandemiconthe overalldiagnosticandtherapeuticprocessforpatientsofemergency departmentandthosewithacutecerebrovasculardisease. JClinMed. 2020;9(12):3842.

11.GuoF,QinY,FuH,etal.TheimpactofCOVID-19onemergency departmentlengthofstayforurgentandlife-threateningpatients. BMC HealthServRes. 2022;22(1):696.

12.SharmaR,LlinasRH,UrrutiaV,etal.Collateralspredictoutcome regardlessoftimelastknownnormal. JStrokeCerebrovascDis. 2018;27(4):971–7.

13.ScaleaTM,RubinsonL,TranQ,etal.Criticalcareresuscitationunit:an innovativesolutiontoexpeditetransferofpatientswithtime-sensitive criticalillness. JAmCollSurg. 2016;222(4):614–21.

14.ElﬂeinJ.Numberofcumulativecasesofcoronavirus(COVID-19) worldwidefromJanuary22,2020toFebruary2,2023,byday.2023. Availableat: https://www.statista.com/statistics/1103040/ cumulative-coronavirus-covid19-cases-number-worldwide-by-day/ AccessedFebruary10,2023.

15.AdeoyeO,NyströmKV,YavagalDR,etal.Recommendationsfor theestablishmentofstrokesystemsofcare:a2019update. Stroke. 2019;50(7):e187–210.

16.StrokeUnitTrialists’ Collaboration.Organisedinpatient (strokeunit)careforstroke. CochraneDatabaseSystRev. 2013;2013(9):CD000197.

17.NawabiNLA,DueyAH,KilgallonJL,etal.EffectsoftheCOVID-19 pandemiconstrokeresponsetimes:asystematicreviewandmetaanalysis. JNeurointerventionalSurg. 2022;14(7):642–9.

18.BenaliF,StolzeLJ,RozemanAD,etal.Impactofthelockdownonacute stroketreatmentsduringthe ﬁrstsurgeoftheCOVID-19outbreakinthe Netherlands. BMCNeurol. 2022;22(1):22.

19.ArefHM,ShokriH,RoushdyTM,etal.Pre-hospitalcausesfordelayed arrivalinacuteischemicstrokebeforeandduringtheCOVID-19 pandemic:astudyattwostrokecentersinEgypt. PloSOne. 2021;16(7):e0254228.

20.SimonettoM,WechslerPM,MerklerAE.Stroketreatmentintheeraof COVID-19:areview. CurrTreatOptionsNeurol. 2022;24(4):155–71.

ORIGINAL RESEARCH

AssessingTeamPerformance:AMixed-MethodsAnalysisUsing

Interprofessional insitu Simulation

AshleyC.Rider,MD,MEHP*

SarahR.Williams,MD,MHPE*

VivienJones,BS†

DanielRebagliati,BA‡

KimberlySchertzer,MD,MS*

MichaelA.Gisondi,MD*

StefanieS.Sebok-Syer,PhD*

SectionEditor:LauraWalker,MD

*StanfordUniversity,DepartmentofEmergencyMedicine,PaloAlto,California † RoyalCollegeofSurgeons,Dublin,Ireland ‡ AlbanyMedicalCollege,Albany,NewYork

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedJanuary21,2024;AcceptedMarch1,2024

ElectronicallypublishedJune11,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18012

Introduction: Optimizingtheperformanceofemergencydepartment(ED)teamsimpactspatientcare, buttheutilityofcurrent,team-basedperformanceassessmenttoolstocomprehensivelymeasurethis impactisunderexplored.Inthisstudyweaimedto1)evaluateEDteamperformanceusingcurrentteambasedassessmenttoolsduringaninterprofessionalinsitusimulationand2)identifycharacteristicsof effectiveEDteams.

Methods: Thismixed-methodsstudyemployedcasestudymethodologybasedonaconstructivist paradigm.Sixty-threeeligiblenurses,technicians,pharmacists,andpostgraduateyear2–4emergency medicineresidentsatatertiaryacademicEDparticipatedina10-minuteinsitusimulationofacriticallyill patient.Participantsself-ratedperformanceusingthe TeamPerformanceObservationTool (TPOT)2.0 andcompletedabriefdemographicform.Tworatersindependentlyreviewedsimulationvideosand ratedperformanceusingtheTPOT2.0, TeamEmergencyAssessmentMeasure (TEAM),and Ottawa CrisisResourceManagementGlobalRatingScale (OttawaGRS).Followingsimulations,weconducted semi-structuredinterviewsandfocusgroupswithinsituparticipants.Transcriptswereanalyzedusing thematicanalysis.

Results: Eighteenteam-basedsimulationstookplacebetweenJanuary–April2021.Raters’ scores wereontheupperendofthetoolsfortheTPOT2.0(R14.90,SD0.17;R24.53,SD0.27,IRR[inter-rater reliability]0.47),TEAM(R13.89,SD0.19;R23.58,SD0.39,IRR0.73),andOttawaGRS(R16.6,SD 0.56;R26.2,SD0.54,IRR0.68).Weidentiﬁedsixthemesfromourinterviewdata:teammember entrustment;interdependentenergy;leadershiptone;optimalcommunication;strategicstafﬁng;and simulationempoweringteamperformance.

Conclusion: Currentteamperformanceassessmenttoolsinsufﬁcientlydiscriminateamonghigh performingteamsintheED.Emergencydepartment-speciﬁcassessmentsthatcapturefeaturesof entrustability,interdependentenergy,andleadershiptonemayofferamorecomprehensivewayto assessanindividual’scontributiontoateam’sperformance.[WestJEmergMed.2024;25(4)557–564.]

INTRODUCTION

Patientcareintheemergencydepartment(ED)depends onhighlyeffectiveinterprofessionalteams.EDteamsare

dynamic,complextotrain,andsubjecttothepreparednessof individualteammemberswhilecaringforcriticallyill patients.Althoughteamtraininghasbeenchampionedby

theNationalAcademyofMedicinetoreduceadverseevents, the ﬂuidnatureofEDteamsmakessuchtrainingcomplex.1 Additionally,individualteammembercontributionscan inﬂuencethereadinessofanEDteam.Previousresearchhas shownthatindividualperformanceandcommunication failuresaresubstantialcontributorstoadverseevents,2,3 affectingtheinterdependentnatureofteam-basedcare.4,5 Therefore,evaluatinghowwellexistingteamperformance assessmentsareatcapturingindividualandteam-based performanceisnecessarytoensureaccuratemeasurementof teamsunderthedirestcircumstances.

TheAgencyforHealthcareResearchandQualityandthe USDepartmentofDefenserigorouslydevelopedmeasures thatevaluateteamwork.1 Themostwidelyusedtoolfor assessingteamperformanceandpatientsafetyistheTeam StrategiesandToolstoEnhancePerformanceandPatient Safety(TeamSTEPPS) TeamPerformanceObservation Tool (TPOT),nowwithasecondversion,TPOT2.0.This 23-iteminstrumentintegrates ﬁveareasofcompetence:team leadership;teamstructure;situationmonitoring;mutual support;andcommunication.6 The TeamEmergency AssessmentMeasure (TEAM)isanalternate12-itemtool thatalsomeasuresteamperformance,butitwasdesigned speciﬁcallyforteamassessmentintheEDsetting.7 The OttawaCrisisResourceManagementGlobalRatingScale (OttawaGRS)isanothertoolthatassessescrisisresource managementskillsofleader-teammemberinteractions.8 Althoughthesetoolshavesomevalidityevidence,8–13 the extenttowhichtheyreliablyandaccuratelymeasureteambasedperformanceinvariouscontextswarrantsfurther investigationtounderstandhowtobestassessanindividual’ s contributionstoEDteamperformance.

Furthercomplicatingteamassessmentisthecriticalrole ofdyads14 andtheinterdependenceofindividualswithin teams.4,15 InterprofessionalmembersoftheEDteamare inseparablytiedtooneanother,andoftenthereisnochoice whethersomeonebecomespartoftheteam.IntheED,teams areformedoutofnecessitytoprovideacutecareforcritically illpatients.Thesecircumstancesessentiallyrequire immediateentrustmentamongindividualteammembers, whichisnotalwaysfeasibleorrealistic.Underlyingthe theoryofinterdependenceistheideathatsomepairingsof teammemberswillbemoreeffectivethanothers;therefore, identifyingkeyfactorsthatinﬂuenceteammemberdynamics iscritical.14,15 Thisconceptualframinghasimplicationsfor howEDteam-basedperformance(ie,whereteamsrapidly formtomeettheemergentneedsofpatients)isassessed.

Duetoourincompleteunderstandingoftheimportant elementsthatcontributetoindividualandteam performance,wesetouttoexploretheeffectivenessof currentteam-basedperformanceassessmenttoolsintheED setting.Usinganinterprofessional,insitusimulation,we aimedtodothefollowinginthisstudy:1)evaluatethe effectivenessofTPOT2.0,TEAM,andOttawaGRS

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencydepartmentteamsaredynamic andcomplex,withbothindividualandteam factorsthatimpactpatientcare.

Whatwastheresearchquestion?

Weaimedtounderstandtheabilityof performancetoolstoassessEDteamsaswell asidentifycharacteristicsofeffectiveteams.

Whatwasthemajor ﬁndingofthestudy?

EDteamsinthesimulationwereratedhighly onalltoolswithgoodinterratercorrelations 0.46,0.68,and0.72foreachofthetools.

Howdoesthisimprovepopulationhealth?

Abetterunderstandingofinterdependent teamfactorswillallowustoeducateandtrain moreeffectivepatientcareteams.

team-basedassessmenttoolsintheEDsetting;and2) identifycharacteristicsofeffectiveteamsthatareattributable toindividualsandmaynotbecapturedwithinexistingteambasedassessments.

METHODS

Weusedmixed-methodscasestudymethodologyinthe contextofateam-based,insitusimulationtoexplorethe effectivenessofteam-basedassessmentsandexplorethe relationshipbetweenteamdynamicsandindividuals’ teambasedperformance.16,17 Weusedaconstructivistparadigm, whichholdsthatanindividual’sperspectiveisthebasisfor realityandthatmultiple,sociallyconstructedrealitiescan existatonceforthisresearch.18,19 Wechosecasestudy methodologytounderstandthevariousperspectivesofteam participantsandobserversinthecontextofan ED-basedsimulation.

AllEDnurses,technicians,pharmacists,and postgraduateyear(PGY)2–4emergencymedicineresidents withinoneacademichealthsystemwereeligibleto participateinthisstudy.WeexcludedPGY-1residentsdueto theirlimitedexperienceleadingresuscitations.Thestudy tookplaceinalarge,suburban,academicEDatatertiary carefacility.Weconductedsimulationstwiceperweek duringlow-volumehours;strictpoliciesforcancellationwere followedbasedonEDvolumeandpatientcareneeds.The StanfordUniversityInstitutionalReviewBoardapproved thisstudy(#55327).

QuantitativeStudyDesignandDataCollection

Usingconveniencesampling,wesolicitedvolunteersto participateinsimulationsheldoverafour-monthperiod (January–April2021).Eachsimulationincludedanurse,a resident,apharmacistand,insomecases,anEDtechnician. Attendingswerenotincludedtoensurethatpatientcare wouldnotbedisrupted.Priortothesimulatedcase,the63 participantsreceivedatwo-minutepre-brieffromaninpersonfacilitatoronexpectationsforthesimulation,goalsof thesession,andconﬁdentiality.Weobtainedwrittenconsent forstudyparticipationandvideorecordingofthe simulations,andparticipantscouldoptoutofthestudy atanytime.

Weconductedasimulatedcaseofapatientpresenting withsepsisandanarrhythmiausingthehigh-ﬁdelityHAL patientsimulator(GaumardScientiﬁcCompanyInc,Miami, FL)andequipmentpropsthataretypicallyavailableinan EDpatientroom.TheEDpharmacistsuppliedsimulated criticalcaremedicationsforuseduringthescenario.We recordedthesimulationforasynchronousrating.Thecase wasfollowedbya10–15minutedebriefwithallteam members,whichwasnotrecordedtoprotectthe psychologicalsafetyofparticipants.Afterthedebrief,the participantscompletedaself-ratingfortheentireteamusing theTeamSTEPPSTPOT2.0toincreasefamiliaritywiththe componentsofTeamSTEPPS,aswellasabriefdemographic formthatincludedtrainingyear/yearsofworkexperience, age,andgender.Weomitteditems2d,5c,and5donthe TPOT2.0,asthesewerenotrelevanttoourstudyprotocol.

Werecruitedtwoboard-certiﬁedemergencyphysicians fromoutsideinstitutionstoassessthesimulationvideo recordings.Thetworatersunderwentatwo-hourtraining sessionwheretheywereintroducedtotheprojectandthe threeinstruments.Thefacilitatoralsoreviewedanexample case,whichthereviewersindependentlyscoredandwerethen calibratedagainsteachother.Theraterssubsequently watchedanexamplevideoanddeliberatedeachitemonthe scoringsheetuntiltheyarrivedataconsensus.Ratersthen independentlyreviewedallrecordedsimulationsforwhich consentwasprovidedbyallteammembers.Ratersassessed teamperformancewiththeTPOT2.0andTEAM.They assessedleadershipbycompletingtheleadershipcategories onTPOTandTEAM,aswellastheOttawaGRS.Onlythe TPOT2.0assessmentbytheraterswasusedforcomparative dataanalysistouseobjectivethird-partyratingsratherthan theself-assessmentfromparticipants.

QualitativeStudyDesignandDataCollection

Weinvitedallvolunteerstaffparticipantsviaemailwho completedthesimulationcomponentofthestudyto participateinanindividual,semi-structuredinterviewvia Zoom(ZoomVideoCommunications,SanJose,CA).A totalof10EDstaffmembersvolunteeredtoparticipateinthe semi-structuredinterview,including ﬁvenurses,four

pharmacists,andoneEDtechnician,andeachparticipant receiveda$25giftcardascompensationfortheirtime.We alsoconductedtwofocusgroupswith ﬁveresidentteam leaders.Eachsessionlasted30–60minutes.Asinglefemale interviewer(AR)conductedallinterviewsandfocusgroups withpredeterminedquestionsthatwerethenallowedto progresstoopendialogue.

DataAnalysis-Quantitative

Wecollecteddemographicinformationandcalculated measuresofcentraltendencyforeachgroup.Wealso analyzedrater’saveragescoresandstandarddeviationsfor eachofthetools.Weperformedacorrelationanalysisofthe within-raterandbetween-raterscoresoneachtool.Wealso comparedteam-basedleaderperformancebasedonthe OttawaGRSwiththeleadershipsubsetontheTEAMand TPOT2.0.Wegeneratedvalidityevidence20,21 fortheTPOT 2.0usingcontentvalidity,internalstructure,andrelationship toothervariables.Contentvaliditywasassessedby examiningwhichperformancemeasuresparticipants thoughtshouldbeincludedinanassessmenttool.We examinedinternalstructurebyassessingcorrelations betweentheinter-raterreliabilityandselfvsraterscores. Relationshiptoothervariableswasmanifestedasconcurrent validitybycomparingthetools.Weperformeddataanalysis usingIBMSPSSv27(SPSSInc,Chicago,IL)andMicrosoft Excelv16.6(MicrosoftCorporation,Redmond,WA).

DataAnalysis-Qualitative

Ofthe63participants,15(24%)agreedtotheinterview. Wetranscribedandanonymizedtheinterviewsusingthe HIPAA-compliantsoftwareTranscribeMe!(TranscribeMe Inc,Oakland,CA)program.Twocoders(VJandDR)who werenotinvolvedineitherthesimulationorinterview processunderwentqualitativetrainingconsistingofprereadingonthematicanalysisandcompletionofaDedoose webinarv9.0.17(Dedoose,ManhattanBeach,CA)webinar. Coderscompletedaone-hourtrainingsessionusingan excerptofatranscripttodemonstratethecodingprocess.A secondexcerptwasdoneinrealtime.Thecoderswerethen given fivedaystocodethe firsttranscript.Thiswasreviewed bybothcodersandothermembersoftheresearchteamto discussandidentifypatterns.Codersthenreadalltranscripts priortostartingthe firstcodinground.Inaccordancewith BraunandClarke’ssixphasesofanalysis,22 aftercomplete read-throughofthecodedtranscripts,codersthengenerated initialcodesonthesecondreview.

Aftertheinitialround,tworesearchers(VJandDR) discussedandrefinedallindependentlycreatedcodes. Consensuswasachievedwithreviewofeachtranscriptona unifiedcodelist.Twoothermembersoftheresearchteam (ARandSW)thenreviewedthetranscriptsandcodesto developthemes.Investigatortriangulationofthemes,with attentiontothequantitative findings,wasperformedbya

thirdmemberoftheresearchteam(SS).Initialcodeand excerpttothemecategorizationresultedin67%independent agreementbetweenthetwosecondaryreviewers.Codingwas thenrevised,consolidated,andmodiﬁedbasedonconsensus. Tworesearchers(ARandSW)performedaroundoffocused re-codingandthemegeneration,anda ﬁnalreviewer(AR) performedthelastroundofcodereviewandeditswithin existingthemes.

Regardingreﬂexivity,bothcoders(DRandVJ)had signiﬁcantexperiencewithhealthcareteamsandcrisis resourcemanagementaspriorsimulationtechnicians,but werenotemployedfull-timeintheED.Whilethislimited theircontextforsomeofthequalitativeanalysis,itallowed themtofocusonteamworkandleadershipfeatureswithout preconceivednotions.Thecodereviewers(ARandSW)are emergencyphysicianswhopracticeattheacademichealth centerwherethestudywasconducted.Bothcodereviewers havebeeninvolvedinresidencyprogramleadership.AR facilitatedalltheinterviewsbutwasblindedtotheidentityof residentsandstaffduringcoding.

RESULTS

QuantitativeAnalysis

Wecompleted18simulationswith63participantsfrom January–April2021.Somecaseshadapharmacistwhohad participatedinmultiplesimulations(duetothelimited numberofclinicalpharmacistsemployedintheED);

otherwise,participantswerepartofascenarioonlyonce. Participantdemographicsarelistedin Table1 alongwiththe meanself-ratedTPOT2.0score.Missingdatapointswere omittedfromtheanalysis.

Thedescriptivestatisticsofraterscoresoneachscenario wereontheupperendofthescaleforeachofthetools.The tworaters’ scoresclusteredhighforthe ﬁve-pointTPOT2.0 (R14.90,SD0.17;R24.53,SD0.27),thefour-pointTEAM tool(R13.89,SD0.19;R23.58,SD0.39),andthesevenpointOttawaGRStool(R16.6,SD0.56;R26.2,SD0.54). Allthreescaleswerenotedtohavescoresthatcrowded aroundthemaximum.Therewerehighcorrelationsoftotal scoreforagivencasereviewedwithinthesamerater, particularlyforTEAMandOttawaGRS.Inter-rater correlationswere0.46,0.68,and0.72,respectively,forthe TPOT2.0,Ottawa,andTEAM(Table2).Yearinresidency (PGY-2,PGY-3,PGY-4)wasnotcorrelatedtoraters’ scores oneachofthetools.

QualitativeAnalysis

Weidentiﬁedsixthemesrelatedtotheindividualand team-basedperformance(Table3),includingthefollowing: 1) teammemberentrustment ;2) interdependentenergy ;3) leadershiptone ;4) optimalcommunication ;5) strategic staf ﬁ ng ;and6) simulationempoweringteamperformance Theconceptofentrustmentstemsfromthecompetencybasedmedicaleducationliterature.23 Inthesettingof

Table1. DemographiccharacteristicsandmeanscoreonTeamPerformanceObservationTool2.0.

GroupYearsofexperienceMaleFemaleMeanscoreonself-ratedTPOT ResidentsPGY-2(7residents)

PGY-3(5residents)

PGY-4(6residents)

Nurses8(3–30)51193

Techs3(1–10)5790

Pharmacists5(1–17)11688

PGY,postgraduateyear; TPOT,TeamPerformanceObservationTool.

Table2. Inter-ratercorrelationsforeachteamandleaderperformancetool.

Rater2TEAM0.450.540.660.940.731.00

TPOT,TeamPerformanceObservationTool; Ottawa,OttawaCrisisResourceManagementGlobalRatingScale; TEAM,TeamEmergencyAssessmentMeasure.

Table3. Themesreﬂectingeffectiveleadershipandteamperformance.

ThemeDescriptionExemplaryquotes Teammember entrustment

Theexpectationofteammemberstocompetently executetheirinterprofessionaltaskswithout supervisionorinterjectionandhaveasubstantial cross-understandingofrolestoprovidesupportof otherteammembertasksthroughanticipationand automaticity.

• Iguesshavingtrust,also,that,forexample,weneedIV access.Ineedtogiveepinephrineorwhatever.Justhaving thattrustthatyourteammembersaregoingtobeableto carrythatout,andthatyoudon’thavetoworryabout, “Okay. Isthishappening?Isthisnothappening?” Sohavingthat interpersonaltrustbetweenyou,yourprovider,yourother teammatesisreallyimportant.RN,participantE

• Peoplearethatwelltrainedandthingshappenautomatically, right?Youdon’tneedthedoctortobelike, “Hey,canweget anIVline?Canyouputthemonthemonitor?” Ithappens automatically.Sointhatsense,Ithinkthereisaverygood understanding,atleastinmysituation,ofwhereeveryone fallsintoplace.Pharmacist,participantH

Interdependent energy

Leadership tone

Theabilityforoneindividualtoinﬂuenceothers withnon-verbalcuesandgeneraldispositionthat inturnimpactstheenergyandperformanceof teammembers.

Optimal communication

Theidealdemeanorofaleaderthatbalances collaborativeanddecisiveactionswhile maintainingcontinuousopencommunicationand vulnerabilitywiththeteam.

• Soifthey’re,Iguess,Idon’twanttosayoutgoing,butif they’resoftspoken,ittendstobealittlebitmoreofa struggle.AndthenIthinkthatiftheyare– yeah.Ithink generally,ifthey’reawarmerperson,theteamtendstorally aroundwithalittlebitmoreexcitementoralittlebitmore energyversussomeonewithamore ﬂataffect,then everyonecomesinkindoftomatchthat.Pharmacist, participantJ

• Thatisaskill,foryoutokindofseesomeonegoingthrough averycriticalsituation,tobeabletotransformtheenergyinto somethingpositive.RN,participantC

• Ithinkhavingademeanorthat’ssortofopenandmakes peoplecomfortabletospeakup,whetherit’swithanidea theyhaveorsomethingtheyseethatsomeoneelseisnot doingrightoranything,justfeelingcomfortablespeakingup.

EDtech,participantB

• Idon’tknowifsayingasenseofhumilityistherightwayof sayingthisfortheteamleaderbutrealizingthatyoumaynot knoweverythingineverysinglemoment.

Resident,participantK

Strategic

Communicationthatisindividualizedandspoken inanappropriatetoneatanappropriatetimeto contributetothesharedmentalmodel.

Teamsizesshouldbedesignedtomeettheneeds ofthepatientcarescenario,withsmallerteams helpingtooptimizenoiseandspace.

• You’resayingthesamewords.It’sjustyourtoneisallthat’s different.Ittakesthesameamountoftime.You’renotsaving anytime,butyourtoneisimpartingasenseofurgencyfor whateverreason.AndIthinkthatbreaksdownteamwork whenpeoplearehavingtoneissues.EDtech,participantB

• Backtocommunicationforme,somakingsure – Idon’tknow howIwouldrateitorhowIwouldwordit,butwhetherthere wasclearinstructionandclearfeedback,Iguess,sothat way,youcandeterminehowwellsomethingwasunderstood orcommunicatedbetweenpeople.RN,participantE

• Ithinkthatreallydependsontheresuscitationyouaredoing. Soforthescenarioinoursimulationinparticular,Ithinkthe sizeoftheteamwasperfect.Youusuallyonlyneedone physicianandmaybeanurse,andthenplusorminus pharmacyjustdependingonhowyourinstitutionruns.Butif youarerunningacomplextraumaticresuscitation,then you’regoingtoneedmorehands,especiallywithCPR.

Resident,participantL

• Oh,definitelyhavingasmallerteamwithmorespecific definedrole,definitelyintheaspectofcrowdcontrolitmade italoteasier.Pharmacist,participantD

(Continuedonnextpage)

Table3. Continued.

ThemeDescriptionExemplaryquotes

Simulation empowering team performance Simulationisperceivedasasafeenvironmentto practiceskillsandcriticallyreﬂectduringthe debrieftobuildupteammemberentrustment

team-basedperformances, teammemberentrustment means trustingthatateammemberwillbeabletocompletearolespeciﬁctaskwithoutoversightorspeciﬁcdirection.Such entrustmentdecisionsmayneedtobemaderapidlyinthe settingofadhocEDteamsandiscriticalforbuilding relationshipsthatdriveteamdynamics.

Withinourdata,characteristicssuchasageandgenderof teammemberswerenotperceivedtoimpactentrustment. Ourparticipantsnotedthatpersonalityandprevious experiencewithsomeonemanagingacriticallyillpatientwas importantforteammemberentrustment.Inthefollowing quote,oneparticipantcommentsthatwitnessingaleader’ s abilitytomanagecriticallyillpatientsinspiredentrustment intheirleadershiprole. “Idon ’ tthinkit ’ snecessarilya numberofshifts.WhatIthinkitis,it ’ sseverityofcases.So, youmighthaveoneshiftwithsomeoneandjusthaveakiller ofadaywithESI[EmergencySeverityIndex]1sand2sand watchedthispersonrockit,andyou ’ relike, “ Okay,Iknow they ’ reonit. ” (ParticipantG,RN) Asthisteammember describes,familiaritywasanindicatorusedbyparticipantsto makequickentrustmentdecisionsintheEDsetting.

Interdependentenergy wasdescribedastheinfluenceof confidenceanddemeanorthatanindividualteammember hasduringaperformancethatappearedtoalterteam dynamicsandimpactteamsynergy.Severalparticipantsalso mentionedtheimportanceoftone-settingforacollaborative environmentand findingabalanceofhumilityand confidence,ashighlightedbythiscommentabout leadership tone “ Ihaveneverworkedwiththatdoctorbefore.ButIcan telljustbyhisdemeanorandhistonethatheknew.Hewas prettycon fi dentonwhatwasgoingon.Sothatmademe relaxandkindofcon fi dentaswell. ” (ParticipantF,RN)

Optimalcommunication wasalsonotedasakeyfactor. Thisincludesappropriatetiming,directedtowardaspecific individual,executionusingareasonabletone,and facilitationofasharedmentalmodel. Strategicstaf fi ng , specificallysmallteams,wasdescribedbyparticipantsto

• Ithinkthatallhelpeduslearnwhatpeople’sfeelingsare duringascenariolikethatandhowwecanhelpmakea differenceforthosepeoplewhenwe’rekindoftakingcareof sickpatients,especiallypatientsthatcanchangetheirclinical statusquickly,andthatthatparticularelementcanhelpyou bettertakecareofthosepatients,havingthatteamthat understandseverybodyelse’sneedsandthoughtsaswell. Resident,participantM

• Yeah,Iactuallyreallydidenjoythatsimulation.IfeltIwasa bitunpreparedwhenIwascomingintoit.Butjustbeingable tofreelyworkinasafeenvironment,that’snotreallywiththe patientwithsomeone’slifeinthebalance,Ithinkthat’sreally agreatopportunityforustobeabletogrowandjustsmooth outanykinksthere,getbetterwithourskills.

RN,participantA

optimizeperformance,withexamplessuchaskeepingthe noiselevellowandallowingfordirectcommunicationto individuals.Finally, simulationempoweringteam performance reﬂectsthatthesimulationwasdescribedby participantsasawaytopracticeskillsandsubsequently reﬂectupontheexperienceduringaninterprofessionalteam debrief.Thesessionallowedteammemberstofoster relationships,providefeedback,andbuildentrustment.

DISCUSSION

Weusedaninterprofessional,insitusimulationto evaluateteamperformanceusingmultipleinstruments.A mixed-methodsapproachallowedustogatherquantitative ratingsofperformanceandqualitativelyidentifyfeaturesof optimalinterprofessionalteamperformance.Wefoundthe twoteamassessmenttools,TPOT2.0andTEAM,poorly discriminatedwhenteamswereassessedasfunctioningwell together.Thisleaveslittleopportunityforcapturing individualcontributionstoteamperformanceforsubsetsof individualswithintheteam.Ourqualitative ﬁndingsalso suggestthattheseperformancemeasuresdonotcapture someofthedynamicinterdependentteamfeaturesthatdrive teamfunctionality.5 Movingforward, ﬁndingawayto capturedynamicfeaturesofteamrelationshipbuildingand interdependencecancomprehensivelyprovideamore accurateassessmentofteamperformance.

Our findingssuggestthattheTPOT2.0lackssufficient validityevidenceforuseintheED.Theoverallclusteringof highscoresmaysuggesteitherstrongperformerswithinour sample,itemsthataretooeasy,orvagueanchorpointsthat madeitdifficultforraterstodiscriminate.Alternatively,this toolmaynotbeoptimizedfordifferentiatingindividual performancewithinhigh-performingteams.Theinter-relater reliabilityIRRoftheTPOTwaslowat0.46(Table2),which mayreflectlimitedrateragreementand,therefore,reliability ofthetool.Finally,weidentifiedseveralfeaturesofteam performancethatparticipantsfeltwerenotsufficiently

capturedintheassessmenttool,mainlyentrustmentfeatures relatedtoanticipationandautomaticity,leadershiptone, andinterdependentenergy.

Additionally,ourqualitativeanalysisprovidedinsighton thefeaturesofteamdynamicsthatmaybeimportantfor optimizingperformance.Entrustmentamongfellowteam membersoccurswhenindividualsservinginvarious interprofessionalrolesaretrustedtofunctionwithinthe scopeoftheirpractice.Entrustmentinourqualitative analysiswaslargelydrivenbystrongrolecompetence, anticipation,andautomaticity.Whilecompetencemaycome fromtrainingandexperience,anticipationandautomaticity areuniquelyimportantforeachmemberofarapidlyforming adhocteaminhigh-stakessituationsliketheED.Because everyresuscitationisslightlydifferent,automaticityand anticipationcannotbebasedonanalgorithmbutratheron pattern-recognitionandcreationofsharedunderstanding,an innatelyinterdependentprocess.Whileanticipationis reﬂectedintheTEAMtool,neitherisexplicitly representedintheTPOT.Otherfeaturesthatarehighly importanttoEDteamstoemphasizeinperformance toolsincludedinterdependentenergyandtone ofcommunication.

Situatingthese ﬁndingsinthebroaderliterature,ED teamsareinterdisciplinaryactionteamsthattaskmultiple, highlyspecializedprofessionalswithacriticalsituation.24 FernandezetalproposedarobustmodelforEMteamwork taxonomytocapturetheprocessaswellastheoutcome.25 Thisincludesthestagesofplanningprocesses,action processes,reﬂectionprocesses,andsupportingmechanisms. Accordingtothismodel,teamswillgobackandforth between actionprocesses focusedongoalsand transition processes thatallowforplanning.Bothstagesare highlydependentuponinterpersonalfactorsbetween teammembers.

Twooftheactionprocesses “backupbehavior” of managingteammembers’ tasksand “coordination” ofthe inherentlyinterdependentorderofactivities are fundamentallydependentonthisdescribedconstructofteam memberentrustment.25,26 Thisidearesonateswiththe conceptofcollaborativeinterdependence15 inwhichteam memberscometogetherandleveragethestrengthsofone another.Entrustmentmaybeanecessarysteptoward establishingateam’scollaborativeinterdependenceasits absencemayleadtoabreakdowninteamfunctioning. Ourstudyhelpeddiscernteammemberactionsandfactors thatmaycontributetorapidentrustabilityandguidethese actionprocesses,eveninadhocteams,including demonstrationofrolecompetency,automaticfulﬁllment ofduties,andanticipationofnextactions.Toimprove interprofessionalteamperformanceassessment,weneed moregranularresuscitation-speciﬁcperformancemeasures thatcaptureteammemberentrustment,23 leadershiptone, andinterdependence.4,23

EducationalImplications

Our findingthatpostgraduateyear(PGY)leveldidnot correlatewithteamperformancescoreshighlightsthe challengeofassessingresuscitationleadershipduetothe interdependentnatureofteamperformance.5,27–28 Inthe movetowardcompetency-basededucationand implementationofEntrustableProfessionalActivitiesinthe workplace,29 thisiscriticallyimportant.APGY-2may,for instance,befalselyassessedasfullyentrustablebasedonthe resuscitationofapatientintheclinicalsetting,wheninfact theirperformancewashighlyinfluencedbyother experiencedteammembers.Thisunderscorestheinherent challengesofresidentassessmentintheclinicalsetting,dueto theconstantinterdependentworkflowswithotherteam members.Weproposethatfutureteamassessmentskills involveleadershiptoneandenergyasplayedoutinthe interdependentworkflowoftheteam.Thiscanonlybe accuratelyassessedinthecontextofinterprofessionalteams intheworkplacethroughcollectionofbothobservationsand gatheringteammemberexperienceoftone,energy, andentrustment.

LIMITATIONS

Weperformedthisstudyatasingleacademicinstitution and,thus,the findingsrepresentthecultureand characteristicsofthatsetting.Furtherresearchisneededto assessthetransferabilityofour findingstoothercontexts. Thestudyparticipantswerefromaconveniencesample, whichmaylimitthegeneralizabilityoftheseresults. Furthermore,thenursingstaffwasnotedtobevery experiencedwithamedianofeightyearsinpractice;thismay havepositivelyinfluencedteamperformanceand contributedtothehighscoresweobservedacrossthetools.It isalsopossiblethat filmingthescenariosmayhave contributedtoaHawthorneeffect.Whileallparticipants wereofferedanopportunitytoparticipateinthequalitative interviews,onlyasmallersubsetdid,whichlimitsthe transferabilityofour findingsasthosechoosingtoparticipate maybedifferentthanthosewhodidnot.Finally,thecase usedamannequininsteadofarealpatient,whichoffersa blanketofpsychologicalsafetythatarealclinicalscenario doesnot.

CONCLUSION

Thismixed-methodsstudyidentiﬁedlimitationsofcurrent toolsforassessingteam-basedperformanceandoffers opportunitiesforimprovement.Futuretoolsassessingteam performanceshouldfocusoncapturingentrustment, leadershiptone,andinterdependence.

AddressforCorrespondence:AshleyC.Rider,MDMEHP,Stanford University,DepartmentofEmergencyMedicine,900WelchRd., Suite#350,PaloAlto,CA94304.Email: ashrider@stanford.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisresearchwasgenerously supportedbygrantfundingfromtheEmergencyMedicine Foundation/CouncilofResidencyDirectorsinEmergencyMedicine EducationScholarshipStarterGrant.Therearenootherconflictsof interestorsourcesoffundingtodeclare.

REFERENCES

1.ClancyCMandTornbergDN.TeamSTEPPS:assuringoptimal teamworkinclinicalsettings. AmJMedQual. 2007;22(3):214–7.

2.HaydenEM,WongAH,AckermanJ,etal.Humanfactorsandsimulation inemergencymedicine. AcadEmergMed. 2018;25(2):221–9.

3.SutcliffeKM,LewtonE,RosenthalMM.Communicationfailures:an insidiouscontributortomedicalmishaps. AcadMed. 2004;79(2):186–94.

4.Sebok-SyerSS,ChahineS,WatlingCJ,etal.Consideringthe interdependenceofclinicalperformance:implicationsforassessment andentrustment. MedEduc 2018;52(9):970–80.

5.Sebok-SyerSS,ShawJM,AsgharF,etal.Ascopingreviewof approachesformeasuring ‘interdependent’ collaborativeperformances. MedEduc. 2021;55(10):1123–30.

6.SalasE,SimsDE,BurkeCS.Isthereabig5inteamwork? SmallGroup Res. 2005;36(5):555–99.

7.BoetS,EtheringtonN,LarriganS,etal.Measuringtheteamwork performanceofteamsincrisissituations:asystematicreviewof assessmenttoolsandtheirmeasurementproperties. BMJQualSaf. 2019;28(4):327–37.

8.KimJ,NeilipovitzD,CardinalP,etal.Apilotstudyusinghigh-ﬁdelity simulationtoformallyevaluateperformanceintheresuscitationof criticallyillpatients:theUniversityofOttawaCriticalCareMedicine, High-FidelitySimulation,andCrisisResourceManagementIStudy. Crit CareMed. 2006;34(8):2167–74.

9.ZhangC,MillerC,VolkmanK,etal.Evaluationoftheteamperformance observationtoolwithtargetedbehavioralmarkersinsimulation-based interprofessionaleducation. JInterprofCare. 2015;29(3):202–8.

10.McKayA,WalkerST,BrettSJ,etal.Teamperformanceinresuscitation teams:comparisonandcritiqueoftworecentlydevelopedscoringtools. Resuscitation. 2012;83(12):1478–83.

11.KarlgrenK,DahlströmA,BirkestamA,etal.TheTEAMinstrumentfor measuringemergencyteamperformance:validationoftheSwedish versionattwoemergencydepartments. ScandJTraumaResuscEmerg Med. 2021;20;29(1):139.

12.CooperS,CantR,PorterJ,etal.Managingpatientdeterioration: assessingteamworkandindividualperformance. EmergMedJ. 2013;30(5):377–81.

13.CooperS,CantR,ConnellC,etal.Measuringteamworkperformance: validitytestingoftheTeamEmergencyAssessmentMeasure(TEAM) withclinicalresuscitationteams. Resuscitation. 2016;101:97–101.

14.WalkerK,AsoodarM,RudolphJ,etal.Optimisingexpertdyad performanceinacutecaresettings:ascopingreviewprotocol. BMJ Open. 2021;11(7):e047260.

15.Sebok-SyerSS,LingardL,PanzaM,etal.Supportiveandcollaborative interdependence:distinguishingresidents’ contributionswithinhealth careteams. MedEduc. 2023;57(10):921–31.

16.BaxterPandJackS.Qualitativecasestudymethodology:study designandimplementationfornoviceresearchers. QualRep. 2008;13(4):544–59.

17.EdwardsDJA.Typesofcasestudywork:aconceptualframeworkfor case-basedresearch. JHumanistPsychol. 1998;38(3):36–70.

18.YinRK. CaseStudyResearch:DesignandMethods,3rded.Thousand Oaks,CA:SagePublishing,2003.

19.LincolnYS,LynhamSA,GubaEG.Paradigmaticcontroversies, contradictions,andemergingconﬂuences,revisited. TheSage HandbookofQualitativeResearch.ThousandOaks,CA:SAGE Publications,2011,p.97–128.

20.DowningSM.Validity:onmeaningfulinterpretationofassessmentdata. MedEduc. 2003;37(9):830–7.

21.CookDAandBeckmanTJ.Currentconceptsinvalidityandreliability forpsychometricinstruments:theoryandapplication. AmJMed. 2006;119(2):e7–16.

22.BraunVandClarkeV.Usingthematicanalysisinpsychology. QualRes Psychol. 2006;3(2):77–101.

23.TenCateOandTaylorDR.Therecommendeddescriptionofan entrustableprofessionalactivity:AMEEGuideno.140. MedTeach. 2021;43(10):1106–14.

24.RosenmanED,BranzettiJB,FernandezR.Assessingteamleadership inemergencymedicine:themilestonesandbeyond. JGradMedEduc. 2016;8(3):332–40.

25.FernandezR,KozlowskiSW,ShapiroMJ,etal.Towarda deﬁnitionofteamworkinemergencymedicine. AcadEmergMed. 2008;15(11):1104–12.

26.TeslukPE,MathieuJE,ZaccaroSJ,etal.Taskandaggregationissues intheanalysisandassessmentofteamperformance.InBrannickMT, SalasE,PrinceC(Eds.). TeamPerformanceandMeasurement: Theory,Methods,andApplications.Mahwah,NJ:LawrenceErlbaum Associates,1997.

27.TenCateOandChenHC.Theparts,thesum,andthewhole:evaluating studentsinteams. MedTeach. 2016;38(7):639–41.

28.HodgesB.Assessmentinthepostpsychometricera:learningtolovethe subjectiveandcollective. MedTeach. 2013;35(7):564–8.

29.TenCateO,BalmerDF,Caretta-WeyerH,etal.Entrustable professionalactivitiesandentrustmentdecisionmaking:a developmentandresearchagendaforthenextdecade. AcadMed. 2021;96(7S):S96–104.

JeffreyB.Brown,BS

AjayK.Varadhan,BS

JacobR.Albers,BA,MS

ShreyasKudrimoti,BA

EstelleCervantes,MD

PhillipSgobba,MD,MBS

DawnM.Yenser,C-TAGME

BryanG.Kane,MD

SectionEditor:JeffreyDruck,MD

LehighValleyHealthNetwork,UniversityofSouthFloridaMorsaniCollegeofMedicine, DepartmentofEmergencyandHospitalMedicine,Allentown,Pennsylvania

Submissionhistory:SubmittedApril20,2023;RevisionreceivedFebruary27,2024;AcceptedMarch5,2024

ElectronicallypublishedJune20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18082

Introduction: Evidence-basedmedicine(EBM)isacriticalskillforphysicians,andEBMcompetency hasbeenshowntoincreaseimplementationofbestmedicalpractices,reducemedicalerrors,and increasepatient-centeredcare.Likeanyskill,EBMmustbepracticed,receivingiterativefeedbackto improvelearners’ comprehension.Havingresidentsdocumentpatientinteractionsinlogbookstoallow forresidencyprogramreview,feedback,anddocumentationofcompetencyhasbeenpreviously describedasabestpracticewithinemergencymedicine(EM)todocumentpractice-basedlearning (PBL)competency.Quantifyinghowresidentsusetheinformationtheyquery,locate,evaluate,and applywhileprovidingdirectpatientcarecanmeasuretheefﬁcacyofEBMeducationandprovideinsight intomoreefﬁcientwaysofprovidingmedicalcare.

Methods: Practice-basedlearninglogsweresurveyscreatedtorecordresidentEBMactivityon-shift andwereplacedintoourresidencymanagementsoftwareprogram.Residentswererequiredtosubmit 3–5surveysofEBMactivityperformedduringa28-dayrotationduringwhichadditionalinformationwas sought.ThisstudyincludedallPBLlogscompletedbyEMresidentsfromJune1,2013–May11,2020. Usingqualitativemethodology,acodebookwascreatedtoanalyzeresidents’ free-textresponsestothe prompt: “Basedonyourresearch,wouldyouhavedoneanythingdifferently?” Thecodebookwas designedtogenerateathree-digitcodeconveyingtheeffectoftheresearchedinformationonthepatient aboutwhomthelogwaswritten,aswellaswhethertheinformationwouldaffectfuturepatientcareand whetherthesedecisionswerebasedonscientiﬁcevidence.

Results: Atotalof10,574logswereincludedforprimaryanalysis.Intotal,1,977(18.7%)logsindicated thattheevidenceacquiredthroughresearchwouldaffectfuturepatientcare.Ofthese,392(3.7%) explicitlystatedthattheEBMactivityconductedaspartofourprojectledtoreal-timechangesinpatient careintheEDandwouldchangefuturemanagementofpatientsaswell.

Conclusion: WepresentaproofofconceptthatPBLlogactivitycanleadtointegrationofevidencebasedmedicineintoreal-timepatientcare.Whileaconveniencesample,ourcohortrecordedevidence ofbothlifelonglearningandapplicationtopatientcare.[WestJEmergMed.2024;25(4)565–573.]

INTRODUCTION

Medicaldiagnosticsandtreatmentsareconstantly changing,makingitdifﬁcultforphysicianstostaycurrent withthecaretheyprovide.Evidence-basedmedicine(EBM), whichistheprocessofresearchingandapplyingnewmedical information,fallsunderthebroadereducationalcategoryof practice-basedlearning(PBL).1,2 Evidence-basedmedicineis acriticalskillforphysicians,andEBMcompetencyincreases implementationofbestmedicalpractices,reducesmedical errors,andimprovespatient-centeredcare3,4.EBMis frequentlyusedtogeneratepoliciesandguidelinesto improvethequalityofcaredelivered.5 Thus,itiscrucialto learnandapplyEBMskillsthroughoutmedicaltraining. Likeanyskill,EBMmustbepracticed,receivingiterative feedback.Priorliteraturehasdemonstratedthevalueofthe useoflogbookstodocumentresidentprogression towardcompetency.6

TheAccreditationCouncilonGraduateMedical Education(ACGME)hasmandatedthatresidency programsmonitorresidentperformanceinmultipleareas, includingEBM,withinthePBLcompetency.1 Resident competenceismeasuredbyobservableandmeasurable ACGMEMilestonebehaviors.7 Speciﬁcapproachestothese requirementsarenotexternallydeﬁned;rathertheyareleftto boththeprogramdirectorandtheappointedprogram evaluationcommittee(PEC).1 Havingresidentsdocument patientinteractionsinlogbookstoallowforresidency programreview,feedback,anddocumentationof competencyhasbeenpreviouslydescribedasbestpractice withinEMtodocumentPBLcompetency.8 Priorstudyof EBMhasdemonstratedthatpostgraduateexperienceand genderbothimpactthelearningneedsofresidents.9

Evidence-basedmedicineconsistsoffourkeysteps:asking ananswerablequestion;efficientlysearchingforevidence; appraisingtheevidenceforreliability;andapplyingthat evidence.10 A2010surveyofEMprogramdirectorsand facultyreportedthatthemostimportantEBMskillsets developedbyresidentsweretheabilitytoappraisethe reliabilityofevidencethey findandapplyresearch findingsto patientcare.8 Residentsurveyscanbeusedtorecordhow eachindividualapproachesEBM,althoughthisapproach hasthesameinherentlimitationsofallsurveystudies.The FresnotestofEBMisastandardizedmeansofassessment andfeedbackonthetopic.11 Thetesttakesaround40 minutestocompleteand12minutestograde.12 However, noneoftheseEBMeducationstudiesmeasureitsimpacton directpatientcare,despiteKirkpatrick’shierarchyplacing impactonpatientcareatthetopoftheeducational evaluationpyramid.13

Priorresearchhasdemonstratedthatreal-timeEBMmay leadtoimplementationofbestcarepractices.14 Quantifying howresidentsusetheinformationtheyquery,locate, evaluate,andapplywhenprovidingdirectpatientcarecan measuretheefﬁcacyofEBMeducationandyieldinsightinto

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Quantifyinghowresidentsuseinformation retrievedfromscienti ﬁ cevidenceis animportantsubjectinneedof furtherinvestigation.

Whatwastheresearchquestion? Doesevidencefoundbyresidentsimpacttheir currentorfutureclinicalpractices?

Whatwasthemajor ﬁndingofthestudy?

18.7%oflogsshowedthattheEBMsearch wouldaffectfuturepatientcare,and 3.7%stateditchangedEDpatientcarein realtime.

Howdoesthisimprovepopulationhealth? Moreeffectivequanti ﬁ cationofevidencebasedclinicalpracticechangeswillallow instructorstoidentifyeducationalgapsand closethem.

moreefﬁcientwaystoprovidemedicalcare.15 Ourpurposein thisstudywastoreviewresidents’ PBLpatientlogsasa measureofEBMactivityamongresidentsandtodetermine thedirectimpactofthisEBMactivityonbothcurrentand futurepatientcare.

METHODS

Thiswasaninstitutionalreviewboard-approved retrospectivereviewofself-reportedlearningconductedatan ACGME-approvedpostgraduateyear(PGY)1–4EM residencyprogram,whichtrainsapproximately14residents peryear.Theprogramislocatedatanindependentacademic centerwithinanintegratedhealthcarenetwork.TheEBM curriculumatthisinstitutionwastaughtprimarilywithin interactivejournalclubsbasedonPGYandwas supplementedwithdidacticsthatinvolvedreal-timeaudience responsequestions,inaccordancewithbestpractices.9 The corejournalclub(attendedbyPGY-1and-2residents) measurededucationalefﬁcacywiththeFresnotestofEBM andhadtopicsbasedonitscontent.11 Residentstookthe FresnotestofEBMandreceivedfeedbackontheir performanceonthatinstrumentduringprotectedtimein grandroundsinMayorJuneattheendofPGY-2. Seniorjournalclub(attendedbyPGY-3and-4residents) focusedoncriticalappraisal,knowledgetranslation,and implementationscience.Theseniorjournalclubscontained

separatelearninggoalsandassignments.Dependingon grandrounddidacticschedulingandfacultyavailability,the audienceresponsesystemquestionsandinteractive discussionsoccurredbothinlargegroup(allresidentsPGY 1–4)andsmallgroups-basedsettings(PGY1,2inoneroom, andPGY3,4inanother).Bothjournalclubsusedarecurring 12-monthcurriculumcontainingstandardizedEBM teachingarticlespairedwithtopicalclinicalexercises (Table1).Corejournalclubmaterialswereassignedtothe PGY-1and-2residentsandseniormaterialstothePGY-3 and-4residents.

Supplementalmaterialswereusedbyallresidentsduring twoone-hourEBMdidacticsheldoutsidejournalclub.Inthe fall,thelecturecovered2x2grids/likelihoodratios/Bayesian

logic.Inthespring,thelecturereviewedcommonlyused researchmethodologies.Theclinicalcontentofthe DecemberandJunejournalclubswasrapidabstractreview fromthemostrecentmeetingsoftheAmericanCollegeof EmergencyPhysicians(December)andtheSocietyfor AcademicEmergencyMedicine(June).Theclinicalcontent fortheremainingjournalclubswasselectedfromrecent literaturetohighlightthecoretopicbeingtaughtthatmonth. AfterreviewandapprovalbythePEC,residentswere requiredtodocumentEBMactivityintheprogram’ s procedurerecorder.Theserecords,referredtoasPBLlogs, weredevelopedfrompatientfollow-uplogsdisseminatedby theCouncilofResidencyDirectorsinEmergencyMedicine (CORD).7,16 Table2 demonstratestheelementsofthePBL

Table1. Theevidence-basedmedicinecurriculumadministeredtoresidentsoverthecourseofayear.

Month/Topic (Fresno question)Evidence-basedmedicinecoreteachingarticleSeniorandsupplementalmaterials

July PICOquestion (1a,1b)

August Hierarchyand locationsof evidence (2,3,11,12)

September Searchstrategies (2,3,4)

GuyattG,MeadeMO,AgoritsasT,etal.(2015).Whatis thequestion?InGuyattG,RennieD,MeadeMO,Cook DJ(Eds.), Users’ GuidestotheMedicalLiterature:A ManualforEvidence-BasedClinicalPractice,3rded (1–9)NewYork,NY:McGrawHill.

BhandariM,GiannoudisPV.Evidence-basedmedicine: Whatitisandwhatitisnot. Injury.2006;37(4):302–6.

McKibbonA,WyerP,Jaeschke,R,etal.(2002). Findingtheevidence.InGuyattG,RennieD,Meade MO,&CookDJ(Eds.), Users’ GuidestotheMedical Literature:AManualforEvidence-BasedClinical Practice2nded. (29–58).NewYork, NY:McGraw-HillMedical.

Seniorjournalclub:Residentasteacher. BarrettNF,GopalB.Usingthe ﬁvemicroskills withdifferentlearningpreferences. FamMed 2008;40(8):543–5.

Seniorjournalclub:Knowledgetranslation LangES,WyerPC,HaynesRB.Knowledgetranslation: closingtheevidence-to-practicegap. AnnEmergMed 2007;49(3):355–63.

Seniorjournalclub:Implementationscience deWitK,CurranJ,ThomaB,etal.Reviewof implementationstrategiestochangehealthcare providerbehaviourintheemergencydepartment. CJEM.2018;20(3):453–60.

October Externalvalidity (5)

RothwellPM.Externalvalidityofrandomisedcontrolled trials: “towhomdotheresultsofthistrialapply?” Lancet.2005;365(9453):82–93.

November

Likelihoodratios (8)

December

Numberneeded totreat (9)

HaydenSR,BrownMD.Likelihoodratio:apowerfultool forincorporatingtheresultsofadiagnostictestinto clinicaldecisionmaking. AnnEmergMed 1999;33(5):575–80.

CordellWH.Numberneededtotreat(NNT). AnnEmergMed.1999;33(4):433–6.

Supplementalarticleson2x2grids: LoongTW.Understandingsensitivityandspeciﬁcitywith therightsideofthebrain[publishedcorrection appearsinBMJ.2003Nov1;327(7422):1043]. BMJ 2003;327(7417):716–9. GallagherEJ.Evidence-basedemergencymedicine/ editorial.Theproblemwithsensitivityandspeciﬁcity. AnnEmergMed.2003;42(2):298–303.

Supplementallecture:Bayesianlogic.Thisadditional lectureoutsideofjournalclubintroducesbasic2x2grid conceptsandextendsthemintohowtouseEBMon shifttoachieveclinicaldiagnosis. SlawsonDC,ShaughnessyAF.Teachinginformation mastery:thecaseofbabyJeffandtheimportanceof Bayes’ theorem. FamMed.2002;34(2):140–2.

Nosupplementalmaterialsgiventhismonth.Both residentgroupsusedcorematerialsindicated immediatelytotheleft.

(Continuedonnextpage)

Table1. Continued.

Month/Topic (Fresno question)Evidence-basedmedicinecoreteachingarticleSeniorandsupplementalmaterials

January Signi ﬁcance (7)

SingerAJ,ThodeHCJr,HollanderJE.Research fundamentals:selectionanddevelopmentofclinical outcomemeasures. AcadEmergMed 2000;7(4):397–401.

February

Criticalappraisal: diagnostics

March

Criticalappraisal: therapeutics

SchranzDA,DunnMA.Evidence-basedmedicine,part 3.Anintroductiontocriticalappraisalofarticleson diagnosis. JAmOsteopathAssoc.2007;107(8):304–9.

CardarelliR,VirgilioRF,TaylorL.Evidence-based medicine,part2.Anintroductiontocriticalappraisalof articlesontherapy. JAmOsteopathAssoc 2007;107(8):299–303.

April Communication MontoriVM,DevereauxPJ,StrausS,etal.(2002). Advancedtopicsinmovingfromevidencetoaction: decisionmakingandthepatient.InGuyattG,RennieD, MeadeMO,&CookDJ(Eds.), Users’ Guidestothe MedicalLiterature:AManualforEvidence-Based ClinicalPractice2nded. (643–61).NewYork, NY:McGraw-HillMedical.

May (OPENEBM topic,research day)

June

Con ﬁdence intervals (10)

Note:TopicdeterminedbyEBMTrackResidents Note2:Question6ontheFresno(internalvalidity)is reviewedintheappraisalofarticlesineachjournal club.

YoungKD,LewisRJ.Whatisconﬁdence?Part1:The useandinterpretationofconﬁdenceintervals. Ann EmergMed.1997;30(3):307–10.

Seniorjournalclub:Sourcesofcriticalappraisal.These sourcesareusedforthecriticalappraisalforms throughouttheyear.

Formsinclude AnnalsofEmergencyMedicine (https:// www.annemergmed.com/content/ebemform)andthe CentreforEvidenceBasedMedicine,whichhasa collectioninmultiplelanguages(https://www.cebm.ox. ac.uk/resources/ebm-tools/critical-appraisal-tools).

Supplementalarticleonmethodology: ThompsonCB,PanacekEA.Researchstudydesigns: experimentalandquasi-experimental. AirMedJ 2006;25(6):242–6.

Supplementallecture:ReviewofMethodology Thislectureisgivenoutsideofjournalclubtoreview andreinforcethehierarchyofevidenceandthe internalvalidityofarticles.

Nosupplementalmaterialsgiventhismonth.Both residentgroupsusedcorematerialsindicated immediatelytotheleft.

PICO,population,intervention,control,andoutcomes; EBM,evidence-basedmedicine.

logs’ associatedexpectations,andareasoffeedbackbyPGY. TheselogswerefromaconveniencesampleofEBMactivity andwerenotarecordofallpatientsseen.Onefaculty memberreviewedeverylog,andeachresidentwas

providedwithindividualizedfeedbackfromthesame facultymember.

ResidentswererequiredtocreatetheirPBLlogsduring rotationsintheemergencydepartment(ED).Theselogswere

Table2. Practice-basedlearninglogsandexpectations,stratiﬁedbypostgraduateyear.Thetoprowindicatespractice-basedlearninglog categories,whilerows2–4indicatestheexpectedcapabilitiesofresidents.

PGYClinicalquestion Clinical question answer Methodofobtaining information Basedonyourresearch,would youhavedoneanythingdifferently?

1PICOquestion, searchstrategy Identifysourceofinformation andverifyreliability

2SearchstrategyEvidencefoundIdentifysigniﬁcanceoftheinformation

3 + 4 EvidencefoundCriticalappraisalofinformationreliability, applicationofinformationtopractice

PGY,postgraduateyear; PICO, population,intervention,control,andoutcomes.

subsequentlyplacedintoourresidencymanagement softwareprogram(NewInnovationsInc,Uniontown,OH). ResidentswererequiredtosubmitsurveysofEBMactivity performedduring28-dayEMrotations.Thenumber requiredperrotationbythePECvariedbetweenthe academicyearsincludedinthisstudyfromahighof ﬁveat thebeginningofthecohortdowntothreeattheend.The annualnumberofEMrotationsvariedbyPGY,fromsix (PGY1)toeight(PGY4).Thenumberofresidentsperclass atthebeginningofthecohortwas13,andthecomplement increasedto16duringthestudy.

WeincludedallPBLlogscompletedbyEMresidentsfrom June1,2013–May11,2020.Recordswereanonymizedto PGYyearandgender,inaccordancewithHadleyetal.9 No otheridentiﬁerswereincludedinthisstudy.Usingqualitative methodologydescribedbyMacQueen,wecreateda codebooktoanalyzeresidents’ free-textresponsestothe prompt: “Basedonyourresearch,wouldyouhavedone anythingdifferently?”17 Thegoalofthecodebookwasto categorizeandquantifytheeffectofeachlogonaresident’ s patientcare.Eachlogwasassignedathree-digitcodebased ontheanswertothreequestions.The ﬁrstdigitofthecode correspondedtotheanswertothequestion, “Didthe researchaffectthecareofthecurrentpatientaboutwhichthe logwaswritten?” Theseconddigitrepresentedparticipant answerstothequestion, “Willinformationresearched changethefuturecareofpatients?” Lastly,thethirddigit representedtheanswertothequestion, “Werethechanges describedindigittwoinconcordancewiththeresearchthey found?” Digitswereassignedtoanswereachofthese questions(Table3).

Logswerecodedbythreeindividualswithasingleoverridingadjudicator.Allindividualsinvolvedincodinglogs mettocodethe ﬁrst200logstogethertocreateaconsensus forgradingandmetthroughouttheentiretyoftheprojectto reviewlogswithunclearcoding.Inter-raterreliabilitywas

notformallymeasured.Weconductedsubgroupanalysis basedonPGYandresidentgenderviathechi-squaretestto assessfordifferencesinlogcoding.Iftheresidentdidnot specifytheirgenderorPGY,weexcludedthelogfromthe respectivesubgroupanalysis.

RESULTS

Atotalof11,145logswereenteredduringthestudy period.Theselogsweresubmittedby137residents,ofwhom 48(37%)werefemale.Weexcludedatotalof571logsfrom analysis:298wereincomplete,and273wereduplicates.After theseexclusions,10,574logsansweredtheprompt, “Based onyourresearch,wouldyouhavedoneanything differently?” andwereincludedinprimaryanalysis(Figure).

The fivemostcommonlogcodesaccountedfor approximately85.4%(n = 9,034)ofthetotallogs.Themost commonlogcodewas231in3,343logs(31.6%),which signifiedself-directedlearningwithoutapplicationof knowledgetothecurrentpatientandwithoutspecifying applicationofknowledgetofuturepatients.Thesecondmost commoncodewas331in2,263logs(21.4%),whichsimilarly recordedself-directedlearningwithoutspecificationof applicationofknowledgetothecurrentorfuturepatients. Researchconfirmingresidents’ plansofcarewascodedas 221andtotaled1,319logs(21.4%).Thenexthighestcount was211in1,062logs(10.0%),whichrepresentedlogsthatdid notchangethecareofthecorrespondingpatientbut reportedlywouldchangethecareoffuturepatients.Thecode 131accountedfor1,047(9.9%)logs,whichchangedthecare ofthecorrespondingpatientandmayormaynotchange futurecareofpatients.

Themostimpactfullogswerethosethatspeciﬁcallystated thattheresearchconductedwouldchangefuture managementofpatients(eg,codedas111,211,311,411).In total,1,977logs(18.7%)indicatedtheevidenceacquired throughresearchwouldaffectfuturepatientcare.Ofthese,

Table3. Practice-basedlearninglogcodebook.Theanswerstothesethreequestionswerecodedtogenerateathree-digitnumber describingtheimpactaresident’sresearchhadontheirperformance.

Digit1:Did research affectcare?

Digit2:Will researchaffectcare inthefuture?

Digit3:Isthechangeinfuture carebasedontheresearched evidence?

392(3.7%ofentirestudysample)explicitlystatedthatthe EBMactivityconductedaspartofourprojectledtorealtimechangesinpatientcareintheEDandwouldchange futuremanagementofpatientsaswell.Afulllistofthe10 mostcommoncodescanbefoundin Table4

Postgraduateyearsubgroupanalysisfound first-year residentsrecordedthemostlogs(602,23.3%)thatindicated researchwouldleadtoafuturechangeinpatient management(allcodesincluding1astheseconddigit).There wasasignificantdifferenceintheselogsbetweenPGY (P < 0.001),andatrendwasseenwhereincreasingPGYwas associatedwithdecreasedchanceofalogchangingfuture patientcare.Thenumberoflogsindicatingfuturecare changesincreasedinPGY4,potentiallyduetodedicated feedbackreceivedontheirPBLlogs.Therewasnosignificant differenceinthenumberoflogsthatrecordedbothreal-time changeandfuturemanagementchangebetweenPGY (P = 0.70).Subgroupanalysisofresidentgenderfoundno significantdifferenceincurrentorfuturepatientcare resultingfromevidencefound.Whilenotmeetingthestudy’ s significancecriterionof α < 0.05,moremalesindicatedrealtimeandfuturecarechangeintheirlogs(254),ascompared totheirfemalecounterparts(106, P = 0.05).Subgroup analysiscanbeseenin Table5

DISCUSSION

Evidence-basedmedicineformsthecornerstoneof modernclinicalpractice,andeffectivelyteachingresidentsto conducttheirownEBMinformationacquisitionand

Table4. The10mostcommonlyreportedpractice-basedlearning logcounts,stratiﬁedbypostgraduateyear.

CodeTotal(%)PGY1(%)PGY2(%)PGY3(%)PGY4(%)

PGY,postgraduateyear.

appraisalisparamountingraduatemedicaleducation.While boththeACGMEandCORDrequirethatEBMbetaught throughoutresidency,thereislittledataassessingtheimpact andrelativebeneﬁttoresidentsofEBMsearchmethods.Our analysisincluded10,574PBLlogsfrom137residentsacross eightacademicyears.Ourresultsshowedthat18.7%oflogs indicatedthatresidentsacquirednewevidence-based medicalinformationandappliedthatknowledgeinreal-time tochangethecurrentorfuturecareoftheirpatients.These positiveeducationallogswerefoundmoreofteninthelogsof PGY-1and-4residentsthaninthoseofPGY-2and-3 residents.Thisobservationmayberelatedtobackground searchesleadingtonewknowledge(PGY1)andtheabilityto criticallyappraise(PGY4).Changinglearningstylesin residencyhasbeenshowntobelinkedtothenumberofhours worked,andinourtrainingprogramthePGY-2and-3 residentshavemoreintenserotationsthaninPGY-1.18 AnothercontributingfactortotheincreaseseeninPGY-4 residentscouldbethededicatedfeedbackonthiscomponent ofthePBLlog,whichisprovidedtoPGY-3and-4 residents(Table2).

Evidence-basedmedicine,likeotherresidencyprocedures, isalearnedskillthatmustbepracticed.19 Logsare consistentlyusedacrossresidencyprogramstotrackprogress oftraditionalskills;however,thereislimitedliterature

Figure. Practice-basedlearninglogstudyinclusioncriteriaand selectionprocess.

Table5. Distributionofpractice-basedlearninglogsandtheireffects,stratiﬁedbygenderandpostgraduateyear.

Totalnumberoflogs(%)

Gender

Futurecarechange (eg,111,211,etc)(%) P-value

Real-timeandfuturecarechange (eg,111only)(%) P-value

Female3,505(34.3)617(33.1)0.27106(29.4)0.05

Male6,705(65.7)1,246(66.9)254(70.6)

Total10,210(100.0)1,863(100.0)360(100.0)

Postgraduateyear

12,587(24.5)602(30.5) <0.00197(24.7)0.70

22,565(24.3)477(24.1)92(23.5)

32,247(21.3)388(19.6)92(23.5)

43,175(30.0)510(28.3)111(28.3)

Total10,574(100.0)1,977(100.0)392(100.0)

describinghowtotrackEBMskillprogression.20 Some elementsofteaching,particularlyprovidingfeedbackto learners,areacknowledgedasbeneﬁcialtoskill development.21 Theapproachdescribedhere,usinga program ’straditionallogandfacultyfeedbacktoassess EBMlikeotherproceduralcompetencies,hasbeendescribed asabestpractice.8,21 Inadditiontothediscussionand demonstrationofEBMskillsincludingappraisalthat occurredinjournalclub,individualfeedbackwasgivenbya singlefacultymember(asshownin Table2)ofalllogsinthe clinicalcompetencycommitteemeetingsandinresidents’ semi-annualevaluations.Minimalliteratureexistswherein theeffectofresidentEBMactivityonpatientcarewas measured.Friedmanetaldidinvestigatethisquestion; however,thestudywascriticizedfornotofferingawayfor residentstoimprovetheirappraisalskills.22,23

ByconductingEBMlearninginaninteractivejournal clubsetting,supplementedwithdidacticsthatinvolvedrealtimeaudienceresponsequestions,studentswereableto engagewiththeirinstructorsandreceivemore comprehensivefeedbackontheirmethodsandthe implicationsoftheir ﬁndings.Inaddition,weusedan electronictoolthatdirectlylinkedEBMresourcestothe electronichealthrecordtoeaseaccessduringrotations. Theseexpandedfunctionalitiesalsoallowedustomonitor theimplementationofresidents’ newlyacquiredknowledge moredirectly.Byspeciﬁcallyaskinghowtheactivity impactedpatientcare,thePBLlogsenabledtheresidency programtogatherinformationonACGMEPhase3 Outcomesdata.24

Akey ﬁndingofourstudywasthehighnumberoflogs thatdemonstratedreal-timelearning.Whileonly18.7%of logsexplicitlystatedareal-timeorplannedfuturechangein patientcare,over65%oflogsreportedthatresearchledto informationlearned.Thisisanimportant ﬁnding,asselfdirectedlearningisagrowingacademictopic.Themost

recentiterationoftheACGMEMilestonesforEMincluded EBMwithintwoPBLcategories.7 Practice-basedlearning1 (Evidence-basedandInformedPractice)hasatlevels1,2,3, and4behaviorsthatcanbemeasuredwiththePBLlogs. Further,PBL2(ReﬂectivePracticeandCommitmentto PersonalGrowth)hasasbehavioralanchorstheabilityto self-identifygapsanddeterminewaystoclosethem.ThePBL logs,bymeasuringself-directedlearning,contributeto measuringthesebehaviorsinaneffectiveway.AstheLiaison CommitteeonMedicalEducationhasmade “self-directed learning” (Standard6.3)amandatedpartofundergraduate medicaleducation,theapproachtoEBMdescribedherecan effectivelyextendandmeasurethatbehavior.25 Thereare currentlynoexistingresourcestodoso;thus,ourstudy modelprovidesanovelwayforresidencyprogramstotrack self-directedlearningofEBMviaPBLlogs.

LIMITATIONS

Despiteourlargestudypopulation,ourstudyhad multiplelimitations.TheEBMcurriculumofferedand describedin Table1 maydifferfromthatofferedatother academicsites.Therefore,thewaythatresidentsused informationmaynotberepresentativeofEMresidentsat otherinstitutions.TherecordedEBMactivitywasa requirementforourresidents,includingaminimumnumber ofPBLlogsusingpeer-reviewed,publishedsourcesof medicalinformation.Thiscohort,therefore,hadthegeneral limitationsofconveniencesampling,aswellasthepossibility ofbias,asEBMactivitieswerenotasthoroughly documentedasproceduralattempts.Tothatend,thelogs presentedlikelyrepresentonlyafractionoftheEBMactivity performedduringthestudyperiodasonlyalimitednumber oflogs(3–5)wererequiredforeach28-dayEMblock. Finally,ourqualitativemethodologyrequiredthe interpretationandcategorizationofEBMlogs,which introducedthepossibilityforinterpretationbiasinour

results.However,thelargenumberoflogs,theuseof multipleresearchteammemberswithasinglearbiter,andthe codingschemadevelopedminimizedtheseconcerns.

CONCLUSION

Wepresentaproofofconceptthatpractice-basedlearning logactivitycanleadtointegrationofevidence-based medicineintoreal-timepatientcare.Additionally,we provideaframeworkforqualitativemeasurementofEBM researchandapplicationskillsamonglearners.Ourcohort recordedevidenceofbothlifelonglearningandapplication topatientcare.Thisapproachcaneasilybegeneralizedto otherEMresidenciestoallowforbothmonitoringofresident PBLcompetencyandACGMEreporting.

AddressforCorrespondence:BryanG.Kane,MD,LehighValley HealthNetwork,USFMorsaniCollegeofMedicine,Departmentof EmergencyandHospitalMedicine,LVHN-M-South5th Floor,2545 SchoenersvilleRd.,Bethlehem,PA18017. Email: Bryan.Kane@lvhn.org

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

REFERENCES

1.AccreditationCouncilforGraduateMedicalEducation. ACGME CommonProgramRequirementsforGraduateMedicalEducationin EmergencyMedicine.Availableat: https://www.acgme.org/what-we-do/ accreditation/common-program-requirements/ AccessedMarch20,2023.Published2022.

2.SackettDL,RosenbergWM,GrayJA,etal.Evidencebasedmedicine: Whatitisandwhatitisn’t. BMJ. 1996;312(7023):71–2.

3.SegalMM,WilliamsMS,GropmanAL,etal.Evidence-baseddecision supportforneurologicaldiagnosisreduceserrorsandunnecessary workup. JChildNeurol. 2014;29(4):487–92.

4.MillerFG,JoffeS,KesselheimAS.Evidence,errors,andethics. PerspectBiolMed. 2014;57(3):299–307.

5.RotterT,deJongRB,LackoSE,etal2019.Clinicalpathwaysasa qualitystrategy.InBusseR,KlazingaN,PanteliD,etal.(Eds.), ImprovingHealthcareQualityinEurope:Characteristics,Effectiveness andImplementationofDifferentStrategies.Copenhagen, Denmark:EuropeanObservatoryonHealthSystemsandPolicies, 2019.

6.TariqM,BhulaniN,JafferaniA,etal.Optimumnumberofprocedures requiredtoachieveproceduralskillscompetencyininternalmedicine residents. BMCMedEduc. 2015;15:179.

7.AccreditationCouncilforGraduateMedicalEducation.Emergency MedicineMilestones.2021.Availableat: https://www.acgme.org/ globalassets/PDFs/Milestones/EmergencyMedicineMilestones.pdf AccessedJanuary16,2023.

8.CarpenterCR,KaneBG,CarterM,etal.Incorporatingevidence-based medicineintoresidenteducation:aCORDsurveyoffacultyandresident expectations. AcadEmergMed. 2010;Suppl2(Suppl2):S54–61.

9.HadleyJA,WallD,KhanKS.Learningneedsanalysistoguideteaching evidence-basedmedicine:knowledgeandbeliefsamongsttrainees fromvariousspecialities. BMCMedEduc. 2007;7:11.

10.GreenML.Evidence-basedmedicinetrainingininternalmedicine residencyprogramsanationalsurvey. JGenInternMed. 2000;15(2):129–33.

11.RamosKD,SchaferS,TraczSM.ValidationoftheFresno testofcompetenceinevidencebasedmedicine. BMJ. 2003;326(7384):319–21.

12.Argimon-PallàsJM,Flores-MateoG,Jiménez-VillaJ,etal. Psychometricpropertiesofatestinevidencebasedpractice:the SpanishversionoftheFresnotest. BMCMedEduc. 2010;10:45.

13.KirkpatrickJDandKirkpatrickWK. Kirkpatrick’sFourLevelsofTraining Evaluation. Alexandria,VA:AssociationforTalentDevelopment,2016.

14.ConwayP.Clinicalresearch,patientcare,andlearningthatisreal-time andcontinuous.InOlsenLA,SaundersRS,McGinnisJM(Eds.), PatientsChartingtheCourse:CitizenEngagementandtheLearning HealthSystem.Washington,DC:NationalAcademiesPress,2011.

15.ConnorL,DeanJ,McNettM,etal.Evidence-basedpracticeimproves patientoutcomesandhealthcaresystemreturnoninvestment:Findings fromascopingreview. WorldviewsEvidBasedNurs. 2023;20(1):6–15.

16.CouncilofResidencyDirectorsinEmergencyMedicine.CORD. Availableat: https://www.cordem.org/.AccessedMarch20,2023.

17.MacQueenKM,McLellanE,KayK,MilsteinB.Codebookdevelopment forteam-basedqualitativeanalysis. CultAnthropolMethods. 1998;10(2):31–6.

18.BaldwinDCJrandDaughertySR.Howresidentssaytheylearn:a national,multi-specialtysurveyof ﬁrst-andsecond-yearresidents. J GradMedEduc. 2016;8(4):631–9.

19.LingLJandBeesonMS.Milestonesinemergencymedicine. JAcute Med. 2012;2(3):65–9.

20.HalalauA,HolmesB,Rogers-SnyrA,etal.Evidence-basedmedicine curriculaandbarriersforphysiciansintraining:ascopingreview. IntJ MedEduc 2021;12:101–24.

21.HatalaR,CookDA,ZendejasB,etal.Feedbackforsimulation-based proceduralskillstraining:ameta-analysisandcriticalnarrative synthesis. AdvHealthSciEducTheoryPract. 2014;19(2):251–72.

22.FriedmanS,SayersB,LazioM,etal.Curriculumdesignofacase-based knowledgetranslationshiftforemergencymedicineresidents. Acad EmergMed. 2010;Suppl2:S42–8.

23.KatsilometesJ,GaluskaM,KrausCK,etal.Multisiteassessment ofemergencymedicineresidentknowledgeofevidencebasedmedicineasmeasuredbytheFresnoTestof Evidence-BasedMedicine. JOsteopathMed. 2022;122(10):509–15.

24.SchneiderSMandChisholmCD.ACGMEoutcomeproject:phase3in emergencymedicineeducation. AcadEmergMed. 2009;16(7):661–4.

25.LiaisonCommitteeonMedicalEducation.FunctionsandStandardsofa MedicalSchool.2022.Availableat: https://lcme.org/publications/ AccessedMarch2,2023.

ORIGINAL RESEARCH

Whatthe Fika ?ImplementationofSwedishCoffeeBreaks DuringEmergencyMedicineConference

JesseZaneKellar,MD,MBA*

HannaBarrett,DO,MPH*

JaclynFloyd,MD‡

MichelleKim,MD†

MatthiasBarden,MD‡

JasonAn,MD†

AshleyGarispe,DO*

MatthewHysell,MD§

SectionEditor:MuhammadWaseem,MD

*SaintAgnesMedicalCenter,DepartmentofEmergencyMedicine, Fresno,California

† RiversideCommunityHospital,DepartmentofEmergencyMedicine, Riverside,California

‡ EisenhowerHealth,EmergencyMedicineResidency,RanchoMirage,California

§ EmergencyMedicineResidencyCorewellHealthSouth,GraduateMedical EducationDepartment,St.Joseph,Michigan

Submissionhistory:SubmittedSeptember12,2023;RevisionreceivedMarch6,2024;AcceptedMarch18,2024

ElectronicallypublishedJune20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18462

Introduction: InthisstudyweaimedtoinvestigatetheeffectsofincorporatingSwedish-style ﬁka (coffee)breaksintothedidacticscheduleofemergencymedicineresidentsontheirsleepinesslevels duringdidacticsessions.FikaisaSwedishtraditionthatinvolvesadeliberatedecisiontotakeabreak duringtheworkdayandusuallyinvolvespastriesandcoffee.WeusedtheKarolinskaSleepinessScale toassesschangesinsleepinesslevelsbeforeandaftertheimplementationof ﬁka breaks.

Methods: Thestudydesigninvolvedarandomizedcrossovertrialapproach,withdatacollectedfrom emergencymedicineresidentsoveraspeciﬁcperiod.Thisapproachwasdonetominimizeconfounding andtobestatisticallyefﬁcient.

Results: Resultsrevealedtheaveragesleepinessscalewas4.6and5.5on ﬁka andcontroldays, respectively(P = 0.004).

Conclusion: Integrationof ﬁka breakspositivelyinﬂuencedsleepinesslevels,thuspotentiallyenhancing theeducationalexperienceduringresidencydidactics.[WestJEmergMed.2024;25(4)574–578.]

INTRODUCTION

Emergencymedicine(EM)residencyisknownforits demandingschedulesandhigh-stressenvironment.The intensityofresidencytrainingcanleadtostress,fatigue,and reducedwell-being.1 Atthesametime,didacticsplaya crucialroleinprovidingresidentswiththenecessary knowledgeandskillstodeliverhigh-qualitypatientcareand areakeycomponentoflearningadvancement.Weekly conferencesessionsmayvaryinlengthfromprogramto programbuttypicallycomprise ﬁvehoursofprotectedtime devotedtolearningfundamentalEMcontenteveryweek. Muchworkhasbeendoneinrecentyearstoimprovethe qualityoftheseconferences,suchasimplementingshorter lectures,interactivesessions,team-basedlearning,and

flippedclassrooms.2 However,littleworkhasfocusedon mitigatingresidentfatigueanddecreasedattentionattheend oftheconferencesession.Researchinadultlearningdata revealsthattheattentionspanoftheadultlearnerdecreases dramaticallyafter15–20minutes.3 Consequently,itisnot difficulttoassumethatafterthreeorfourhoursof conference,theattentionspanoftheaverageadultlearner hasbeenspent.Onepossiblewaytoaddressthesechallenges istoincorporatebreaksinconferencedaysinspiredbythe Swedishcustomof atttaen fi ka ,orsimply fi ka (coffee),into conferencedays.

Introducing ﬁ ka breakscanprovideresidentswithmuchneededopportunitiesforrelaxationandself-care.The Swedesareknownforhavingahighlybeneﬁcialworkand

lifebalancecomparedtopeopleinothercountries.4 One proposedexplanationisthecultureofconscientiouslytaking regularlyscheduledbreaks,knownas ﬁ ka ,duringthe workdaytorelaxandregroup.5 Thatlogiccouldbe extrapolatedintoresidenteducation.Ifresidentscould participatein ﬁ ka andengageinpleasantconversationswith timeawayfromtheintenselearningenvironment,itcould helpalleviatestress,boostmorale,andimprove mentalwell-being.

Inthisstudyweexploredthepotentialadvantagesof taking15-minute fi ka breaksinconjunctionwithmonitoring sleepinesslevelsusingtheKarolinskaSleepinessScale(KSS). Forthepurposesofthisstudy,fourEMresidencyprograms implemented fi ka breaksduringresidentconferencesto assesswhethertakinga15-minute fi ka breakafterthesecond hourofdidacticsimpactedresidentalertness.Ourgoalwasto exploretheconceptof fi ka andhowitmayimproveEM residents’ alertnessduringweeklyconference.

METHODS

StudyDesignandSetting

Weconductedamulticenter,randomizedcrossovertrial fromAugust25,2022–January5,2023todeterminethe associationbetweenresidentfatigueduringconferenceswith andwithouta ﬁ ka breakamongEMresidents.FourEM residenciesparticipatedinthisstudy,whichwasreviewed andapprovedbyeachhospital’srespectiveinstitutional reviewboard. Table1 outlinesdeﬁningcharacteristicsofthe foursites.

ForfatigueassessmentweusedtheKSS,avalidatedselfassessmenttoolusedtomeasureanindividual’slevelof sleepinessoralertnessatagivenmoment.6 Decreasedlevels ofalertnessusingtheKSSscorehavebeenassociatedwith deceasedperformanceandcognitivefunction.7,8 Developed byresearchersattheKarolinskaInstituteinSweden,the scaleconsistsofaseriesoflevels,typicallyrangingfrom1–9, whereeachlevelcorrespondstoadifferentdegreeof sleepiness.6 Participantsareaskedtoratetheircurrentlevel ofsleepinessbasedonthedescriptionsprovidedforeach level.Lowernumbersonthescaleindicatehigherlevelsof alertness(1 = extremelyalert),whilehighernumbersindicate increasinglevelsofsleepiness(9 = verysleepy,greateffort

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Whileinteractivesessionsand ﬂ ipped classroomshavebeenimplementedto optimizelearningduringresidency conferences,littleisknownabouthowto optimizebreaks.

Whatwastheresearchquestion?

DoesimplementationofaSwedish ﬁ kabreak improvethelevelofalertnessforemergency medicineresidentsduringconference?

Whatwasthemajor ﬁndingofthestudy?

AveragesleepinessontheKarolinska SleepinessScaleimprovedfrom5.5oncontrol daysto4.6on ﬁ kadays(p = 0.004).

Howdoesthisimprovepopulationhealth?

Thisstudyhighlightstheimportanceof structuredconferencebreaksleadingtomore alertresidentsandhopefullyahigherquality learningenvironment.

keepingawake, ﬁghtingsleep).5 TheKSSisoftenusedin sleepresearch,clinicalsettings,andstudiesrelatedtofatigue andsleepdisorderstogaininsightsintopeople’ssubjective perceptionoftheirownalertnessordrowsiness.6

Instructionswereprovidedduringintervention(ﬁ ka )and controldates,askingtheEMresidentstocirclethenumber thatrepresentedtheirperceivedlevelofsleepinessatthat pointintime.Anadditionalunrelatedwellnessquestionwas includedinthequestionnairetokeepthisstudyblind.During the ﬁrstphaseofthestudy,thefoursitesweresplitrandomly intotwogroups.Thetwogroupswerethenrandomly assignedtwocontroldatesandtwointerventiondates.One groupstartedwithcontroldates,followedbyintervention dates.Thesecondgroupstartedwithinterventiondates,

Table1. Participatingresidencyprogram’sbaselinecharacteristics.

Table2. Datesofcontrolandinterventionbysite.

SitenumberDateofcontrolDateofintervention(Fika)

1September28, October5 September14, October12

2September21, October5 September1, December15

3August25, January5

4October13, December8

September1, December15

October20, November3

followedbycontroldates.Thiswasdonetohelpoffset possiblefatiguedifferencesduetothepassageoftime. Table2 demonstratesthecontrolandinterventiondatesof eachsite.

Duringtheinterventiondays,a15-minuteSwedish-style ﬁ ka breakwasaddedintotheEMconferencescheduleafter thesecondhourofconference.The ﬁkabreaksweretobe heldinalocationoutsidethelectureareawhereEMresidents wereprovidedwithcoffee,non-caffeinatedbeverages, pastries,andsnacks.Residentswereinstructedthatthere shouldnotbeanywork-relateddiscussion,asthisbreak servestoencouragesocializationandrelaxingconversation. Oncontroldays,normalbreaksoccurredasscheduled duringEMconference.Duringbothphases,thesurveywas conductedbeforethelasthourofconference.

SelectionofParticipants

StudyparticipantswereEMresidentsacrossthefour participatinghospitals.Therewere25postgraduate(PGY) year-1residents,18PGY-2residents,16PGY-3residents, and4PGY-4residentsforatotalof98residents.Atotalof64 residentsparticipatedinatleastonesurveyduringboththe controland ﬁ ka sessionstoallowpairedcomparison.

Interventions

Theinterventioninthisstudyconsistedofimplementinga 15-minute ﬁ ka breakafterthesecondhouroflecturewhere coffee,non-caffeinatedbeverages,pastries,andsnackswere madeavailable.Thiswasconductedtwiceoverseveral months.Oncontroldays,participatingsiteshadinstructions tonotchangeanyregularscheduledcurriculumbreaksor limitthefoodanddrinkthatwerenormallypresent.Normal breaksatparticipatingsitesrangedfrom10–15minutes,and allprogramshadfoodandcaffeinateddrinksavailableon controldays.

DataAnalysis

WecompiledthenumericaldataobtainedfromtheKSS surveystakenbytheEMresidentsfromthecontroland ﬁ ka sessionsforanalysisandseparateditintotwosubgroups, consistingofaresidencysitesubgroupandaPGYsubgroup.

Theresidencysitesubgroupwasbrokendownintoeach respectiveparticipatingresidencyprogram,andthePGY subgroupwasbrokendownintoeachPGYclass(1–4).We usedapairedsample t -testtocomparethemeanKSSofthe residentcohortbothbeforeandafterimplementationof ﬁ ka . ThiswasdoneforindividualEMresidencyprogramsandfor allEMresidencyprogramsparticipatingasalargercohort.

RESULTS

Sleepinesson Fika vsControlDays

Figure1 presentsthemeanresultsofthesleepiness measuredondayswhere fi ka wasimplementedvscontrol. Theaveragesleepinesswas4.6on fi ka daysand5.5on controldayswithstandarddeviationof2.2and2.1, respectively,P-value = 0.004.Thisindicatesthatresidents weremoreawakeondayswhen fi ka wasimplemented,and thisresultwasstatisticallysignificant. Figure2 demonstrates

Figure1. MeanKarolinskaSleepinessScalescoresfor Fika vs controldays.Meansleepinessondayswhen ﬁka wasimplemented wasimprovedcomparedtocontrol.Averagesleepinessscalewas 4.6(SD2.2)and5.5(SD2.1),respectively,on ﬁka andcontroldays, respectively.

Figure2. Resultsofself-reportedKarolinskaSleepinessScale scoreson fika daysvscontroldays,separatedbyparticipating residencies.Site3showedmostimprovementofsleepinessfromthe Fikaintervention,with3.3(SD2.1)on fika daysvs6.2(SD2.0)on controldays,whileSite2showedtheoppositeeffect,with5(2.4)on fika daysvs4.8(SD2.2)oncontroldays,althoughthedifferencewas notstatisticallysignificant.

theresultsoftheKSSseparatedbyparticipatingresidency programs.Site3hadthebiggestimprovementinsleepiness (3.3on fi ka daysvs6.2oncontroldays).Site2hadtheleast improvementinalertnessandactuallyshowedthat fi ka interventionincreasedsleepinessinresidents(5.0on fi ka days vs4.8oncontroldays),althoughthedifferencewasnot statisticallysignificant.

Figure3 depictsthealertnessbyresidencyyearfrom allparticipatingresidencyprograms.Wefoundthat improvementinalertnesswasmorevisiblein ﬁrst-and second-yearresidentscomparedtothird-andfourth-year residents.Duetolowsamplesize,however,thisdifference waslikelybychanceandnotstatisticallysigniﬁcant.

DISCUSSION

The findingssuggestthattheinclusionof fi ka breaks intotheEMresidencydidacticspositivelyinfluenced participants’ sleepinesslevels.Thereducedsleepinessduring conferencesessionscouldpotentiallyenhanceresidents’ attention,engagement,andknowledgeretention,leadingto improvededucationaloutcomes.

ImprovedLearningOutcomes

Whiletheprimarygoalofresidencyconferencesisto impartmedicalknowledgeandskills,theeffectivenessof learningcanbeenhancedbyincorporating fi ka breaksand monitoringsleepinesslevelswithKSS.Studieshaveshown thatbriefbreaksduringlearningsessionscanimprove attentionandretentionofinformation.Bysteppingaway fromconferencelecturesessionsandusingtheKSS,we wereabletoassessresidents’ levelsofsleepinessand determinetheeffectivenessofthebreaksinreinvigorating theirfocus.These findingscanbeusedtooptimizethe timinganddurationof fi ka breaks,ensuringthatthey contributetoimprovedlearningoutcomesandbetter knowledgeretention.

FosteredSocialInteractions

Buildingastrongsenseofcommunityandfosteringsocial interactionsisvitalforresidentoverallwell-being.9 Fika breaksprovideanidealplatformforresidentstoconnectona morepersonallevel,shareexperiences,anddevelop supportiverelationshipswiththeirpeersandfaculty members.Theseinformalinteractionsencourageopen communication,collaboration,andmentorship opportunities.Byalsoconsideringthesleepinesslevelswith KSSduringthesebreaks,organizerscantailorthefrequency andstructureof ﬁ ka sessionstopromoteoptimalsocial interactionswhilemitigatingtheriskofresidentsbecoming excessivelyfatiguedordrowsy.

LIMITATIONS

Thestudyhasseverallimitations,includingarelatively smallsamplesizeandashortinterventionperiod.Future researchcouldinvolvelargerstudieswithextended interventionperiodstofurtherexplorethelong-termeffects of ﬁ ka breaksonEMresidencyconferencedays.During controldays,residentscouldhaveconsumedcoffeeorsoda thatcontainedcaffeine.Lasty,theeffectofdifferenttypeof breakscouldalsobeconsidered,suchasawalkorother intentionalbreak,todeterminewhetherthatactivityhasthe sameeffect.Allparticipatingsitesoncontroldayshadslight variationsinthenatureandlengthofbreaks.

CONCLUSION

IncorporatingSwedish-style ﬁ ka breaksintoemergency medicineresidencyconferencesimprovedtheoverall alertnessinEMresidents.Residencyprogramsshould considerthisuniqueapproachtoprioritizeresidentwellness andoptimizeeducationalexperiences.Furtherresearch canexplorethelong-termeffectsof ﬁ ka breaksand KarolinskaSleepinessScalemonitoringonresident burnout,performance,andcareersatisfactioninEM residencyprograms.

AddressforCorrespondence:JesseZaneKellar,MD,MBA, DepartmentofEmergencyMedicine,SaintAgnesMedicalCenter, 1303EastHerndonAvenue,Fresno,CA93720-3309. Email: jesse.kellar@vituity.com

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

Figure3. Sleepinessscalebyresidencyyear.Resultsshow fika interventionhadgreatestimprovementinsleepinessamongPGY-1 residents,withsleepinessof4.4(SD2.1)on fika daysand5.8 (SD1.8)oncontroldays,althoughthiseffectwasnotstatistically significantduetosmallsamplesize. Volume25,No.4:July2024WesternJournal of EmergencyMedicine

REFERENCES

1.LinM,BattaglioliN,MelamedM,etal.Highprevalenceofburnout amongUSemergencymedicineresidents:resultsfromthe2017 NationalEmergencyMedicineWellnessSurvey. AnnEmergMed. 2019;74(5):682–90.

2.WoodDB,JordanJ,CooneyR,etal.Conferencedidacticplanningand structure:Anevidence-basedguidetobestpracticesfromthecouncilof emergencymedicineresidencydirectors. WestJEmergMed. 2020;21(4):999–1007.

3.CooperAZandRichardsJB.Lecturesforadultlearners:breakingold habitsingraduatemedicaleducation. AmJMed. 2017;130(3):376–81.

4.OECDBetterLifeIndex.Work-lifebalance.2014.Availableat: https:// www.oecdbetterlifeindex.org/topics/work-life-balance/ AccessedMarch31,2022.

5.QuitoA.ThisfourletterSwedishwordisthesecrettohappinessatwork. 2016.Availableat: https://www.weforum.org/agenda/2016/03/ the-swedish-secret-to-happiness-at-work.AccessedMarch31,2022.

6.KaidaK,TakahashiM,AkerstedtT,etal.ValidationoftheKarolinska SleepinessScaleagainstperformanceandEEGvariables. ClinNeurophysiol. 2006;117(7):1574–81.

7.AkerstedtT,AnundA,AxelssonJ,etal.Subjectivesleepinessisa sensitiveindicatorofinsufﬁcientsleepandimpairedwakingfunction. JSleepRes. 2014;23(3):240–52.

8.LoJC,OngJL,LeongRL,etal.Cognitiveperformance,sleepiness,and moodinpartiallysleepdeprivedadolescents:theneedforsleepstudy. Sleep. 2016;39(3):687–98.

9.RajKS.Well-beinginresidency:asystematicreview. JGradMedEduc. 2016;8(5):674–84.

KathleenS.Williams,MD*

TatianaGrifﬁth,MD†

SeanGaynor,Esq.‡

ThomasJohnson,DO*

AlisaHayes,MD*

SectionEditor:MelanieHeniff,MD,JD

BRIEF EDUCATIONAL ADVANCES

*MedicalCollegeofWisconsin,DepartmentofEmergencyMedicine, Milwaukee,Wisconsin

† HealthpartnersRegionsHospitalEmergencyMedicine,St.Paul,Minnesota ‡ LeibKnottGaynorLLC,Milwaukee,Wisconsin

Submissionhistory:SubmittedMarch20,2023;RevisionreceivedFebruary20,2024;AcceptedFebruary29,2024

ElectronicallypublishedJune14,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.17809

Background: ItisanunfortunatetruththatEmergencyMedicine(EM)physicianswill,atsomepoint, havecontactwiththemedicolegalsystem.However,mostEMresidencytrainingprogramslack educationonthelegalsystemintheircurriculum,leavingEMphysiciansunpreparedforlitigation.To ﬁll thisgap,wedesignedahigh-yieldandsuccinctmedicallegalworkshophighlightinglegalissues commonlyencounteredbyEMphysicians.Weaimedtodeterminetheeffectivenessofthiscurriculumby measuringpreandpostknowledgequestions.

Methods: Atwo-hoursessionincludedacase-baseddiscussionofcommonmisconceptionsheldby physiciansaboutthelegalsystem,properstepswheninteractingwiththelegalsystemandreviewof legaldocuments.Thissessionwasdevelopedwiththeinvolvementofourhospitallegalcounseland discussedrealencounters.Theeffectivenessofthesessionwasdeterminedusingpre-andpostsessionsurveysassessingparticipantknowledgeandcomfortapproachingthescenarios.

Results: Atotalof34EMresidentshadtheopportunitytocompletethisworkshopasapartoftheir conferencecurriculum.Atotalof26participantscompletedthepre-surveyand19participants completedthepost-survey.Noparticipantshadprevioustraininginthelegalaspectsofmedicine, includinghandlingasubpoena,servingasawitness,orgivingadeposition.

Thepre-surveydemonstratedthattherewassigniﬁcantuncertaintysurroundingtheprocesses, deﬁnitions,andthelegalsysteminteraction.Manyparticipantsstatedtheywouldnotknowwhattodoif theyreceivedasubpoena(85.71%),werecalledasawitnessinatrial(96.43%)orreceive correspondencefromalawyer(96.43%).

Thepostsurveyrevealedanincreasedknowledgebaseandconﬁdencefollowingthesession. 100%ofresidentsreportedknowingwhattodoafterreceivingasubpoena,beingcalledasawitnessand understandingtheprocessinvolvedingivingadeposition.Allresidentsreportedthatthesessionwas beneﬁcialandprovidedcrucialinformation.

Conclusion: EMresidentshavelimitedbaselineunderstandingofhowtoapproachcommonlegal scenarios.Educationalmaterialsavailableforthiscurriculumtopicarelimited.Basedontherapid knowledgeincreaseobservedinourresidents,webelieveourworkshopcouldbeadaptedforuseat otherresidencyprograms.[WestJEmergMed.2024;25(4)579–583.]

BACKGROUND

Emergencyphysicians(EP)areatthefrontlineofacute careandasaresulthavefrequentinteractionswiththe UnitedStatesmedicolegalsystem.Physiciansinspecialties considered “highrisk,” includingemergencymedicine(EM), experienceahigherrateofmalpracticeclaimsthanaverage, with99%ofphysiciansinthesespecialtiesexperiencing malpracticelitigationbytheageof65.1 However,only18% ofEMresidencyprogramsdevotemorethanfourhoursper yearofcurriculumtimetomedicolegaltopics,including itemssuchasmedicalmalpracticeandriskmanagement education.2 InasurveyofAustralianEPs,41%of respondentsreportedreceivingtraininginthisarea.Also, while71%hadattendedcourtasanexpertwitnesses,only 23%consideredthemselvesskilledinparticipatingin courtroomtrials.3

Whilesimilardatadoesnotexistevaluatingthe preparationofEPsintheUS,previousstudiessupportthat lackofmedicolegaleducationimpairsaphysician’sabilityto assistthecourtandformanaccurateopinion.3 Asolid educationalfoundationinthelegalaspectsofmedicineis especiallyimportantforEPs,whoofteninteractwithpatient populationsrequiringinteractionwiththemedicolegal system.Thesesituationsincludeabuse,assault,domesticor gunviolence,othertraumaticinjury,andforensictoxicology. Historically,trainingfocusedonthisareahappenedinreal time,withfewinstitutionsimplementingforensicmedicine trainingtobetteraddresstheirpatients’ forensicneeds.4

Muchofthecurrentliteraturepertainingtomedicolegal educationisfromcountriesoutsidetheUS.InanAustralian EMtrainingprogram,asix-monthforensicmedicine rotationimprovedthetechnical,assessment,andclinical skillsoftheirEMresidents.5 IntheUS,fewresidency programshaveimplementeddirectsimulationsoftrial scenarios,educationallectures,andcase-baseddiscussionsto improvetheirresidents’ abilitytointeractwiththelegal system.Theseprogramshistoricallyhaveconsumed substantialtime,witharangeofsixhourstoseveralmonths induration.Partnershipswithlocallawschoolshaveallowed EMresidentstoreceivehands-onexperiencewith malpracticelitigationandhavebeenshowntoimprovetheir conﬁdenceinnavigatingthelegalsystem.6,7 TheAmerican BoardofEmergencyMedicinehasincludedunderstanding legalconceptsinits “ModeloftheClinicalPracticeof EmergencyMedicine.”8 However,itisstilltobedetermined howbesttocoverthesetopicsaspartoftheEM trainingcurriculum.

OBJECTIVES

Weaimedtodeterminewhetheratwo-hour,case-based curriculumdevelopedwithourhospitallegalcounselwould efﬁcientlyimproveourresidents’ comfortwithapproaching threecommonlegalscenariosencounteredbyEPsand

strengthenresidentunderstandingoftheirownrightswithin themedicolegalsystem.

CURRICULARDESIGN

Afterrepeatedinstancesofourresidents’ receiving subpoenas,wereachedouttoourhospitallegalcounsel regardingtheneedtodevelopacurriculumfocusedon commonscenariosencounteredbyEPs.Ashort,30-minute, didacticreviewwasdeveloped,andthreecasescenarioswere introduced.Ourlegalcounselwasabletomodifyactual documentsandformsthathadbeensenttophysicianswhom hehadpreviouslyrepresentedandusethemtocreatesmallgroupdiscussionssurroundinghowtobestapproachthese scenarios(see Supplement).Topicscoveredbythethreecase scenariosincludedrespondingtoasubpoena,servingasa witness,andbeinginvolvedinadeposition.Thissessionwas heldinAugust2021.

Thelearnersweregiventimetoreviewthedocumentsand answerdiscussionquestionsregardingthecaseasasmall group.Theythenreturnedtothelargergrouptoreviewtheir ﬁndingsandreceivefeedbackfromEMfacultyandourlegal counselregardingtheirconclusions.

IMPACT/EFFECTIVENESS

Priortothebeginningoftheworkshop,participantswere askedtocompleteananonymous,voluntarysurvey. Residentswereaskedtocompleteanidenticalsurvey immediatelyfollowingthecompletionoftheworkshop.The surveyincludedninemultiple-choicequestionsaimedat evaluatingtheresidents’ baselinemedicolegalknowledge and ﬁvequestionsassessingtraineecomfortwitheachtopic highlightedinthesession,usingaLikertscale.Examplesof knowledgequestionsincludedthefollowing: “The differencesbetweenbeingdeposedandtestifyingincourt are____ ”;and “IfIamsubpoenaedtotestifyforapatientI saw,whatshouldmynextstepbe?” Approvalforthisstudy wasobtainedfromtheQualityImprovement/Quality AssessmentReviewCommitteeoftheDepartmentof EmergencyMedicineattheMedicalCollegeofWisconsin andwasdeemedinstitutionalreviewboard-exempt.

Atotalof34postgraduateyear1–3EMresidentshadthe opportunitytocompletethisworkshopasapartoftheir weeklyconferencecurriculum.Thepre-surveywasstartedby 29participantswith26completingallquestions.Thepostsurveywascompletedby19participants.Alltheparticipants statedthattheydidnothaveprevioustraininginthelegal aspectsofmedicine,includinghandlingasubpoena,being calledasawitness,orgivingadeposition.Postgraduateyear oftrainingwasnotaskedonthesurveytoavoididentiﬁcation oftheparticipants,giventhesmallsamplesize.

Thepre-surveydemonstratedtherewassigniﬁcant uncertaintysurroundingtheprocesses,deﬁnitions,and intentionsofthelegalsystem(Figure1).Alargemajorityof participantsstatedtheywouldnotknowwhattodoifthey

receivedasubpoena(85.71%),werecalledasawitnessina trial(96.43%),orreceivedcorrespondencefromalawyer (96.43%).Responsesrevealeduncertaintywiththegoalof depositionandhowitdifferedfromtrial,withonly40.74%of residentsindicatingthatpracticefortrialwasnotanincluded goaland56.26%knowingthatonlyonepersonisbeing questionedduringdeposition.

Residentslefttheworkshopwithadeeperunderstanding oftheirlegalrightsandtheproperstepstotakewhen contactedregardinglitigation.Onthepost-survey,100%of residentsreportedknowingwhattodoafterreceivinga subpoena,beingcalledasawitnessforatrial,and understandingtheprocessinvolvedingivingadeposition, and94.74%agreedthattheywereawareofthepolicy statementsbytheAmericanCollegeofEmergency Physicianssurroundingactingasanexpertwitness.Whenthe sessionwasevaluatedoverall,100% “stronglyagreed” the

sessionwashelpful.Thesepre-andpost-sessionchangesin self-assessmentofknowledge(questionsnotedin Figure1) werefoundtobestatisticallysigniﬁcant(P < 0.05)whena chi-squaredanalysiswasperformed.

Regardingknowledgerelatedtothegoalofadeposition, differencesbetweenadepositionandatrial,obligationsto respondtoalawyer,residents’ correct-responserate improvedafterthesession(Figure2).Thesedifferenceswere notfoundtobestatisticallysigniﬁcant.However,whenwe performedachi-squaredanalysiswefoundastatistically signiﬁcantimprovementinknowledgerelatedtobeing contactedbyalawyer(P < 0.05).

Attheendoftheworkshop,therewasadistinctshiftfrom residentslackingabasicunderstandingofthemedicolegal system,orwhatrolephysiciansserve,tobeingwellprepared forthedepositionprocessandhowtoproperlyrespondtoa legalcorrespondence.Residentswereprovidedwiththe

Figure1. Pre-andpost-surveyscenarioresultsdemonstrateimprovementinself-reportedknowledgeofemergencyresidentsonhowto approachseveralcommonlegalscenarios.

Figure2. Knowledge-basedquestionsassessedbeforeandafterthesessiondemonstrateanincreaseincorrectresponse,althoughthe majoritywerenotstatisticallysigniﬁcant.

frameworkrequiredtonavigatelitigationandprovideda spacetodiscusscommonmedicolegalscenariosthatEPs face.Theseresultswereachievedinarelativelybrieftime frame,whichindicatesthatshort,case-basedscenarioscan beimplementedtoeffectivelyimproveresidentknowledge andprovidethemwithinformationthatcanbeimmediately applied.Basedonthesuccessofthisworkshop,webelieve thatsimilarmedicolegalsessionscouldbeadaptedforother residencyprogramstoreducethegapbetweenexperience andeducation.

Ourworkshopmodeldidhavelimitationsincluding limitedsamplesizeandutilizationofasingletrainingsite. BecauseeachstatewithintheUShasitsownlegalnuances, nolegalcurriculumcanbeuniversallyappliedtoall residencyprograms.Additionally,weobserveda27%drop inparticipationonthepost-surveywhencomparedtothe pre-survey.Sustainabilityoftheimpactweobservedhasnot yetbeenassessedinadelayedfashion.

Movingforward,integratingmethodsusedbyother programs,includingexpandingtomultiplesessions, leveragingpartnershipswithlocallawschools,usingmock trialscenarios,orcreatingforensicscienceelectives,may furtherbolsterthiscurriculum.Weidentifythatthenumber oftopicscoveredinthiscurriculumarelimited.Certainly, additionalworkcanbedonetofurtherexpandthisbasiclegal educationtocoverthescenariosEPsroutinelyencounter.

CONCLUSION

Basedonthecurrentliteratureandtheexperiencesofour residents,EMtraineesareunpreparedfortheirencounters withthelegalsystemandrequiremoreeducationonthis topic.Giventhefrequentcontactthatemergencyphysicians havewiththemedicolegalsystem,furtherworkisessentialto improvetraineepreparednessforcontactwiththelegal system.Thereremainsavastopportunityforthisareaof residenteducationtofurthergrowanddevelop.Medical educatorswithinEMshouldcontinuetoexplorehowtobest coverthesetopicswithintheirownprograms.

AddressforCorrespondence:KathleenS.Williams,MD,Medical CollegeofWisconsin,DepartmentofEmergencyMedicine,8701W. WisconsinAve.,Milwaukee,WI53226.Email: kswilliams@mcw.edu

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

REFERENCES

1.JenaA,SeaburyS,LakdawallaD,etal.Malpracticeriskaccordingto physicianspecialty. NEnglJMed. 2011;365(7):629–36.

2.ReliasMedia.Emergencymedicineresidencyprogramsdevotelittle timetomalpracticeeducation.2019.Availableat: https://www. reliasmedia.com/articles/145185-emergency-medicine-residencyprograms-devote-little-time-to-malpractice-education AccessedNovember24,2021.

3.CunninghamNYandWeilandTJ.Currentleveloftraining,experience andperceptionsofemergencyphysiciansasexpertwitnesses:apilot study. EmergMedAustralas. 2009;21(6):497–502.

4.SmockWS.Developmentofaclinicalforensicmedicinecurriculumfor emergencyphysiciansintheUSA. JClinForensicMed. 1994;1(1):27–30.

5.YoungS,WellsD,SummersI.Speciﬁctraininginclinicalforensic medicineisusefultoACEMtrainees. EmergMedAustralas. 2004;16(5–6):441–5.

6.CuratoMandShlahetA.Reportofacollaborationbetweenalaw schoolandanemergencymedicineresidencyprogramforafull-scale medicalmalpracticelitigationsimulation. AEMEducTrain. 2019;3(3):295–8.

7.DrukteinisDA,O’KeefeK,SansonT,etal.Preparingemergency physiciansformalpracticelitigation:ajointemergencymedicine residency-lawschoolmocktrialcompetition. JEmergMed. 2014;46(1):95–103.

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

ORIGINAL RESEARCH

TheEvolutionofBoard-CertiﬁedEmergencyPhysiciansand StafﬁngofEmergencyDepartmentsinIsrael

NoaaShopen*

RaphaelTshuva‡

MichaelJ.Drescher‡§

MiguelGlatstein*†‡

NetaCohen*†‡

RonyCoral∥

ItayRessler¶

Pinchas(Pinny)Halpern‡

SectionEditor:ChrisMills,MD,MPH

*TelAvivMedicalCenter,DepartmentofEmergencyMedicine,TelAviv,Israel

† TelAvivMedicalCenter,DepartmentofPediatricEmergencyMedicine,TelAviv,Israel

‡ SacklerFacultyofMedicine,TelAvivUniversity,TelAviv,Israel

§ RabinMedicalCenter,PetachTikva,Israel,afﬁ liatedwiththeSacklerFacultyof Medicine,TelAvivUniversity,TelAviv,Israel

∥ PsychiatryUnit,ShebaMedicalCenter,RamatGan,Israel,afﬁliatedwiththeSackler FacultyofMedicine,TelAvivUniversity,TelAviv,Israel

¶ TelAvivMedicalCenter,OncologyDivision,Psycho-OncologicalService, TelAviv,Israel

Submissionhistory:SubmittedNovember1,2023;RevisionreceivedFebruary22,2024;AcceptedMarch4,2024

ElectronicallypublishedJune14,2024

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

DOI: 10.5811/westjem.18541

Introduction: Emergencymedicine(EM)wasrecognizedasaspecialtyinIsraelin1999.Fifty-nineofthe 234(25%)attendingphysiciansworkinginemergencydepartments(ED)nationwidein2002wereboardcertiﬁedemergencyphysicians(EP).A2012studyrevealedthat123/270(45%)ofEDattendingswere EPs,andthattherewere71EMresidents.TheEPsprimarilyworkedmidweekmorningshifts,leavingthe EDsmostlystaffedbyotherspecialties.Ourobjectiveinthisstudywastore-evaluatetheEPworkforcein IsraeliEDsandtheiremploymentstatusandsatisfaction10yearsafterthelaststudy,whichwas conductedin2012.

Methods: Weperformedathree-part,prospectivecross-sectionalstudy:1)asurvey,senttoallEDsin Israel,toassessthenumbers,leveloftraining,andspecialtiesofphysiciansworkinginEDs;2)an anonymousquestionnaire,senttoEPsinIsrael,toassesstheirdemographics,training, employment,andworksatisfaction;and3)interviewsofaconveniencesampleofEPsanalyzed byathematicapproach.

Results: Therewere266board-certiﬁedEPs,141(53%)ofwhomwereemployedinEDsfull-timeor part-time.Sixty-twonon-EPsalsoworkedinEDs.TheEPswerepresentintheEDsprimarilyduring weekdaymorningshifts.Therewere273EMresidentsnationwide.Atotalof101questionnaireswere completedandrevealedthatEPsworkingpart-timeintheEDworkedfewerhours,receivedhigher salaries,andhadmoreyearsofexperiencecomparedtoEPsworkingfulltimeornotworkingintheED. Satisfactioncorrelatedonlywithworkingparttime.Meaningfulwork,diversity,andrewarding relationshipswithpatientsandcolleaguesweremajorpositivereasonsforworkingintheED.Feeling undervalued,carryingaheavycaseload,andhavingcomplicatedrelationshipswithotherhospital departmentswerereasonsagainstworkingintheED.

Conclusion: Ourstudy findingsshowedanincreaseinthenumberoftrainedandin-trainingEPs,anda decreaseinthepercentageofboard-certifiedEPswhopersevereintheEDs.Emergencymedicinein Israelisatacrossroads:morephysiciansarechoosingEMthanadecadeago,butretentionofboardcertifiedEPsisamajorconcern,asitisworldwide.Werecommendtakingmeasurestomaintaintrained andexperiencedEPsworkingintheEDbyallowingpart-timeEDpositions,introducing dedicatedacademictime,anddiversifyingEProles,functioning,andworkroutine.[WestJEmergMed. 2024;25(4)584–592.]

INTRODUCTION

TheIsraeliMinistryofHealth firstrecognizedemergency medicine(EM)asasubspecialtyin1999.Candidateshadto beboardcertifiedineitheranesthesiology,internalmedicine, generalsurgery,familymedicine,ororthopedics.Initially, recognitionasspecialistsinEMwasissuedto36selected physicianswithlongexperienceandleadershippositions workinginemergencydepartments(ED),andthe firstEM boardsexamswereofferedin2002.1 Anationalsurvey conductedin2002revealedthatonly59of234attending physiciansworkinginEDsnationwidewereboardcertified inEM,andthattheywereprimarilyworkingweekday morningshifts,leavingtheEDstaffedatothertimes largelybyresidentsfromotherspecialties.Inaddition,there were37residentsintheEMsubspecialty residencyprogram.2

EmergencymedicinewasaccreditedbytheIsraeliMedical AssociationScientificCouncilasaprimaryspecialtyin2012, andthe firstresidentsenrolledinEDtrainingprograms.A secondnationalsurveyconductedduringthatyearshowing that123of270attendingphysiciansemployedinEDs nationwidewereboard-certifiedemergencyphysicians(EP). ThedistributionoftheworkinghoursforEPshadremained mostlyunchangedcomparedtothepreviousdecade,with trainedEPsprimarilyworkingweekdaymorningshifts.The numberofEMsubspecialtyandspecialtyresidentshadrisen to71in2012.3

Inthesameyear,alaboragreementbetweentheIsrael MedicalAssociation,aprofessionalorganization representing95%ofIsraeliphysicians,andtheMinistryof Healthstipulatedtheemploymentmechanismthat recognizestheuniquenessofthenatureoftheworkof emergencyphysicians:afull-timepositionforEPswas deﬁnedas36hoursperweekthatmaybedivided ﬂexiblyon weekdaymorningsandevenings.Additionalworkinghours, aswellasnightandweekendwork,areconsideredovertime.

ChangesintheEDworkforcehavebeenseeninrecent yearsinmanywesterncountriesandhavehadamajorimpact onEDs.IntheUnitedStates,aninsufficientnumberofEPs intheearly2000sseemstohavebeenresolvedbythe2020s,at leastinurbanareas.4–6 IntheUnitedKingdom(UK),anEM staffingcrisisinducedtheestablishmentofataskforce,which wasabletogreatlyimprovethesituation.7–10 Webelievethat ourstudycanshedsomelightabouttheEMstaffingcrisis, notonlyinIsraelbutglobally.

Ourgoalsinthisstudyweretore-evaluatethe characteristicsoftheEPworkforceinIsrael,aswellasthe employmentstatusandworksatisfactionofboard-certified EPsworkingbothinandoutoftheED.Wealsosurveyedthe compositionofspecialistphysiciansworkinginthevarious EDsinIsraeltodocumentthenumberofboard-certifiedEPs andtheirworkplacesandtoexaminethefactorsthat influencethemtopersistintheirworkinEDsortomoveto otherareasofpractice.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

In2002,25%ofattendingphysiciansworking inIsraeliEDswereemergencyphysicians (EP).By2012,45%ofEDattendings wereEPs.

Whatwastheresearchquestion?

Whatisthestatusin2022?Andwhatfactors affecttheretentionofEPs?

Whatwasthemajor ﬁndingofthestudy?

In2022,69%ofEDattendingswereEPs,but only59%ofallEPsworkedinEDs.Part-time employmentisafactorinpredictingEPs ’ satisfaction(OR9.8,P = 0.02).

Howdoesthisimprovepopulationhealth?

Anationwideorganizationaleffortisrequired tomaintaintrainedandexperienced personnelworkinginIsraeliEDs.

METHODS

StudyDesignandSetting

Thiswasaprospective,cross-sectionalstudywiththree components.Weconductedaquestionnaire-basedsurvey designedtoassessthenumberandpercentageoffull-time equivalent(FTE),leveloftraining,andspecialty(ifany)of physiciansworkinginEDs.Weenquiredaboutstaffmember variationsatvarioustimesduringthedayaswellasduring theweek(Appendix1).Thesurveywasadaptedfromand designedtolargelyreplicatepreviouslypublishedworkforce studiesofthesamepopulationin2003and2012.2,3 The surveywassenttotheadministrativestaffat all25IsraeliEDs.

Ananonymousquestionnairewassenttoall334boardcertiﬁedEPsinIsraeltoretrievedataontheirdemographics (age,gender,maritalstatus,andnumberofchildren); training(yearsofpractice,hospital,andtypeofresidency); placeofemployment;andworksatisfaction.The questionnairewasemailedtoalllicensedEPsinIsraelwith thehelpoftheIsraelMedicalAssociation.Allrespondents wereaskediftheywouldbewillingtoparticipateinanindepthinterview.Thosewhoagreed EPsemployedinEDs andothervarious ﬁeldsofpractice createdaconvenience sampleforthethirdcomponentoftheresearch:aqualitative analysisofin-depthinterviews.Theinterviewsweresemistructured,designedbytheresearchteam,conducted telephonically,recorded,andtranscribedforanalysis. Intervieweeswereaskedabouttheirfeelingsandopinions

regardingworkintheED,the ﬁeldofEM,andtheirmotives forcareerchoices.Thequalitativeanalysisofthedata obtainedduringtheinterviewswasbasedonathematic approach.Twoindependentresearchers,bothwithmaster’ s degreesinpsychology,analyzedthedataandfollowedthesix phasessuggestedbyBraunandClarke’sguidefor thematicanalysis.11

StatisticalAnalysis

WeperformeddataentryandanalysiswithSPSS Statistics,version28(SPSSInc,Chicago,IL).Questionnaire responseratewascalculatedbasedontheAmerican AssociationofPublicOpinionResearchguidelines.We describedcategoricalvariablesbynumbersandpercentages, andcontinuousvariablesbymean ± standarddeviation, median,andinterquartilerange.Normaldistributionwas assessedusingtheShapiro-Wilktest.Weassesseddifferences incontinuousvariablesbetweentwogroupswithANOVA forvarianceswithnormaldistributionandtheKruskalWallistestforvarianceswithnon-normaldistribution. Differencesbetweencategoricalvariableswereassessedwith thechi-squaredorFisherexacttest,asappropriate,andwe assesseddifferencesbetweenmediansbyaMann-WhitneyU testforindependentmeans.Criteriaforsatisfaction,which wereconsideredimportantbasedonaliteraturereview,7,8,12 wereenteredintoamultivariatemodelinwhichodds ratiosand95%conﬁdenceintervals(CI)werecalculated

forfactorsfoundtobesigniﬁcantaccordingtoatwo-tailed P -valueof <0.05.

RESULTS

NationalDataandDatafromHospitals

Weobtainedinformationfrom25/25IsraeliEDswitha surveyresponserateof100%,althoughdataonminorpoints fromthreeEDswasincomplete.Therewere266boardcertiﬁedEPsofwhom141(53%)wereemployedfulltimeor parttimeinEDsnationwide.Sixty-twonon-EPattendings werealsoemployedintheEDs.Theaveragenumbers ofattendings(bothEPsandnon-EPs)perED,stratiﬁed bylargehospitals(>700beds),mediumhospitals (400–700beds),andsmallhospitals(<400beds),areshown in Table1.

AFTEisaunitthatindicatestheworkloadofan employedpersoninawaythatmakesworkloads comparable.AFTEof1.0isequivalenttoafull-timeworker, whileanFTEof0.5representshoursworkedthatare equivalenttohalfofthoseworkedbyafull-timeworker.

ThepresenceofEPsintheEDbyshiftisshownin Figure1.TheEPswerepresentintheEDsprimarilyduring weekdaymorningshifts,andtheirpresencewaslimited duringnightandweekendshifts,mainlyinlargehospitals. ThenumbersofallactiveEPs,activeEPsworkingtheEDs, non-EPattendingsworkingtheED,andEMresidentsin Israelareshownin Figure1 and Table2.

Table1. Averagenumberofemergencydepartment(ED)attendingsemployedinIsraeliEDsbyhospitalsizein2021. Hospitalsize*

ED,emergencydepartment; EP,emergencyphysician; FTE, full-timeequivalent. *Large =>700beds;medium = 400–700beds;andsmall =<400beds.

Figure1. Meannumberofemergencydepartmentattendingphysiciansbyshift.

Table2. Israeliphysicianworkforceinemergencydepartmentsnationwide,byyear.

Year ActiveboardcertiﬁedEPs

Activeboard-certiﬁed EPsemployed inEDs1 EM residents Non-EPattendings employedinEDs

Totalnumberof attendingsemployed intheEDs

Totalnumberof physiciansemployed intheEDs 20035959 – 175234234 201215411071147257328 202223914127362203476

SurveyResults

QuantitativeAnalysis

Of334questionnairessent,106physiciansresponded; five responseswereexcludedduetoincompletereplies,fora responserateof30%.Seventy-nineoftherespondentswere employedinadultsEDsand22inpediatricEDs.Themean ageofthecohortwas45 ± 10years,and65%weremales (Table2).Thirty-fiveofthe79EPsinadultsEDS(44%) workedfulltime,29(37%)workedparttime,and15(19%) didnotworkinanyED.Acomparisonofage,gender, numberofchildren,residencytype,timeinpractice,andED weeklyhoursrevealedthattheyweresignificantlydifferent betweenthesethreegroups(P < 0.05)(Table3).Medical experience(inyears)wassignificantlyloweramongfull-time

ED,emergencydepartment; EP,emergencyphysician; EM,emergencymedicine. 1Full-timeandpart-timeemployment. Volume25,No.4:July2024WesternJournal

workerscomparedtobothpart-timerworkersandthosewho nolongerworkedinanED.Themeannumberofweekly workinghours(eitherintheEDorinanotherdepartment) wassigniﬁcantlyhigherforfull-timerscomparedtothose whohadlefttheED.Bothtotalsalaryandsalaryperhour weresigniﬁcantlydifferentbetweenthethreegroupsinfavor ofthegroupwhohadlefttheED(Table3).

WorkSatisfaction

Sixty-nineofthe83EPrespondentswhoworkedinanED (83%),completedthework-satisfactionsectionofthesurvey. Themeanagewas49years(SD10),47(65%)weremale, 59(82%)weremarriedorinarelationship,and37(51%) workedfulltime.Fortyphysiciansreportednotbeing

Gender,female,n(%)18(38.3)3(10.0)4(28.6)0.02

Familystatus

Married7(13.7)1(3.1)2(11.1)

Single43(84.3)27(84.4)14(77.8)0.19

Divorced1(2.0)4(12.5)2(11.1)

Children

Residencypath,n(%)

Direct8(15.7)11(34.4)1(5.6)

Fellowship37(72.5)11(34.4)9(50.0) <

Bylicenseonly1(2.0)10(31.3)7(38.9) Yearsinpractice14.0

*AveragemonthlysalaryinIsraelin2021 – 12,000NIS. Valuesaregivenmean ±SDunlessindicatedotherwise. NIS,NewIsraelishekel.

Table3. Demographicsofsurveyparticipants.

Table4. Factorspredictingemergencyphysicianjobsatisfaction. VariableaOR(95%CI)

Age(years)0.9(0.8–1.0)0.17

Gender2.7(0.4–15.7)0.26

Familystatus1.5(0.02–97.6)0.97

Numberofchildren1.2(0.5–2.8)0.63

Part-timeposition(vsfulltime)9.8(1.2–74.9)0.02

EmergencyphysicianinadultED(vspediatric)7.8(0.5–107.4)0.12

Salary(grade)1.4(0.8–2.6)0.17

EDannualvisits1.0(0.9–1.0)0.33

aOR,adjustedoddsratio; ED,emergencydepartment.

satisfied,and29reportedthattheyweresatisfied. Table4 displaysamultivariateregressionmodelforEDattending physiciansatisfaction.Part-timeworkwastheonly significantindependentpredictorofsatisfaction,withan adjustedoddsratioof9.8(95%CI1.2–74.9), P = 0.02.

QualitativeAnalysis

Sixty-sixofthe83EPrespondentswhoworkedinanED (80%)completedthesurveysectionontheEDwork environment.Mostofthemreportedthattheyhadaheavy workloadandastressfulworkenvironment(93%foreach). Only37%feltproperlyappreciated,andonly41%felt adequately ﬁnanciallycompensated.Mostofthem(81%) hadsocialsatisfaction(ie,enjoyedrelationshipwith colleagues),and75%hadprofessionalsatisfaction(for furtherdetailsonworkenvironmentintheED, see Appendix2).

Thirty-oneofthesurveyrespondentswhowereEPs currentlyworkinginanED(45%)reportedconsidering leavingtheEDforvariousreasons.Wecomparedtheir reasonswiththosestatedbyphysicianswhohadlefttheED and,interestingly,fewrespondentsineachgroupstatedthat salarywasveryinfluentialinconsideringleaving(11%)orin theirdecisiontoleave(7%)theED,despitethemajor differenceinsalaries.Lackofopportunityforprofessional advancementwasmoreinfluentialinthegroupthatwas consideringleaving(38%)comparedtothegroupthathad left(13%).Goodsocialrelationshipswithco-workerswasan importantfactorforstayingintheED,bothforthosewho hadleftandforthosewhoconsideredleaving,70%and66% (respectively)statingitas “influential” and “ very influential.” Worksatisfactionwasalsoasignificantfactorin bothgroupsforstayingintheED(80%and77%, respectively,statingitas “influential” and “veryinfluential”).

Weinterviewed19EPswhorangedinagefrom 30–75years;12weremale.SixteenworkedinadultEDsand threewerepediatricEPs;sevenworkedfulltimeandthree workedparttime,andninehadlefttheED(twoformilitary service,twoforafellowshipprogramabroad,andonewho

retired).OfthoseworkinginEDs,eightworkedinlarge hospitals(ﬁvedifferenthospitals),oneinamedium-size hospital,andoneinasmallhospital.Nineworkedina centralhospital,andoneworkedinaperipheralhospital.

Thethematicanalysisyieldedtwomajoraxes:axis1in favorofworkingasanEP,andaxis2againstworkingasan EP.Eachaxishadthreecorrespondingthemes,andeach themehadseveralsub-themes.(See Table5 fordetailsonthe themes).Threemainthemeswerefoundonbothaxes: internalmotivationalfactors;externalfactors;and relationships.Those ﬁndingswereinlinewithresultsfrom thequantitativeanalyses.Forexample,limitedcareer advancementopportunitieswerefoundtobesigniﬁcantin boththequantitativeandqualitativeanalyses(axis2,theme 2).Thetwosafeguardingfactorsthatemergedinbothtypes ofanalysisweremeaningfulwork(axis1,theme1)anda goodrelationshipwiththemultidisciplinaryEDpersonnel (axis1,theme3).

DISCUSSION

TheImportanceofanEmergencyPhysicianPresencein theED

ItiswidelyacknowledgedthatthepresenceofEPsinthe EDishighlybeneficialforpatientcare.13 Researchcarried outin2014inalarge,urbanIsraelimedicalcenterfoundan advantagetothepresenceofEPsintheEDcomparedto physiciansboard-certifiedinotherspecialtiesintermsof lengthofstayintheED.14 Shorteningthepatient’slengthof stayinanEDreducedEDcrowding,aparameterthatwas foundtobeassociatedwithreducedmortality.15 Astudyina ruralAustralianmedicalcenterEDshowedimprovementin patientwaittimeandaccessblock(thesituationwhere patientswhohavebeenassessedintheEDandrequire admissionareboardedintheEDduetoalackofinpatient bedcapacity)whenEPswerepresent.16 AnotherAustralian studyshowedthatpatientscaredforbyEMresidents benefittedfromthepresenceofanEPattending.17 Several UKstudiesalsofoundclinicalbenefitinthepresenceofan EPattendingintheED.18–20 Onestudynotedthatsenior

Table5. Themesofthein-depthinterviewswithIsraeliemergencyphysicians.

ProsforworkingasanemergencyphysicianConsforworkingasanemergencyphysician

1.Internalmotivationalfactors

-Meaningfulwork

-Positivepreviousexperience -Personalresponsibility

-Receivingimmediatefeedback -Senseofauthority

-Intellectualsatisfaction(learningandteachingopportunities)

2.Externalfactors

-Patientsandcarediversity.

-Case-managing

-Holisticapproachtopatientcare -Dynamicnatureofthe ﬁeld -Suitablecompensationforextrahours

3.Relationships

-Rewardingpatient-doctorrelationship

-GoodrelationshipswithmultidisciplinaryEDpersonnel

-GoodrelationshipswithEDmanagement

EP,emergencyphysician; ED,emergencydepartment.

doctorinputinpatientcareintheEDaddedaccuracyto dispositiondecisions,thusimpactingpatientsafetyand improvingdepartmental ﬂow. 18 Anotherstudycarriedoutin apediatricEDshowedthatthepresenceofEPswasalsocost effective,resultinginfeweradmissions,shorterwaittime, andfewerpatientcomplaints.19 Theseandotherstudies promotedarecommendationfor24/7EPpresenceinEDsin theUK.20

EmergencyDepartmentClinicalWorkforce

Wefoundadecreaseinthenumberofnon-EPattending physiciansworkinginEDsnationwide,andaparallel increaseinthenumberofEMresidents.Therewasan increaseinthenumberofEPattendingsworkingintheEDs, butthepercentageofboard-certiﬁedEPsemployedinEDs wasdecreasing,evenafterconsideringthenumberofretired physicians(Figure2).ThetwoearlierstudiesontheIsraeli EDworkforcein20032 and20123 foundthatthepresenceof EPsintheEDswasmostlylimitedtoweekdaymorning shifts.The2012studyshowedsomepresenceofEPson weekends,butonlyinlarge(>700beds)hospitals.The ﬁndingsofthemostrecentstudy,conductedin2022,showed asimilartrend,withanincreaseinthepresenceofEPsduring morningshiftsandasmallerincrease,ifany,intheirpresence duringevening,night,andweekendshifts.(See Appendix1 forfurtherdetails.)

1.Internalmotivationalfactors: -Feelingundervalued -Feelingincompatiblewithrole -Effectsonone'smentalhealth -Effectsonfamilyrelationships

2.Externalfactors:

-Limitedcareeradvancementopportunities

-Intensecaseload

-Verbalandphysicalabusefrompatientsandtheirrelatives -Unsuitablebaselinewages

-Workconditions(stafﬁng,lackofappropriateequipment,lackof sustenanceandrest)

3.Relationships

-Poorrelationshipswithhospitalmanagement -Complicatedrelationshipswithconsultingexpertsfrom otherdepartments

-Complicatedrelationshipsandtensionwithother hospitaldepartments

InsufﬁcientnumbersofEPsworkinginEDswereevident intheUnitedStates(US)intheearly2000s.4 Aspartofthe efforttorectifythisshortage,Camargoetaldevelopeda formulacalculatingthenumberofEPsrequiredforthe properfunctionofanED.Thecalculationwasbasedupon severalassumptions:1)aboard-certiﬁedEPwaspresentatall times;2)anaveragephysiciancanattend2.8patientsper hour;and3)therewasa40-hourworkweek,withone-third ofthosehoursdedicatedtonon-clinicalwork.Theformula thoseauthorscreatedis:

Numberofneededdoctors = annualnumberofEDvisits 3548

Baseduponthismodel,theauthorsconcludedthatonly 55%ofthecurrentEPdemandwasbeingmetintheUSin 2005.4 Usingdataonphysicians’ workforceandpatient volumes,anothergroupfoundthatthe2016shortageinEPs intheUSwasdecreasingyearly.6 Afollow-upstudy, conductedin2020,anticipatedthattheshortagewouldbe resolvedasearlyas2021,especiallyinurbanzones. Furthermore,thatstudypredictedthat,afterextrapolating currenttrendsinresidencygraduationandaccountingfor increasedpatientvolumes,theEPworkforcecouldbe oversuppliedby20–30%bytheyear2030.5

Active board-certified EPs employed in EDs

Active board-certified EPs

% of board certified EPs working inEDs

Comparisonbetweenworkforcesin2003,2012,and2022.

ThespecialtyofEMsufferedasimilarstaffingcrisisinthe UK,whichledtotheestablishmentofataskforcededicated to findingasolution.7,8 TheBritishCollegeofEmergency Medicineestablisheda “ruleofthumb” forEDstaffingthat consideredsustainabilityandtheneedforresident supervision.Accordingtotheproposedguideline,12–16 certifiedEPsarerequiredforbasiccoverageforanEDwith 100,000visitsperyear,assumingthepresenceofcompetent residentsandphysicianassistants.21 Followingthe recommendationsofthetaskforce,changesinpracticeand policy,throughinnovationsaswellasrecognitionofthe particularstressesposedbyacareerinEM,ledtorapid growthofEMintheUKintermsofbothattending physiciansandresidents.9,10 AshortageofEPsinAustraliain 2008causedsomepolicymakerstoadvocateforthe employmentofgeneralpractitionersinEDs,22 ashadbeen doneearlierinIsrael(buttoalesserdegreeafterthe establishmentofanEMresidency).Ourcurrentstudy showedsimilar findings.We,too,observedamajorlackin highlytrainedpersonnelintheED,whichshouldeventually beresolvedthankstotheincreasingnumbersofresidents inEM.

Severalstudiesfoundthatburnoutplayedanimportant roleinEPturnover.10 Highburnoutrateswerealso demonstratedinIsraeliEPsinarecentstudy,andthatthe rateworsenedasaresultoftheCOVID-19pandemic.23 Low jobsatisfactionwaslinkedwithleavingandintention toleavetheED,accordingtootherreports.24,25 Thisissueisa matterofconsiderableconcern:inourcurrentstudy, 60%oftheEPswerefoundtohavelowlevelsof worksatisfaction.

Thequalitativeanalysisofourstudyrevealedthatthe factorscontributingtoworksatisfactionseemtobe universal:teamwork;continuedtrainingandengagingin academicactivities;andworkdiversity.26–30 Stressand problematiccommunicationwiththeadministrationwere alsofoundtobenegativefactorsinEPretention.26,27,30,31 OurdatashowedthatmostEPs ﬁndtheirworktobevery stressful.Notably,despitethedifferenceinsalariesbetween EPswholefttheEDandthosewhoremainedinfull-and part-timeworkandthedissatisfactionwiththebaseline salaries,salarywasrarelythemajorreasonforleavingor consideringleavingtheED.Thiscorrelateswiththe ﬁnding ofourpreviousstudy,inwhichphysicianswholeftreported

EP emergency physicians; ED emergency department; EM emergency medicine

Non-EP attendings employed in EDs

EM residents

Figure2.

lowersalariesintheEDbutdidnotstatethatsalarywasa majorreasonforleaving.28

Tothebestofourknowledge,theapplicationofa flexible employmentmodeltoincreaseretentionintheEDhasrarely beendiscussedintheliterature.Part-timeemploymentwas suggestedbyJamesetalasameansofmotivatingveteran physicianstocontinueworkingintheED.29 Inanother small,qualitativestudy,thesuitabilityofEMfor flexible workingwaslistedasbeingafactorinfluencingthecareer choiceofbeinganEP.32

Theconceptofpart-timeworkforphysiciansingeneralis overtwodecadesoldandhasbeenassociatedwithyounger andfemaledoctorsseekingabetterwork-lifebalance.Inthe late1990saseriesofarticlesdebatedthepossibleimpactof ﬂexibleandpart-timeemploymentondoctors,includingits effectonprofessionalismandcareersustainability.The matterofpatients’ continuityofcarewasalsodebated.33–35 Part-timeemploymentbecamemorecommonamong primarycarephysiciansandpediatricians,butitseffecton doctors’ wellbeingandpatientoutcomewasrarely researched.36 Parkertonetalfoundhigherquality performanceforprimarycarephysiciansworkingparttime, andPanattonietalfoundhigherpatientsatisfaction.37,38

Accordingtoour ﬁndings,part-timeemploymentinthe EDisanindependentpredictorforphysiciansatisfaction. Furtherstudyisrequiredtodeterminewhetherapplicationof thisemploymentmodelimprovesworksatisfactionand increasesretentionofEPs.Potentially,apart-timework modelcouldalsoallowforalargerandmorediverse EDworkforce.

LIMITATIONS

Thisstudyhasseverallimitationsthatbearmention.First, werelieduponself-reporteddatafortheEDs.Secondly,the questionnairehadarelativelylow(30%)responserateand wassubjecttoresponsebiasandunder-representationof variousgroups:our ﬁndingsshowedthatwhile41%ofEPs arenotemployedinEDs,only19%ofthesurveyrespondents belongedtothegroupofEPswhohadlefttheED,rendering thatgroupunder-representedinthesurvey.Other,lesseasily identiﬁedgroupsmayalsobeunder-represented. Additionally,thein-depthinterviewswereconductedwitha smallconveniencesampleandwerethussubjectto selectionbias.

CONCLUSION

EmergencymedicineinIsraelisatacrossroads.Onthe onehand,alargerthanevernumberofyoungdoctorshave chosenEMfortheirresidencytraining.Ontheotherhand, theretentionofboard-certiﬁedEPsisamajorconcern.Itis ourviewthatanationwideorganizationaleffortisrequired tomaintaintrainedandexperiencedcliniciansworkingin ourEDs.

AddressforCorrespondence:NoaaShopen,MD,TelAvivSourasky MedicalCenter,DepartmentofEmergencyMedicine,6Weizmann St.,TelAviv6423906,Israel.Email: noasho@tlvmc.gov.il

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

REFERENCES

1.HalpernP,WaismanY,SteinerIP.Developmentofthespecialtyof emergencymedicineinIsrael:comparisonwiththeUKandUSmodels. EmergMedJ. 2004;21(5):533–6.

2.DrescherMJ,Aharonson-DanielL,SavitskyB,etal.Astudyof theworkforceinemergencymedicineinIsrael:2003. JEmergMed. 2007;33(4):433–7.

3.DrescherMJ,WimpfheimerZ,DarawshaA,etal.Astudyofthe workforceinemergencymedicineinIsrael2012:Whathaschangedin thelastdecade? IntJEmergMed. 2015;8(1):47.

4.CamargoCAJr,GindeAA,SingerAH,etal.Assessmentofemergency physicianworkforceneedsintheUnitedStates,2005. AcadEmergMed. 2008;15(12):1317–20.

5.ReiterMandAllenBW.Theemergencymedicineworkforce: shortageresolving,futuresurplusexpected. JEmergMed. 2020;58(2):198–202.

6.ReiterM,WenLS,AllenBW.Theemergencymedicineworkforce: proﬁleandprojections. JEmergMed. 2016;50(4):690–3.

7.ReynardKandBrownR.Aclinicalanalysisoftheemergencymedicine workforcecrisis. BrJHospMed(Lond). 2014;75(11):612–6.

8.HughesG.Theemergencymedicinetaskforce:aninterimreport. Emerg MedJ. 2013;30(5):348.

9.SmithE,ServiceDesignandConﬁgureationCommittee.RCEM Workforcerecommendations2018:Consultantstafﬁnginemergency departmentsintheUK.2018.TheRoyalCollegeofEmergency Medicine.Availableat: https://rcem.ac.uk/wp-content/uploads/2021/11/ RCEM_Consultant_Workforce_Document_Feb_2019.pdf AccessedJanuary10,2023.

10.DarbyshireD,BrewsterL,IsbaR,etal.'Wherehaveallthe doctorsgone?'Aprotocolforanethnographicstudyoftheretention probleminemergencymedicineintheUK. BMJOpen. 2020;10(11):e038229.

11.BraunVandClarkeV.Usingthematicanalysisinpsychology. QualRes Psych. 2006;3(2):77–101.

12.ShanafeltTD,BooneS,TanL,etal.BurnoutandsatisfactionwithworklifebalanceamongUSphysiciansrelativetothegeneralUSpopulation. ArchInternMed. 2012;172(18):1377–85.

13.ArnoldJL.Internationalemergencymedicineandtherecent developmentofemergencymedicineworldwide. AnnEmergMed. 1999;33(1):97–103.

14.TrotzkyD,TsurAM,FordhamDE,etal.Medicalexpertiseasacritical inﬂuencingfactoronthelengthofstayintheED:aretrospectivecohort study. Medicine(Baltimore). 2021;100(19):e25911.

15.EpsteinSK,HuckinsDS,LiuSW,etal.Emergencydepartment crowdingandriskofpreventablemedicalerrors. InternEmergMed. 2012;7(2):173–80.

16.O’ConnorAE,LockneyAL,SloanPD,etal.Doesthepresence ofanemergencyphysicianimproveaccessbasedquality indicatorsinaruralemergencydepartment? EmergMedAustralas. 2004;16(1):55–8.

17.SacchettiA,CarraccioC,HarrisRH.Residentmanagementof emergencydepartmentpatients:Iscloserattendingsupervision needed? AnnEmergMed. 1992;21(6):749–52.

18.WhiteAL,ArmstrongPAR,ThakoreS.Impactofseniorclinicalreviewon patientdispositionfromtheemergencydepartment. EmergMedJ. 2010;27(4):262–5,296.

19.GeelhoedGCandGeelhoedEA.Positiveimpactofincreased numberofemergencyconsultants. ArchDisChild. 2008;93(1):62–4.

20.TheCollegeofEmergencyMedicine.EmergencyMedicineConsultants WorkforceRecommendations.2010.TheCollegeofEmergency Medicine.Availableat: https://rcem.ac.uk/wp-content/uploads/2021/11/ EM_Consultants_CEM_Workforce_Recommendations_Apr_2010.pdf AccessedJanuary10,2023.

21.HigginsonI,MannC,MoultonC. “Rulesofthumb” formedicaland practitionerstafﬁnginemergencydepartments.2015.TheCollageof EmergencyMedicine.Availableat: https://rcem.ac.uk/wp-content/ uploads/2021/11/Rules_of_Thumb_for_Medical_and_Practitioner_ Stafﬁng_in_EDs.pdf.AccessedJanuary10,2023.

22.WillcockSM.Gettingbackintotheemergencydepartment:diversifying generalpracticewhilerelievingemergencymedicineworkforce shortages. MedJAust. 2008;189(2):113–4.

23.ShopenN,SchneiderA,MordechaiRA,etal.Emergencymedicine physicianburnoutbeforeandduringtheCOVID-19pandemic. IsrJ HealthPolicyRes. 2022;11(1):30.

24.LloydS,StreinerD,ShannonS.Predictivevalidityoftheemergency physicianandglobaljobsatisfactioninstruments. AcadEmergMed. 1998;5(3):234–41.

25.Feitosa-FilhoGS,KirschbaumM,NevesYCS,etal.Characteristicsof trainingandmotivationofphysiciansworkinginemergencymedicine. RevAssocMedBras(1992). 2017;63(2):112–7.

26.Estryn-BeharM,DoppiaM-A,GuetarniK,etal.Emergencyphysicians accumulatemorestressfactorsthanotherphysicians-resultsfromthe FrenchSESMATstudy. EmergMedJ. 2011;28(5):397–410.

27.FitzgeraldK,YatesP,BengerJ,etal.ThepsychologicalhealthandwellbeingofemergencymedicineconsultantsintheUK. EmergMedJ. 2017;34(7):430–5.

28.HallKNandWakemanMA.Residency-trainedemergencyphysicians: theirdemographics,practiceevolution,andattritionfromemergency medicine. JEmergMed. 1999;17(1):7–15.

29.JamesFandGerrardF.Emergencymedicine:Whatkeepsme,what mightloseme?AnarrativestudyofconsultantviewsinWales. Emerg MedJ. 2017;34(7):436–40.

30.MurphyJFA.Medicalstaffretention. IrMedJ. 2014;107(1):4–5.

31.SmithEandDasanS.Asystemunderpressure. BrJHospMed(Lond). 2018;79(9):495–9.

32.TakakuwaKM,BirosMH,RuddyRM,etal.Anationalsurveyof academicemergencymedicineleadersonthephysician workforceandinstitutionalworkforceandagingpolicies. AcadMed. 2013;88(2):269–75.

33.GoldbergIandHornungR.Areparttimedoctorsbetterdoctors? Doctorsneed ﬂexibletrainingand ﬂexiblejobs. BMJ. 1998;316(7138):1169–70.

34.Sahleen-VeaseyCandMorrisonL.Areparttimedoctorsbetterdoctors? Fulﬁlleddoctorsarebetterdoctors. BMJ. 1998;316(7138):1170.

35.ManningC.Areparttimedoctorsbetterdoctors?Continuityofcareis likelytosuffer. BMJ. 1998;316(7138):1170.

36.CullWL,O’ConnorKG,OlsonLM.Part-timeworkamongpediatricians expands. Pediatrics. 2010;125(1):152–7.

37.ParkertonPH,WagnerEH,SmithDG,etal.Effectofpart-timepractice onpatientoutcomes. JGenInternMed. 2003;18(9):717–24.

38.PanattoniL,StoneA,ChungS,etal.Patientsreportbettersatisfaction withpart-timeprimarycarephysicians,despitelesscontinuityofcare andaccess. JGenInternMed. 2015;30(3):327–33.

HeidiRoche,MD*†

BrandonA.Knettel,PhD‡§

ChristineKnettel,MD∥

TimothyFallon,MD*†

JessicaDunn,MD¶

EDUCATIONAL ADVANCES

*DepartmentofEmergencyMedicine,MaineMedicalCenter,Portland,Maine

† TuftsUniversitySchoolofMedicine,Portland,Maine

‡ DukeUniversitySchoolofNursing,Durham,NorthCarolina

§ DukeGlobalHealthInstitute,Durham,NorthCarolina

∥ DepartmentofEmergencyMedicine,UniversityofNorthCarolinaSchoolofMedicine, RexHospital,ChapelHill,NorthCarolina

¶ DepartmentofEmergencyMedicine,EmoryUniversitySchoolofMedicine, Atlanta,Georgia

SectionEditor:WendyMacias-Konstantopoulos,MD,MPH,MBA

Submissionhistory:SubmittedApril29,2023;RevisionreceivedJanuary30,2024;AcceptedFebruary23,2024

ElectronicallypublishedJune11,2024

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

DOI: 10.5811/westjem.18103

Thereisrecognitioninthe ﬁeldofemergencymedicine(EM)thatsocialdeterminantsofhealth(SDoH) arekeydriversofpatientcareoutcomes.LeadersinEMarecallingforcurriculaintegratingSDoH assessmentandintervention,publichealth,andmultidisciplinaryapproachestoEMcarethroughout medicalschoolandresidency.ThisintersectionofSDoHandtheemergencycaresystemisknownas socialemergencymedicine(SEM).Currently,therearefewresourcesavailableforEMtrainingprograms tointegratethiscontent;asaresult,fewEMtraineesreceiveadequateeducationinSEM.Toaddressthis gap,wedevelopedafour-parttraininginSEMtailoredtoEMresidencyprogramsandmedicalschools.

Thiscurriculum,knownasRISE-EM(ResidentInstructioninSocialEmergencyMedicine),usesvideo lectures,caseexamples,andgroupdiscussionstoengagetraineesanddevelopcompetencyin providingsoundcarethatisgroundedinevidence-basedprinciplesofSEM.Inthecurrentstudy,we testedRISE-EMbydeliveringthevideolecturestoresidentsandmedicalstudentsintwotraining programs.Weadministeredpre-andpost-courseknowledgetestsandapost-courseparticipant attitudessurveytoassesstheacceptabilityandpotentialefﬁcacyoftheprogramforimprovingSEM knowledgeandattitudesamongEMlearners.

WefoundittobebothfeasibleandacceptabletointroduceSEMcontentinresidencyconferences, withpreliminarydatashowingstatisticallysigniﬁcantimprovementinknowledgeofthecontentandselfefﬁcacytoapplyittotheirclinicalpractice.Insummary,RISE-EMhasbeenhighlyvaluedbyEMlearners andviewedasastrongsupplementtotheirexistingtraining,andithasbeenshowntosuccessfully improveSEMknowledgeandattitudes.[WestJEmergMed.2024;25(4)593–601.]

BACKGROUND

Healthiscloselyintertwinedwithmultiplecomplex aspectsofaperson’sdailylife,aninteractiontermedsocial medicine.Severalstudieshavedemonstratedthatsocial determinantsofhealth(SDoH),whichmayincludepersonal, social,economic,andotheraspectsofwell-being,may contributeto40%orgreateroftotalhealthoutcomes, whereasclinicalinterventions,bothinpatientandoutpatient, wereestimatedtocontributeamere12–20%.1 Forexample, althoughtheclinicianmaydiagnosepneumoniaand

prescribeantibiotics,thepneumoniawillnotimproveifthe patientcannotaccessthetreatmentduetocostorother barriersorcontinuestoliveinanenvironmentthatdoesnot alloworpromotehealing.2

Inthe19th century,Virchowstated: “Medicineisasocial science,andpoliticsisnothingmorethanmedicineonalarge scale.”3 However,onlyrecentlyhasthe ﬁeldofemergency medicine(EM)beguntoappropriatelyemphasizetheneed forinterventionsbeyondmedicalcare,atbothpoliticaland societallevels.4,5 Socialmedicine,atermthatincludes

considerationsofSDoH,socialepidemiology,andsocial scienceintheprovisionofmedicalcare,emphasizesconcepts ofhealthequity,advocacyandinterdisciplinaryapproaches toimprovingpatientoutcomesandreducing healthdisparities.6

Giventhelargeimpactofsocialdeterminantsonhealth,it seemsnaturaltoemphasizetraininginsocialmedicineacross thestagesofmedicaleducation.Someundergraduate programsandmedicalschoolshavebegunimplementing newsocialmedicinecurricula;however,thesemodules continuetomakeuponlyasmallsegmentofmosttraining programs. 7–9 Inresponsetoagrowingbodyofresearchand interestinsocialmedicine,medicalleaders,includingthe AccreditationCouncilforGraduateMedicalEducationand theAmericanCollegeofEmergencyPhysiciansACGME andACEP,arecallingformoreexposuretosocialmedicine throughoutmedicalschoolandresidencytraining.10–12

ManyEMleadershaveexpressedvalidconcernsregarding thechallengesofaddressingSDoHintheED,oftenbasedon lackofresourcestoeffectivelyimplementnewservicesinan alreadyoverburdenedsystem.Theemergencydepartment (ED)isperceivedbymanymembersofthecommunityasa settingwheretheycanseeksupportforunmetsocialneeds,a patternthatplacesasubstantialburdenoncaresystemsnot designedforthispurpose.13,14 However,asasystemthat providescareatalltimes,regardlessofcomplaintorpatient circumstance,theEDisarguablythecaresettingmostcritical forintegratingprinciplesofsocialmedicine.15–17

ThisreevaluationoftheroleofEMhasoccurredina changingclimateofsocialwelfare,wheretheEDhasbecome partofacriticalsocialsafetynet.15 Itisbecomingclearthatit isnolongeracceptabletotreatthemedicaletiologiesof healthproblemsalone,whenSDoHplaysuchakeyrolein ourpatients’ experienceofdiseaseandillness.Giventheir frontlineinteractionwithSDoH,emergencyphysiciansare inakeypositiontoleadaparadigmshiftfrommerely treatingdownstreamdiseasetoleadingchange,systemically andcollaboratively,inupstreampreventativehealth factors.4,15,17,18 ThisintersectionofSDoHandthe emergencycaresystemisknownassocialemergency medicine(SEM),apromisingapproachtorespondingtothe unmetsocietaldemands ﬂoodingtheED.Emergency cliniciansmustembraceanexpandedroletoguidethe healthcaresystemandpolicymakersindesigningasystem thatintegratessocialandmedicalaspectsofcare.15

Despitetheseescalatingrolesandresponsibilitiesofthe emergencycaresystem,therehasbeenlittleinclusionofsocial medicineingraduateEMeducation,andmanyEMeducation leadershaveidentifiedthisasanareaofneed.13,17–19Atthe timethisprojectwasstarted,therewereonlyfoursocial medicineandpopulationhealthfellowshipsinEMnationally. Thisnumberhasgrownto11bytimeofpublication,reflecting thegrowingacknowledgmentofthis field.20 Theseresidency tracksandfellowshipsareimportantinpavingthewayforthe

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Theintersectionofsocialdeterminantsof healthandemergencymedicineisan importantareaoftrainingforwhichlittle openaccesstrainingmaterialexists.

Whatwastheresearchquestion?

Canasocialemergencymedicine(SEM) curriculumincreaseresidentlearners ’ SEM knowledgeandself-ef ﬁ cacy?

Whatwasthemajor ﬁndingofthestudy?

OurcurriculumimprovedSEMknowledge andself-ef ﬁ cacyinacohortof26students (P < 0.001).

Howdoesthisimprovepopulationhealth?

OpenaccesseducationmaterialforSEMcan assistinfacilitatingthedevelopmentofSEM skillsandself-ef ﬁ cacyforresidentsintheir clinicalpractice.

budding ﬁeldofSEMbutarehardertotranslatetoother programsseekingtoadoptSEMcontent.

Onewaytoofferacurriculumorcontentthatiseasily adaptableintovariousprogramsisFreeOpenAccess MedicalEducation(FOAMed).Thisopenaccesseducation isprominentinEM,andexistingonlinematerialfocuses heavilyonstandardboardexamcontent,procedural competence,andcutting-edgetherapies.Giventhepaucityof SEMtoolsavailableonline,projectsarecurrentlyinthe workstooffersupplementalblogpostsorcasescovering SEMmaterial.However,atthistime,tothebestofour knowledge,aunifyingcurriculumwithobjectives,ordered lectures,andsupplementalmaterialdoesnotexistin FOAMedform,accessibletothegreaterEMeducation community.ToaddressthisgapintrainingresourcesforEM residentsandmedicalstudents,wedevelopedafour-part SEMtrainingcurriculumtobedeliveredbyvideowith accompanyingcaseexamplesandgroupdiscussions, knownasResidentInstructioninSocialEmergency Medicine(RISE-EM).

OBJECTIVES

WedescribethedesignofRISE-EMand ﬁndingsfrom pilotingthecurriculumwiththreecohortsofEMresidents andmedicalstudents.Ourobjectivewiththesepilotcohorts wastotestthepreliminaryfeasibility,acceptability,and potentialforimpactofRISE-EMinfacilitatingthe

developmentofSEMskillsforlearnersintheirclinical practice.Thethreecourseobjectivesareasfollows:

1.ExposeEMresidentsandmedicalstudentstothe conceptsofSEM

2.Providelearnerswithavocabularythattheycanuseto proactivelyaddressSDoH

3.TeachSEMskillsthatlearnerscanuseintheEDwhen workingwithpatients

CURRICULARDESIGN

TheRISE-EMcurriculumwasbuiltuponacore foundationinsocialmedicineprinciplesandcurriculum objectivesfromtheSocialMedicineReferenceToolkit.6 The toolkitwasvalidatedthroughananalyticalreviewby15 socialmedicineprogramsworldwideandpublishedbya nationalorganizationofphysiciansandpublichealth scientistsknownastheSocialMedicineConsortium.

TheSEM-speciﬁcmaterialwasdevelopedusingdiverse publishedworks,includingaseriesfromtheInventingSocial EmergencyMedicineConsensusConferencein2017,a summitcomposedofleadersfrommanyorganizations, includingtheAndrewLevittCenterforSocialEmergency MedicineandACEP.21 Wealsoreviewedtheprimary literaturetoidentifychallengesandsuccessfultechniques relatedtoteachingSDoHcontent.Throughoutthemodules, difﬁcultconceptswererepeated,explainedinmultiple differentways,andincorporatedintoclinicalscenariosto encourageunderstandinganddepthofprocessing.

“Nudges,” athemethroughoutRISE-EM,wereinspiredby nudgetheory,aconceptinbehavioraleconomicsand politicaltheory.22

TheRISE-EMcurriculumisbasedonvideolectures, whichallowsittobeusedasynchronouslyorsynchronously, inonesittingorovermultiplesessions.Thecurriculum consistsoffourvideomodules(Figure1),each approximately20minutesinlength(AppendixA).The sessionsweredesignedtobeshortenoughto ﬁtintomost conferencesortoholdtheattentionofabusyresidentoutside thehospital.Thevideosusemotifsandengagingdiscussions carriedthrougheachvideotoencouragedepthofprocessing andtoassistwithrecall.Theeducationalmodalitywas chosentofacilitateeasyadoptionbyEMresidencyand medicalstudenttrainingprogramswithteachingguides providedandtheabilityto ﬁtintovariousdidacticschedules andbothin-personandvirtualformats.

METHODS

Wecompletedaprospectivecohortstudydesignedtotest thefeasibility,acceptability,andpotentialefﬁcacyofRISEEMinimprovingSEMknowledgeandattitudesamongEM learners.WetestedthecurriculumwithtwogroupsofEM residents.Group1consistedofresidentsandmedical studentsatasoutheasternEMresidencyconferencein October2020.Group2consistedofresidentsata northeasternEMresidencyconferenceinNovember2021. Wearrangedforparticipationbysendinganintroductory emailthrougheachresidency’semaillistserv(AppendixB). Participantsweregiventwoweekstocompletepre-course materialandtwoweekstosubmitpost-coursematerialafter theintervention.Asthiswasapilotfeasibilitystudy ofaneducationalinnovation,thestudysizewasdetermined bythenumberofresidentsandmedicalstudentswho chosetoparticipateatthetwoinstitutionswherethe

Figure1. Coursemodulesbyindividualobjectives.

curriculumwastested.Thisresearchwasconductedwiththe approvalofeachinstitution’sinstitutionalreview board(IRB).

Learnerswhowishedtoparticipateinthestudyfolloweda linkintheintroductoryemail,providedtheirinformed consenttoparticipate,andwereaskedtotakea20-minute pre-testandsurveyonasecuresurveywebsite,withresponses collectedanonymously.Studyparticipantsthenwatchedthe fourvideolectures(delivereddifferentlytoGroup1and Group2,seebelow).Afterwatchingallthevideos, participantsengagedinalivegroupdiscussionduring standardresidencydidactictime.Theywerethenaskedto completeasecond20-minuteonlinesurvey,comprisingthe sameknowledgetestandadditionalquestionsaboutthe feasibilityandacceptabilityofthecourseforfuturedelivery. Reminderemailsforcompletionwereautomaticallysentto individualsevery ﬁvedaysafterinitialpre-coursematerial completion,foramaximumofuptothreetimesasdeﬁnedin ourIRBapplication.Thisstudyprotocolisillustrated in AppendixC

SurveyInstruments

Thepre-coursesurveybeganwithbasicdemographic questionsandeightadditionalquestionsrelatedtointerest andself-efﬁcacyinapplyingSEMprinciplesinclinical practice(AppendixD).The19-itempre-andpostknowledgetestswereidentical,composedof4–5multiplechoicequestionsofcontentfromeachRISE-EMlecture, with19intotal(AppendixE).Eachcorrectresponse received1pointforatotalscoreof0–19.Thecoursecontent questionsweredesignedtoassessbaselineandpost-course SEMknowledge.

Thepost-coursesurveyconsistedofthesameeightitems toassessforchangeininterestandself-efficacy(ie, “Followingmycompletionofthiscourse,Ifeelconfidentin assessingandaddressingsocialdeterminantsofhealthinmy clinicalencounters”).Feasibilitywasassessedbyrecording thenumberofmodulescompletedbyeachparticipant.We alsoevaluatedacceptabilityandperceptionsofcourse qualitywithninequestionsadaptedfromtheStudent EvaluationofEducationalQuality(SEEQ)instrument.23 Thepost-coursesurveyconcludedwithopen-ended questionsregarding1)specificrecommendationsfor improvingthecourse,2)contentthatwasmostuseful, 3)missingcontentorareastoadd,and4)waysthecourse changedtheirperspectiveonsocialmedicine,ifatall(see AppendixF forthefullitems).

StatisticalAnalysis

Weuseddescriptivestatisticstosummarizecharacteristics ofthestudysample.Weassessedthepotentialefficacyofthe RISE-EMcurriculumbycomparingparticipants’ pre-and post-curricularscoresonknowledgeandself-efficacyitems usingpairedsamples t -tests.Adequatefeasibilitywasdefined

byatargetofatleast80%ofparticipantscompletingallfour coursemodulesandthepost-coursesurvey.Forthe acceptabilityandcoursequalityquestionsderivedfromthe SEEQ,wedeﬁnedadequateacceptabilityasatleast80%of participantsindicatingthattheyfullyagreedwiththeitem.It isimportanttonotethatthesequantitativecomparisonsare exploratoryinnatureduetothesmallsamplesizeinthis pilotstudy.

Toanalyzeparticipantresponsestoopen-endedquestions, weusedanappliedthematicapproachtoqualitative analysis.24 Twostudyinvestigatorsreadtheresponses independentlytoidentifycommonthemesanddevelopa preliminarycodebook.Theinvestigatorsthencametogether todiscussthesepreliminarythemes,identifysimilaritiesand differencesinthecodebooks,andcombinethethemesintoa single,cohesivecodebook.Theteamthenre-analyzedthe qualitativeresponsesontothe finalcodebook,definedthe codesindescriptivememos,andreviewedthecodesto identifyrepresentativequotations.Werandomlyselected five participants’ (26.3%)responsestobere-codedbyasecond reviewerandevaluatedforinter-coderagreementusinga pre-establishedthresholdof80%agreement.25 Inter-coder agreementontheseresponseswas90.5%,whichexceededthe desiredthreshold,anddisagreementsidentifiedintherecodingprocesswerereconciledbythetworeviewersuntil consensuswasreached.

IMPACT/EFFICACY

Participants

ParticipantsinGroup1watchedthemodulesin conferenceoverthecourseofanhour,andthenengagedina 20-minutegroupdiscussion.Intotal,sixparticipants(of36 totaleligibletrainees)inGroup1enrolledinthestudy.Allsix enrolledparticipantscompletedboththepre-andpost-test andsurveymaterial.InGroup2,23participants(of30total eligibletrainees)enrolledinthestudy.Participantswatched thevideomodulesontheirownandthenhada50-minute groupdiscussioninconference.TwoparticipantsinGroup2 (8.3%)didnotcompletepost-coursematerial.

Althoughbothgroupshadmaterialpresentedduring regularlyschedulededucationalsessions,Group2completed allvideomodulesasynchronouslyimmediatelyfollowing thepre-coursematerial,possiblyexplainingthehigherrate ofparticipation.

Participantshadameanageof30yearsandarelatively equalgenderdistribution(Table1).Themajorityof participantswhoidentiﬁedasWhiteethnicity(24,83%)anda relativelyevenspreadbetweenlevelsoftrainingataboutonethirdofparticipantsperpostgraduateyearPGYyearinthe combinedcohort,plustwofourth-yearmedicalstudents participatinginGroup1.Baselineenthusiasmandinterest wasveryhighforSEM.Approximatelyhalfofparticipants reportedpriorcourseworkinsocialmedicine,rangingfrom

Table1. Participantdemographicsandothercharacteristics.

Group1(n = 6) number(%)

Group2(n = 23) number(%)

Combinedcohort(N = 29) number(%)

Age(years),mean(range)29(27–33)30(27–37)30(27–37)

Femalegender1(17%)13(57%)14(48%)

Ethnicity

White4(67%)20(87.0%)24(83%)

Black1(17%)0(0%)1(3%)

HispanicorLatino1(17%)0(0%)1(3%)

Asian0(0%)1(4.3%)1(3%)

Morethanonerace/ethnicity0(0%)1(4.3%)1(3%)

Declinedtorespond0(0%)1(4.3%)1(3%)

Leveloftraining1

MS42(33%)0(0%)2(7%)

PGY-11(17%)8(34.8%)9(31%)

PGY-21(17%)9(39.1%)10(35%)

PGY-32(33%)6(26.1%)8(28%)

ConsidersSEMimportant

“Yes” 6(100%)22(96%)28(97%)

“Somewhat” 0(0%)1(4%)1(3%)

InterestedinlearningmoreaboutSEM

“Yes” 6(100%)19(82.6%)25(86%)

“Somewhat” 0(0%)4(17%)4(14%)

Priorcourseworkinsocialmedicine1(17%)15(65.2%)16(55%)

MS4,fourth-yearmedicalstudent; PGY,postgraduateyear; SEM,socialemergencymedicine.

self-study,singlelecturesanddiscussions,orshort workshops,toformalcoursesasacorecomponentofthe medicalschoolcurriculum.

ImprovementinSEMKnowledgeandSelf-Efﬁcacy

InGroup1,sixparticipantscompletedpre-andpostcourseassessments.SEMknowledgesigniﬁcantlyimproved

by3.2pointsonaverage,from7.0to10.2(t (5) = 3.63, P = 0.015),whileself-efficacysignificantlyimprovedby4.8 pointsonaverage,from12.3to17.1of18possible (t (5) = 3.24, P = 0.023).InGroup2,pre-andpost-course assessmentsofthe21participantsalsoshowedstatistically significantimprovementinbothknowledgeandself-efficacy (Table2).KnowledgeofSEMimprovedby2.5pointson

Table2. Post-coursetestanalysisshowingchangein\knowledgeofsocialemergencymedicineandself-efﬁcacyandcompletionof modules(n = 27).

Group1(n = 6)Group2(n = 21)Combined(n = 27)1

SEMknowledge + 3.2points(t(5) = 3.63, P = 0.015)2 + 2.5points(t(20) = 4.07, P < 0.001) + 2.7points(t(26) = 5.00, P < 0.001)

Self-efﬁcacy + 4.8points(t(5) = 3.24, P = 0.023) + 5.8points(t(20) = 8.89, P < 0.001) + 5.5points(t(26) = 9.28, P < 0.001)

Videomodulescompleted byparticipants(percentcompleted) 6(100%)21(100%)27(100%)

1Note:Twoparticipantscompletedthepre-coursesurveyonly.

2Pairedsample t-test:t(degreesoffreedom) = t-value, P-value. SEM,socialemergencymedicine.

average,from8.2to10.7(t (20) = 4.07, P = 0.001).Selfefﬁcacyalsosigniﬁcantlyimprovedby5.8pointsonaverage, from8.0to13.8(t (20) = 8.89, P < 0.001).

FeasibilityandAcceptability

Inthetwocohortscombined,surveyparticipants completed100%ofthevideomodules,while27ofthe29 (93.1%)enrolledparticipantscompletedthepost-course survey,exceedingourpre-establishedthresholdforfeasibility (Table2).Twenty-ﬁveparticipantswhocompletedthepostcoursesurvey(92.6%)feltthecoursecontentwasimportant andthattheywouldrecommendthecoursetoothers,far exceedingourpre-establishedthresholdforacceptability, whiletwoparticipants(7.3%)agreedwiththese statements “somewhat.”

Anoverwhelmingmajorityofparticipants(86%)feltthat thecoursewasorganizedinamannerthatfacilitated understandingtheunderlyingconceptsofSEMandfeltthe numberofsessions(76%)andlengthofeachsession(79%) was “justright” (Table3).Regardingthecontentofthe modules,participantsfeltoverallthemoduleseffectively explainedandillustratedthepresentedconcepts(90%), contrastedtheimplicationsofvarioustheories(90%),and adequatelydiscussedcurrentdevelopmentsinthe ﬁeld (90%).See Tables2 and 3 forcompletequantitative resultssummary.

QualitativeFindings

Forthe fiveopen-endedquestions,25participants(five fromGroup1and20fromGroup2(86.2%)answeredsome orallofthesequestions(see Table4).Regarding recommendationsforcourseimprovement,manyresponses suggestedbreakingcontentintodifferentdaysorsessionsto allowmoretimetoprocessthecontent.Manyparticipants alsosuggestedthattheinstructionshouldincludemore examplesofhowtoapplythecontent,includingbothcasebasedandaction-focusedexamples.Asoneparticipant shared,itwouldbehelpfultogive “morespecificexamples. Theonesprovidedwereveryhelpful.” Whenaskedabout missingcontent,threeparticipantsagainpointedtothe benefitofincludingmoreexamples,including “ more concretewaystoincorporateSEMintomypracticeina varietyofsettings.” Other,lesscommonrecommendations forimprovementincludedadesireforashortquizaftereach moduleandthesuggestiontorepeatkeyinformationmore oftenacrosssessions.

Insharingthemosthelpfulcontent,fourparticipants appreciatedtheintroductiontoSDoH,which “wasthemost generalizableformyEDandincludedthehardestfactsthatI wasunawareofpreviouslyregardingtheeffectsof homelessness.” Threeparticipantsnotedthatotherhelpful contentincludedwaystotakeactionasacliniciantoward addressingSDoH.Whenaskedtodescribehowthecourse changedtheirviewsonsocialmedicine, ﬁveparticipants

Table3. AcceptabilityandorganizationresponsesregardingRISEEMcourse(n = 27).

Acceptabilityquestions

Feltthecoursewasimportant

“yes” 6(100%)19(90.5%)25(93%)

“somewhat” 0(0%)2(9.5%)2(7%)

Wouldrecommendthecoursetoothers

“yes” 6(100%)19(90.5%)25(93%)

“somewhat” 0(0%)2(9.5%)2(7%)

Courseorganizationquestions

Feltthecoursewasorganizedinahelpfulmanner

“yes” 5(83%)20(95%)25(86%)

“somewhat” 1(17%)0(0%)1(3%)

Noresponse0(0%)1(5%)1(3%)

Feltthenumberofsessionswastoomany,justright,notenough

“justright” 2(33%)20(95%)22(76%)

“toomany” 0(0%)1(5%)1(3%)

“notenough” 4(67%)0(0%)4(14%)

Feltthelengthofeachsessionwastoolong,justright,tooshort

“justright” 5(83%)18(86%)23(79%)

“toolong” 1(17%)3(14%)4(13.8%)

Modulecontentquestions

Moduleseffectivelyexplainedandillustratedthepresented concepts

“yes” 6(100%)20(95%)26(90%)

“somewhat” 0(0%)1(5%)1(3%)

Modulescontrastedtheimplicationsofvarioustheories

“yes” 5(83%)19(90%)24(83%)

“somewhat” 1(17%)2(10%)3(10%)

Modulesadequatelydiscussedcurrentdevelopmentsinthe ﬁeld.

“yes” 5(83%)21(100%)26(90%)

“somewhat” 1(17%)0(0%)1(3%)

Ratethelevelofinstruction(justright,toobasic)

“justright” 6(100%)20(95%)26(90%)

“toobasic” 0(0%)1(5%)1(3%)

reportedplanstoimplementachangeintheirclinical practice,and ﬁveindicatedthatthecoursereinforcedthe importanceofSDoH.Forexample,oneparticipantstated thatRISE-EM “reinforced[SDoH]importanceandhas motivatedmetoconsiderSDoHineverypatientandthink moreabouthowthisisimpactingtheirhealthandwhatmy roleisinaddressingtheseintheED.”

LIMITATIONS

Theprimarylimitationofourresearchisthesmallsample sizeandself-selectionofresidentswhochosetoparticipatein thiseducationalinnovation.Participantswithhighinterestin

Table4. Topthemesinqualitativeresponses,sortedbytopic,withexemplarquotes. Majorthemes,byquestionExemplarquote

Recommendationstoimprove,change(questions1–2)

Breakcontentintodifferentdays,sessions

Moreexamples

Mostusefulcontent(question3)

Lecture1 – introductiontoSEM

Waystotakeactionasacliniciantoward addressingSDoH

Missingcontent(question4)

Morereal-lifeexamples

Nursingconsiderationandinvolvement

Perspectivechange(question5)

Planstoimplementachangeintheirclinical practice

ThecoursereinforcedtheimportanceofSDoH

“Iwouldhavelikedtohavedoneoneatatimewithadiscussionbetweeneach.”

“Morespeciﬁcexamples.Theonesprovidedwereveryhelpful.”

“WasthemostgeneralizableformyEDandincludedthemosthardfactsthatI wasunawareofpreviouslyregardingtheeffectsofhomelessness.”

“Ithinkeducating[clinicians]goesalongway,butinordertomaximizethe changeinaddressingSEMIthinktherestoftheEDstaffshouldbeincludedin theseeducationalefforts.”

“MoreconcretewaystoincorporateSEMintomypracticeinavarietyofsettings.”

“Ithinkeducating[clinicians]goesalongway,butinordertomaximizethe changeinaddressingSEMIthinktherestoftheEDstaffshouldbeincludedin theseeducationalefforts.”

“Reinforced[SDoH]importanceandhasmotivatedmetoconsiderSDoHinevery patientandthinkmoreabouthowthisisimpactingtheirhealthandwhatmyrole isinaddressingtheseintheED.”

“ThiscoursedoesagreatjobofraisingawarenessoftheneedforSEM, emphasizingtheimportanceandfeasibilityofaddressingit.”

SEM,socialemergencymedicine; ED,emergencydepartment; SDoH,socialdeterminantsofhealth.

SEMmaterialmayhaveself-selectedintothestudy,leading tohigherratingsforacceptability.Giventheimportancewe placedonensuringthatresidentsdidnotfeelinappropriately compelledtoparticipate,thiswasananticipatedresult. Futuretestingoftheinterventionshouldincorporatelarger andmorediversesamplesandmayincludetestingin programswherecompletionofthesemodulesisamandatory componentoftraining.Additionally,participantstookthe sametesttwice,whichmayhavecontributedtoapractice effectthatfalselyelevatedimprovement.Futurestudiesmay incorporateacontrolgrouptocompareimprovementof thosewhoreceivethetrainingascomparedtothosewho completetheassessmentsonly.

AnotherconsiderationisthatGroup1participants watchedthevideosinconference,inasinglehour-long sitting,whereasthematerialwasdesignedtobespacedout overfoursessions.Thisformatwaschosenasitbestmetthe needsandtimeavailableoftheresidencyprogramatthe time.Group2watchedthevideosasynchronously;sothe timespentbetweenvideolectureswasundeﬁned.These differencesincoursedelivery(conferencevshome)and abilitytospacelecturesoutovertimemayhaveledto unmeasureddifferencesinresultsbasedontrainingformat.

CONCLUSION

Leadersinemergencymedicineandsocialmedicine combinedforcestocreateanew ﬁeldofstudy,education,and

interventions:socialemergencymedicine,theinteraction betweensocialfactorsandtheemergencycaresystem.26 Just asthe fieldwasinitsearlystagesofdevelopment,COVID-19 struck,puttingintothepubliceyesocialdisparitiesandthe growingburdenontheemergencycaresystem.27–29 The resultingwaveofdemandforaddressingsocialmedicinein theEDhastrickledintoresidenteducation,asevidencedby theincreasednumberofrelatedfellowshipsandACGME recommendations.30 Now,withgrowingawarenessofthe importanceofaddressingsocialdeterminantsofhealthin EM,ourvideomodulesoffer flexible,FOAMedresourcesto theprogramorclerkshipdirector.Over90%ofparticipants feltthecoursecontentwasimportantandwouldrecommend thecoursetoothers.Furthermore,RISE-EMshowed potentialefficacyinimprovingSEMknowledgeandgrowth ininterestandself-efficacyinapplyingSEMcompetencies. Weidentifiedaneedforaneasilyimplementableand educationallysoundcurriculumtoimproveknowledgeof socialdeterminantsofhealthinEMtrainingprogramsfor bothresidentsandmedicalstudents.Wecreatedadidactic videoserieswithcorecontentthatcanbeintegratedinto existingEMtraining.TheRISE-EMcurriculumisafeasible, acceptableformoffreeopenaccessmedicaleducationto assistinfacilitatingthedevelopmentofSEMskillsandselfefficacyforresidentsintheirclinicalpractice.Residents demonstratedimprovedknowledgeofSEMconceptsand improvedcomfortinapplyingSEMtotheirpractice.Given

theparticipantsinthestudywererecruitedfromtwoseparate EMresidencies,wefeelthatthiscurriculumisadaptableto otherEMprograms.Infuturestudiesweaimtoincludea largersamplesizetoallowforgreaterstatisticalpowerand moreadvancedstatisticalanalysis,includingassessing differentdeliveryformatsandevaluatingdifferencesin RISE-EMimpactandoutcomesbasedonvarious learnercharacteristics.

AddressforCorrespondence:HeidiRoche,MD,MaineMedical Center,22BramhallStreet,Portland,ME04102.Email: heidi. roche@mainehealth.org

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

REFERENCES

1.BooskeBC,AthensJK,KindigDA,etal.Differentperspectivesfor assigningweightstodeterminantsofhealth.2010.Availableat: https://www.countyhealthrankings.org/sites/default/ﬁles/ differentPerspectivesForAssigningWeightsToDeterminantsOfHealth. pdf.AccessedFebruary6,2023.

2.HsiehD.Achievingthequadrupleaim:treatingpatientsaspeopleby screeningforandaddressingthesocialdeterminantsofhealth. AnnEmergMed. 2019;74(5S):S19–24.

3.VirchowR.Derarmenarzt.(Doctorforthepoor). MedicinischeReform 1848;74(5):125–7.

4.FahimiJandGoldfrankL.Principlesofsocialemergencymedicine. AnnEmergMed. 2019;74(5S):S6–10.

5.SchneckP.Dieeditionsgeschichtederwochenschriftdiemedicinische reform(1848/49)undderbriefwechselrudolfvirchowsmitseinem verlegergeorgreimer. NTMIntJHistoryandEthicsofNaturalSciences, TechnologyandMedicine. 2007;15(3):179–97.

6.StevensC,ForbushL,MorseM.Socialmedicinereferencetoolkit. Availableat: https://static1.squarespace.com/static/ 5666e742d82d5ed3d741a0fd/t/5900ae6fa5790a1226d0e330/ 1493216881354/Social+Medicine+Toolkit+.pdf AccessedJune9,2020.

7.BolenC,DharamsiS,GibbsT.Thesocialaccountabilityofmedical schoolsanditsindicators. EducHealth(Abingdon). 2012;25(3):180–94.

8.AssociationofAmericanMedicalColleges.Socialdeterminantsfor healthbyacademiclevel.Availableat: https://www.aamc.org/ data-reports/curriculum-reports/data/social-determinants-healthacademic-level.AccessedApril25,2023.

9.LewisJH,LageOG,GrantBK,etal.Addressingthesocialdeterminants ofhealthinundergraduatemedicaleducationcurricula:asurveyreport. AdvMedEducPract. 2020;11:369–77.

10.VanderbiltAA,BaughRF,HoguePA,etal.Curricularintegrationof socialmedicine:aprospectiveformedicaleducators. MedEducOnline. 2016;21:30586.

11.DopeltK,DavidovitchN,YahavZ,etal.Reducinghealthdisparities:the socialroleofmedicalschools. MedTeach. 2014;36(6):511–7.

12.Sanson-FisherRW,WilliamsN,OutramS.Healthinequities:theneed foractionbyschoolsofmedicine. MedTeach. 2008;30(4):389–94.

13.AndersonES,HsiehD,AlterHJ.Socialemergencymedicine: embracingthedualroleoftheemergencydepartmentinacutecareand populationhealth. AnnEmergMed. 2016;68(1):21–5.

14.MaloneRE.Whitherthealmshouse?Overutilizationandtherole oftheemergencydepartment. JHealthPolitPolicyLaw. 1998;23(5):795–832.

15.GordonJA.Thehospitalemergencydepartmentasasocialwelfare institution. AnnEmergMed. 1999;33(3):321–5.

16.RodriguezRM,FortmanJ,CheeC,etal.Food,shelterandsafetyneeds motivatinghomelesspersons’ visitstoanurbanemergencydepartment. AnnEmergMed. 2009;53(5):598–602.e1.

17.CleryMandKhaldunJ.Emergencyphysiciansascommunityhealth advocates. AnnEmergMed. 2019;74(5S):S62–5.

18.AndersonE,LippertS,NewberryJ,etal.Addressingsocial determinantsofhealthfromtheemergencydepartmentthroughsocial emergencymedicine. WestJEmergMed. 2016;17(4):487–9.

19.AxelsonDJ,StullMJ,CoatesWC.Socialdeterminantsofhealth:a missinglinkinEMtraining. AEMEducTrain. 2017;2(1):66–8.

20.GoldbergL,UrquhartS,DesCampR,etal.Trainingfutureleaders: socialemergencymedicinefellowships.2021.Availableat: https://apps. aaem.org/UserFiles/SocialPopulationJulyAugust2021.pdf AccessedMarch6,2022.

21.AlterHJ.Forewordtoconferenceproceedings,inventingsocial emergencymedicine. AnnEmergMed. 2019;74(5S):S1–2.

22.ThalerRH. Nudge:ImprovingDecisionsAboutHealth,Wealth,and Happiness.NewYork,NY:PenguinBooks,2009.

23.MarshHW.SEEQ:areliable,valid,andusefulinstrumentforcollecting students’ evaluationsofuniversityteaching. BrJEducPsychol. 1982;52(1):77–95.

24.GuestG,MacQueenKM,NameyEE.(2012). Appliedthematicanalysis ThousandOaks,CA:SAGEPublications,Inc.

25.CampbellJL,QuincyC,OssermanJ,etal.Codingin-depth semistructuredinterviews. SociolMethodsRes. 2013;42(3):294–320.

26.AlterHJ.Socialemergencymedicineconferencelaysfoundationforthe ﬁeld.2018.Availableat: https://www.acepnow.com/article/ social-emergency-medicine-conference-lays-foundation-for-the-ﬁeld/ AccessedJune6,2020.

27.HimmelsteinGandDesmondM.Evictionandhealth:aviciouscycle exacerbatedbyapandemic.2021.Availableat: https://www.rwjf.org/en/ insights/our-research/2021/04/eviction-and-health-a-vicious-cycleexacerbated-by-a-pandemic.html.AccessedMarch10,2022.

28.FindlayS,OkoroU,LeeS,etal.63theimpactoftheCOVID-19 pandemiconsocialdeterminantsofhealthonpatientsinarural academicemergencydepartment. AnnEmergMed. 2021;78(2S):S31.

29.MogharabV,OstovarM,RuszkowskiJ,etal.Globalburdenofthe COVID-19associatedpatient-relateddelayinemergencyhealthcare:

apanelofsystematicreviewandmeta-analyses. GlobalHealth. 2022;18(1):58.

30.CoJPTandWeissKB.CLERpathwaystoexcellence,version2.0: executivesummary. JGradMedEduc. 2019;11(6):739–41.

ORIGINAL RESEARCH

RuralandEthnicDisparitiesinOut-of-hospitalCareand TransportPathwaysAfterRoadTrafﬁcTraumainNewZealand

RebbeccaLilley,PhD* GabrielleDavie,MBios*

BridgetDicker,PhD†‡ PapaarangiReid,MBChB§ ShanthiAmeratunga,PhD∥¶# CharlesBranas,PhD** NicolaCampbell,BSc* IanCivil,MBChB†† BridgetKool,PhD∥

*UniversityofOtago,DunedinSchoolofMedicine,DepartmentofPreventiveand SocialMedicine,InjuryPreventionResearchUnit,Dunedin,NewZealand

† AucklandUniversityofTechnology,DepartmentofParamedicine,FacultyofHealth andEnvironmentalSciences,Auckland,NewZealand

‡ HatoHoneStJohn,MtWellington,Auckland,NewZealand

§ WaipapaTaumataRau-UniversityofAuckland,TeKupengaHauoraMaori,Faculty ofMedicalandHealthSciences,Auckland,NewZealand

∥ UniversityofAuckland,SchoolofPopulationHealth,SectionofEpidemiologyand Biostatistics,Auckland,NewZealand

¶ TeWhatuOra(HealthNewZealand)CountiesManukau,PopulationHealth Directorate,Auckland,NewZealand

# MonashUniversity,DepartmentofEpidemiologyandPreventiveMedicine,Faculty ofMedicineNursingandHealthSciences,Melbourne,Australia

**ColumbiaUniversityMailmanSchoolofPublicHealth,DepartmentofEpidemiology, NewYork,NewYork

†† AucklandDistrictHealthBoard,TraumaServices,Auckland,NewZealand

SectionEditor:ScottGoldstein,MD

Submissionhistory:SubmittedJune11,2023;RevisionreceivedDecember13,2023;AcceptedJanuary18,2024

ElectronicallypublishedJune4,2024

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

DOI: 10.5811/westjem.61342

Introduction: Theout-of-hospitalemergencymedicalservice(EMS)careresponsesandthetransport pathwaystohospitalplayavitalroleinpatientsurvivalfollowinginjuryandarethe ﬁrstcomponentofa well-functioning,optimisedsystemoftraumacare.Despitelongstandingchallengesindelivering equitablehealthcareservicesinthehealthsystemofAotearoa-NewZealand(NZ),littleisknownabout inequitiesinEMS-deliveredcareandtransportpathwaystohospital-levelcare.

Methods: Thispopulation-levelcohortstudyonout-of-hospitalcare,basedonnationalEMSdata, includedtraumapatients <85yearsinagewhowereinjuredinaroadtrafﬁccrash(RTC).Inthisstudywe examinedthecombinedrelationshipbetweenethnicityandgeographicallocationofinjuryinEMSout-ofhospitalcareandtransportpathwaysfollowingRTCsinAotearoa-NZ.Analyseswerestratiﬁedby geographicallocationofinjury(ruralandurban)andcombinedethnicity-geographicallocation(rural Maori,ruralnon-Maori,urbanMaori,andurbannon-Maori).

Results: Inatwo-yearperiod,therewere746eligiblepatients;ofthese,692weretransportedtohospital. IndigenousMaoricomprised28%(196)ofvehicleoccupantsattendedbyEMS,while47%(324)of patients’ injuriesoccurredinarurallocation.TheEMStransportpathwaystohospitalforruralpatients wereslowertoreach firsthospital(totalinslowesttertileoftime44%vs7%, P ≥ 0.001)andlongerto reachdefinitivecare(directtransport,77%vs87%, P = 0.001)comparedtourbanpatients.Maori patientsinjuredinarurallocationwerecomparativelylesslikelythanruralnon-Maoritobetriagedto prioritytransportpathways(fastestdispatchtriage,92%vs97%,respectively, P = 0.05);slowertoreach firsthospital(totalinslowesttertileoftime,55%vs41%, P = 0.02);andhadlessaccesstospecialist traumacare(reachedtertiarytraumahospital,51%vs73%, P = 0.02).

Conclusion: AmongRTCpatientsattendedandtransportedbyEMSinNZ,therewasvariabilityinout-ofhospitalEMStransportpathwaysthroughtospecialisttraumacare,stronglypatternedbylocationofincident andethnicity.These ﬁndings,mirroringotherhealthdisparitiesforMaori,provideanequity-focused evidencebasetoguideclinicaland policydecisionmakerstooptimizethedeliveryofEMScareandreduce disparitiesassociatedwithout-of-hospitalEMScare.[WestJEmergMed.2024;25(4)602–613.]

INTRODUCTION

Recentdecadeshaveseentheevolutionofout-of-hospital emergencymedicalservices(EMS)fromtransportationof patientstoemergencydepartments(ED)throughto cliniciansofadvancedout-of-hospitalhealthcareand deliveryofmajortraumapatientsdirectlytoappropriatecare viaarangeoftransportationmeansanddestination pathways.1 TheseEMSresponsesandthetransport pathwaystohospitalplayakeyroleinpatientsurvivaland arethe ﬁrstcomponentofawell-functioning,optimised systemoftraumacare.Internationallythereisgrowing recognitionofthecriticalneedtoeliminateinequitiesin healthcare.Pooreroutcomesfollowingmajorinjuryfor residentsofruralcommunitiesandforindigenousand minoritizedethnicgroupsarewelldocumented,2 with evidenceoflongertimestoreachdeﬁnitivecareforrurally locatedinjuredpatients3–6 andlowerstandardsofEMScare andtransportforracialandethnicminorities.7 However, littleisknownaboutdifferentialaccesstoordeliveryofoutof-hospitalEMScareforruralandethnicsub-groups,in particularwhetherdisparitiesintraumaoutcomescanbe reducedbymoreequitableaccesstoEMScareand designatedtransportpathways.

Population-leveldataonEMS-deliveredout-of-hospital careandtransportpathwaystohospitalcanhelpinformthe optimisationofnationalEMSsystems,addressinequities, andimprovepatientoutcomesfollowingmajortrauma,yet majorknowledgegapsremainintheseareas.Thenational healthcaresystemofAotearoaNewZealand(NZ)hashad longstandingchallengesindeliveringequitablelevelsof accesstohealthcareservicestoindigenousMaoriandtorural communities.8–10 Maori,asindigenouspeopleofAotearoa, arepartnerstothehealthequitycommitmentsunderTe Tiriti – TreatyofWaitangiwiththeCrown,yetthey experiencepervasiveinequities.11 Previousresearchhas identifiedlongertheoreticalaccesstimestoout-of-hospital EMScareforMaori,whicharehypothesizedtoreflect,in part,thehigherproportionofMaoriresidinginruralregions withlimitedtimelyaccesstohealthcareservices.12,13 Improvementsintraumaoutcomes,therefore,require investigationofinter-relatedinequitiesbasedonboth geographyandethnicity.Thismajorgapinknowledgeis reflectedinthenationalEMSsystemsofothernationswith comparablehealthsystemcontextsandsimilarlysituated ruralremoteandindigenouspopulations,therebyfurther motivatingtheneedforinvestigation.

Theactualout-of-hospitalEMScareresponsesand transportpathwaystohospitalexperiencedbyunder-served ruralandMaoripopulationsandtheinterconnectedand overlappinggeographicandethnicdisparitiesremain unexploredatanationallevel.Deeperunderstandingof sourcesofdisparitiesinEMScareandtransportpathwaysto hospitalarethe ﬁrststepinguidingqualityimprovements andplanningforequitableout-of-hospitalEMSservices.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Poorerinjuryoutcomesinrural, indigenous,andminoritycommunities arewelldocumented.

Whatwastheresearchquestion?

Whataretheruralandethnicinequitiesin out-of-hospitalcareandtransportpathways followingtraf ﬁ ccrashesinNewZealand?

Whatwasthemajor ﬁndingofthestudy?

DisparitiesweremostevidentinruralM aori: lesslikelyto ﬁ rstbetransportedto(33vs 56%,p < 0.001),oreverreachatertiarycare hospital(51vs73%,p < 0.001).

Howdoesthisimprovepopulationhealth?

Moreequity-focusedplanningandinvestment inruralEMSservicestoreducedocumented disparitiesinEMScarewouldbene ﬁ tboth ruralandindigenouspopulations.

Ourobjectiveinthisanalysiswastodescribepotential geographic,andintersectionalgeographicandethnic inequities,inout-of-hospitalcareandthetransport pathwaystohospitaldeliveredbyNZEMSprofessionals followingmajortraumaduetoroadtrafﬁc crashes(RTC).

METHODS

StudyDesignandSetting

Inthisobservationalstudyweusedaretrospectivecohort basedontwoyears(2016–2018)ofclinicalandEMS utilisationdatafromNZ’stworoadambulanceservices: HoneHatoStJohn,servicing97%ofNZ’sgeographical area;andWellingtonFreeAmbulance,servicingthe remaininggreaterWellingtonandWairarapa.Datais routinelycollectedinaprescribedformatbyambulancestaff tocreateacollectiveelectronicadministrativeresource comprisedofindividualelectronicpatientreport forms(ePRF);thisobjectivedatawasusedfor analysis.Thefullstudyprotocolhasbeen publishedelsewhere.14,15

Out-of-hospitalEMSarepredominantlybasedonthe provisionofemergencyroadambulanceservices.Road servicesarepredominantlydispatchedinthe ﬁrstinstance. Airservices,operatinghelicoptersonaregionalbasis,are dispatchedonanas-neededbasistoprovideadditional

clinicalcaretoaccessremotesitesorfacilitatetimely transportofseriouslyinjuredpatients.Emergencymedical serrvicesarereadilyaccessibleviaasingle,national emergencytelephonenumber(111)withtwonational ambulancecontrolcentrestriaginganddispatching appropriateEMS.FundingforEMSservicesprovided within24hoursofaninjuryincidentiscoveredbyNZ’ s universalno-faultinjuryprovider,theAccident CompensationCorporation.16

NewZealand’straumasystem,coveringthetwomain islandsof265,000km2 andapproximately fivemillion people,isdesignedaroundfourregionalnodesoftrauma carewith22trauma-receivinghospitals.17,18 Eachnodehas atleastonemetropolitan,tertiarytraumahospitalservice providingintensivecare,advancedresources,andservices aroundtheclock,generallysimilartoLevel1American CollegeofSurgeons-verifiedtraumacentres.19 Regional traumahospitalsarecapableofinitialresuscitation, stabilisation,intensivecareand,insomeinstances,definitive managementofinjuredpatients.Smallruralhospitalsare capableofbasicnon-specialisttraumaserviceswithlimited traumaspecialisationandresources.18,20

TheNewZealandMajorTraumaDestinationPolicy, whichisappliedinout-of-hospitaltraumaresponses,was introducedin2017toimprovesurvivalfrommajortrauma.21 Thepolicyoutlinestheeligibilitycriteriatobeassessedby EMSprofessionalsatthescenefordirecttransfertoamajor traumacentre.20

SelectionofParticipants

ToobtainadatasetofEMS-attendedmajortrauma patients,weundertooklinkagebetweenelectronicrecordsof EMSattendanceandtheNewZealandTraumaRegistry (NZTR),aregistryofallhospitalisedmajortraumapatients.

Studyparticipantswereindividualsaged0–84yearswho hadsufferedamajortraumaasdefinedbytheNZTR(Injury SeverityScore,[ISS] >12,ordiedinorout-of-hospital)and hadbeenattendedbyaroadEMSprofessionalbetween 1December2016–30November2018.Attendancebyair EMSprofessionalswascapturedintherecordsofattendance takenbyroadEMSprofessionals.Weexcludedpatientswith incompleteclinicalrecords.Forthisanalysisstudy participantswererestrictedtomotorvehicleoccupantswho sustainedinjuriesduringaRTCtoallowforanyinequitiesin EMScaretobeidentifiedirrespectiveofdifferencesininjury mechanism.Tofocusonthosepatientswiththemostto benefitfromtimelyEMScareandtransport,analyseswere conductedonpatientsassessedbyambulancestaffashaving anon-sceneEMStriageconditionofstatus1(critical, immediatethreattolife)orstatus2(serious,potentialthreat tolife).Analysesdescribeallnon-transported(ie,diedon scene,refusedtransport)andtransportedpatients,andthen focusonEMSpathwaysbyrestrictinganalysestothose transportedfromthescenebyEMS.

Measurements

Weobtainedsociodemographiccharacteristicsofage, gender,andethnicityfromtheMinistryofHealth’sNational HealthIndexdatabase.Ethnicityiscollectedinnational healthdatausingestablisheddatacollectionprotocolsand allowsforpeopletoself-identifyuptothreeseparateethnic affiliations.InaccordancewithTeTiritiprinciplesand ethnicitydataprotocolsinNZ,22 ethnicitywascategorisedas Maoriandnon-Maori,prioritisingMaoriifanyofthe MinistryofHealth-recordedethnicity fieldswereMaori. Thegeographiclocationofinjuryincidentwasdetermined byapplyingthe2018GeographicalClassificationforHealth (GCH)toEMS-recordedco-ordinatesofthepatient’ s location;thetwomajor-levelGCHclassificationsofruralor urbanwasused.23 Wedeterminedthe “rurality” oftheinjury incidentbyapplyingthe2018GCHtoEMS-recordedcoordinatesofthepatient’slocation;thetwomajor-levelGCH classificationsofruralorurban(includessuburban)were used.23 Weusedpopulation,drive-timethresholds,and stakeholderworkshopstoclassifysmallareasintoGCH categories,whichwerethenvalidatedquantitatively.Injury characteristicsincludeddominantinjurytype(bluntor penetrating)andpresenceoftraumaticbraininjuryas assessedonscenebyEMSstaff.TheNZTRprovideddataon ISS,whichisautomaticallycodedusingAbbreviatedInjury Scalecodesenteredathospitaldischarge.WeclassifiedISS valuesintotwogroups:survivable(ISS ≤ 25)andreduced survivability(ISS > 25).

Wedeterminedon-scenepatientstatusandvitalsigns fromEMSstaffdata.TheGlasgowComaScale(GCS) indicatesthedegreeofpatientconsciousnessrangingfrom entirelyunresponsive(scored3)tonormalresponse(scored 15):categorised ≤10and >10.Pulseratewasgroupedinto oneoftwocategories:60-130beatsperminuteor “<60or >130.” Systolicbloodpressurewasdichotomised: <90and ≥90millimetersofmercury.Life-threateningeventsthat couldjeopardisepatientsurvivalweredeﬁnedusingthe methodologyofGomesetal(2010).24 Weidentiﬁedthese eventsusingEMSclinicalimpressionscapturedonsceneand groupedthemintoairway(A),breathing(B),circulation(C), andneurologicaldisability(N)basedonthecommonly used ‘AirwayBreathingCirculation’ approachfor identifyingandtreatinglife-threateningeventsfollowing trauma(Figure1).25,26

OutcomeMeasures

OutcomemeasuresofEMScareandtransportusedinthis studywerepredominantlycapturedinemergencyroad ambulancestaffdata,whichwecategorisedasfollows. MeasuresofEMSinfrastructureandpracticelevelat incident includedthehighestpracticelevelofcrewattending theincidentcategorisedintothreecategoriesreﬂectingthe increasinglevelofskillofEMSstaffonscene:emergency medicaltechnician(EMT),paramedic,andintensivecare

Life-threatening event

A life-threatening event was defined as any of the following:

Aobstructed airway, or partially obstructed airway combined with respiratory rate*<12

B at least one of chest contusion, haemothorax, pneumothorax, absent breathing,or ineffective breathing combined with respiratory rate*<12 or >30

C at least one of blood loss considered life-threatening, clinical shock**, absent circulation or compromised circulation combined with systolic blood pressure*<90

Ntraumatic brain injury (TBI) combined with Glasgow Coma Scale (GCS)*≤13

*Either the initial or last EMS recorded observation

**Clinical shock was defined as having an initial or final EMS recorded shock index (heart rate divided by SBP) of ≥1.98 for those under 1 year, ≥1.5 for those 1-6 years or ≥1.4 for those older than 6 years.

Out-of-hospital intervention

An out-of-hospital intervention (successful or unsuccessful) for a life-threatening event was defined as any of the following:

Ainsertion of airway (laryngeal mask or oropharyngeal), intubation (excluding rapid sequence intubation (RSI) on TBI patient with GCS≤10)

BCPR, chest decompression, administered oxygen

C tourniquet, pelvic splint/wrap/binding/sling, administered any of adrenaline, atropine, sodium chloride or the combination of calcium chloride and sodium bicarbonate (for crush injury)

NRSI on patient identified as having TBI with GCS*≤10.

Figure1. Deﬁnitionoflife-threateningeventandout-of-hospitalinterventions(consistentwithGomesetal,2010).24

EMS,emergencymdicalservics; CPR,cardiopulmonaryresuscitation.

paramedic(ICP).Avariableindicatingwhetherasingle vehiclecrewattendedtheincidentwasgeneratedfromEMS vehicleattendancecount.

EMStransportpathwaystotraumacare included measuresof ﬁnalcomputer-aideddispatchtriagestatusas assignedbytheEMSprofessional,directtransporttohighest levelofhospitalcareduringthecareepisode,andwhether transportinvolvedairambulance.Wealsoincludedthelevel oftraumacareofthe ﬁrstreceivinghospital(level1[L1] beingthehighestlevelinNZ),andwhetherthepatient reachedatertiarytraumahospital(L1)duringtheepisodeof care.Totaltimetoreachhospitalwasgroupedaccordingto theoveralldistributionofthisvariable,withtheslowest tertile(ie,slowestthird)correspondingtototaltimes ≥113 minutes.Wecalculatedtheoreticalaccesstimetohospitallevelcare(categorisedinto <60minutes, ≥60minutes);this measurecapturestheestimatedshortesttimetakentotravel fromtheroadambulancebaselocationtothelocationsofthe incident,andthentothehospitallocation.27

EMSinterventions deliveredtoaddresslife-threatening eventsidentifiedinthepatientonscenewereidentifiedand classifiedusingamodifiedversionofclassificationfrom Gomesetal(2010)24 (Figure1).

Wecreatedaggregatemeasuresof ‘anylife-threatening event’ and ‘anyout-of-hospitalinterventionreceived’ . Unmetneedwasmeasuredbyidentifyingthosewithalifethreateningeventwhoreceivednoout-of-hospital interventiononscene.

PrimaryDataAnalysis

Analysesdescribethetransportstatusforthetotalcohort andthepatternsofEMScarereceivedandtransport pathwaysforthetransportedsub-cohortreceivingEMScare,

usingfrequenciesandproportions.Weusedchi-squaredtests tocompareproportions,with t -testsusedtocomparemeans betweenthoseinjuredindifferentgeographicallocations (rural/urban)andbetweenthoseincombinedethnicitygeographicallocations(ruralMaori/ruralnon-Maoriand urbanMaori/urbannon-Maori).Followingtheadviceof Rothman,28,29 noadjustmentwasmadeformultiple comparisons.Instead, P valueshavebeenprovidedto sufﬁcientprecision,sothatreaderscanapplyathresholdfor signiﬁcanceiftheywish.30 Statisticalanalyseswere performedusingStataSE,version17(StataCorp,College Station,TX).31

RESULTS

CharacteristicsofStudySubjects

Thestudypopulationwascomprisedof3,333patients attendedbyanout-of-hospitalEMSprofessional;ofthese, 748mettheinclusioncriteria(Figure2).Atotalof 56patientsinthiscohortwerenottransported:onewho declinedtransportand55patientswhodiedonscene (Table1).Therewasnoevidenceofdifferencesinthe distributionofon-scenedeathsbylocationofincidentor ethnicity.However,whencomparedtotheoverall proportionofMaoriintheNZpopulation(17%oftheNZ populationaged ≤85years17),Maoriwere disproportionatelyrepresentedamongston-scenefatalities duetoRTC(19/55,36%ofon-sceneRTCfatalities, χ 2 = 4.82 P = 0.03).Ofthosemeetingthecriteria,692(93%)were transportedtoahospitalbyanEMSprofessionalandare describedfurther.

Thetransportedcohorthadameanageof42yearsand waspredominantlymale(59%)(Table2).IndigenousMaori comprised28%(196patients)ofstatus1and2vehicle

Figure2. Flowdiagramofvehicleoccupantcohortselection.

occupantsattendedbyEMS,while47%(324)ofpatients’ injuriesoccurredinarurallocation.Allinjuriessustainedby vehicleoccupantswereclassiﬁedasbluntinjuries. Differencesinpatientdemographicsandon-sceneclinical statusinthecohortwereevidentforMaori(Table2).Rural Maoriwereonaveragefouryearsyoungerwhileurban Maoriwere11yearsyoungercomparedtotheirnon-Maori counterparts.DespitesimilaraverageISSscoresand proportionsofverysevereISSscores(ISS ≥ 25),on-scene EMSclinicaltriagingassessmentsdifferedmarkedly. However,ISSiscalculatedposteventandisnotavailableon scenetoinformclinicaltriagingassessmentsbyambulance staff.Ahigherproportionofruralnon-Maoripatientswere clinicallyassessedashaving “potentiallylife-threatening” injuries(79%vs68%ofruralMaori, P = 0.03)whilethe

oppositewasobservedintheurbansetting(73%ofurban non-Maorivs84%ofMaori, P = 0.01).Theincidenceofan assessmentofGCS ≤ 13,indicatingmoderatetoseverebrain injury,washigherinurbanMaoripatients(16%vs9%in urbannon-Maori, P = 0.05).

MainResults

Table3 examinesdifferencesinEMSinfrastructureand transportpathwaysbyincidentlocationalone.Overall,most ofthetransportedcohort(94%)weretriagedintothefastest dispatchresponse(“purple-red”),weretransporteddirectly totheirhighestlevelofcareachievedduringthecareepisode (82%),andwereattended,onscene,bythehighestpractice levelofICP(74%)(Table3).Single-vehiclecrewattendance wasuncommon,occurringin12%ofattendedpatients. Overall,alowerproportionofpatientsinjuredrurallywere directlytransportedtothehighestlevelofcareachievedin thecareepisode(77%vs87%ofurbanpatients)(Table3). Patientsinruralareastooklongertoreachin-hospitalcare (44%vs7%,out-of-hospitaltime ≥ 113minutes, P < 0.001). Ruralpatientshadsigniﬁcantlylowertheoreticalaccessto healthcarewith60minutes(2%vs40%, P < 0.001) andahigherlevelofairtransport(51%vs4%ofurban patients, P < 0.001).

Table4 examinestheintersectionaldifferencesbetween incidentlocationandethnicity.EthnicdifferencesinEMS transportpathwaystohospital-levelcareweremostevident forruralMaoripatients.Comparedtoruralnon-Maoria lowerproportionofruralMaorireceivedthefastesttriaged dispatch(92%Maorivs97%non-Maori, P = 0.05), first attendedatertiarytraumahospital(33%vs56%, P < 0.001),orreachedatertiarytraumahospital (51%vs.73%, P < 0.001).Thetotalout-of-hospitaltimeto reachthe firsthospitalwas,onaverage,slowerforrural Maoriwith55%intheslowesttertileoftotaltransporttimes (ietakingatleast113minutes,orlonger)toreach first hospital,comparedwith41%ofruralnon-Maoripatients (P = 0.02).Therewasnoevidenceofdifferencesin theoreticalaccess <60minutes(P = 0.2)oruseofair

Table1. Emergencymedicalservicestransportstatusofroad-trafﬁccrashvehicleoccupantcohort,byincidentlocationand ethnicity(n = 748).

(n = 748)

(n = 345)

(n = 397)

(n = 93)

Transported692(92.6)324(93.9)364(91.7)85(91.4)239(95.6)109(90.8)253(93.7)

Diedonscene55(7.3)21(6.1)33(8.1)0.38(8.6)11(4.4)0.111(9.2)17(6.3)0.3

Declinedtransport1(0.1)

Missingitems:Ofthosetransported,4patientsaremissingincidentlocation,and8patientsareadditionallymissingethnicity.Ofthosewho diedonscene,1patientismissingincidentlocation,and7patientsareadditionallymissingethnicity.

Table2. Patientdemographics,injurycharacteristicsandpatientstatusonscene,byincidentlocationandethnicity(n = 692). Combinedincidentlocationandethnicity IncidentlocationRuralUrban

Meanage42.4241.5943.170.838.4142.80.0335.0846.49 <0.001

MeanISS19.4719.4819.490.519.1819.590.319.9619.270.8 n(%)n(%)n(%)n(%)n(%)n(%)n(%)

Male409(59)190(59)217(60)0.754(63)136(57)0.269(69)147(58)0.3

Maori196(28)85(26)109(30)0.2

Rural324(47)

TBI50(7)19(6)31(8)0.16(7)13(5)0.59(8)22(84)0.8

ISS >25128(18)61(19)67(18)0.916(19)45(19)0.924(22)42(17)0.2

Immediatethreattolife530(77)248(76)278(76)158(68)190(79)0.0392(84)186(74)0.01

Systolicbloodpressure (<90mmHg)

23(3)13(4)9(2)0.25(6)8(3)0.33(3)6(2)0.8

GCS(≤13)82(12)40(12)42(11)0.710(12)30(13)0.818(16)24(9)0.05

Pulse(<60or >130bpm)43(6)25(8)18(5)0.110(12)15(6)0.110(9)8(3)0.2

Missingdata:4casesmissinglocation,2caseswereadditionallymissingethnicity.Therewasasmallamountofmissingdata:4missing rurality;2missingethnicityindicator;15missingsystolicbloodpressure;2missingpulse. GCS,GlasgowComaScore; ISS,InjurySeverityScore; bpm,beatsperminute; mmHg,millimetresofmercury.

Table3. Emergencymedicalservicesinfrastructureandtransportpathways,totalandbyincidentlocation(n = 692).

Incidentlocation

Total(692)* Rural(324)Urban(364) n(%)n(%)n(%) P-value

EMSinfrastructureandpracticelevel

Intensivecareparamedic513(74.1)240(74.1)269(73.9)1

Singlecrewattendance87(12.5)38(12.5)49(14.5)0.4

EMStransportpathways

Fastestdispatchresponse654(94.5)310(95.7)340(93.5)0.2

Directtransporttode ﬁnitivecare*572(82.6)251(77.5)318(87.4)0.001

Transportinvolvedairambulance183(26.4)166(51.2)16(4.4) <0.001

FirstattendedL1hospital385(55.6)163(50.3)220(60.4)0.009

L1deﬁnitivecare*hospital469(67.8)217(66.9)249(68.4)0.6

Theoreticalaccess < 60minutes162(23.4)16(1.9)146(40.1) <0.001

Totaltimetoreachhospital(slowesttertile)173(25.0)145(44.8)28(7.7) <0.001

Missingdata:4casesmissinglocation.

*Highestlevelofhospitalcareachievedduringthecareepisode; ∧ slowesttertileoftimes,lowerboundary113minutes;allpercentagesare calculatedascolumnpercentages.

EMS,emergencymedicalservices; L1,Level1.

transportation(P = 0.7)byethnicityforruralpatients. Additionally,therewasnoevidenceofsubstantivesigniﬁcant differencesinEMStransportpathwaysbetweenMaoriand non-Maoripatientsinjuredinurbanlocations.

Aspresentedin Table5,somedifferencesinreceiptoflifesavingEMSinterventionswereobservedbyincident location:agreaterproportionofruralpatientsreceivedan EMSintervention(54%ruralvs44%urban, P = 0.01).

Table4. Emergencymedicalservicesinfrastructureandtransportpathways,bycombinedincidentlocationandethnicity(n = 692).

Combinedincidentlocationandethnicity

RuralUrban

Maori(85)Non-Maori(239)Maori(109)Non-Maori(253) n(%)n(%) P-valuen(%)n(%) P-value

EMSinfrastructureandpracticelevel

Intensivecareparamedic61(71.8)179(74.9)0.587(79.8)180(71.2)0.09

Singlecrewattendance14(17.9)24(10.6)0.0910(9.6)39(16.8)0.08

EMStransportpathways

Fastestdispatchresponse78(91.8)232(97.0)0.05102(93.6)236(93.3)1

Directtransporttode ﬁnitivecare*62(72.9)189(79.1)0.293(85.3)224(88.5)0.3

Transportinvolvedairambulance45(52.9)121(50.6)0.72(1.8)14(5.5)0.1

FirstattendedhospitalL128(32.9)135(56.5) <0.000162(56.9)157(62.1)0.4

L1deﬁnitivecare*hospital43(50.6)174(72.8) <0.000171(65.1)176(69.6)0.4

Theoreticalaccess <60minutes2(2.4)14(5.8)0.248(44.0)98(38.7)0.3

Totaltimetoreachhospital(slowesttertile)47(55.3)98(41.0)0.027(6.4)21(8.3)0.5

Missingdata:4casesmissinglocation,2casesmissingethnicity.

*Highestlevelofhospitalcareachievedduringthecareepisode;^slowesttertileoftimes,lowerboundary113minutes;allpercentagesare calculatedascolumnpercentages.

EMS,emergencymedicalservices; L1,Level1.

Table5. Life-threateningproblemsandpotentiallylife-savingEMSinterventions,byincidentlocationandethnicity(n = 692).

Incidentlocation

TotalRuralUrban n(%)n(%)n(%) n = 692n = 324n = 364 P-value

Anylife-threateningeventsexperienced115(16.6)45(13.8)69(18.9)0.07

Anypotentiallylife-savingEMSinterventionreceived338(48.8)176(54.3)160(43.9)0.01

Presenceoflife-threatingevent,noEMSintervention47(6.8)15(4.6)32(8.8)0.03

Life-threateningeventn = 115n = 45n = 69

Airway(A)problem0(0.0)0(0.0)0(0.0) –

Breathing(B)problem90(78.3)30(66.7)59(85.5)0.4

Ofthosewith(B),receivedtreatment46(51.1)18(60.0)27(45.8)0.2

Circulation(C)problem16(13.9)11(24.4)4(5.8)0.004

Ofthosewith(C),receivedtreatment8(50.0)5(45.5)2(50.0)0.8

Neurotrauma(N)problem11(9.6)5(11.1)6(8.7)0.7

Ofthosewith(N),receivedtreatment1(<0.0)1(<0.0)0(0.0)0.3

Missingdata:4casesmissinglocation,2casesmissingethnicity. EMS,emergencymedicalservices.

Additionallyofthosepresentingwithalife-threatening event,agreaterproportionofurbanpatientsreceivedno recordedEMSintervention(5%ruralvs.9%urban, P = 0.03).Whilesmallpercentagestheylikelyreﬂectthe closerproximityofhospital-levelcareinurbansettings. Therewasnostrongevidenceofdifferencesinpercentages thatidentiﬁedwithlife-threateningeventsorthatreceived

EMSinterventionsbetweenMaoriandnon-Maoriineither ruralorurbanlocations.

Forthoseexperiencinglife-threateningeventsthe majorityexperiencedbreathingproblems(78%),withjust overhalfthesepatientsreceivingoneofthepotentiallylifesavingEMSinterventionsin(outlinedin Figure1)toaddress theseconcernswhileoutofhospital.Similarly,onlyhalfof

thosewithlife-threateningcirculatoryproblems(8of16) receivedanidentiﬁableEMSintervention(outlinedin Figure1).Therewerefewsubstantivedifferenceswhen examinedbyincidentlocation(Table5);however,rural patientsweremorelikelytohavearecordedcirculatory problemthanurbanpatients(P = 0.004).Similarly,there werefewintersectionaldifferencesbylocationandethnicity (resultsnotshownin Table5)withtheexceptionoflifethreateningevents,whichweremoreprevalentinurbannonMaoricomparedtoruralnon-Maori(13%ruralvs20% urbannon-Maori,chi2 = 4.45, P = 0.03).

DISCUSSION

DisparitiesinEMStransporttimesinrurallocated patientsarecommon,andlongerEMStransporttimesare thoughttoplayanimportantroleinsurvivalfollowingmajor traumaticinjuryevents.3–6 Theexaminationofdisparities haslargelybeenlimitedtoruraldifferencesintransport times,however,andthereislittleknownaboutdifferential transportationpathwaysorEMScarereceived,despitewellknownruralandethnicdisparitiesinmajortrauma outcomes.2 Ourstudyidentifiedconsiderabledifferencesin EMSresponseandtransportpathways,withthese differencespatternedbytheinter-relationshipbetweenthe geographicallocationoftheincidentandethnicity.Similarto previousstudies,weidentifiedalowerproportionofthose injuredinrurallocationswhoweredirectlytransported tothehighestlevelofcareachievedduringthecare episode.Similarly,thoseinjuredinrural(comparedto urban)locationsweremorelikelytotakelongertoreach firsthospitalandweremorelikelytoinvolveair ambulancetransportation.3,4,6

Inexaminingtheintersectionofgeographiclocationof injuryandethnicitywefoundoverlappingdisparitiesthat wouldnothavebeenidentifiedbyexaminingthesesourcesof disparitiesindividually.Comparisonsofrurallylocated indigenousMaoripatientstoruralnon-Maoripatients revealedthatdespitesimilaron-sceneISSpresentation,rural Maoriweretriagedtoslowerdispatchandon-sceneresponse pathwaysandtooklongertoreach firsthospital.Rural Maoriwerelesslikelytoreachhigh-levelspecialisttrauma careandfacilities,bothasa firsthospitaloratanytime duringtheepisodeofcare.Theoppositewasobservedfor Maoripatientsinjuredinanurbanlocation,whichwere morelikelytobeprioritised;thismayhavebeenduetohigher incidenceofconcussivesymptomsidentifiedonsceneusing theGCS.Incombination,these findingssuggestthatthere areadditionalchallengesassociatedwithprovidingequitable out-of-hospitalcareforMaoriinjuredinrurallocations, potentiallysetinplacebyout-of-hospitaltriagingprocesses.

Tothebestofourknowledgethisisthe ﬁrststudyto describetheinter-relationshipbetweenruralandethnic disparitiesforout-of-hospitalEMScareandtransport pathwaystohospital-levelcarefollowingRTCtraumaina

nationalcontext.Rurallylocatedpatients,particularly rurallylocatedMaoripatients,wereidentifiedasbeing particularlyunderservedbyout-of-hospitalEMSfollowing anRTC,despitesimilaron-scenepresentation.Delaysalong pathwaysofcareanddifferencesinqualityofcareresulting inexcessMaorimortalityhavealsobeenidentifiedforrural MaoriinotherareasofhealthcareinNZ,includingcancer care. 32–34 Morespecifically,ethnicallypatterneddelaysin carehavebeenfoundforout-of-hospitalcardiacarrest (OHCA)inNZ.MaoripatientshadfewEMS-witnessed OHCAandahigherlevelofbystanderintervention, suggestingEMSassistancearriveslaterorhelpisnotsought immediately,resultinginpoorer30-daysurvivalforMaori patients.35 RecentexaminationofEDprocessesinNZalso identifieddelaysincareexperienced,althoughahigher proportionofMaoriEDpresentationsareself-presentations (unattendedbyout-of-hospitalEMS)andweretriagedtobe seenwithinalongertimeframe.36

ThissituationisnotuniquetoNZ.Ourstudyexpands uponexistingliteratureregardinghealthinequitiesinother countries,especiallyruralindigenousdisparitiesinAustralia, Canada,andtheUnitedStates.WhilenotspeciﬁctoEMS manystudiesofhealthcareaccessandutilisationhavefound rurallocationtobeabarriertohealthcarethat disproportionatelyaffectsremote,ruralindigenous populations.37 Factorspresentingasbarrierstohealthcare forindigenouscommunitiesincluderurallocation, communication,culturaldifferences,andpooraccesstothe positivesocialdeterminantsofhealth.37,38 Withregardtothe provisionofemergencytraumacare,rurallocationspresent challengessuchaslongdistancesandtraveltimes,limited traumacareresourcesandskilledstaff.39 Highermortality ratesfollowingtraumaticinjuriesinruralareashavebeen attributedtolongerincident-discoverytimes,longerout-ofhospitaltime,limitedaccesstomajortraumain-hospital care,anddelaysinreceivingdeﬁnitivein-hospitalcare.3,5 Mixedevidenceforanintersectionalrelationshipbetween ‘ race ’/ethnicityandinsurancestatushasbeenreportedatthe leveloftraumahospitalcareintheUShealthcaresystembut hasnotbeenexaminedintheout-of-hospitalsetting.2

Understandingthecomplexintersectionalrelationship betweenthegeographiclocationofinjuryandethnicityis importanttooptimisingtheplanningandtargetingof healthcaredelivery.Thebarriersgeneratedbygeographical location,suchaslongerdistancesandtimestotravelto centralisedtertiaryhospital-levelcare,invariablylocatedin metropolitancentres,areexacerbatedbyethnicity.For example,inNZ,Maoriaremorelikelytoliveinruraland moreremoteplaces.32 Theinterweavingofcomplexsystemic andstructuralfactors,includinginstitutionaland interpersonalracism,differentialdistributionofthesocial determinantsofhealth,lessaccesstospecialistcare,and longerandslowerpathwaysthroughhealthsystems,all underpinnedbytheprocessofcolonisation,arewell

recognisedtogeneratehealthinequities.11,40 National healthcarereformscurrentlyunderwayinNZarestrongly focusedonaddressinginequitiesforqualityimprovementsin thehealthcaresystem.41 Our ﬁndingssuggestthataddressing theoverlapbetweenruralandethnicdisparitiesthrough strong,equity-focussedplanningandprioritisationand throughincreasedinvestmentinruralserviceshasthe potentialtoimprovethedeliveryofruralEMSforboth indigenousandnon-indigenouspopulations.

Achievingequitablehealthcareisapersistentchallengefor healthcaresystemsworldwide.Our ﬁndingssuggesttheneed forbetterresourcingofruralEMSservicewithparticular attentiontoinequitiesexperiencedbyruralMaori communities.GreaterrecruitmentandtrainingofMaori EMSprofessionalswouldaddressMaoriunderrepresentationamongstprofessionalEMSstaffandreduce hesitancyinaccessingunrepresentativeservices,aswellas reducepatientexperiencesofinstitutionalandinterpersonal racisminNZhealthcare.42–44 QualitativeanalyseswithEMS professionalsarealsorequiredtounderstandethnicandrural differencesincoverageofEMSservices,infrastructure, stafﬁng,training,experience,skilllevels,anddeploymentfor ruralcommunities.Itisimportantthatthisincludesthe perspectivesofMaoriandruralEMSstaffandpatientvoices. Tounderstandethnicbarrierstoaccessingcarefollowing traumafurtherresearchshouldalsoincludeaMaori-led investigationofthecontinuumoftraumacarefromout-ofhospitalEMSdispatchtriagethroughtoaccesstoposthospitalrehabilitationservices,includinganydifferences betweenruralandurbancare.

OurstudyfoundEMStriagingprocesses(especiallyfor prioritisationofEMStransportfromthescenetoaL1 hospital)wascomparativelyslowerforruralMaoripatients comparedtoruralnon-Maori.Triagingpolicyisafurther mechanismtoaddressdisparitiesinEMStransportpathways andaccesstotertiary-leveltraumacarebypotentially providingopportunitiestoprioritisebasedonlocationof incidentandethnicity,alongsidelife-threatening presentations.Furtherexaminationofthereasonsfor differencesintriagingandselectionofdestination hospitalareneededgiventhatculturaldifferencesin communicationandinterpretationsofpresentingsymptoms havebeenfoundtoinﬂuenceaccesstohealthcarein indigenouspopulations.

Patient/familyproximityrequestsarecommonreasonsfor hospitalselectioninothercontexts.4,37 Whanau(family) supportforpatientsinhospitaliscriticalforMaorito mitigateagainstconsistentlyreportednegativehospital experiences.45 Recentexaminationofhospitalisationsfor Maoriidentifiedthedifficultiesfortheprovisionofwhanau supportduringahospitaltransfer,oranaway-from-home hospitaladmission,anditispossiblethismayinfluence decisionsondestinationhospitalinsituationswhereachoice exists.46 AdherencetoNewZealand’s2017Out-of-Hospital

MajorTraumaTriagePolicyisbeingexaminedinmore detailtoidentifyunwarrantedclinicalvariationsin transportingEMSpatientsinthiscohort.47

ThequestionremainswhetherthedifferenceinEMS transportandaccesstotertiary-leveltraumacareand facilitiesleadstopoorermortalityoutcomesfollowingan RTC,requiringfurtherexamination.Analysisofthewider cohortincludingnon-transportedpatientsidentiﬁedthat whencomparedwiththenon-indigenousNZpopulation MaoriweredisproportionatelyrepresentedamongstonscenefatalitiesduetoRTC.This ﬁndingsuggeststhatalong withimprovedEMShealthcareresponsefollowingtrauma theremustbeacorrespondingeffortstrengtheningprimary preventionpoliciesandactionsfocusedonaddressing upstreamriskfactorsforRTC,includingthesocialand economicdeterminantsofhealth.

Thisstudyhasmanystrengthsbeyondexaminingthe intersectionbetweengeographyandethnicityrelevantto healthcaredelivery.Theuseofaconsistentmechanismof injury(inthiscasevehicleoccupantsinRTCs),allowedfor theexaminationofruralandethnicdifferenceswithina cohortwithamoreconsistentcasemixandinjury circumstancebetweensub-groups.Additionally,thisstudy utilisedtheruralityofthelocationofinjuryincident,whichis morecloselyalignedtoEMSneedthanpatientresidence. Theprovisionofmanyhealthservicesisplannedonthe distributionoftheusuallyresidentpopulation,whichmisses thehighlymobilenatureofapopulationandtheoccurrence ofinjuryinlocationsawayfromdomicile,especiallyRTC.48 RoadEMSresourcinginNZisbasedontheuseof retrospectivedatatomodelpredicteddemandaccordingto dispatchresponsecategory,numberofincidentsina geographicarea,andspeciﬁedresponsetimesusingspecialist modellingsoftware.

FutureEMSplacementshouldalsoincluderurality, ethnicity,anddeprivationinordertooptimiseservice coverage.Ruralcommunityhealthneeds,includingaccessto healthservices,areoftenoverlooked,especiallyforrural Maoriandforisolatedcommunities,andthisstudycan informPriority3(focusedonplacinghealthservicescloserto ruralcommunities)oftheNZRuralHealthStrategy acknowledgingtheneedtoconsiderplacementofEMS servicesinrelationtowhereruralcommunitiesliveaswellas locationswithhighoccurrenceofRTC.49 Theutilisationof anurban/ruralgeographicclassificationspecifically developedforuseinhealthpolicyandresearch,reducesthe likelihoodofgeographicmisclassification.23 Finally,the universalfree-of-costaccesstoEMSfortraumacare inNZminimisesanyselectionbiasescausedby economicfactors.

LIMITATIONS

Thereareseverallimitationstothisstudy.Weanalysed datacorrespondingtoEMScaredeliveredinNZbetween

2016–2018,whichthereforemaynotreﬂectcurrentEMS practiceordestinationpolicies50 orbedirectlygeneralisable toothercountries.The ﬁndingsarelimitedtoRoadandAir EMScapturedinePRFdatapotentiallyunderestimating EMSusewhenAirEMSserviceutilisationisnotcapturedby ePRFdata.ReasonsforAirEMSactivationornonactivationarenotavailableinePRFdata.PreviouslyselfpresentationtoEDs(ie,walk-ins)hasbeenreportedtobe morecommoninMaoripatients(63%comparedwith57%of non-Maoripresentations)thusthisstudythatanalysed patientsattendedbyEMSmaynotberepresentativeof ethnicdifferenceintheincidenceofmajortrauma.37

MisclassiﬁcationofethnicityoccursforMaori,estimatedata 16%undercountusingethnicityreportedbytheNational HealthIndex,potentiallyunderestimatingdifferences forMaori.51

Analysesarelimitedtothoseinjuredasvehicleoccupants inRTCs,andpatternsofEMScareandpathwaysto transportmaydifferforotherinjurycontexts.Analyses examiningdifferencesinEMSinterventionsdelivered involvedsmallnumbersofpatientslimitingtheabilityto makeinferencesaboutobserveddifferences.Results highlightcomparisonswith P < 0.01orsmaller,allaying concernsaboutfalsepositiveswithmultiplecomparisons. Theadaptedmeasureoflife-threateningeventsidentiﬁes airway,breathing,circulatory,orneurotraumaproblems andwill,therefore,notcaptureallcriticalevents;one suchexampleisarupturedspleenorsevereheadinjury,such ashaemorrhage,notimmediatelyindicatedby on-scenemeasurements.

CONCLUSION

ThisstudyidentifiedseveraldisparitiesinEMStransport pathwaysthatarestronglyintertwinedwithruralityand ethnicity.These findingsprovideanevidencebasetohelp guideclinicalandpolicydecision-makersinidentifying opportunitiestooptimisethedeliveryofEMScareandto reduceoverlappingdisparitiesassociatedwithEMScare, nationallyandinternationally.Greaterequity-focused planningandinvestmentinruralEMSservicesto reducedocumenteddisparitiesinEMStriage,transport.and accesstohighqualityspecialisttraumacareisclearly warrantedandwouldbenefitbothindigenousandnonindigenouspopulations.

DECLARATIONS

EthicsApprovalandConsenttoParticipate

TheHealthandDisabilityEthicsCommittee(reference 18NTB142)providesethicsapproval.Accessapprovalsto studydatasetswasobtainedfromtheNewZealandTrauma Registry(NZTR)DataGovernanceGroup;Ministryof HealthforextractsfromtheNationalHealthIndex

database;andfromStJohnandWellingtonFreeAmbulance forEMSdata.

AvailabilityofDataandMaterials

Therawdatathatsupportsthe ﬁndingsofthisstudyare availablefromHoneHatoStJohn,WellingtonFree AmbulanceandtheNZTR.Restrictionsapplytothe availabilityofthisdata.Deriveddataisavailablefromthe correspondingauthoronrequest.

AddressforCorrespondence:RebbeccaLilley,UniversityofOtago, DunedinSchoolofMedicine,DepartmentofPreventiveandSocial Medicine,InjuryPreventionResearchUnit,P.O.Box52,Dunedin, NewZealand,9054.Email: rebbecca.lilley@otago.ac.nz

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.ThisprojectisfundedbyaHealth ResearchCouncilofNewZealandprojectgrant(HRC18/465). Therearenootherconflictsofinterestorsourcesoffunding todeclare.

REFERENCES

1.LindströmV,BohmK,KurlandL.PrehospitalcareinSweden:froma transportorganizationtoadvancedhealthcare. NotfRettMed. 2015;18(2):107–9.

2.HaiderAH,WeygandtPL,BentleyJM,etal.Disparitiesin traumacareandoutcomesintheUnitedStates:asystematicreview andmeta-analysis. JTraumaAcuteCareSurg. 2013;74(5):1195–205.

3.GrossmanDC,KimA,MacDonaldSC,etal.Urban-ruraldifferencesin prehospitalcareofmajortrauma. JTrauma. 1997;42(4):723–9.

4.NewgardCD,FuR,BulgerE,etal.Evaluationofruralvsurbantrauma patientsservedby9-1-1emergencymedicalservices. JAMASurg. 2017;152(1):11–8.

5.AlanazyARM,WarkS,FraserJ,etal.Factorsimpactingpatient outcomesassociatedwithuseofemergencymedicalservicesoperating inurbanversusruralareas:asystematicreview. IntJEnvironResPublic Health. 2019;16(10):1728.

6.McGufﬁeAC,GrahamCA,BeardD,etal.Scottishurbanversusrural traumaoutcomestudy. JTrauma. 2005;59(3):632–8.

7.SoaresWE,KnowlesKJ,FriedmanPD.Athousandcuts:racial andethnicdisparitiesinemergencymedicine. MedCare. 2019;57(12):921–3.

8.Goodyear-SmithFandAshtonT.NewZealandhealthsystem: universalismstruggleswithpersistinginequities. Lancet. 2019;394(10196):432–42.

9.MinistryofHealth. TatauKahukuraMaoriHealthChartBook2015, 3rd ed.Wellington:MinistryofHealth.2015.Availableat: https://www. health.govt.nz/system/ﬁles/documents/publications/tataukahukura-maori-health-chart-book-3rd-edition-oct15.pdf AccessedOctober10,2023.

10.PriskD,GodfreyAJ,LawrenceA.Emergencydepartmentlengthofstay forMaoriandEuropeanpatientsinNewZealand. WestJEmergMed. 2016;17(4):438–48.

11.WaitangiTribunalReport. Hauora,WaitangiTribunalReport Wellington:WaitangiTribunal.2019.

12.GurneyJK.Thelongroadtogoodcare. NZMedJ. 2022;135(1565):9–11.

13.LilleyR,deGraafB,KoolB,etal.Geographicalandpopulation disparitiesintimelyaccesstoprehospitalandadvancedlevel emergencycareinNewZealand:across-sectionalstudy. BMJOpen. 2019;9(7):e026026.

14.KoolB,LilleyR,DavieG,etal.Evaluatingtheimpactofprehospitalcare onmortalityfollowingmajortraumainNewZealand:aretrospective cohortstudy. InjPrev. 2021;27(6):582–6.

15.HatoHoneStJohn.AnnualReportAuckland:StJohn.2022.Available at: https://www.stjohn.org.nz/news–info/our-performance/ annual-reports/.AccessedOctober10,2023.

16.AccidentCompensationCorporation.AccidentServices:AGuidefor DHBandACCstaff2018.2019.Availableat: https://www.acc.co.nz/ assets/provider/accident-services-a-guide-for-dhb-and-acc-staff.pdf AccessedOctober10,2023.

17.StatisticsNewZealand.EstimatedPopulationofNZ.2021.Availableat: https://www.stats.govt.nz/indicators/population-of-nz AccessedOctober10,2023.

18.BalasubramaniamSandCivilI.TraumasysteminNewZealand. Emerg CritCareMed. 2022;2(2):80–2.

19.FlabourisA,CivilIDS,BaloghZ,etal.TheNewZealandTraumaSystem Veriﬁcation. JTraumaAcuteCareSurg. 2020;89(3):585–96.

20.NewZealandMajorTraumaRegistry&NationalTraumaNetwork. AnnualReport2018-19.2022.Availableat: https://www.majortrauma. nz/assets/Publication-Resources/Annual-reports-and-strategic-plans/ National-Trauma-Network-Annual-Report-2018-19.pdf AccessedOctober10,2023.

21.NationalTraumaNetwork,AmbulanceSector.NewZealandOut-ofHospitalMajorTraumaTriagePolicy.2021.Availableat: https://www. majortrauma.nz/assets/Publication-Resources/Out-of-hospitaltriage/Major-Trauma-Triage-Policy-ﬁnal-June-2021.pdf AccessedOctober10,2023.

22.MinistryofHealth.HISO10001:2017EthnicityDataProtocols.2017. Availableat: https://www.tewhatuora.govt.nz/assets/Our-healthsystem/Digital-health/Health-information-standards/hiso_100012017_ethnicity_data_protocols_21_apr.docx AccessedOctober10,2023.

23.WhiteheadJ,DavieG,deGraafG,etal.Deﬁningruralhealthin AotearoaNewZealandanovelgeographicclassiﬁcationforhealth purposes. NZMedJ. 2022;135(1559):24–40.

24.GomesE,AraújoR,CarneiroA,etal.Theimportanceof pre-traumacentretreatmentoflife-threateningeventsonthemortalityof patientstransferredwithseveretrauma. Resuscitation. 2010;81(4):440–5.

25.LottC,AraujoR,CassarMR,etal.TheEuropeanTraumaCourse(ETC) andtheteamapproach:past,presentandfuture. Resuscitation. 2009;80(10):1192–6.

26.AmericanCollegeofSurgeons. AdvancedTraumaLifeSupport ProgramforDoctors,FacultyManual, 7th ed.Chicago,IL:American CollegeofSurgeons,2004.

27.LilleyR,KoolB,DavieG,etal.Preventableinjurydeaths: identifyingopportuntiestoimprovetimelinessandreachof emergencyhealthcareservicesinNewZealand. InjPrev. 2018;24(5):384–9.

28.RothmanKJ.Noadjustmentsareneededformultiplecomparisons. Epidemiology. 1990;1(1):43–6.

29.RothmanKJ.Sixpersistentresearchmisconceptions. JGenInternMed. 2014;29(7):1060–4.

30.AmrheinVandGreenlandS,McShane.Scientistsriseupagainst statisticalsigniﬁcance. Nature. 2019;567(7748):305–7.

31.StataCorp.(2021). StataStatisticalSoftware:Release17.College Station,TX:StataCorpLLC.

32.CrengleS,DavieG,WhiteheadJ,etal.Mortalityoutcomesand inequitiesexperiencedbyruralMaoriinAotearoaNewZealand. Lancet RegHealthWestPac. 2022;18:28:100570.

33.GurneyJ,WhiteheadJ,KerrisonC,etal.Equityoftravelrequiredto access ﬁrstdeﬁnitivesurgeryforliverorstomachcancerinNew Zealand. PLoSOne. 2022;17(8):e0269593.

34.GurneyJ,McLeodM,StanleyJ,etal.Disparitiesinpost-operative mortalitybetweenMaoriandnon-IndigenousethnicgroupsinNew Zealand. NZMedJ. 2021;134(1542):15–28.

35.DickerB,ToddVF,TunnageB,etal.Ethnicdisparitiesintheincidence andoutcomefromout-of-hospitalcardiacarrest:aNewZealand observationalstudy. Resuscitation. 2019;145:56–62.

36.CurtisE,PaineS-J,JiangY,etal.Examiningemergencydepartment inequities:descriptiveanalysisofnationaldata(2006–2012). Emerg MedAustralas. 2020;32(6):953–9.

37.MarroneS.Understandingbarrierstohealthcare:areviewofdisparities inhealthcareservicesamongindigenouspopulations. IntJCircumpolar Health. 2007;66(3):188–98.

38.ProbstJC,MooreCG,GloverSH,etal.Personandplace:the compoundingeffectsofrace/ethnicityandruralityonhealth. AmJPublic Health. 2004;94(10):1695–703.

39.MorganJMandCallejaaP.Emergencytraumacareinruralandremote settings:challengesandpatientoutcomes. IntEmergNurs. 2020;51:100880.

40.RobsonB.Whatisdrivingthedisparities?In:DewKandMathesonA (Eds.), UnderstandingHealthInequalitiesinAotearoaNewZealand. Dunedin,NewZealand:OtagoUniversityPress,2008.

41.DepartmentofthePrimeMinisterandCabinet.FutureofHealth.Te AnamataoTeOrangaWellington:DepartmentofthePrimeMinisterand

Cabinet.2022.Availableat: https://www.futureofhealth.govt.nz/ AccessedOctober10,2023.

42.MedicalCouncilofNewZealand.(2017). TheNewZealandMedical Workforcein2017.Wellington:MedicalCouncilofNewZealand.

43.MorrisonTAandTunnageB.ReportingMaoriparticipationinparamedic educationandtheEMSworkforceinNewZealand. AustralasJ Paramed. 2014;11(5).

44.HarrisR,TobiasM,JeffreysM,etal.Effectsofself-reportedracial discriminationanddeprivationonMaorihealthandinequalitiesinNew Zealand:cross-sectionalstudy. Lancet. 2006;367(9527):2005–9.

45.GrahamRandMasters-AwatereB.ExperiencesofMaoriofAotearoa NewZealand’spublichealthsystem:asystematicreviewoftwo decadesofpublishedqualitativeresearch. AustNZJPublicHealth. 2020;44(3):193–200.

46.CormackD,Masters-AwatereB,LeeA,etal.Understandingthecontext ofhospitaltransfersandaway-from-homehospitalisationsforMaori. NZ MedJ. 2022;135(1565):41–50.

47.MajorTraumaNationalClinicalNetwork.NewZealandOut-of-Hospital MajorTraumaTriagePolicy.2017.Availableat: https://www.

majortrauma.nz/assets/Publication-Resources/Out-of-hospital-triage/ bbebfb_12ccb22c9dc648ee8ab5fd095ebc9ba6.pdf AccessedOctober10,2023.

48.DavieG,LilleyR,deGraafB,etal.Accesstoadvanced-level hospitalcare:differencesinprehospitaltimescalculatedusing incidentlocationscomparedwithpatients’ usualresidence. InjPrev. 2022;28(2):192–6.

49.MinistryofHealth.RuralHealthStrategyWellington,NZ:Ministryof Health;2023.Availableat: https://www.health.govt.nz/publication/ rural-health-strategy.AccessedOctober10,2023.

50.MajorTraumaNetwork.Out-of-HospitalMajorTrauma DestinationPolicyWellington,NewZealand.2017.Availableat: https://www.majortrauma.nz/publications-resources/traumaresources-and-guidelines/out-of-hospital-training/ AccessedOctober10,2023.

51.HarrisRB,PaineS-J,AtkinsonJ,etal.Westilldon’tcount: theunder-countingandunder-representationofMaoriin healthanddisabilitysectordata. NZMedJ. 2022;135(1567):54–64.

ORIGINAL RESEARCH

Department:Clinician,Staff,andPatientPerspectives

OlenaMazurenko,MD,PhD,MS*

AdamT.Hirsh,PhD†

ChristopherA.Harle,PhD*‡

CassidyMcNamee,MPH*

JoshuaR.Vest,PhD,MPH*‡

SectionEditor(s):NikhilGoyal,MD

*IndianaUniversity,RichardM.FairbanksSchoolofPublicHealth,Department ofHealthPolicyandManagement,Indianapolis,Indiana † IndianaUniversity,SchoolofScience,Indianapolis,Indiana ‡ RegenstriefInstitute,CenterforBiomedicalInformatics,Indianapolis,Indiana

Submissionhistory:SubmittedNovember14,2023;RevisionreceivedFebruary12,2024;AcceptedFebruary20,2024

ElectronicallypublishedMay29,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18577

Introduction: Healthcareorganizationsareunderincreasingpressurefrompolicymakers,payers,and advocatestoscreenforandaddresspatients’ health-relatedsocialneeds(HRSN).Theemergency department(ED)presentsseveralchallengestoHRSNscreening,andpatientsarefrequentlynot screenedforHRSNs.Predictivemodelingusingmachinelearningandartiﬁcialintelligence,approaches mayaddresssomepragmaticHRSNscreeningchallengesintheED.Becausepredictivemodeling representsasubstantialchangefromcurrentapproaches,inthisstudyweexploredtheacceptabilityof HRSNpredictivemodelingintheED.

Methods: Emergencyclinicians,EDstaff,andpatientperspectivesontheacceptabilityandusageof predictivemodelingforHRSNsintheEDwereobtainedthroughin-depthsemi-structuredinterviews (eightpergroup,total24).Allparticipantspracticedatorhadreceivedcarefromanurban,Midwest, safety-nethospitalsystem.Weanalyzedinterviewtranscriptsusingamodiﬁedthematicanalysis approachwithconsensuscoding.

Results: Emergencyclinicians,EDstaff,andpatientsagreedthatHRSNpredictivemodelingmustlead toactionableresponsesandpositivepatientoutcomes.Opinionsaboutusingpredictivemodelingresults toinitiateautomaticreferralstoHRSNservicesweremixed.Emergencycliniciansandstaffwanted transparencyondatainputsandusage,demandedhighperformance,andexpressedconcernfor unforeseenconsequences.Whileaccepting,patientswereconcernedthatpredictionmodelscanmiss individualswhorequiredservicesandmightperpetuatebiases.

Conclusion: Emergencyclinicians,EDstaff,andpatientsexpressedmostlypositiveviewsaboutusing predictivemodelingforHRSNs.Yet,clinicians,staff,andpatientslistedseveralcontingentfactors impactingtheacceptanceandimplementationofHRSNpredictionmodelsintheED.[WestJEmerg Med.2024;25(4)614–623.]

INTRODUCTION

Screeningfor,andaddressing,patients’ health-related socialneeds(HRSN)isanincreasinglycommonaspectof patientcare1,2 thatissupportedbynumerousprofessional organizations3 andpolicymakers.4,5 Patients’ HRSNs encompassavarietyofnonclinical,socioeconomic,and contextualfactorsthatareessentialdriversofmorbidity,

mortality,utilization,disparities,andcosts.6,7 The emergencydepartment(ED)isapotentiallyappropriate settingforHRSNscreening,asahighproportionofED patientsreportHRSNs,8–11 patientswithHRSNoftenhave difﬁcultyaccessingprimarycareservices,12 andEDs frequentlyarethesourceofcareforunderservedand vulnerablepopulations.13,14

TheEDpresentsseveralchallengestoHRSNscreening, andpatientsarefrequentlynotscreenedforHRSNs.1,15,16 Forexample,EDworkﬂowsaresometimesunclearabout whichcareteammembersshouldscreenfororinterveneon patients’ HRSNs.1,10,15,17 Also,arecentSocietyfor AcademicEmergencyMedicinepanelnotedthat,giventhe resourcesrequired,itisdebatablewhetherEDsshould engageintargetedoruniversalHRSNscreening.18 Ideally, HRSNscreeningshouldalsohelpidentifyacourseofaction foraddressingpatients’ HRSNs.19–21 Yetclinicians experiencedwithscreeningeffortsreporthavinginsufﬁcient informationtoreferpatientstoappropriateservices.22,23 As furthercomplication,somepatientsmaydeclinetoshare HRSNstheydeemstigmatizingorunrelatedtotheir clinicalneeds.24,25

Predictivemodelingusingmachinelearningandartificial intelligence(ML/AI)approachesmayaddresssomepragmatic HRSNscreeningchallengesintheED.Predictivemodeling involvesapplyingstatisticalorcomputersciencemethodsto healthcaredatatoprospectivelyclassifypatientsaccordingto underlyingrisks.26 Predictivemodelsinclinicalinformation systemshavedemonstratedpromiseinidentifyingpatients withHRSNs.27–29 Becausepredictivemodelingisautomated, itcaneliminatesomepragmaticchallenges,includingtime constraints,workflowchallenges,orstaffavailability.Also, automatedpredictivemodelingoperatesasauniversal screeningprogram.Thus,itislesssusceptibletobiasesthat leadtoselectivelyadministeredscreeningquestionnaires,21 missingdataduetopatientnonresponse,oromissionsin clinicaltextbecausecliniciansfailedtorecordneedsorpatients didnotdisclosethem.30–32 Furthermore,predictivemodeling cancapitalizeonthegrowingvolumeofdatainelectronic healthrecords(EHR),healthinformationexchange,anddata fromnon-healthcareorganizationsthatreflectpatients’ social circumstancesandfactors.33,34 Thisdatacanprovidea longitudinalandcomprehensivepatientoverviewandisnot dependentonasinglehealthcareorganizationfordata collection.Finally,theriskscorescreatedbypredictive modelingcanbetheinputstoclinicaldecisionsupportsystems thatreferpatientstoneededservices.29

ImplementingHRSNpredictivemodelinginEDsettings representsasubstantialchangefromcurrentapproachesof questionnaire-basedscreeningorcollectingHRSNdata duringpatientexaminations.1 Suchchangescanelicitmixed reactionsfromrelevantparties,despitetheirpotential advantages.Forexample,physicians,non-physician clinicians,andhealthcareadministratorsfavorexplainable predictivemodelswithclearrules;thus,theymaybeless receptivetoadvancedpredictionmodelsthatareless interpretable.35 Inthisstudy,weexploredtheacceptabilityof HRSNpredictivemodelingbyconductingin-depth,semistructuredinterviewswithemergencyclinicians,EDstaff, andpatients.Thisstudyincreasesunderstandingofclinician, staff,andpatientperceptionsofpredictivemodelingfor

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Theemergencydepartment(ED)haschallenges inscreeningpatientsforhealth-relatedsocial needs(HRSN).Artiﬁcialintelligencebased predictivemodeling,todeterminewhichpatients needsocialresouces,mayaddresssomeHRSN screeningchallenges.

Whatwastheresearchquestion?

Ourgoalwastoexploretheperspectiveof emergencyclinicians,EDstaff,andpatients ontheacceptabilityandusageofHRSN predictivemodelingintheED.

Whatwasthemajor ﬁndingofthestudy?

Emergencyclinicians,EDstaff,andpatients agreedthatarti ﬁ cialintelligence-based predictivemodeling,toscreenpatientsforthe needforsocialservices,mustleadtoactions andpositivepatientoutcomes.

Howdoesthisimprovepopulationhealth?

PredictionmodelsforHRSNscanpotentially improvescreeningandcontributetoaddressing theHRSNneedsofpatientsintheED.

HSRNsandhowpredictivemodelingcouldbeimplemented inEDencounters.

METHODS

Toexploretheperceptionsofemergencyclinicians,ED staff,andpatients,weadoptedamodiﬁedthematicanalysis approach36 andreportedourmethodsfollowingthe StandardsforReportingQualitativeResearch(SRQR) recommendations.37 Theresearchteamhadexpertisein healthinformatics,clinicaldecisionsupportsystems, HRSNs,healthdisparities,andclinicalcare.

ContextandSamplingStrategy

Werecruitedemergencyclinicians,EDstaff,andpatients whopracticedatorhadreceivedcarefromanurban, Midwest,safety-netteachinghospitalsystem.Allresearch teammembershavepriororongoingresearchcollaborations withthishealthcareorganization.Eligibleemergency cliniciansincludedphysicians,residents,fellows,andnurse practitionersandwererecruitedthroughpresentationsto facultygroupsandemails.EligibleEDstaffincludedsocial workers,casemanagers,andregisterednursesandwere recruitedthroughemailincooperationwithorganizational

leadership.Therecruitmentpresentationsandemails providedguidanceonhoweligibleindividualscouldcontact theresearchteamtoexpresstheirinterestinparticipatingin ourstudy.Lastly,werecruitedadult(≥18yearsold)patients byphonecallstopatientrepresentativesidentiﬁedbythe organization’sCommunityRelationsDepartmentandby emailstorecentEDpatientswhohadconsentedtobe contactedforresearchopportunities.

DataCollectionInstruments

Ourinterviewguideincludedquestionstogather perspectivesoncollectingandusingHRSNinformation throughtraditionalmeans(eg,surveyanddiscussionswith patients).Additionally,theguideaskedaboutthe acceptabilityandusageofpredictivemodelingforHRSNsin theED.BecausepredictivemodelingforHRSNwouldlikely beimplementedininformationtechnology-baseddecision support,theinterviewquestionswereinformedbyconcepts fromtworelevantframeworks:the ﬁverightsofclinical decisionsupport38 frameworkandthecontextual informationmodel.39

Inourinterviewswithcliniciansandstaff,wereferenced clinicalexamplesofsepsisriskscoringoropioidusescores. Thesereferencesweredesignedtofacilitateunderstandingby drawingparallelstoclinicalrisksoftenestimatedviathe applicationofstatisticalorcomputationalmethods.Like predictivemodeling,suchscoringapproachesleverage multiplepatientdataelementstoarriveatanoverallmeasure ofrisk.Incontrast,wecouldnotassumepatientswouldhave thetrainingin,orthedirectapplicationof,computational methodstoaggregatedatatosupportdecisions.Therefore,in ourinterviewswithpatients,wereferencedonlinestreaming servicerecommendationsortargetedmarketing(eg, advertisementsorcoupons)thatdrawonpriordata collectiononconsumerstoillustratetheapplicationof predictivemodelingineverydayexperiences.

Wepilotedtheinterviewguidesforlengthandcontent withthefourmembersofourstudy’sadvisorypanel:anurse practitioner;asocialworker;andtwopatients.Thesepilots werenotincludedinthe ﬁnalanalyticaldata.Theadvisory panelalsoassiststheresearchteamininterpretingthe ﬁndingsinthecontextoftheirdiverseperspectivesandlived experiences.Thisstudyispartofalargerprojecttoimprove thecollectionanduseofpatienthealth-relatedsocialneedsin theED.

DataCollectionMethods

Allinterviewswereconductedusinganonlinemeeting platformfromDecember2022–May2023.Oneteam memberledtheinterviewsofclinicians(physiciansandnurse practitioners).Asecondteammemberledtheinterviewsof staff(nurses,socialworkers,andcaremanagers),andthe thirdteammemberledtheinterviewsofpatients.All interviewersweresupportedbyatleastoneadditionalteam

memberfornotetaking.Interviewslasted,onaverage,33 minutes.Wemetrepeatedlyduringthedatacollection processtoassesstheemergenceofnewinformation. Saturationwasdeterminedwhentheresearchteamagreedno newthemeswerebeingidentiﬁed.Werecordedallinterviews withconsentfortranscriptionpurposes.Beforeeach interview,participantsreportedage,gender,andrace/ ethnicityusingaweb-basedsurvey.Cliniciansandstaff alsoreportedtheircredentialsandyearsinpractice. Wemonitoredrecruitmentprogresstoensure participantdiversity.

EthicalIssues

Allparticipantsprovidedwrittenconsentbeforedata collection.ThestudywasapprovedbytheIndiana UniversityInstitutionalReviewBoard.

Analyses

Weanalyzedinterviewtranscriptsusingamodified thematicanalysisapproach.36 Clinicianandstafftranscripts wereanalyzedindependentlyfrompatienttranscripts.This decisionwasbasedontwoconsiderations: first,cliniciansand staffhadday-to-dayexperiencewithHRSNdatacollection andapplicationsand,therefore,broaderexperiencesthan patients;andsecond,theresultsofHRSNscreening approachesarepredominatelyclinician-facing;ie, questionnaireresults,predictionmodels,oreveninterviews duringexaminationaremeanttodrivedecisionsandactions ofclinicians,notpatients.Webeganwiththeclinicianand stafftranscripts.Weconductedpreliminaryscreeningsof threeinterviewtranscriptsthroughalinebylinereading processtoidentifyinitialthemesandconfirmthatinterview questionsyieldedresponsesinformingourstudyquestions. Onceallinterviewswerecompleted,wescreenedallinterview transcriptstocreateaninitialcodebook.Wethentestedthe codebookreliabilitybyindependentlyapplyingthecodesto threetranscripts.Wethenmetanddiscussedtheaccuracy andconsistencyofthecodebookandmadenecessary adjustments.Uponcompletingthecodebookdevelopment, threeteammembersconsensuscodedeachtranscript.Next, twocodersindependentlycodedthesametranscriptsand thenmettoadjudicateanydifferencesthroughdiscussionto reachconsensus.40 Weagreedona finalsetofoverarching themesandrepresentativequotes.Theaboveprocesswas repeatedonthepatienttranscripts.

Oncealltranscriptswereconsensuscoded,weundertook axialcodingtoidentifycommon,overarchingthemes.We thenmettoresolvedifferencesandarriveata finalsetof themes.Throughoutthisprocess,weemployedestablished proceduresinthequalitativemethodsliteraturetoensurethe rigorandvalidityofour findings.41–43 Theseprocedures includedpracticingreflexivity(continuallyquestioning interpretations,seekinganswersinthedatatoverifyor challengeinterpretations,becomingawareofone’ s

preconceptionsandbiases),depthofdescription(seekingout therichdetailsofparticipants’ words),andsearchingfor alternativeexplanationsorinterpretations.Weused co-occurrenceandstratiﬁcationtocompareviewsabout predictivemodelingandtraditionalmethodsofHRSN informationcollection.Weconductedtheentire analysisusingDedoosequalitativeanalysissoftware, version8.2(SocioCulturalResearchConsultants,Los Angeles,CA).Asafurthercheckonourinterpretation, wereviewedasummaryofour ﬁndingswithouradvisory panelmembers.

RESULTS

Participantsincludedeightemergencyclinicians,eightED staff,andeightpatients(Table1).Participantsweremostly female(66.7%)fromdiverseracialandethnicbackgrounds. Themeanagewas42.1years.Clinician,staff,andpatient viewsofpredictivemodelingforHRSNsduringED encountersencompassedthreebroadthemes: impact ; performancerequirements ;and barriersandfacilitatorsto implementation (Table2).

Impact

Emergencyclinicians,staff,andpatientsagreedthat HRSNpredictivemodelingshouldbedesignedtoenable actionableresponsesandtoresultinpositivepatient outcomes.Furthermore,clinicianandstaffacceptanceof predictivemodelingtoolswascontingentontheexpectation thatroutineuseofthesetoolswouldleadtotangible improvementsinpatientoutcomes.Forcliniciansandstaff, thepreferencewasthatpredictivemodelingwouldleadto referrals,promptstocollectadditionalinformation,andthe initiationofconnectionstoservicesthatwouldchangethe patient’shealthstatus.Asonestaffmemberpointedout:

“ Ithinkitwouldhelp ifascorewaslikegenerated and ifwehadlikeadropdownboxthathad resources ::: Thatwecaneithereducatethepatienton orgivedirectlytothepatient,orcoworkersinthe hospitallikesocialwork,or ﬁ nancialadvicethatwe cansendthepatienttobeforetheyleavethe[ED],to kindofgetthem ontherighttrack.Ifeellikewe knowpatientshavetheseissues,butwedon ’ tknowhow togoaboutitand ::: helpthem. ” (#10)

Whilecliniciansandstaffpreferredthepredictive modelingtosupportactions,theyhadmixedopinionsabout thepredictivemodelingresultsbeingusedtoinitiate automaticreferralstoHRSNservices.Someparticipants preferredautomaticorders.Forexample,aphysicianstated:

“Whateveryoucanautomatewouldbeideal. [EHR] automaticallygeneratesadischargepacketthatprints thefoodvoucherandthatprintsallofthedischarge paperworkandthenthepatientgetsit,andtheygetthe referraltoprimarycare,theygetthereferraltosocial work,andthenitallkindofworksout ” (#8)

Otherspreferredreceivingrecommendationstheycould discardafterconsultingwiththepatient,suchasdescribedby onenurse:

“Ithinkhavingautomaticreferralsandappointment scheduledwouldbegreat,butIalsothinkthatittakesa consciousandmindfulpersonwhenthey’respeakingto thepatientabouteverythingtogobackinandcancelthe appointmentsorchangethembasedoffofthepatient’ s schedule,becausesomeofthemtheymight,mightfeel offendedthat, ‘Oh,you’realreadymakingaplanforme. Icantakecareofmyself.I’ mgrown. ’” (#9)

Table1. Demographicsofparticipants.

Table2. Themesandillustrativequotesfromclinicians,staff,andpatientsonthepotentialuseofriskpredictionapproachestohealth-related socialneedsintheemergencydepartmentsetting.

ThemeDescription&representativequotes

ImpactPredictivemodelingforHRSNsleadstoactionableresponsestocreatepositivepatientoutcomes

EmergencyclinicianIthinkwhatwillsolidifyitformeisstartingtoseesomepositiveimpactofusingthat.(#4)

Knowingtheservicesthatarebeingprovidedbecauseofthisdecision.We’regoingtoincreasethe numberofhomelesspeopleoffthestreetandgetthemintoshelters.We’regoingtoprovidethis numberofpatientswithfoodorifweseethevalueaddedofthattool,itwillgetused.Ifit’s ‘let’suse thistoolforthesakeofusingthetool,’ butweactuallydon’tseeimprovementoritactuallyaddresses theunmetneedthentherewillbesomehesitation.(#6)

EDstaffHavingthealgorithmthat ﬂagsoursocialworkwouldbemorebeneﬁcial.Becausetheycouldtakethe timewiththepatienttosetuptheresources.Whereaskindofonthemedicalend,anurse’stimeisthin already.(#15)

PatientInanidealworldtheywouldconnectyouwithasocialworkerwhowouldbeabletoassistyouwith thosethingswithresources.(#18)

Stuffthatwe’veidentiﬁedisthatthis,this,this,andthisandwejustwannareachoutandseeifthere’s anythingwecandotohelpyou,connectyouwithresources It’sgonnagetaddressed.(#19)

ButIalsothinkthatthatitcouldreallyaidinhelping.[Clinicians]seealotofpeople,andtheyhaveto makealotofguessesandalotofjudgmentsonwhatsomebodymightneed.Ifit’smydoctorwhoI’ve beenseeingforyears,thentheirguessesaregoingtobealotbetterthansomebodyseeingsomebody intheemergencyroomforthe ﬁrsttime,whohasabsolutelynorecord.But,youknow,ultimately havingsomemorestatisticalinformationtobeabletosortthroughthenoise (#21)

PerformancerequirementsDetailsaboutthefunctioningofpredictivemodelingforHRSNsrequiredforacceptance

EmergencyclinicianHowuptodateisit?Howrepresentativeofourpopulationisit?Howdoesitkeepupdatingitselfover time?Ifitdoesallofthatverywell,theninreal-time,itwouldbeupdatingitselfwithdate,newdata everyday,andrelearningandthenreprocessingandthenshowingupontheEHR.(#1) EDstaffIwouldwanttoknowwho’sgatheringtheinformation.Whatdeterminesascore?(#13) Iwouldprobablyguaranteethatover50%ofpatientsweseeisgoingtopingthisalgorithm.(#15) PatientIwouldhopethat[riskprediction]wouldn’tdiscriminateagainstanyonebasedontheir ﬁnancialstatus oranythinglikethat.(#18)

IthinkIhavetherighttoknowthatyou’redoingthat,youknow?Idon’tthinkthatyoushoulddoitin somesecretivefashionandthencometomewiththesequestionswhenitwouldbesomucheasierif youjusttoldme, “Look,youknow,weidentifycertainpatternsand – Howevertheysayit,atleastlet thepersonknow.(#19)

Ijustdon’twantthecomputersystemjustassuming, ‘Oh.Shesaidthatsheneedspublic transportation.Oh,thatmustmeanthatshehasahousingissue’– Itdoesn’tmeananyofthat.It’sjust, itiswhatitis.Don’tmakeapplesoutoforangesorvice-versa.Justleaveitwhereitis.(#24) Barriersandfacilitatorsof implementation Contextsandconditionsthatwouldimproveadoptionandusage

EmergencyclinicianHonestly,beinginateachinghospital,gettingtheresidentsonboard ﬁrstsometimesiseasier,'cause youcangetalittlebitofupwardteaching.Iftheresidentsstartusingit,itkindofforcesourattendings tostartusingit,too.(#2)

EDstaffThere’salotofcreaturesofhabitthatdon’tlikechange.(#12)

PatientIfyouhaveanurseoradoctororthemedicalteamoraprogramoratabletoranything, itwillbe approachedinatrustingenvironment.Becausethewholepurposeistohelpthesocialneed.Wereally needtomakesureisthattheapproachisfriendlyandthatwhoeverdoesitistrainedtotrulygettothe socialneed,notjustto ﬁllouttheform,buttomakesureandinvitethepatient, ‘Hey,wewantto understandyouinourcommunityandwewanttohelpyouineveryneedthatyouhave.’ (#20)

HRSN,health-relatedsocialneeds; ED,emergencydepartment; EHR,electronichealthrecord.

Onephysicianwasstronglyagainstitduetotheunknown legalrisks: “Whenthemachinemessesup,who,whoarewe gonnasue?Thehospital?Thepersonwhocoded?The clinician?Allof'em?Wedon ’ thaverulesforthat,yet. ” (#1)

Relatedly,somepatientshesitatedaboutautomatic referralstoaddresstheirHRSNs;rather,theypreferredtobe consultedontheirpost-EDcareoptions.Thisishowone patientdescribedit: “ Idon ’ twantsomebodyjustto automaticallytakeactiononit.Iwantthemtojustsay ‘ Here ’ swhatwecanofferyou. ’ Somepeoplefeelbetter abouthavingashuttleversustakingpublic transportation ::: becausedependinguponthedayis dependinguponwhichkindofhelpIwouldwant. ” (#24)

Additionally,patientsreportedthatresultsfromHRSN predictionmodelswouldhavetheadditionalbeneﬁtof helpinginitiateconversationsabouttheirneedsorthat assistancewouldnotsolelydependuponpatientshavingto disclosesensitiveinformation.Thisishowapatientdescribed thepotentialbeneﬁtsofpredictionmodels:

“Ifapersoncouldcomeduetothisalgorithmandbringup thingsthatImightnothavebroughtupmyselforwere reluctanttobringup.MaybeIdon ’ twanttotellpeople I ’ mpoor.MaybeIdon ’ twanttotellpeoplethatwe ’ re strugglingathome.MaybeIdon ’ twanttotellpeople thatIjustlostmycar,becauseIcouldn ’ tmakethe paymentsoIhavetransportationissues.Youknow, whateveritis.Everybody ’ sembarrassmentlevelis different,butyeah,ifanursecouldcomeinandsay, youknow, “ Hey,letmetalktoyouaboutthis.We havethisprogram.Idon ’ tknowifitpertainstoyouor not,butwehavethisprogramandifyouareinterested, Icouldprobablydosomethingandmaybeseeifwecan getyouintoit. ” (#17)

PerformanceRequirements

Emergencycliniciansandstaffwantedadditionaldetailed informationaboutHRSNpredictivemodelingtodetermine thepotentialforacceptingitintheirclinicalpractice.This additionalinformationincludedtransparency,performance, andconcernsforunforeseenconsequences.Regarding transparency,emergencycliniciansandstaffwantedtoknow thedata’snature,timing,andqualityunderlyingaprediction model.Theyalsowantedtoknowhowoftenprediction modelswouldbeupdatedbasedonchangesinapatient’slife. AsoneEDnursepractitionerdescribedit:

“Isitgoingtochangewithnewinformation?Where ’ sthat newinformationcomingfrom?Sixmonthsagosomeone maynothavehadajobandnocar,orwerelivingin [shelter],andthennowtheyhaveajob,theyhavea subsidizedlivingapartment,theyknowhowtoutilize publictransporttogetaround,thingslikethat.Our

populationissomewhattransient,butyouhavechanges thathappentopeoplethatcomeprettyregularly.And sometimes,it ’ spositivechanges. ” (#3)

Anursehadasimilaropinion: “Iwouldneedtoknow wherewegottheinformationfrom isitsomethingthey ﬁ lledoutontheirown? ” (#12)

Likecliniciansandstaff,EDpatientsalsowanted transparencyinhowanHRSNpredictionmodelwould operateandbeusedintheircare.Asonepatientputit: “It wouldbeokaythatthey ’ repullingtheinformation,butI wouldwanttoknowwhatthatcomputersystemisdoingwith thatinformation.Aretheysellingmyinformation?Isitkept inprivacy?Thatwouldbeabigconcern. ” (#18)

Cliniciansandstaffunderscoredaneedforahighperformingpredictionmodel.However,theyacknowledged thecomplexityofHRSNdata,asonephysicianpointedout that “withanythingsocial,therecanbealotofagrayarea. ” (#3)Thus,severalcliniciansandstaffjudgedprediction modelperformanceintermsoffacevalidityinsteadof speciﬁcperformancemetrics.Thisishowoneemergency physicianexplainedit:

“Iseesomethinglikeariskscore [ie,theproductof predictivemodeling] hereasatriggerformetostart askingsomequestions.So,ifIgointotheroom,andI askapatientaboutsomethings,andI ’ mgettingavery con ﬁ rmatoryresponsethere,Ithinkthatwould probablymakemeleanmoreontoamodellike that. ” (#4)

Similartothatideaofa “ con ﬁ rmatoryresponse, ” one physicianwouldchecktoseewhetherpredictivemodeling results “matchesyourgestalt. ” (#6)Likewise,anursesaid thatshewantedtoseethatthepredictionmodel “kindof tracks ” withwhatshecouldobserve.(#10)

Patientsvscliniciansandstaffhaddifferentperspectives onthenegativeconsequencesofpoor-performingHRSN predictivemodeling.Patientswereconcernedthatprediction modelsmightmissindividualswhorequiredservices.Thisis howonepatientdescribedit: “Becausethatcomputerized programcouldpickpeopleupthatdon ’ tneedtobepickedup thatreallyneedtobeanddismissingpeoplethatreallyneed itout. ” (#23)

Furthermore,somepatientsexpressedreservationsabout potentialbiasesinherentin,orresultingfrom,predictive modeling.Forexample,onepatientnotedthethreatsif predictivemodelingdidnotaccountforpotentialdifferences inpatientbackgrounddemographics, “becauseinthatcaseit doesn ’ thelp.Itjustbecomesanextensionofanalready biasedsystem . ” (#22)Otherpatientsnotedthatresultsfrom thepredictionmodelsshouldnotbeusedtomakeother assumptionsaboutpatients’ needsortotreatpatients differently.Incontrast,emergencycliniciansandstaff

expressedconcernswithpotentialover-identiﬁcationandthe wastingofresources.Onephysicianstated: “IfIstarted seeingatrendofmysocialworkeriscomingtome, frustrated,because ‘ Hey,I ’ vedoubledmyvolumeof consults,andI ’ mseeingallthesepatients,andIcan ’ tdo anythingforanyofthem. ’ Thatwouldbemore concerning. ” (#4)

BarriersandFacilitatorstoPredictiveModeling Implementation

Participantsacknowledgedthatpredictivemodelingisa potentiallyusefulmethodformeasuringandactingupon HRSNs.Giventheirfamiliaritywithclinicalriskscores,the emergencycliniciansandstaffweregenerallyfavorable towardthepredictivemodelingconcept.Nevertheless,they dididentifyseveralfactorsandrequirementsthatwould facilitatetheadoptionofHRSNpredictivemodeling.For example,emergencycliniciansnotedthevalueofclinical championsandspeciﬁctraining.Aphysiciannoted: “[The] majorityofpeoplewhoworkinourdepartmenthaveadesire toworkwithunderservedpopulations,andthenthosepeople mightbeopentotryingsomething.Probablyhavinglike,a positionchampioninthedepartmentisagoodidea. ” (#5) Inaddition,EDstaffindicatedthatvisiblepositiveimpacton theirpatientscanfacilitateadoption,butthatcompeting demandsfortimeandattention,aswellasgeneralinertia, couldinhibitit.Anursedescribeditthusly:

“Becausepeoplegetcaughtupintheireverydaylifeand noonewantstostopwhatthey ’ redoingtohavetolearn somethingelsebecauseitfeelslike, ‘ Idon ’ thavetimeto dothatandthat ’ sjustgonnaslowmedown. ’” (#16)

Severalpatientsdescribedtheneedforhealth professionalstobetrainedtobebettercommunicatorswhen askingaboutHRSNs,ingeneral,orinresponsetoa predictionmodelbeingused.Thisviewmayhavebeen rootedinpriorexperiencesoffeelinglike “justanumber ” (#23)tothehealthcaresystem.

DISCUSSION

Emergencyclinicians,EDstaff,andpatientsweremostly positiveaboutusingpredictivemodelingforHRSNs.Their viewthatpredictivemodelingiscompatiblewiththe healthcareenvironmentwasbasedontheirpastexperiences delivering(otherclinicalscores)andreceiving(consumer experiences)care.Nevertheless,clinicians,staff,andpatients raisedseveralkeyissuesthatdampenedtheiracceptanceof HRSNpredictionmodelsintheED.

First,participantsnotedthatpredictivemodelingcan supportincreasedawarenessofHRSNs.Butthisaloneis insufﬁcienttoaddressHRSNs.Formaximumimpact,itmust becomplementedbyastraightforwardcourseofactionfor patientcare.Forexample,predictivemodelingconnectedwith

adecisionsupportsystemorreferralsystemcouldhelp cliniciansdirectpatientstorelevantresourcesmoreefﬁciently andeffectively.44 Thisthemefromthecurrentinterviews alignswithpriorworkinwhichcliniciansemphasizedtheneed forHRSNscreeningeffortstodirectlyinformclinical decisions,referralpathways,andinterventions.22,23 Also consistentwithpriorliteratureonHRSNscreening,45 we foundthatpatientsexpectbeneﬁcialactionsresultingfrom healthcareorganizations’ usingHRSNriskpredictive modeling.Notably,ourparticipantssuggestedpredictive modelingcouldbeanavenuetoinitiatefurtherHRSNdata collectionorinvestigationandserveasaconversationstarter, leadingtomorecomprehensiveclinicalencounters.

Second,participantsenvisionedpredictivemodelingasa complementto,ratherthanareplacementof,thehuman-tohumancomponentofHRSNsscreeningefforts.Emergency cliniciansandstaffwantedtocheckpredictionmodel recommendationsforconsistencywithclinicalexpertise, withtheoptiontooverrideautomatedorderstriggeredbya patientHSRNwhennecessary.Similarly,patientsstressed thatoutcomesorrecommendationsfromanyprediction modelsneededtorespectandprioritizetheirautonomy, specificallytheirpreferencetodeclineortailorservices. Ampleevidencesuggeststhatevenifpatientshaveidentified HRSNs,largepercentagesmaynotwantanyservicesor actionstakenontheirbehalf.46 Wenotethatthisthemeis somewhatintensionwiththeprecedingtheme.Thatis,while pairingpredictivemodelingwithautomatedreferralsor defaultorderswouldhaveefficienciesofscopeandscale,it runstheriskofnotrespectingpatientpreferences.

Itispossibletoeasethesetensionsthroughprocessesthat ensurehumaninput.Forexample,predictivemodelingcould triggerautomatedmessagestopatientportalsaskingabout thedesirabilityofservicesorpromptinquiriesfromcase managersorpatientnavigators.Suchprocesseswould respectpatientpreferencesandclinicalexpertknowledgeand couldenhancethesafetyandacceptabilityofpredictive models.47,48 Still,whileincorporatinghumaninputcould havebeneﬁts,itcouldalsointroduceotherimplicit (orexplicit)biasesintoaddressingHRSN.Additionally, incorporatingclinicalexpertiseintotheprocessincreases theworkﬂowredesignandintegrationburden.Thus, futureimplementersofHSRNpredictivemodelingshould carefullyevaluateboththemodeloutputsandthehuman useoftheseoutputsfortheirrolesinintroducingor mitigatingbiases.

Relatedly,participantswantedtransparencyinprediction models.Theartiﬁcialintelligenceandmachinelearning(AI/ ML)communitieshavemadesubstantialmethodological advancesinfosteringmodelexplainability,oftentoillustrate theimportanceofdifferentmodelinputsorperformance underdifferingcircumstances.49 Whilevaluable,thisisnot thetypeoftransparencythehealthcareprofessionals describedtofosteracceptanceandtrust.Participantsinthis

studyappliedexpertjudgmentstoboththedatasourcesand thepredictions’ perceivedreliability.Suchexpertjudgments oninputsandresultsareakeycomponenttotrustinga predictionmodelintheclinicalmedicine ﬁeld.48 Whetherexpertopinionaboutdatainputsand conﬁrmationwithclinicalexperienceisjustasapplicableto HRSNsisnotasclear.TheHRSNsarenotaprimaryfocus inphysicianandnursetraining,whichlikelycontributesto thefactthatHRSNsareseldomlyandinconsistently documented.50 Anotherpotentialcontributoristhat individualshaveimplicitbiasesthatmaycausethemto overlookoroveremphasizecertainpatientcharacteristics.51 Thus,trustintheunderlyingdatashouldnotbedismissed. Still,forimplementersofmoreadvancedanalytic interventionsforHRSNs,eventualend-useracceptancemay bemorerealizedthroughactualperformanceandchangesin patientoutcomes.

LIMITATIONS

First,thestudyresponsesanddiscussionsmaybe influencedbythecharacteristicsofparticipantswhoagreed tobeinterviewedforthisstudy.Second,emergencyclinicians andstaffwereallpartofasinglehealthcaresystem.Thus,our findingsmayonlygeneralizetosimilarsettings.Third,we usedcommonexamplestomakepredictivemodelingsalient toourparticipants.Theseexampleswereidentifiedbyour advisorypanelmembersduringthepilotingoftheinterview guide.Nevertheless,useofdifferentexamplescouldaffect perceptionsandresponses.Relatedly,theAI fieldis undergoingrapidevolution.Asaresult,perspectivesonML andotherAI-basedtoolsmayswiftlytransformas individualsaccumulateexperiencewiththesetechnologies andengageinongoingdialogueaboutthem.

CONCLUSION

Emergencyclinicians,EDstaff,andpatientsexpressed mostlypositiveviewsaboutusingpredictivemodelingfor health-relatedsocalneeds.Nevertheless,clinicians,staff,and patientsnotedseveralcontingentfactorsimpactingthe acceptanceandimplementationofHRSNpredictionmodels intheED.

AddressforCorrespondence:OlenaMazurenko,MD,PhD,MS, IndianaUniversity,RichardM.FairbanksSchoolofPublicHealth, DepartmentofHealthPolicyandManagement,1050Wishard Boulevard,RG6040Indianapolis,Indiana46202. Email: omazuren@iu.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.ThisworkwassupportedbytheAgency forHealthcareResearch&Quality1R01HS028008(PI:Vest).

JoshuaR.VestisafounderandequityholderinUppstorms,LLC,a healthtechnologycompany.Therearenootherconﬂictsofinterest orsourcesoffundingtodeclare.

REFERENCES

1.Samuels-KalowME,BoggsKM,CashRE,etal.Screeningforhealthrelatedsocialneedsofemergencydepartmentpatients. AnnEmerg Med. 2021;77(1):62–8.

2.CartierYandGottliebL.TheprevalenceofsocialcareinUShealthcare settingsdependsonhowandwhomyouask. BMCHealthServRes. 2020;20(1):481.

3.GusoffG,FichtenbergC,GottliebLM.Professionalmedicalassociation policystatementsonsocialhealthassessmentsandinterventions. PermJ. 2018;22:18–092.

4.DepartmentofHealthandHumanServices.Medicareprogram;hospital inpatientprospectivepaymentsystemsforacutecarehospitalsandthe long-termcarehospitalprospectivepaymentsystemandpolicy changesand fiscalyear2023rates;qualityprogramsandmedicare promotinginteroperabilityprogramrequirementsforeligiblehospitals andcriticalaccesshospitals;costsincurredforqualifiedandnonqualifieddeferredcompensationplans;andchangestohospitaland criticalaccesshospitalconditionsofparticipation; finalrule. FedRegist. 2022;87(153):48780–9499.

5.TheJointCommission.NewRequirementstoReduceHealthCare Disparities.2022.Availableat: https://www.jointcommission.org/ -/media/tjc/documents/standards/r3-reports/r3_disparities_july20226-20-2022.pdf.AccessedFebruary9,2023.

6.PruittZ,EmechebeN,QuastT,etal.Expenditurereductionsassociated withasocialservicereferralprogram. PopulHealthManag. 2018;21(6):469–76.

7.DavisCI,MontgomeryAE,DichterME,etal.Socialdeterminantsand emergencydepartmentutilization: ﬁndingsfromtheVeteransHealth Administration. AmJEmergMed. 2020;38(9):1904–9.

8.MalechaPW,WilliamsJH,KunzlerNM,etal.Materialneedsof emergencydepartmentpatients:asystematicreview. AcadEmergMed. 2018;25(3):330–59.

9.KwanBM,RockwoodA,BandleB,etal.Communityhealthworkers: addressingclientobjectivesamongfrequentemergencydepartment users. JPublicHealthManagPract. 2018;24(2):146–54.

10.WallaceAS,LutherB,GuoJW,etal.Implementingasocial determinantsscreeningandreferralinfrastructureduringroutine emergencydepartmentvisits,Utah,2017-2018. PrevChronicDis. 2020;17:E45.

11.MolinaMF,LiCN,ManchandaEC,etal.Prevalenceofemergency departmentsocialriskandsocialneeds. WestJEmergMed. 2020;21(6):152–61.

12.FioriKP,HellerCG,RehmCD,etal.Unmetsocialneedsandno-show visitsinprimarycareinaUSnortheasternurbanhealthsystem, 2018–2019. AmJPublicHealth. 2020;110(S2):S242–50.

13.AndersonES,LippertS,NewberryJ,etal.Addressingsocial determinantsofhealthfromtheemergencydepartment throughsocialemergencymedicine. WestJEmergMed. 2016;17(4):487–9.

14.ByhoffE,DeMarchisEH,HesslerD,etal.PartII:Aqualitativestudyof socialriskscreeningacceptabilityinpatientsandcaregivers. AmJPrev Med. 2019;57(6Suppl1):S38–46.

15.RobinsonT,BryanL,JohnsonV,etal.Hunger:amissedopportunityfor screeninginthepediatricemergencydepartment. ClinPediatrPhila. 2018;57(11):1318–25.

16.NazA,RosenbergE,AnderssonN,etal.Healthworkerswhoask aboutsocialdeterminantsofhealtharemorelikelytoreport helpingpatients:mixed-methodsstudy. CanFamPhysician. 2016;62(11):e684–93.

17.ShankarKN.Socialoutreachintheemergencydepartment:arewe doingenough? AnnEmergMed. 2015;66(3):341–2.

18.FurbacherMD,FockeleMD,DelBuonoMD,etal.2021SAEM consensusconferenceproceedings:researchprioritiesfordeveloping emergencydepartmentscreeningtoolsforsocialrisksandneeds. West JEmergMed. 2022;23(6):817–22.

19.InstituteofMedicine.(2014). Capturingsocialandbehavioraldomainsin electronichealthrecords:Phase2.Washington,DC:TheNational AcademiesPress.

20.O’GurekDTandHenkeC.Apracticalapproachtoscreeningforsocial determinantsofhealth. FamPractManag. 2018;25(3):7–12.

21.GargA,Boynton-JarrettR,DworkinPH.Avoidingtheunintended consequencesofscreeningforsocialdeterminantsofhealth. JAMA. 2016;316(8):813–4.

22.GoldR,BunceA,CowburnS,etal.Adoptionofsocialdeterminantsof healthEHRtoolsbycommunityhealthcenters. AnnFamMed. 2018;16(5):399–407.

23.KostelanetzS,Pettapiece-PhillipsM,WeemsJ,etal.Healthcare professionals’ perspectivesonuniversalscreeningofsocial determinantsofhealth:amixed-methodsstudy. PopulHealthManag. 2022;25(3):367–74.

24.Semple-HessJE,PhamPK,CohenSA,etal.Communityresource needsassessmentamongfamiliespresentingtoapediatricemergency department. AcadPediatr. 2019;19(4):378–85.

25.DeMarchisEH,HesslerD,FichtenbergC,etal.PartI:Aquantitative studyofsocialriskscreeningacceptabilityinpatientsandcaregivers. AmJPrevMed. 2019;57(6Suppl1):S25–37.

26.AggarwalCC(Ed.). DataClassiﬁcation:AlgorithmsandApplications NewYork,NY:ChapmanandHall/CRC,2014.

27.KasthurirathneSN,VestJ,MenachemiN,etal.Assessingthecapacity ofsocialdeterminantsofhealthdatatoaugmentpredictivemodels identifyingpatientsinneedofwraparoundsocialservices. JAmMed InformAssoc. 2018;25(1):47–53.

28.KasthurirathneSN,GrannisS,HalversonPK,etal.Precision health–enabledmachinelearningtoidentifyneedforwraparoundsocial servicesusingpatient-andpopulation-leveldatasets:algorithm developmentandvalidation. JMIRMedInform. 2020;8(7):e16129.

29.VestJR,MenachemiN,GrannisSJ,etal.Impactofriskstratiﬁcationon referralsanduptakeofwraparoundservicesthataddresssocial determinants:asteppedwedgedtrial. AmJPrevMed. 2019;56(4):e125–33.

30.BergM.Practicesofreadingandwriting:theconstitutiverole ofthepatientrecordinmedicalwork. SociolHealthIlln. 1996;18(4):499–524.

31.BanslerJ,HavnE,MønstedT,etal.(2013).Physicians’ progressnotes. InBertelsenOW,Ciolﬁ L,GrassoMA,PapadopoulosGA(Eds.), ECSCW2013:Proceedingsofthe13thEuropeanConferenceon ComputerSupportedCooperativeWork,21-25September2013, Paphos,Cyprus.London,UK:SpringerLondon.

32.WeinerSJ,WangS,KellyB,etal.Howaccurateisthemedicalrecord? Acomparisonofthephysician’snotewithaconcealedaudiorecording inunannouncedstandardizedpatientencounters. JAmMedInform Assoc. 2020;27(5):770–5.

33.BazemoreAW,CottrellEK,GoldR,etal. “Communityvitalsigns”: incorporatinggeocodedsocialdeterminantsintoelectronicrecordsto promotepatientandpopulationhealth. JAmMedInfAssoc. 2016;23(2):407–12.

34.CantorMN,ChandrasR,PulgarinC.FACETS:usingopendatato measurecommunitysocialdeterminantsofhealth. JAmMedInform Assoc. 2017;25(4):419–22.

35.KennedyGandGallegoB.Clinicalpredictionrules:asystematicreview ofhealthcareprovideropinionsandpreferences. IntJMedInf. 2019;123:1–10.

36.MaguireMandDelahuntB.Doingathematicanalysis:apractical,stepby-stepguideforlearningandteachingscholars. IrelJHighEduc. 2017;9(3):3352–33514.

37.O’BrienBC,HarrisIB,BeckmanTJ,etal.Standardsforreporting qualitativeresearch:asynthesisofrecommendations. AcadMed. 2014;89(9):1245.

38.DouthitB,RichessonRL,MarsoloK,etal.RealWorldEvidence:Clinical DecisionSupport:DeﬁnitionsandUses.In: RethinkingClinical Trials:ALivingTextbookofPragmaticClinicalTrials.Bethesda, MD:NIHPragmaticTrialsCollaboratory.Availableat: https:// rethinkingclinicaltrials.org/chapters/conduct/real-worldevidence-clinical-decision-support/deﬁnitions-and-uses-for-cds/ UpdatedOctober24,2022.AccessedApril12th,2024.

39.CallenJL,BraithwaiteJ,WestbrookJI.Contextualimplementation model:aframeworkforassistingclinicalinformationsystem implementations. JAmMedInformAssoc. 2008;15(2):255–62.

40.AzungahT.Qualitativeresearch:deductiveandinductiveapproachesto dataanalysis. QualResJ. 2018;18(4):383–99.

41.CharmazK. ConstructingGroundedTheory:APracticalGuideThrough QualitativeAnalysis.ThousandOaks,CA:SAGE,2006.

42.DaviesDandDoddJ.Qualitativeresearchandthequestionofrigor. QualHealthRes. 2002;12(2):279–89.

43.BorkanJ.(Immersion/crystallization.In:CrabtreeBandMillerW(Eds.), DoingQualitativeResearch.ThousandOaks,CA:SAGE,1999.

44.NationalAcademiesofSciences,Engineering,andMedicine. IntegratingSocialCareintotheDeliveryofHealthCare:Moving UpstreamtoImprovetheNation’sHealth.Washington,DC:National AcademiesPress,2019.

45.BeidlerLB,RazonN,LangH,etal. “Morethanjustgivingthemapieceof paper”:interviewswithprimarycareonsocialneedsreferralsto community-basedorganizations. JGenInternMed. 2022;37(16):4160–7.

46.MarchisEHD,AlderwickH,GottliebLM.Dopatientswanthelp addressingsocialrisks? JAmBoardFamMed. 2020;33(2):170–5.

47.BakkenS.AIinhealth:keepingthehumanintheloop. JAmMedInform Assoc. 2023;30(7):1225–6.

48.DuránJMandJongsmaKR.Whoisafraidofblackboxalgorithms?On theepistemologicalandethicalbasisoftrustinmedicalAI. JMedEthics. 2021.Inpress.

49.HagrasH.Towardhuman-understandable,explainableAI. Computer. 2018;51(9):28–36.

50.WangM,PantellMS,GottliebLM,etal.Documentationandreviewof socialdeterminantsofhealthdataintheEHR:measuresandassociated insights. JAmMedInformAssoc. 2021;28(12):2616.

51.HallWJ,ChapmanMV,LeeKM,etal.Implicitracial/ethnicbias amonghealthcareprofessionalsanditsinﬂuenceonhealthcare outcomes:asystematicreview. AmJPublicHealth. 2015;105(12):e60–76.

ORIGINAL RESEARCH

“Let’sChat!” ImprovingEmergencyDepartmentStaff SatisfactionwiththeMedicationReconciliationProcess

KurtSchwieters,BS*†

RichardVoigt,MD* SuzetteMcDonald,MA* LoriScanlan-Hanson,MS,RN* BreannaNorman,BS* ErinLarson,DNP*‡ AlexisGarcia,MHA* BoMadsen,MD,MPH* MariaRudis,PharmD*§ FernandaBellolio,MD,MSc* SaraHevesi,MD*

SectionEditor:BrianYun,MD,MBA,MPH

*MayoClinic,DepartmentofEmergencyMedicine,Rochester,Minnesota † IdahoCollegeofOsteopathicMedicine,Meridian,Idaho ‡ MayoClinic,DepartmentofNursing,Rochester,Minnesota § MayoClinic,DepartmentofPharmacy,Rochester,Minnesota

Submissionhistory:SubmittedMay25,2023;RevisionreceivedFebruary16,2024;AcceptedFebruary28,2024

ElectronicallypublishedMay21,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18324

Introduction: Patientswhostayintheemergencydepartment(ED)forprolongedperiodsoftimerequire veriﬁcationofhomemedications,aprocessknownasmedicationreconciliation.Thecomplexnatureof medicationreconciliationcanleadtoadverseeventsandstaffdissatisfaction.Amultidisciplinaryteam wasformedtoimproveaccuracy,timing,andstaffsatisfactionwiththemedicationreconciliationprocess.

Methods: BetweenNovember2021–January2022,stakeholdersweresurveyedtoidentifygapsinthe medicationreconciliationprocess.Thisprojectimplementededucationonrole-specifictasks,aswellas a “Let’schat!” huddle,bringingtogethertheentirecareteamtoperformmedicationreconciliation.We usedreal-timeevaluationsbyfrontlinestafftoevaluateeffectivenessduringplan-do-study-actcycles andobtainfeedback.Followingtheimplementationperiod,stakeholderscompletedthepost-intervention surveybetweenJune-July2022,usinga4-pointLikertscale(0 = verydissatisfiedto3 = verysatisfied). Wecalculatedthechangeinstaffsatisfactionfrompre-interventiontopost-intervention.Differencesin proportionsand95%confidenceintervalsarereported.ThisstudyadheredtotheStandardsforQuality ImprovementReportingExcellence(SQUIRE2.0)andfollowedtheLeanSixSigmarapidcycleprocess improvement(define-measure-analyze-improve-control).

Results: Atotalof111front-lineEDstaff(physicians,nursepractitioners,physicianassistants, pharmacists,nurses)completedthepre-interventionsurvey(of350EDstaff,correspondingtoa31.7% responserate),and89stakeholderscompletedthepost-interventionsurvey(a25.4%responserate). Subjectivefeedbackfromstaffidentifyingcausesoflowsatisfactionwiththeinitialprocessincludedthe following:complexityofprocess;uncleardelineationofstaffroles;timeburdentocompletion;high patientvolume;andlackofstandardizedcommunicationoftaskcompletion.Overallsatisfaction improvedaftertheintervention.Thegreatestimprovementwasseeninthecorrectmedication(difference 20.7%,conﬁdenceinterval[CI]6.3–33.9%, P < 0.01),correctdose(25.6%,CI11.4–38.6%, P < 0.001) andtimelasttaken(24.5%,CI11.4–37.0%, P < 0.001).

Conclusion: Thereisasteeplearningcurvetoeducatemultidisciplinarystaffonanewprocessand implementtheassociatedchanges.Withgoalstoimpactthesafetyofourpatientsandreducenegative outcomes,engagementandawarenessoftheteaminvolvedinthemedicationreconciliationprocessis criticaltoimprovestaffsatisfaction.[WestJEmergMed.2024;25(4)624–633.]

INTRODUCTION

ProblemDescription

Thereisashortageofinpatientbedsinournation’ s hospitals.Thisshortageresultsinthefrequentpracticeof retainingto-be-admittedpatientsintheEDuntiltheir inpatientbedbecomesavailable.Thispracticeisknownas “EDboarding.”1 PatientssubjectedtoEDboardingsustain aprolongedEDlengthofstay(LOS).Inmanyinstances,the EDLOSbecomessolengthythatthesepatients’ usual,or “home,” medicationsmustbecorrectlyadministeredwhile theyremainintheED,2 ratherthanbeingadministeredonly afterthepatientarrivestotheirinpatientbed.Toenable accurateadministrationofthese “home” medications,the processof “medicationreconciliation” mustoccurwithin theED.

“Medicationreconciliation” istheprocessofveriﬁcation ofthenamesofthepatient’susualmedications,aswellas theirdosagesandtimesofadministration.Medication reconciliationfor “boarded” patientatourinstitutionhas becometheresponsibilityoftheEDstaff,whoalsomust correctlyobtainandadministermedicationsnewlyordered bytheemergencyphysician.TheEDmedicationhistoryand reconciliationprocessiscomplexanderrorprone,3 particularlyinthesettingofcompeting,urgentprioritiesin theED,andresultsinahighriskofadversepatient outcomes.4 Weidentiﬁedastaffsatisfactiongapinthe processofmedicationreconciliationinourEDandsoughtto improvethisprocess.

AvailableKnowledge

Allpatientsadmittedtothehospitalrequireamedication reconciliation,definedbytheJointCommissionasthe processofreviewingandconfirmingmedicationsthata patientiscurrentlytakingtothemedicationsthatareordered forthepatient.5,6 Toavoiderrors,theJointCommission NationalPatientSafetyGoalrequiresthatagoodfaitheffort bemadetoobtaincompletemedicationinformationfromthe patient.Despitethiseffort,errorsstilloccur.7 Amedication discrepancy,definedasinconsistenciesbetweentwoor moremedicationlists,impactsnearlyallpatientsadmitted tothehospital,increasingpotentialharmtopatients.8 Adversedrugevents(ADE)duetounintentional discrepanciesintheadmissionmedicationlisthavebeencited asthemostcommoncauseofpreventabledrugevents.9 Ifnot recognizedearly,medicationdiscrepanciescanleadtoan increasedriskofreadmissions,EDvisits,andprolonged hospitalstays.9

Allocatingamemberofthepharmacistteamtohandle thisspeciﬁctask,asisdonewithpatientsadmittedto inpatientbeds,couldensuresafeandtimelymedication reconciliation,subsequentlyimprovingpatientcare.10 Inthe stateofMinnesota,however,thelawprecludespharmacy techniciansfromobtainingmedicationhistoriesandtaking responsibilityformedicationreconciliation.11 Using

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

MedicationreconciliationforboardingED patientsiscomplexandcanleadtoadverse eventsandstaffdissatisfaction.

Whatwastheresearchquestion?

Howcanweimprovetheprocessof medicationreconciliationfor boardingpatients?

Whatwasthemajor ﬁndingofthestudy?

Afterimplementationofthemedication reconciliationimprovementproject,staff satisfactionscoreimprovedanaverageof 20 – 25.6%forcorrectmedication,dose,and timelasttaken.

Howdoesthisimprovepopulationhealth?

Havingastreamlinedprocessformedication reconciliationandorderingensuresthatall patientsaccuratelyreceivetheirhome medicationswhileboardingintheED.

pharmaciststoobtainmedicationhistoriesandperform medicationreconciliationisanoptioninsomeEDsbutnotin ours.Thislimitationisnotuniquetoourfacility,becausein Minnesotapharmacytechniciansarenotallowedtoobtain orreviewapatient’smedicationlist.Further,giventhatthere isanationalpharmacistshortage12 andthatpractice advisoriesarisingfromtheAmericanCollegeofEmergency Physicians(ACEP)andotherorganizationshavelong statedthatitispreferabletohavepharmacistsfocustheir clinicaleffortsonbedsidepatientcare,13 wedetermined thatnon-pharmacistemergencycliniciansmustbecome involvedintheprocessofmedicationreconciliationat ourfacility.

Rationale

Atourinstitution,thereislowstaffsatisfactionwiththe currentmedicationhistory,reconciliationandhome medicationorderingprocessforpatientswithextendedLOS inourEDobservationunit(EDOU)andbehavioralhealth (BH)area.Standardprocessesforperformingmedication historiesandorderinghomemedicationsasusedinthe inpatientsettingaredifﬁcultintheEDgivenotherpriorities andurgenttasksinthisenvironment,thetimerequired, multipleinterruptions,andthelackofadedicatedroleto performthetask.14 Dissatisfactionwiththeprocessmay contributetodelays,inaccuracies,andsafetyevents.

Interprofessionaltrainingmodulesfortakingmedication historiesandmedicationreconciliationintheEDhavebeen showntoimproveemployeecommunication,behavior, knowledge,andattitude.15 Despitepreviouseducational initiatives,safetyeventsrelatedtomedicationhistories reconciliationpersist.Thus,wesoughttonewlyassessour currentEDstaffsatisfactiontofurtherimprovetheprocess forEDOUandBHpatients.15

SpeciﬁcAims

InthisprojectweaimedtoassessandimproveEDstaff satisfactionwiththemedicationreconciliationprocessfor patientswithprolongedEDstay,includingEDOUandBH boardingpatients,by20%.

METHODS

Thisqualityimprovement(QI)initiativewasabeforeand-afterstudyandconsideredtobeexemptfrom institutionalreviewboardreview.WefollowedtheStandards forQualityImprovementReportingExcellence:(SQUIRE 2.0)standardizedmethodologicalguidelines.Weusedthe LeanSixSigmarapidcycleprocessimprovementto overcomebarrierstoprotocoluseand ﬁdelitywiththedeﬁnemeasure-analyze-improve-control)framework.16 Inthis studyweusedvoluntarilyprovided,anonymousstaffsurvey information.Ourpre-interventionsurveywassentoutin November2021,andourpost-interventionsurveywas completedinJuly2022.

Context

StakeholdersincludedEDfront-linestaff(ie,attending physicians,emergencymedicine[EM]residents,nurse practitioners[NP],physicianassistants[PA],pharmacists, registerednurses[RN],careteamassistants[CTA],ED psychiatryconsultteam[psychiatry-speciﬁcphysician, resident,andNPorPA]),EDqualitystaff,andpatientsand theirfamilies.TheCTAsareEDemployeeswhofacilitate movingpatientsontheelectronichealthrecord(EHR)track board,communicatingwithconsultingservices,scheduling outpatientappointments,andingeneralhavingoverall awarenessofpatient ﬂowthroughoutthedepartment.Our studyteamincludedrepresentativemembersofthevarious stakeholdergroups,allofwhomvolunteeredtheirtimeto thisproject.

Ourinstitutionisanacademicmedicalcenterembedded withinalargerhealthcaresystemintheMidwest.Wehavea volumeof78,000visitsperyearandareaLevelItrauma andstrokecenter.Ofthe70bedsintheED,fourare dedicatedforBHpatientsandnineareusedforED observation.Wehaveathree-yearEMresidencytraining programwithnineresidentsperyearaswellasanNP/PA EMfellowship.Variousresidentprogramsrotatethrough theED.Wehave12ED-speci ﬁ cNPsorPAs.Our

pharmacistsprovide24/7coveragetoourdepartment,and wehaveapharmacyresidencyprogramwithonefellow peryear.

Themedicationhistoryandreconciliationprocessusedin ourEDatthetimethisstudywasinitiatedlackedaclear delineationofeachclinician’sroleintheprocess.Aneed existedforeachpatient’smedicationlisttobeveriﬁed, butourproceduresdidnotdeﬁnewhichEDfrontline staffmustperformthistask.Allpatientswhowillbe admittedandareEDOUorBHboardingrequirea medicationreconciliation.

Interventions

Figure1 illustratesthetimelineandsummaryofour projectandthemultipleplan-do-study-act(PDSA)cycles.

Figure1. Plan,do,study,act(PDSA)cycles. EDOU,emergencydepartmentobservationunit.

Figure2. Fishbonediagram:stakeholderdissatisfactionwithcomponentsofthemedicationreconciliationprocessforpatientsboardinginthe emergencydepartment. ED,emergencydepartment; EHR,electronichealthrecord.

Pre-interventionsurvey

Inthe fi rstquarterof2022,EDstaff(emergency physiciansandresidents,NPs,PAs,pharmacists,and CTAs)receivedanonymouselectronicsurveys(Supplement 1).Thesurveywasdesignedspecifi callytogauge satisfactionwithinitialmedicationhistoryandmedication reconciliationwhenthepatientchangesstatustoED observation/BHboardingandtoidentifybarrierstothe process.StaffmembersintheEDratedsatisfactionona 4-pointLikertscale(verydissatisfi ed = 0tovery satis fi ed = 3).Fromthissurvey,weidenti fiedpotentialgap (s)andtheirrootcauses,fromthestakeholders ’ viewpoints ( Figure2).Wethenfocusedondeterminingwhichkey causeswereamenabletoimprovement.Communication withcareteammemberswasidenti fi edastheunderlying contributingfactorthatwasmostamenabletoa processimprovement.

Thesurveyanditsassociateddataweregeneratedusing Qualtricssoftware,versionNovember2021(Qualtrics InternationalInc,Provo,UT).17

ElectronicHealthRecordAlert

Withknowledgegainedfromthebaselinesurvey,the ﬁrst proposedsteptoamelioratethegapincarewasanalert withintheEHRtothepatientcareteam.Thispop-upwould notifytheassociatedEDteammemberstoperforma medicationreconciliationoncethepatient’sstatuswas changedfrom “inprocess” toEDobservation/BH boarding.Thisproposalwasinitiallydeclinedgivenlimited availabilityofEHRprogrammingresourcesduring thepandemic.

Front-lineStaffEducation

Inthepre-interventionsurvey,staffmembersnotedalack ofcleardelineationofrolesforthemedicationhistoryand reconciliationprocess.ForthePDSAcyclestartingonApril 8,2022,educationalmaterialswerecreatedforstaffmembers todelineaterole-specifictasks(Figure3)aswellasidentifya lineartimelineofhowtheprocessofmedicationhistoryand reconciliationshouldbecompletedtoallowfortime-efficient andsafepatient flowintheED(Figure4).Thisnewprocess includedrole-specifictasksforeachEDteammemberthat wereoptimizedfortheirjob-specificresponsibilitiesandwas designedsothatmedicationordersforEDOUandBH boardingpatientscouldbeverifiedbyapharmacistand errorsminimized.

Theoptimal ﬂowwastheCTAstartsa “Let’sChat” huddle,thebedsidenursecompletesthemedicationhistory, theprimaryclinicianordersthemedicationsbasedonthe completedmedicationhistory,andthepharmacistthen veriﬁesthemedicationordersagainstthecompleted medicationhistory.Thismedicationreconciliationprocess wasanadditionalresponsibilitygiventoEDteammembers whowerealreadyworking;thus,ourprojectdidnotrequire anyadditionalhiringorfull-timeequivalennts.These materialsweredistributedtostaffintheformofemailsand handoutsthatweredisplayedthroughouttheEDforthe durationoftheinitialintervention(April–July2022). Educationalsoincludedinstructionsonhowtoinitiatea “virtual” multidisciplinarychatwithactiveEDcareteam members a “Let’sChat!” huddle withintheEHR (Supplement2).Staffalsohadtheabilitytohaveahuddlein person,iftheypreferred.

Figure3. Educationaldocumentoutliningrole-speciﬁctasks. EHR,electronichealthrecord.

Figure4. Flowdiagram. ED,emergencydepartment; EHR,electronichealthrecord; RN,registerednurse; CTA,careteamassistant.

Attendingphysician-led “Let’sChat!” Huddle

TheEDattendingphysicianisinchargeofthepatient ’ s careandhasthemostresponsibility.Additionally,the attendingphysicianismostfamiliarwithmedicationsand theplanofcareforthepatient ’sEDcourse.The ﬁ rst interventionofthe “Let’ sChat! ” huddlerequiredthe attendingphysiciantosendtheinvitationtothecareteam. Theinvestigatorssentreminderemails,presentedatthe departmentmeeting,andhadin-persondiscussionswith stafftoencourageparticipation.Thiswasmetwith resistance,asattendingswerealreadytakingonalarge workloadmanagingcareforseveralpatientswhile supervisingandteaching.Thesefactorsledinmanycasesto the “Let’ sChat! ” huddlenottakingplaceandthe medicationreconciliationnotbeingperformedoptimally. Regardless,ourteamfeltthatitwasimportanttohavethe attendingphysiciancomfortableandfamiliarwiththis processastheteamleaderinthe ﬁ rstiterationbeforewe transitionedthisresponsibilitytoothers.

Resident/NP/PA-initiated “Let’sChat!” Huddle

InthenextPDSAcycle,startedonJune8,2022,the residentphysician,NP,orPA(whoeverwascaringforthe patient),wastaskedwithinitiatingthe “Let’ sChat! ” huddle.Theseteammembershavesimilarknowledgeofthe patient ’ smedicalhistoryandtreatmentplansbutoversee fewerpatientsatatimecomparedtotheattending physician,whichtheoreticallywouldallowtheNP/PA/ residentphysicianmoretimetoinitiateamultidisciplinary “Let ’sChat!” huddleOurdepartmentisateaching institutionandregularlyhasoff-serviceresidentsrotating throughthedepartment.Often,theseresidentsdonothave thetimetoeducatethemselvesonthemedicationhistory andreconciliationprocessduringtheirbrieftimeinthe ED.Forthisreason,off-serviceresidentswerenotexpected toinitiatethe “Let ’sChat!” huddle;instead,EDresidents andattendingphysicianshelpedthemcomplete thisprocess.

CareTeamAssistant-initiated “Let’sChat!” Huddle

Inthe ﬁnalcycle(June2022),CTAsinitiatedthe “Let’ s Chat” huddle.OurEDCTAshaveoverallawarenessofthe entiredepartmentandfacilitatecommunicationamongteam members,makingthemexcellentatfacilitatingthisprocess. Withgreatresponse,CTAswereabletostartthehuddle promptlyafternotingthepatient’sstatuschangetoED observationorBHboardingintheEHR.Thiscombined approachofaCTA-initiatedelectronic “Let’sChat!” huddle toalertthenurse,clinician(s),andpharmacisttocomplete themedicationhistoryandreconciliation,andthe subsequentroleseachteammemberassumedallowedfor designatedmultidisciplinaryrolesinthemedication reconciliationprocess.

EmergencyDepartmentPsychiatryConsult TeamInvolvement

Duringour ﬁnalcycle(June2022),theEDpsychiatry consultteamalsobecameinvolvedinthe “Let’sChat” huddleforpatientschangingtoBHboardingstatus.They wereinstructedtoparticipateinthevirtualorin-person huddlewiththerestofthecareteammembers.Theywere expectedtoweighinonthepsychiatricmedicationsordered forthepatient.TheEDpsychiatryteamshowedenthusiastic participationinthisprocess.

StudyoftheInterventions

DuringeachPDSAcycle,weusedreal-timeevaluations byfront-lineEDstaff(attendingphysicians,residents,NP/ PAs,RNs,andpharmacists)toevaluatetheeffectivenessof eachinterventioncycle,obtainfeedbackontheprocess,and todeterminehowaccuratelymedicationswereordered (Supplement3).Thiswasinitiallydonebythereceivingnurse intheEDOU(whetherBHboardingorEDobservation patient)butwasexpandedtoincludeallfront-lineEDstaff. WeusedthisinformationinformallytoadjusteachPDSA cycle.Thisservedadualpurposeasitwasalsoareminderto stafftodothe “Let’sChat!” huddle.

Measures

Weinitiallylookedathundredsofchartstoidentify quantitativeindicatorsoferrorsoradjustmentsof medicationreconciliation.Despitesignificanttimededicated tothisdataextraction,ultimatelynousefulquantitativedata wasobtained.Mostoftheseerrorsareidentifiedand correctedinrealtimethroughphonecallsandin-person discussions,makingitdifficulttocaptureerrorsoradverse eventsusingaretrospectivehealthrecordreview.

Ourteamreviewedtheliteraturetoseehowothershad obtainedthisdatainsimilarprojects,butthereisapaucityof informationregardingmedicationreconciliationintheED. Instudiesofthemedicationreconciliationininpatientunits, reviewisfrequentlydonebyapharmacistorpharmacy technician.Duetothelimitationsbasedonstatelawwewere unabletouseapharmacytechnicianintheED.Additionally, inpatientunitslendthemselvestobetterretrospective communicationastheteamsaremoreconsistentdaytoday, allowingthepharmacisttoasktheteamaboutdecisions madethedaypreviously,whereasintheEDourteamsare highlyvariablefromshifttoshift.

Wealsoconsidereddoingaquantitativereviewof reportedmedicationerrorsorpatientsafetyeventsduringthe timebeforeandafterourintervention.Thiswasfelttobe inaccurateasnoteveryeventgetsreported.Duetoour inabilitytoidentifyareliablequantitativemeasureof errorsorsafetyevents,wedecidedtofocusonEDstaff satisfaction.Thethoughtwasthatifstaffaresatisﬁedand engagedintheprocess,therewillbefewererrors.Front-line EDstaffasstakeholderscompletedreal-timeevaluationsto

evaluateeffectivenessduringthePDSAcycles,provide feedbackontheprocess,andcompletedthepre-and post-interventionsurveys.

Analysis

Thesame4-pointLikertscalewasusedforthepostinterventionsurvey.Surveyparticipantswereaskedtheirrole intheED,butthiswasde-identifiedfromtherestofthe responsesforeachsurvey.Responseswerecombinedfor analysis,nomattertheroleintheED,toreflectthe multidisciplinarynatureoftheimpactofthisstudy.We reportaveragesofscoresandoverallsatisfactionwiththe medicationreconciliationprocess.Additionally, stakeholderswereaskedtoprovidefree-textinputabout potentialrootcausesofthegapinsatisfaction.Eachsurvey itemwassummarizedwithfrequencycountsandpercentages foreachresponse,aswellastheoverallmeanresponse.We comparedresponsesbetweenthepre-andpost-intervention surveysusingtwo-sidedWilcoxonrank-sumtestsand presentedthemasdifferencesinproportionswith95% confidenceintervals(CI).Foreachcomponentofthe medicationhistoryandreconciliationprocess,weusedthe averageofthesumof “satisfied” or “verysatisfied” responses toquantifytheoverallpercentagestaffsatisfaction pre-andpost-intervention.

RESULTS

InApril2022,ourteaminitiatedthe “Let’sChat!” huddle toimprovestaffsatisfactionwiththemedicationhistoryand reconciliationprocess.Weadministeredapre-intervention surveythatwascompletedby111of350(31.7%)front-line EDstaffacrossdisciplines.(Onestaffmemberdidnot identifytheirrole).InJune2022,weadministeredpostinterventionsurveysthatwerecompletedby89(25.4%) front-linestaff.Completionratesaresummarizedin Table1

Pre-interventionSurveys

Thepre-interventionsurveyidentiﬁedagapinEDstaff satisfactionwiththemedicationhistoryandreconciliation process.Inlargepart,staffwereverydissatisﬁedwiththe medicationreconciliationprocessforboardingpatients.

Welookedspecificallyateachpartofthe “fiverights” of medicationadministration:rightpatient;rightmedication; rightdosage;rightroute;andrighttime.18 Wefoundthat 70.6%weredissatisfiedorverydissatisfiedwiththeright dosage,and82.7%withtherighttime(timemedication lasttaken).

Post-interventionSurveys

Aftermultipleinterventions(seePDSAcyclesabove),the samesurveywasdistributedtothesameEDstaff.Survey responsesforeachitemaresummarizedin Table2.Some respondentsfailedtoanswereachaspectofthesurvey, causingtheindividualtotalsofeachquestionattimestoadd uptolessthanourtotalnumberofrespondents.Respondents reportedhighersatisfactionwiththemedication reconciliationprocessaftertheinterventionwithregardto gettingtherightmedication(1.69vs1.30; P = 0.004),right dosage(1.51vs1.03; P < 0.001),andtimemedicationwas lasttaken(1.29vs0.81; P < 0.001).Surveyrespondentswere moresatisﬁedwiththemedicationhistoryandreconciliation processgettingtherightpatientpriortotheintervention (averageresponse2.31vs2.16; P = 0.02),likelyattributedto highsatisfactionatbaseline.Therewasnodifferencein satisfactionwiththemedicationreconciliationprocess gettingtherightrouteformedicationbetweenthetwo surveys(P = 0.94).

Whenwecombinedthepercentageofrespondents choosing “satisfied” or “verysatisfied” andcomparedpre-to post-interventionsatisfactionwiththemedicationhistory andreconciliationprocess,wealsosawanoverall improvementinsatisfaction(asshownin Table3).Threeof the “fiverights” ofthecomponentsofmedication reconciliationhadimprovementinstaffsatisfactionoverour statedgoalof20%.Overall,wesawa17.9%improvementin EDstaffsatisfaction(64.7%vs46.8%).

Infree-textresponsesinthepost-interventionsurvey, manystaffmembersnotedthatincreaseduseofthe “Let’ s Chat!” huddlewasfelttobeanadditionalvenuethrough whichallteammembers,knowingtheirrolesintheprocess, canassistoneanothertoensurethatmedication reconciliationiscompleteandaccurate.

Table1. Pre-andpost-interventionsurveycompletionratesoffront-linestaff.

Pre-interventionsurvey(numberandpercentage offront-linestaffmembersresponding)

Post-interventionsurvey(numberandpercentage offront-linestaffmembersresponding)

Physician(37/77[48.1%])Physician(39/77[50.7%])

NP/PA(9/12[75%])

RN(54/150[36%])

NP/PA(8/12[66%])

RN(33/150[22%])

Pharmacist(10/10[100%])Pharmacist(9/10[90%])

Note: Basedon110respondentswhoidentiﬁedtheirrole. NP,nursepractitioner; PA,physicianassistant; RN,registerednurse.

Table2. Summaryofsurveyresults. Verydissatis

Rightpatient

Pre-intervention13(11.7%)9(8.1%)20(18.0%)69(62.2%)2.310.02

Post-intervention5(6.2%)6(7.4%)41(50.6%)29(35.8%)2.16

Rightmedication

Pre-intervention24(21.8%)40(36.4%)35(31.8%)11(10.0%)1.300.004

Post-intervention8(10.0%)22(27.5%)37(46.3%)13(16.3%)1.69

Rightdosage

Pre-intervention35(32.1%)42(38.5%)26(23.9%)6(5.5%)1.03 <0.001

Post-intervention9(11.3%)27(33.8%)38(47.5%)6(7.5%)1.51

Rightroute

Pre-intervention21(19.1%)17(15.5%)36(32.7%)36(32.7%)1.790.94

Post-intervention6(7.5%)12(15.0%)47(58.8%)15(18.8%)1.89

Timemedicationwaslasttaken

Pre-intervention45(40.9%)46(41.8%)14(12.7%)5(4.5%)0.81 <0.001

Post-intervention13(16.5%)33(41.8%)30(38.0%)3(3.8%)1.29

Note: Basedon111responsesreceivedforthepre-interventionsurveyand89responsesreceivedforthepost-interventionsurvey.

Surveyquestion

Pre(percentage respondingsatisﬁed orverysatisﬁed)

Post(percentage respondingsatisﬁed orverysatisﬁed)

Satisfactionwithmedicationreconciliation whenthepatient’sstatuschangestoED observation/BHboarding Rightpatient(80.2%)Rightpatient(86.4%)6.2%No

Timelasttaken(17.3%)Timelasttaken(41.8%)24.5%Yes

Overallpercentsatisfaction46.8%64.7%17.9%No

DISCUSSION

Summary

PatientsareexperiencingincreasingLOSintheED.2 Duringtheseprolongedstays,patientsrequiremedication historyreconciliation1;unfortunatelythisprocessis complicatedandchallenging,leadingtoADE.8 Delineationof rolesandtheelectronicchatfunctionintheEHR(“Let’ s Chat!” huddle)werenovelinterventionsthatledto measurablyincreasedsatisfactionwiththemedicationhistory andreconciliationprocessforEDOUandBHboarding patients.UsingvalidatedframeworksliketheLeanSixSigma, thisprojectincreasedtheunderstandingofhowtoimprovethe qualityofEDcareforBHboardingandEDOUpatients.19

AchatfunctionwithintheEHRallowedforalternative meansofcommunicationandincreasedthe ﬂexibilityand

buy-inofEDstaffmembers.Evidentinthelowreturnof responsestothepost-interventionsurveys,thereisasteep learningcurvetogetalargenumberofmultidisciplinarystaff educatedonthisnewprocessinabusyworkenvironmentto implementthechange.

Interpretation

Lookingatthissystemasawhole,the “Let’sChat!” huddleimprovedfront-linestaffsatisfactionwiththe medicationreconciliationprocess,whichshouldcorrelate withimprovedpatientsafety,decreasedLOS,andpositive patientoutcomes.20 Measuringsatisfactioninspeciﬁcaspects ofthisprocesstapsintothemultidisciplinarynatureof medicationhistoryandreconciliationandcoversmanybases thatcouldbemissedwithasolitaryunitofmeasurement

Table3. Staffsatisfactionwitheachcomponentofthe “5rights”

(eg,LOS,ADEs).Measurementofstaffsatisfactionallows thestakeholderstoapplytheirjudgmentastowhetherthe processwasasuccessorfailure,servingasa “stampof approval” withtheprocess.

Thisnovelstudyisdifficulttocomparetootherresearch, giventhelackofpublishedQIworkcoveringthistopic. Availabilityofpharmacytechniciansisafocalpointofprior studies;however,duetostatestatuteswewereunabletouse thisgroupinourED.9 Inattemptingtofacilitateachange, theeffortsofthe “Let’sChat!” huddlefoundthata collaborativemultidisciplinaryapproachisnecessarytohave impactinthisprocess.Carpenteretaldemonstratedthat knowledgealoneisnecessarybutinsufficienttoimprove healthcareoutcomes;thus,adaptingbehaviorsofclinicians, patients,andstakeholderstonewstandardsofevidencebasedclinicalpracticeisoftensignificantlydelayed.21

Futuredirectionsforresearchincludeworkingonan implementationstudywithevidence-basedinterventions, determininghowtomeasurepatient-orientedhealth outcomes,testingtheeffectivenessoftheimplementation strategy,andincludingcostanalysis, ﬁdelityofthe intervention,andevaluationofunintendedeffectsingroups, amongotherstepsasrecommendedbytheStandardsfor ReportingImplementationStudiesstatement.22

The “Let’sChat!” medicationreconciliationprocesswas approvedasapracticeatthisinstitutiongoingforward.After theprovensuccessoftheproject,theEHRalerthasbeen implemented,alertingCTAstoinitiatea “Let’sChat!” huddlewhenpatientsareplacedonboardingstatus.This automatedprocesscouldpotentiallybeappliedfor dischargingpatientsaswell,whichwouldbroadenitsimpact andfurtherdecreaseEDLOS.

Theengagementandawarenessoftheteaminvolvedin themedicationhistoryandreconciliationprocessiscriticalto thesafetyofourpatients,staffsatisfaction,andoptimal outcomes.Attentiontothemedicationhistoryand reconciliationcontinuestobeanimportantpartofthe patient’sEDvisit.Continuedreinforcementofthe interventions,communicationwithstaff,andmonitoringfor safetyeventsisneededinthefuturetodeterminewhether actualimprovementisrecognizedbystaff.

LIMITATIONS

Becausethiswasasingle-centerstudyitmaynotbe inherentlygeneralizabletootherinstitutionswithfewerED staffresources.Second,staffsatisfactionisimpactedbymany factorsthatarenotpossibletomeasureorcontrol.Therewere lowresponserates(from25.4–31.4%)withthelowest completionrateamongnurseswhoareourlargestandmost heterogeneousgroupofEDstaff.Weshouldalsoacknowledge thatstaffintheemaillistwerenotallworkingclinicallyduring thefour-weekperiodthatthesurveywasopen.

Third,thesamplingpopulationwaslimited,asthesurvey waselective.Thismayhavecontributedtoparticipationbias

fromindividualswithstronglyweightedfeelingstowardthis processtoskewtheresults.Additionally,overallsatisfaction withthisprocessisdifﬁculttoconclude,asanimprovedED medicationreconciliationextendsbeyondthefront-lineED stafftotheinpatientandconsultingpsychiatryteams, hospitalists,andpatientswhowerenotsurveyedfortheir satisfactionandpotentialfeedback.Awidernetcouldbecast inthefutureiterationsofthisprojecttoavoidsurvivorshipbias.

Fourth,byusingstaffsatisfactioninsteadofmeasurable quantitativeinformationabouterrorsorsafetyeventsrelated tomedicationsreconciliation,thedataissubjecttothe responders’ interpretationofthequestion.Quantitativedata isdifﬁculttoswayinthisfashionandisalimitationofusing satisfaction.Fifth,resistanceandintermittentfailureofED stafftoperform “Let’sChat” huddlesduringthephysicianledhuddlecycleduetolackoffamiliaritywithrolescould meanthatthetwo-monthwindowforstafftobefamiliarized withtheinterventionmayhavebeeninsufﬁcientforthemto comfortablyusethenewprocessbeforeansweringthepostinterventionsurvey.Historically,otherimplementation strategieshavedemonstratedaninitialenthusiasmbystaff thatswiftlywanes.Useofawashoutperiodbetween interventionscouldpreventthisattritionandallowformore timeforstafftopassivelyreviewinformationwhilenot havingtouseit.Furtherexperienceanduseofthe “Let’ s Chat!” huddles,ifsustained,willallowstafftobecomemore comfortablewiththeprocess.

Sixth,themethodofstaffeducation(emailandprinted materials)wasselectedbasedonavailabilityofresourcesand notthemosteffectivemethodbackedbyresearchfor distributinginformationandeducatingateam.Furtherwork shouldincludeevaluationofthesustainabilityofthe “Let’ s Chat!” virtualhuddletool,durationoftheeffectivenessof educationstrategiesused,andapplicationtootherpatient groupsdismissedfromtheED.

CONCLUSION

The “Let’sChat!” huddlefacilitatescommunicationand increasessatisfactionamongEDteammembersrelatedto themedicationreconciliationprocess.Theincreaseduseof the “Let’sChat!” huddlewasfelttobeanadditionaland effectivevenuethroughwhichallteammembers,knowing theirrolesintheprocess,canassistoneanothertoensurethe medicationreconciliationiscompleteandaccurate.Ongoing workisneededtocontinuetoimproveandbuildonthe culturechangeforenhancingthemedicationhistoryand reconciliationprocess.

AddressforCorrespondence:SaraHevesi,MD,MayoClinic, DepartmentofEmergencyMedicine,200FirstStreetSW, Rochester,MN55905.Email: hevesi.sara@mayo.edu

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

REFERENCES

1.BaloescuC,KinsmanJ,RaviS,etal.Thecostofwaiting:associationof EDboardingwithhospitalizationcosts. AmJEmergMed. 2021;40:169–72.

2.KoehlJ,SteffenhagenA,HalfpapJ.Implementationandimpactof pharmacist-initiatedhomemedicationorderinginanemergency departmentobservationunit. JPharmPract. 2021;34(3):459–64.

3.PreyJE,PolubriaginofF,GrossmanL,etal.Engaginghospitalpatients inthemedicationreconciliationprocessusingtabletcomputers, JAMIA. 2018;25(11):1460–9.

4.KripalaniS,HartK,SchaningerC,etal.Useofatabletcomputer applicationtoengagepatientsinupdatingtheirmedicationlist. AmJHealthSystPharm. 2019;76(5):293–300.

5.TheJointCommission.Nationalpatientsafetygoals® effectiveJanuary 2022forthehospitalprogram.2018.Availableat: https://www. jointcommission.org/-/media/tjc/documents/standards/nationalpatient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf AccessedJuly21,2022.

6.ChhabraA,QuinnA,RiesA,etal.Evaluationoftimespentby pharmacistsandnursesbasedonthelocationofpharmacistinvolvement inmedicationhistorycollection. JPharmPract. 2019;32(4):394–8.

7.TheJointCommission.2022NationalPatientSafetyGoals.2018. UpdatedOctober25,2021.pg.5.AccessedJuly21,2022.dc8fdcbf7cab-426c-b0d7-ee12c5b6817c(jointcommission.org).

8.VanderNatDJ,TaksM,HuiskesV,etal.Riskfactorsforclinically relevantdeviationsinpatients’ medicationlistsreportedbypatientsin personalhealthrecords:aprospectivecohortstudyinahospitalsetting. IntJClinicalpharmacy. 2022;44(2):539–47.

9.MooreC,WisniveskyJ,WilliamsS,etal.Medicalerrorsrelatedto discontinuityofcarefromaninpatienttoanoutpatientsetting. JGenInternMed. 2003;18(8):646–51.

10.EllisonC,HackettK,LendremD,etal.Exploringmedicines reconciliationintheemergencyassessmentunit:staffperceptionsand actualwaitingtimes. EmergNurse. 2020;28(5):28–33.

11.MinesotaLegislature.Minnesotaadministrativerules:§6800.3850 PharmacyTechnicians.2017.Availableat: https://www.revisor.mn.gov/ rules/6800.3850/#rule.6800.3850.2.AccessedJuly21,2022.

12.BridgemanPJandRynnKO.Medicationreconciliationintheemergency department. AmJHealthSystPharm. 2008;65(24),2325–6.

13.HayesBD,DonovanJL,SmithBS.Pharmacist-conductedmedication reconciliationinanemergencydepartment. AmJHealthSystPharm. 2007;64(16):1720–3.

14.Pérez-MorenoMA,Rodríguez-CamachoJM,Calder´on-HernanzB, etal.Clinicalrelevanceofpharmacistinterventioninanemergency department. EmergMedJ. 2017;34(8):495–501.

15.EisenmannD,StrobenF,GerkenJD,etal.Interprofessionalemergency trainingleadstochangesintheworkplace. WestJEmergMed. 2018;19(1):185–92.

16.OgrincG,DaviesL,GoodmanD,etal.SQUIRE2.0(Standardsfor QualityImprovementReportingExcellence):revisedpublication guidelinesfromadetailedconsensusprocess. BMJQualSaf. 2016;25(12):986–92.

18.FedericoF.The ﬁverightsofmedicationadministration.2007.Available at:~https://www.ihi.org/insights/ ﬁve-rights-medication-administration#: ~:text=One%20of%20the%20recommendations%20to,route%2C% 20and%20the%20right%20time. AccessedMay24,2023.

19.SoutherlandLT,HunoldKM,VanFossenJ,etal.Animplementation scienceapproachtogeriatricscreeninginanemergencydepartment. J AmGeriatrSoc. 2022;70(1):178–87.

20.HittiE,TamimH,BakhtiR,etal.Impactofinternallydeveloped electronicprescriptiononprescribingerrorsatdischarge fromtheemergencydepartment. WestJEmergMed. 2017;18(5):943–50.

21.CarpenterCR,SoutherlandLT,LuceyBP,etal.AroundtheEQUATOR withclinician-scientiststransdisciplinaryagingresearch(Clin-STAR) principles:implementationsciencechallengesandopportunities. JAmGeriatrSoc. 2022;70(12):3620–30.

22.PinnockH,BarwickM,CarpenterCR,etal.Standardsfor reportingimplementationstudies(StaRI)statement. BMJ. 2017;356:i6795.

ORIGINAL RESEARCH

PediatricBurns – WhoRequiresFollow-up?AStudyofUrban PediatricEmergencyDepartmentPatients

TheodoreHeyming,MD*†

AndreaDunkelman,MD‡

DavidGibbs,MD*

ChloeKnudsen-Robbins,MD§

JohnSchomberg,PhD*

ArminTakallou,BS∥¶

BryanLara,BA*

BrookeValdez,MS*

VictorJoe,MD#

SectionEditor:PaulWalsh,MD,MSc

*Children’sHospitalofOrangeCounty,Orange,California

† UniversityofCaliforniaIrvine,DepartmentofEmergencyMedicine, Irvine,California

‡ OrangeCountyGlobalMedicalCenter,DepartmentofGeneralandPlastic Surgery,SantaAna,California

§ UniversityofCincinnatiCollegeofMedicine,DepartmentofEmergencyMedicine, Cincinnati,Ohio

∥ UniversityofCalifornia,Irvine,California

¶ OregonHealthScienceUniversity,SchoolofMedicine,Portland,Oregon

# UniversityofCaliforniaIrvine,DepartmentofGeneralSurgery,Irvine,California

Submissionhistory:SubmittedMarch20,2024;RevisionreceivedFebruary16,2024;AcceptedFebruary28,2024

ElectronicallypublishedJune14,2024

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

DOI: 10.5811/westjem.17984

Introduction: Hundredsofchildrensufferburninjurieseachday,yetcareguidelinesregardingtheneed foracuteinpatienttreatmentvsoutpatientfollow-upvsnorequiredfollow-upremainnebulous.Thisgap intheliteratureisparticularlysalientfortheemergencyclinician,whomustbeabletorapidlydetermine appropriatedisposition.

Methods: ThiswasaretrospectivereviewofpatientspresentingtoaLevelIIpediatrictrauma center,January1,2017–December31,2019,anddischargedwithanInternationalClassificationof Diseases,Rev10,burndiagnosis.Weobtainedandanalyzeddemographics,burncharacteristics,and follow-updatausingunivariateandbivariateanalysisaswellaslogisticregressionmodeling.Patients werestratifiedintothreeoutcomegroups:group1 patientswhounderwentemergentevaluationata burncenterorwereadmittedattheir firstfollow-upappointment;group2 patientswhofollowedupata burncenter(asanoutpatient)orattheemergencydepartment(andweredischargedhome);andgroup 3 patientswithnoknownfollow-up.

Results: Atotalof572patientswereincludedinthisstudy;58.9%ofpatientswere1–5yearsofage. Sixty-ﬁvepatientsmetgroup1criteria,189patientsmetgroup2criteria,and318patientsmetgroup3 criteria.Sixty-ﬁvepercentofpatientsmetatleastoneAmericanBurnAssociationcriteria,and79%ofall burnsweresecond-degreeburns.Flameandscaldburnswereassociatedwithincreasedodds(odds ratio[OR]1.21,OR1.12)ofgroup1vsgroup2 + group3(P = 0.02, P < 0.001).Second/third-degree burnsandconcernfornon-accidentaltraumawerealsoassociatedwithincreasedoddsofgroup1vs2or 3(OR = 1.11,1.35, P ≤ 0.001,0.001,respectively).Scaldburnswereassociatedwithincreasedoddsof group2comparedtogroup3(OR1.11, P = 0.04).Second/thirddegreeburnswerealsoassociatedwith increasedoddsofgroup2vs3(OR1.19, P ≤ 0.001).

Conclusion: Therewerefewstatisticallysigniﬁcantvariablesstronglyassociatedwithgroup1 (emergenttreatment/admission)vsgroup2(follow-up/outpatienttreatment)vsgroup3(nofollow-up). However,onenotable ﬁndinginthisstudywastheassociationofscaldburnswithtreatment(admission orfollow-up)suggestingthatthepresenceofascaldburninachildmaysignifytocliniciansthataburn centerconsultiswarranted.[WestJEmergMed.2024;25(4)634–644.]

INTRODUCTION

ApproximatelyoneUSchildpresentstotheemergency department(ED)foraburninjuryeverysixminutes;10,000 arehospitalizedoverthecourseofayear.1,2 Burninjuries, especiallyinchildren,carrysigniﬁcantriskofphysicaland psychologicalsequelae.2–5 In2017alone,EDcostsrelatingto pediatricburnsamountedtoover$700millionandtotal hospitalizationtoover$1.5billion.6 Advancesinburn therapyhaveledtoanoveralltrendtowardoutpatient management,reducingtheriskassociatedwith hospitalizationandallowingformoreefﬁcienttreatmentand resourceallocation.7,8 However,theprocessofidentifying whichpatientsmaybebestservedbyinpatientcarevsfollowupoutpatienttreatmentvsdischargehomewithoutset follow-upisnotwelldelineated.

TheAmericanBurnAssociation(ABA)haspublished guidelinesregardingtransfer/referraltoregionalburn centers;however,understandingandimplementationof theseguidelineshasvaried.Someclinicianshaveperceived theseguidelinesasabsolutetransfercriteriaandothersas consult/referralcriteria.9 Itis,therefore,unsurprisingthat transfer/consult/referralpracticesdifferwidely,withfrequent reportsofpatientsbeingbothunder-andover-referred.10,11 Interestingly,Andersonetalfoundthatalthoughmost pediatricpatientspresentingtotheirinstitutionwithburn injurieswerelowacuity,amajoritywereadmitted,andsocial factorsandtransferstatusweremorestronglyassociated withadmissionthanburnsizeormechanism.12 Inlightof thesefactors,thedocumentedinconsistencyofnon-burn centerclinician’sevaluationofburns,andthelackof randomizedcontrolstudies,anexpertpaneldevisedupdated guidelinesin2020.13–16 Perhapsthemostimportantmessage fromthisupdateisthereframingoftheABAcriteriaas “consultationguidelines.” Theredonototherwiseappearto besubstantivechangesregardingmorespeciﬁcdisposition recommendationsforpediatricpatients.

Itisnotablethatemergencyphysicians theclinicians mostoftentaskedwiththeinitialevaluationanddecisionto contactburncenters werenotincludeduntilthethirdstage oftheeDelphiprocess.The2020updatealsoincludes recommendationsregardingtelemedicine.While telemedicinecertainlyhasthepotentialtotransformmany aspectsofpatientcare,itsuseinallpatientswithpotentially deepburnsmaybeprohibitivefromatime,technological, legal,andinsuranceperspective.Clearerstandardsregarding whichpatientsmightbeneﬁtmostfromthisprocess,which onesmaybetransferredwithouttelemedicineconsultation, andwhichmaybedischargedhomewithorwithoutfollowupwouldlikelyfacilitateED ﬂowandburncenterprocesses.

Ourobjectiveinthisstudywastodescribecharacteristics ofpediatricburnpatientsdirectlytransferred/admittedtoa burncenter,patientswhofollowedup,andthosewhodidnot followup.Weaimedtoidentifypatientandburn

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Hundredsofchildrensufferburninjurieseach day,butcareguidelinesforinpatient admissionvsoutpatientfollow-uporno follow-upremainnebulous.

Whatwastheresearchquestion?

Aretherevariablesassociatedwithhow emergencycliniciansreferpediatricburn patientsforfollow-up?

Whatwasthemajor ﬁndingofthestudy?

Flameandscaldburns(OR1.21),andnonaccidentaltrauma(OR1.11)hadhigherodds ofevaluationataburncenter(P < 0.001).

Howdoesthisimprovepopulationhealth?

Referraldecisionsforpediatricburnsis challenging;scaldburnsoftenrequire treatmentandshouldalmostalwayswarrant treatmentataburncenter.

characteristicsassociatedwiththesethreegroupstobetter informcliniciandispositiondecisions.Thisthree-tiered approachwaschosenwiththeemergencyclinicianinmindas theymustbeabletodeterminewhichpatientsrequire immediatetransfer,whichmaybeneﬁtfromfollow-up,and whichpatientsmaybedischargedhomewithoutneedfor furtherevaluation.Oursecondaryobjectivewastoexamine thedistributionofpatientsmeetingABAcriteriaamong thesethreegroups.

METHODS

Thisretrospectivechartreviewincludedpatients 0–21yearspresentingtotheEDofapediatricLevelII traumacenterJanuary1,2017–December31,2019whowere dischargedwithanInternationalClassiﬁcationofDiseases, Rev10(ICD-10)burndiagnosis(ICD-10codesmaybe foundinthe supplementarymaterials).Wecollecteddata regardingdemographics,burnmechanism,burnsite,degree ofburn,totalburnsurfacearea(TBSA),ABAcriteria, concernfornon-accidentaltrauma(NAT),andmannerof arrival.ConcernforNATwasconsideredtobepresentif documentedintheemergencyphysician’sorsocialworker’ s note.Wecollectedfollow-updatafromthisinstitution’sED aswellasthetwoburncentersservingthesurrounding

region.Datawasabstractedbythreetraineddataabstractors (BL,AT,BV)usingastandardoperatingproceduremanual. WecollectedandmanagedstudydatausingREDCap electronicdatacapturetoolshostedatChildren’sHospitalof OrangeCounty.TheREDCapdatacollectionformmaybe foundinthe supplementarymaterials.Chartswereidentified viaaqueryusingICD-10diagnosiscode(ICD-10codes T20–31)andEDvisitdate(January1,2017–December31, 2019)asinclusionparameters.Apost-hocinter-rater reliability(IRR)processwascompletedwhereinanewly trainedabstractorusedthesamestandardoperating proceduremanualtoreviewchartsatthemainstudysite.The IRRwasanalyzedusingtheCohenkappa,andalldata variableswereconfirmedashavingaCohenkappa coefficientrangingfrom0.870–1.000;67%ofvariables reviewedresultedinaCohenkappacoefficientof1.000. Thisstudywasapprovedbyallstudyinstitutions’ institutionalreviewboards.Asthiswasaretrospectivechart reviewsubjectswerenotaskedtoconsenttoparticipatein thisstudy.

Westrati fi edpatientsintothreeoutcomegroupsfor analysis:group1patientsrepresentingthoselikelyto requireinterventionsorcarebestprovidedbyaspecialized burncenter(asopposedtowhatmaybeavailableata referringinstitutionorintheoutpatientsetting);group2 patientsrepresentingthosewhosewoundslikelyrequired furtherfollow-up;andgroup3representingthoseatlowest risk(ie,thosewholikelydidnotneedanyfollow-up).Group 1includedpatientswhoweretransferredfromthe presentingEDdirectlytooneofthetworegionalburn centers(ortheirrespectiveEDs)orpatientswhowere admittedattheir fi rstfollow-upvisit.Group2included patientswhofollowedupatoneofthetworegionalburn centers(intheEDorclinic)orthepresentingED(fora burn-relatedvisit).Group3includedpatientswhowerenot knowntofollowup(ie,theydidnotfollowupateitherburn center ’ sclinicorEDorthepresentingEDandwerenot initiallytransferredtoaburncenter).Outcomeswere de fi nedbydisposition,(ie,inclusioningroup1,group2, orgroup3).

UnivariateandBivariateStatisticalAnalysis

Wemeasureddifferencesinthedistributionofcontinuous andcategoricalvariablesreportingfrequencyand proportionsofcategoricalvariablesandmean/standard deviationofcontinuousvariablesacrossoutcomegroups. ThebivariateinferentialstatisticsoftheWilcoxonrank-sum testwereusedtotestthedifferenceindistributionof continuousvariablesofageandtotalburnsurfacearea.We usedthechi-squaretestofproportionstotestthedifferencein distributionofcategoricalvariablesacrossgroups.These bivariateinferentialtestswereappliedtopatientsmeetingthe criteriaofineitheroutcomegroup1oroutcomegroup2or lowerriskoutcomegroup3.Weconductedmissingness

analysisonthosevariableswith >10%missingdata.The Littletestwasconductedonallvariablesmeetingthis missingnessthreshold.

LogisticRegressionModels

Weusedlogisticregressionmodelstotesttheassociation betweendemographics/observedclinicalvariableswiththe probabilityoftreatmentgroup1,2,or3.Variablesthatwere foundtohavehighcorrelationorvarianceinﬂationusingR varianceinﬂationfactormeasurements(R4.03)werepruned fromthemodeldependinguponavariable’sutilityas determinedbythestudyteam.Asthesewerefullmodels,we didnotapplymethodsrelatedtobackward,forward,or stepwisevariableselection.

RESULTS

DescriptiveAnalysis

Atotalof572patientswereincludedinthisstudy;8.04% ofpatientswere <1year;58.9%ofpatientswere1–5years; 18%were5–10years;8.74%were11–15years;and6.29% were >15years.Ofallstudypatients,48.7%weremale, 63.4%wereHispanic,and73.2%hadpublicinsurance(or optedforself-pay).Sixty-ﬁvepatientsweredirectly transferredtoaburncenteroradmittedattheir ﬁrstfollowupvisit(group1),189patientsattendedatleastonefollowupvisit(group2),and318patientsdidnotfollowupatanyof thestudyinstitutions(group3).Atotalof372patients(65%) metatleastoneABAcriteria.Thedistributionof characteristicsbyoutcomegroupisshownin Table1

Therewasasignificantdifferenceassociatedwithgender distributionamonggroups1,2,and3,withahigher percentageofmalesingroups1and3ascomparedto females,andahigherpercentageoffemalesingroup2, P = 0.01.Therewasalsoasignificantdifferenceassociated withburnmechanism,withahigherpercentageofscaldand contactburnsthanotherburnmechanismsinallthree groups;scaldburnswerethepredominantburntypein groups1and2(73.8%and49.2%,respectively), P < 0.001. Thelocationoftheburnwasalsoassociatedwitha significantdifferencebetweengroups1,2,and3,witha predominanceofwrist/hand/palmarburnsingroups2and3 (39.6%and32.3%,respectively)comparedto lowerextremityburnsingroup1(26.1%), P ≤ 0.001(Table1).

Themajorityofallburnsweresecond-degreeburns(79%). Therewasasigniﬁcantdifferenceassociatedwithmeetingat leastoneABAcriteria,with86.1%ofthoseingroup1 meetingthecriteriacomparedto67.7%ingroup2and59.1% ingroup3, P = 0.01.ConcernforNATwasalsoassociated withasigniﬁcantdifference,with23%ofthosein group1withconcernforNATcomparedto8.99%and 6.28%ingroups2and3,respectively (P ≤ 0.001)(Table1).

Table1. Distributionofsociodemographicandclinicalvariablesacrossburntreatmentoutcomegroups.

Patient characteristicsTotaln = 572

Age

Group1,n = 65(directtransfer toburncenteroradmittedat ﬁrstfollow-up)

Group2,n = 189 (patientfollowedup)

Group3,n = 318 (patientdidnot followup) P

<146(8.04%)10(15.3%)16(8.46%)20(6.28%)

1–5years337(58.9%)38(58.4%)100(52.9%)199(62.5%)

5–10years103(18.0%)9(13.8%)44(23.2%)50(15.7%)

11–15years50(8.74%)5(7.69%)15(7.93%)30(9.43%) >1536(6.29%)3(4.61%)14(7.40%)19(5.97%)

Gender

Male279(48.7%)39(60.9%)89(47.0%)178(55.9%)

Female*292(51.0%)25(38.4%)100(52.9%)140(44.0%)

Race

White345(60.3%)36(55.3%)121(64.0%)188(59.1%)

Non-White227(39.6%)29(44.6%)68(35.9%)130(40.8%)

Ethnicity

Hispanic363(63.4%)47(72.3%)119(62.9%)197(61.9%)

Non-Hispanic209(36.5%)18(27.6%)70(37.0%)121(38.0%)

Private153(26.7%)10(15.3%)152(80.4%)257(80.8%)

Public/self-pay419(73.2%)55(84.6%)37(19.5%)61(19.1%)

Burnmechanism <.001

Flame15(2.62%)3(4.06%)3(1.58%)9(2.83%)

Scald261(45.6%)48(73.8%)93(49.2%)120(37.7%)

Steam6(1.04%)0(0%)1(0.52%)5(1.57%)

Chemical40(6.99%)2(3.07%)6(3.17%)32(10.0%)

Electrical5(0.87%)0(0%)3(1.58%)2(0.62%)

Contact215(37.5%)10(15.3%)78(41.2%)127(39.9%)

Other30(5.24%)2(3.07%)5(2.6%)23(7.23%)

Burnsite <.001

Head/neck/face65(11.3%)7(10.7%)12(6.34%)46(14.4%)

Lowerlimb (Includingknees, ankle,foot,sole) 137(23.9%)17(26.1%)56(29.6%)64(20.1%)

Perineum/genitalia9(1.57%)2(3.07%)4(2.11%)3(0.94%)

Trunk/back87(15.2%)15(23.0%)20(10.5%)52(16.3%)

Upperlimb (excludingwrist andhand) 82(14.3%)13(20%)21(11.1%)48(15.0%)

Wrist/hand/palm189(33.0%)11(16.9%)75(39.6%)103(32.3%)

Missingsite3(0.52%)0(0%)1(0.52%)2(0.62%)

Degreeofburn <.001

1st 114(19.9%)4(6.15%)23(12.1%)87(27.3%)

2nd 452(79.0%)59(90.7%)163(86.2%)230(72.3%) (Continuedonnextpage)

Table1. Continued.

Patient characteristicsTotaln = 572

Group1,n = 65(directtransfer toburncenteroradmittedat ﬁrstfollow-up)

Group2,n = 189 (patientfollowedup)

Group3,n = 318 (patientdidnot followup) P-value

3rd 6(1.04%)2(3.07%)3(1.58%)1(0.31%)

Totalburnsurface area(TBSA)** <.001

<1%153(26.7%)5(7.69%)36(19.0%)112(35.2%)

1to1.9%20(3.49%)0(0%)11(5.82%)9(2.83%)

2to4.9%117(20.4%)15(23.0%)47(24.8%)55(17.2%)

5to9.9%42(7.34%)21(32.3%)11(5.82%)10(3.14%)

10to15%10(1.74%)9(13.8%)1(0.52%)0(0%)

>15%5(0.87%)4(6.15%)0(0%)1(0.31%)

Notstated225(39.3%)11(16.9%)83(43.9%)131(41.1%)

WasABAreferral criteriamet? <.001

Yes372(65.0%)56(86.1%)128(67.7%)188(59.1%)

No193(33.7%)9(13.8%)58(30.6%)126(39.6%)

Notstated7(1.22%)0(0%)3(1.58%)4(1.25%)

Wasthereconcern fornon-accidental trauma?

Yes52(9.09%)15(23.0%)17(8.99%)20(6.28%)

No520(90.9%)50(76.9%)172(91.0%)298(93.7%)

*Genderwasrecordedasundeterminedforonepatient.

**MissingTBSAvaluesweresigniﬁcantlyassociatedwithoutcomegroup. ABA,AmericanBurnAssociation.

LogisticRegressionAnalysis-Group1vs2

Age5–10yearswasassociatedwithdecreasedodds(odds ratio[OR]0.86)ofdirecttransfer/admissionat ﬁrstfollow-up (group1),comparedtoattendingatleastonefollow-upvisit (group2), P = 0.04.Flameandscaldburnswereassociated withincreasedodds(OR1.52,OR1.17,respectively)ofa group1vs2outcome,aswasconcernforNAT(OR1.48), P = 0.02, P = 0.02, P = 0.02.Head/neck/facialburns,burns tothetrunk,andburnstotheupperlimb(excludingthewrist/ hand/palm)werealsoassociatedwithincreased oddsofgroup1vsgroup2outcomes(OR1.26,1.22, and1.21,respectively, P = 0.04, P = 0.04, P = 0.04)(Table2).

Group1vsGroup3

Malegenderwasassociatedwithdecreasedoddsofdirect transfer/admissionat ﬁrstfollow-up(group1)comparedto notfollowingup(group3)(OR0.92, P = 0.02).Scaldburns wereassociatedwithincreasedodds(OR1.23,ofgroup1vs group3outcomes, P < 0.001).Second/thirddegreeburnsand concernforNATwerealsoassociatedwithincreasedoddsof group1vsgroup3outcomes(OR1.21and1.49,respectively, P < 0.001, P = 0.003)(Table3).

Group2vsGroup3

Scaldburnswereassociatedwithincreasedoddsoffollowup(group2)comparedtonofollow-up(group3)(OR1.11, P = 0.04).Second/thirddegreeburnswerealsoassociated withincreasedoddsofgroup2vsgroup3outcomes(OR 1.19, P ≤ .0001).Burnstothetrunkwereassociatedwith decreasedoddsofgroup2vsgroup3outcomes(OR0.81, P ≤ .0001)(Table4).

Group1or2vsGroup3

Malegenderwasassociatedwithdecreasedoddsofdirect transfer/admissionat ﬁrstfollow-up(group1),oranyfollowup(group2)comparedtonotfollowingup(group3)(OR 0.904, P = 0.01.)Scaldburnsandsecond/thirddegreeburns wereassociatedwithgroup1or2outcomesvsgroup3 outcomes(OR1.18and1.261,respectively, P ≤ 0.001, P < 0.001).Burnstothetrunkwereassociatedwith decreasedodds(OR0.857,ofgroup1or2outcomes comparedtogroup3, P = 0.03)(Table5).

Group1vs2or3

Flameandscaldburnswereassociatedwithincreased oddsofdirecttransfer/admissionat ﬁrstfollow-up(group1)

Table2. Logisticregressionmodel:estimatedoddsratiosofgroup1vsgroup2.

PatientcharacteristicOddsratio

Age(reference:1–5years)

<1 1.050.871.260.62 5–10years0.860.750.990.04 11–15years0.930.761.150.52 >150.940.751.180.61

Race(reference:non-White)

White0.950.851.070.42

Gender(reference:female)

Male0.940.851.050.29

Ethnicity(reference:non-Hispanic) Hispanic1.040.931.170.50

Insurance(reference:publicinsurance)

Burnmechanism(reference:contact)

Degreeofburn(reference:1stdegree) 2nddegreeor3rddegree1.120.931.350.22

Burnsite(reference:wrist/hand/palm)

Head/neck/face1.261.021.560.04

Lowerlimb(knees,ankle,foot,sole)1.050.911.210.51 Perineum/genitalia1.170.811.670.40 Trunk1.221.011.470.04

Upperlimb1.211.011.450.04

Wasthereconcernfornon-accidentaltrauma?(Reference:No) Yes1.481.072.060.03

vsfollowingupatleastonce(group2)ornotfollowingup (group3)(OR1.21and1.12, P = 0.02, P < 0.001).Second/ thirddegreeburnsandconcernforNATwerealsoassociated withincreasedoddsofgroup1vs2or3outcomes(OR1.11, 1.35,respectively, P ≤ 0.001,0.001)(Table6).

DISCUSSION

Inthisretrospectivestudyweattemptedtodescribethe populationofpediatricpatientspresentingtoourEDwith burninjuriesaswellasinvestigatewhethertheremaybe patientorburncharacteristicsassociatedwithparticular outcomes.Ourstudypopulationreﬂectednationalstatistics withregardtoburnmechanismwithapredominanceofscald

(45.6%)andcontactburns(37.5%).17 Thisappearssimilarto anAustralianstudybyAbeyasundaraetalinwhichthe majorityofburnswerescald,followedbycontact.18 Itis, however,slightlydifferentfromworkbyAbramowiczetal whoexaminedpediatricvisitstotheED(usingthe NationwideEmergencyDepartmentSampledatabase)for burn-relatedinjuriesandreportedthatamajorityofburns wereduetoelectricalappliances,followedbyscaldinjuries.6 Scaldburnsweregenerallyassociatedwithneedfor treatment,bothinourstudy(increasedORsofgroup1or group2outcomes)andinanalysisbyMitchelletal,which demonstratedanalmostthree-foldincreaseinlikelihoodof admissionforpatientswithscaldburnscomparedtoother

Table3. Logisticregressionmodel:estimatedoddsratiosgroup1vsgroup3. PatientcharacteristicsOddsratio

Age(reference:1–5years)

Race(reference:non-White) White1.000.931.080.90

Gender(reference:female) Male0.920.850.980.02

Ethnicity(reference:non-Hispanic)

Insurance(reference:publicinsurance)

Degreeofburn(reference:1stdegree) 2nddegreeor3rddegree1.211.101.34

Burnsite(reference:wrist/hand/palm)

Head/neck/face1.110.961.280.16

Lowerlimb(knees,ankle,foot,sole)1.020.921.130.75 Perineum/genitalia1.230.891.710.22 Trunk1.010.891.130.91

Upperlimb1.070.961.210.22

Wasthereconcernfornon-accidentaltrauma?(Reference:No) Yes1.491.151.93

burnmechanisms.1 Thesepopulation ﬁndingsareespecially importantwhenconsideringlocalinjurypreventionand educationefforts.

Themajorityofpatientsinourstudy(58.9%)were betweentheagesof1–5.Thisdataissimilartothatreported byAbeyasundaraetalwhofoundthatchildrenbetweenthe agesof1–5yearsofageaccountedfor59.3%ofallchildren (0–16yearsofage)intheirstudy.18 Thisislikelyreﬂectiveof developmentalabilitiesachieved(andlacking)duringthis period.Inaddition,thelargepercentageofpatients1–5years ingroup3(62.5%)isperhapsindicativeoftheincreased mobilityofthesechildrencoupledwithincreasedparental concernforburnsinyoungerchildren.

Interestingly,andincontrasttootherstudies,51%of patientsinourstudywerefemale,whereasMitchelletalwho analyzedtheUSNationalElectronicInjurySurveillance systemfrom1990–2014andAbramowiczetalwhoexamined theNationwideEmergencyDepartmentSamplefrom 2008–2013,foundamajorityofpatientsweremale(58.4% and56%,respectively).1,6 Ofnote,however,themajorityof patientsingroup1(likelyrepresentingthemostserious burns)andgroup3(thosewhodidn’tfollowup)weremale comparedtogroup2inwhichthemajoritywerefemale.One possibleexplanationforthisdiscrepancyisincreased parentalconcerninourpopulationforburninjuriesin femalesascomparedtomales.

Table4. Logisticregressionmodelresults:estimatedoddsratiosofgroup2vsgroup3. PatientcharacteristicsOddsratio

Age(reference:1–5years)

<1 1.060.901.260.48

5–10years1.100.981.240.09 11–15years1.020.871.200.82 >151.090.911.300.36

Race(reference:non-White) White1.070.981.170.14

Gender(reference:female)

Male0.930.851.010.09

Ethnicity(reference:non-Hispanic)

Insurance(reference:publicinsurance)

Burnmechanism(reference:contact)

Degreeofburn(reference:1stdegree) 2nddegreeor3rddegree1.191.061.33 <0.001

Burnsite(reference:wrist/hand/palm)

Head/neck/face0.900.751.070.23

Lowerlimb(knees,ankle,foot,sole)0.980.871.110.76 Perineum/genitalia1.130.781.620.52 Trunk0.810.700.94 <0.001

Upperlimb0.880.771.010.08

Wasthereconcernfornon-accidentaltrauma?(Reference:No) Yes1.100.791.540.57

Inthisstudyweexaminedratesoftransfertoaburncenter andadmissionatthe ﬁrstfollow-upvisit(group1).Eleven percentofpatientsinthisstudyfellintothiscategory,similar toadmissionratesreportedbyMitchelletaland Abramowiczetal.1,6 Inaddition,weanalyzedtransfer/ admissionratesandfollow-upbyABAcriteria.Among thoseingroup1,86.1%metABAcriteria;however,67.7%of thoseingroup2metcriteria,and59.1%ofthoseingroup3 evenmetABAcriteria.AlthoughtheABAguidelinesare meanttoassistinbuildinganappropriatereferralsystemand notmeanttobedeﬁnitivecarerecommendations,ourdata suggeststhatadaptationstotheABAcriteriamaybe valuableasmanychildren,includingthosewhodon’tseemto requirefollow-upcare,meetcurrentABAguidelines.

Furtherresearchregardingthislow-riskpopulationwould likelybeneﬁtbothEDsandburnreferralcenters. Severalstudieshaveshownthereisconfusionand differingpoliciesregardingABAguidelinesandtheneedfor referralvstransfervsspecialistconsult.10 Forexample, Johnsonetalreportedthatonly8.2%ofpediatricburn patientsmeetingABAtransferguidelinesweretransferred fromlow-volumehospitals,Doudetalreportedanunderreferralrateof55%,andVanYperenetalfoundthat accordingtothereferralcriteriaoftheAustralianEmergency ManagementofSevereBurnscourse,justover25%of patients(adultandpediatric)wereunder-transferred.19–21 However,Roseetalexaminedthereferralpatternsof childrenpresentingtoanEDintheUnitedKingdom(UK)

Table5. Logisticregressionmodel:estimatedoddsratiosofgroup1or2vsgroup3.

PatientcharacteristicsOddsratio

Age(Reference:1–5years)

<11.0910.9351.2720.27

5–10years1.0620.9511.1860.29 11–15years1.0250.8811.1930.75 >151.0940.9231.2970.30

Race(reference:non-White)

White1.0560.9721.1480.20

Gender(reference:female) Male0.9040.8330.9800.01

Ethnicity(reference:non-Hispanic)

Insurance(reference:publicinsurance)

Burnmechanism(reference:contact)

Degreeofburn(reference:1stdegree) 2nddegreeor3rddegree1.2611.1271.411

Burnsite(reference:wrist/hand/palm) Head/neck/face0.9490.8051.1180.53

Lowerlimb(knees,ankle,foot,sole)0.9860.8811.1040.81

Perineum/genitalia1.1830.8531.6400.32

Trunk0.8570.7480.9820.03

Upperlimb0.9320.8181.0620.29

Wasthereconcernfornon-accidentaltrauma?(Reference:No) Yes1.2770.9611.6980.09

forburninjuriesandreportedthatalthough74%wereunderreferredonly3.2%ofthesepatientssubsequentlyrequired referraltoaburnunitandnonerequiredspecialist intervention,suggestingthatcompleteadherencetotheUK’ s burnreferralcriteria(NationalBurnCareReview)mightnot benecessaryandinfactmightnecessarilyincreasethe workloadofregionalburnunits.22 Notably,Garciaetal examinedadmissionpracticesat34pediatricburncenters acrosstheUSandfoundsignificantvariationinadmission decisionsregardingpatientswithminorburns(<10%TBSA) vsED-initiatedoutpatientmanagement.11 Inthissettingof significantpracticevariationinmultiplecountries, andlackofdefinitiveguidanceregardingbestpractices, weattemptedtoidentifywhichcharacteristics

weremostassociatedwithadmission/transferor follow-upalone.

Burnstothehead/neck/face,trunk,andupperlimbwere allassociatedwithstatisticallysignificantlyincreasedoddsof directtransfer/admissionat firstfollow-upcomparedto attendingatleastonefollow-upvisit.Fewvariableswere associatedwithstatisticallysignificantoddsofgroup2vs group3outcomes.Notably,scaldwasassociatedwith increasedoddsofgroup2vsgroup3outcomes.Itisnot surprisingthatthepresenceofsecond/thirddegreeburnswas almostalwaysassociatedwithsignificantlyincreasedoddsof admissionorfollow-upcomparedtonofollow-up.Concern forNATwasfoundtobeassociatedwithincreasedoddsof group1vs2or3outcomes;however,giventheadditional

Table6. Logisticregressionmodel-estimatedoddsratiosofgroup1vsGroup2or3. PatientcharacteristicOddsratio

Age(reference:1–5years)

<1 1.060.961.170.22

5–10years0.950.881.020.15 11–15years1.000.911.100.97 >151.010.901.120.90

Race(reference:non-White)

White0.980.931.040.56

Gender(reference:female)

Male0.950.901.000.05

Ethnicity(reference:non-Hispanic)

Insurance(reference:publicinsurance)

Burnsite(reference:wrist/hand/palm)

Head/neck/face1.090.981.210.10

Lowerlimb(knees,ankle,foot,sole)1.010.941.090.79

Upperlimb1.080.991.170.07

Wasthereconcernfornon-accidentaltrauma?(Reference:No)

Yes1.351.121.62 <0.001

considerationsnecessarywhenthereisconcernforNAT,itis difficulttodisentanglethesocialvsclinicalconsiderations behindtheramificationsofthis finding.

LIMITATIONS

Limitationsofthisstudyincludeitsrelativelysmallsample sizeand,therefore,limitedpowerandlimited generalizability.Itisimportanttonotethatinthisstudywe usedtheoutcomeofadmissionorfollow-upasaproxyfor requirementofadmissionand/orfollow-up.Inaddition, investigatorknowledgeoffollow-upwaslimitedtopatients returningeithertotheEDofinitialpresentationortothetwo regionalburncenters.Itispossiblethatsomepatientsin group3followedupatoutsideinstitutionsorprimarycare

clinics.However,thepediatricEDinvolvedinthestudyisthe onlypediatric-speciﬁcEDinthestudycounty,andthetwo regionalburncentersaretheonlyburnspecialtycentersin thestudycounty.Wedidnotincludelengthofstayfor patientswhoweredirectlytransferredinthisanalysis,andit ispossiblethatpatientswhoweredirectlytransferredbut dischargedfromtheburncenterEDwereincorrectly apportionedtogroup1.Thismayhaveledtocharacteristics incorrectlyassociatedwithneedfordirecttransfer.

CONCLUSION

Thisstudydemonstratestheimportanceofindividual institution/regionalpopulationdataasitmaydifferfrom nationalestimations,andthesestatisticsmayinforminjury

preventioneducationandoutreachregardingpediatric burns.Thelimitedstatisticallysignificantdataassociated withtransfer/admissionvsfollow-upvsnofollow-upwas surprisingyetilluminatespotentialcausesforthediverse transfer/admissionpracticesdemonstratedinprevious studies.Theseresultshighlightthepotentialroleof telemedicineforexpertguidance;however,futurestudiesare necessarytodeterminewhichpatientsmaybebestsuitedto telemedicineconsults.Onenotable findinginthisstudywas theassociationofscaldburnswithtreatment(admissionor follow-up),suggestingthatthepresenceofascaldburnina childmaysignifytocliniciansthataburncenterconsultis warranted.Futureresearchcouldexpandonthisworkby analyzinglargerpatientpopulationsandexpandingburn andpatientvariablestocapturefurthersignificantdata pointsthatmayhelpimprovecliniciandispositiondecisions.

AddressforCorrespondence:TheodoreHeyming,MD,Children’s HospitalofOrangeCounty,1201W.LaVetaAve.,Orange, CA92868.Email: Theyming@choc.org

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

REFERENCES

1.MitchellM,KistamgariS,ChounthirathT,etal.Childrenyoungerthan 18yearstreatedfornonfatalburnsinUSemergencydepartments. Clin Pediatr(Phila). 2020;59(1):34–44.

2.EwbankC,SheckterCC,WarstadtNM,etal.Variationsinaccess tospecialtycareforchildrenwithsevereburns. AmJEmergMed. 2020;38(6):1146–52.

3.KimLK,MartinHC,HollandAJ.Medicalmanagementofpaediatric burninjuries:Bestpractice. JPaediatrChildHealth. 2012;48(4):290–5.

4.vanBaarME,PolinderS,Essink-BotML,etal.Qualityoflifeafterburns inchildhood(5–15years):Childrenexperiencesubstantialproblems. Burns. 2011;37(6):930–8.

5.PartainKP,FabiaR,ThakkarRK.Pediatricburncare:newtechniques andoutcomes. CurrOpinPediatr. 2020;32(3):405–10.

6.AbramowiczS,AllareddyV,LeeMK,etal.Hospital-basedemergency departmentvisitswithpediatricburns:Characteristicsandoutcomes. PediatrEmergCare. 2020;36(8):393–6.

7.SheckterCC,KiwanukaH,MaanZ,etal.Increasingambulatory treatmentofpediatricminorburns theemergingparadigmforburn careinchildren. Burns. 2019;45(1):165–72.

8.ArmstrongM,WheelerKK,ShiJ,etal.EpidemiologyandtrendofUS pediatricburnhospitalizations,2003–2016. Burns. 2021;47(3):551–9.

9.CarterNH,LeonardC,RaeL.Assessmentofoutreachbyaregional burncenter. JBurnCareRes. 2018;39(2):245–51.

10.BettencourtAP,RomanowskiKS,JoeV,etal.Updatingtheburncenter referralcriteria:resultsfromthe2018eDelphiconsensusstudy. JBurn CareRes. 2020;41(5):1052–62.

11.GarciaDI,LesherAP,CorriganC,etal.Interhospitalvariationof inpatientversusoutpatientpediatricburntreatmentafteremergency departmentevaluation. JPediatrSurg. 2020;55(10):2134–9.

12.AndersonKT,Bartz-KuryckiMA,GarwoodGM,etal.Lettheright onein:highadmissionrateforlow-acuitypediatricburns. Surgery. 2019;165(2):360–4.

13.PhamC,CollierZ,GillenwaterJ.Changingthewaywethinkaboutburn sizeestimation. JBurnCareRes. 2019;40(1):1–11.

14.GovermanJ,BittnerEA,FriedstatJS,etal.Discrepancyininitial pediatricburnestimatesanditsimpacton ﬂuidresuscitation. JBurn CareRes. 2015;36(5):574–9.

15.CarterNH,LeonardC,RaeL.Assessmentofoutreachbyaregional burncenter:Couldreferralcriteriarevisionhelpwithutilizationof resources? JBurnCareRes. 2018;39(2):245–51.

16.BettencourtAP,RomanowskiKS,JoeV,etal.Updatingtheburncenter referralcriteria:resultsfromthe2018eDelphiconsensusstudy. JBurn CareRes. 2020;41(5):1052–62.

17.AmericanBurnAssociation.Burnresearchdataset.2019. Availableat: https://ameriburn.org/research/burn-dataset/ AccessedSeptember12,2023.

18.AbeyasundaraSL,RajanV,LamL,etal.Thechangingpatternof pediatricburns. JBurnCareRes. 2011;32(2):178–84.

19.JohnsonSA,ShiJ,GronerJI,etal.Inter-facilitytransferofpediatric burnpatientsfromU.S.emergencydepartments. Burns. 2016;42(7):1413–22.

20.DoudAN,SwansonJM,LaddMR,etal.Referralpatternsinpediatric burnpatients. AmSurg. 2014;80(9):836–40.

21.YperenDTV,LieshoutEMMV,NugterenLHT,etal.Adherencetothe emergencymanagementofsevereburnsreferralcriteriainburnpatients admittedtoahospitalwithorwithoutaspecializedburncenter. Burns. 2021;47(8):1810–7.

22.RoseAM,HassanZ,DavenportK,etal.Adherencetonationalburncare reviewreferralcriteriainapaediatricemergencydepartment. Burns. 2010;36(8):1165–71.

ORIGINAL RESEARCH

PerceivedVersusActualTimeofPrehospitalIntubation byParamedics

DanielShou,BS*

MatthewLevy,DO,MSc*†

RubenTroncoso,MD*†

BeccaScharf,MSc†

AsaMargolis,DO,MS,MPH*†

EricGarﬁnkel,DO*†

SectionEditor:DanielJoseph,MD

*JohnsHopkinsUniversitySchoolofMedicine,DepartmentofEmergencyMedicine, Baltimore,Maryland

† HowardCountyDepartmentofFireandRescueServices,OfﬁceoftheChief MedicalOfﬁ cer,Marriottsville,Maryland

Submissionhistory:SubmittedJuly12,2023;RevisionreceivedMarch5,2024;AcceptedMarch15,2024

ElectronicallypublishedJune20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18400

Introduction: Situationalawarenessisessentialduringemergentproceduressuchasendotracheal intubation.Previousstudiessuggestthattimedistortioncanoccurduringintubation.However,only in-hospitalintubationsperformedbyphysicianshavebeenstudied.Weaimedtodeterminewhethertime distortionaffectedparamedicsperformingintubationbyexaminingtheperceivedvsactualtotal laryngoscopytime,deﬁnedastimeelapsedfromthelaryngoscopebladeenteringthemouthuntilthe endotrachealtubeballoonpassesthevocalcords.

Methods: Forthisretrospectivestudywecollectedprehospitalintubationdatafromasuburban, fire department-basedemergencymedicalservices(EMS)systemfromJanuary5,2021–May21,2022.The perceivedtotallaryngoscopytimewasqueriedasapartoftheelectronichealthrecord.Video laryngoscopyrecordingswerereviewedbyapanelofexpertstodeterminetheactualtime.Patients >18 yearsoldwhounderwentintubationbyparamedicswithvideolaryngoscopywereincludedforanalysis. Theprimaryoutcomewasthedifferencebetweenactualandperceivedtotallaryngoscopytime. Secondaryanalysisexaminedtherelationshipbetweenhightimedistortion,definedasthehighest quartileoftheprimaryoutcome,andpatientage,paramedicyearsofexperience,perceivedpresenceof difficultanatomy,excesssecretions,useofrapidsequenceintubation,andmultipleintubationattempts. Weconducteddescriptiveanalysisfollowedbylogisticregressionanalysis,chi-squaretests,andFisher exacttestswhenappropriate.

Results: Atotalof122intubationswerecollectedforanalysis,and10wereexcludedduetolackofvideo recording.Finalanalysisincluded112intubations.Meanactuallaryngoscopytimewas50.0seconds(s) (95%confidenceinterval[CI]43.7–56.3).Meanperceivedlaryngoscopytimewas27.8s(95%CI 24.7–31.0).Themediandifferencebetweenactualandperceivedtimewas18s(interquartilerange 6–30).Wecalculatedhightimedistortionashavingadifferencegreaterthan30sbetweenactualand perceivedlaryngoscopytime.Noneofthesecondaryvariableshadstatisticallysignificantassociations withhightimedistortion.Overall,weshowthattheparamedic’sperceptionoftotallaryngoscopytime issignificantlyunderestimatedevenwhenaccountingforparamedicexperienceandperceived airwaydifficulty.

Conclusion: Thisstudysuggeststhattimedistortionmayleadtoanunrecognizedprolongedprocedure time.Limitationsincludeuseofaconveniencesample,smallsamplesize,andpotentialuncollected confoundingvariables.[WestJEmergMed.2024;25(4)645–650.]

INTRODUCTION

Effectiveairwaymanagementisacriticalprehospital intervention,andendotrachealintubation(ETI)haslong beenconsideredanessentialparamedicskilltomanagea patientwithanunstableairwayorineffectivebreathing. WhileETIispotentiallylifesaving,theprocedurecanquickly becomeharmfulifhypoxiadevelopsduringlaryngoscopy.1 Althoughpreoxygenatedhealthypatientsmayhaveasafe apneatimeupto10minutes,themostlikelypatientto requireprehospitalETIisapatientinextremisorcardiac arrestforwhichthereisminimalliteratureregardingsafe proceduretime.2 Themoribundpatientlikelyalreadyhas abnormaloxygenationandventilation,whichfurther complicatesintubation,asanyamountofapneatimecould worsenthepatient’scondition.First-passsuccessandashort proceduretimeisthekeytominimizingadverseevents duringintubation;however,theabilityofparamedicsto maintainawarenessoftheelapsedtimeduringintubation isunknown.3,4

Anesthesialiteratureandhigh-proﬁleeventsdemonstrate thatevenexpertclinicianscansufferfromcognitiveerrors duringintubationthatcauseanunrecognizedprolonged proceduretimeandapoorpatientoutcomefromhypoxia.5,6 Studiesofhealthcareworkerssuggestthatstressful situations,suchasthoseduringanintubationor resuscitation,diminishtheabilitytoaccuratelyidentifythe passageoftime.7,8 Astudyofemergencyphysiciansfound thattheestimatedtimetointubationwassigniﬁcantlyless thantheactualproceduretime.9 However,the generalizabilityofthesestudiestocliniciansoperating outsidethehospitalenvironmentisunknown.Todate,there hasbeenapaucityofstudiesexaminingtheabilityof emergencymedicalservices(EMS)professionalsto estimatetimeduringstressfulsituationsinthe prehospitalenvironment.

Wesoughttoexaminetheperceivedvsactualtotal laryngoscopytime(TLT)duringprehospitalintubation performedbyparamedicsinacountywideEMSsystem.This informationcanbeusedtoinformfuturebestpracticesfor prehospitalintubation.

METHODS

Weperformedaretrospectivereviewcomparingactual TLTvsperceivedTLTamongaconveniencesampleofall patientsintubatedwithvideolaryngoscopyintheprehospital settingfromJanuary5,2021–May21,2022atasingle, combined ﬁreandEMSdepartment.Totallaryngoscopy timewasdeﬁnedastimeelapsedfromthelaryngoscopeblade enteringthemouthuntiltheendotrachealtubeballoon passedthevocalcords.

Patientswereintubatedby firefighterparamedicsfrom HowardCountyDepartmentofFire&RescueServices (HCDFRS).All firefighterparamedicsarelicensedinthe stateofMarylandandmaintainactivecertificationwiththe

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Elevatedstressandanincreasedcognitive loadduringintubationscanreducetheability ofclinicianstoaccuratelydeterminethe passageoftime.

Whatwastheresearchquestion?

Amongparamedics,isthereadifference betweenperceivedvsactualtotal laryngoscopytime(TLT)?

Whatwasthemajor ﬁndingofthestudy?

PerceivedTLT(26. 8seconds,95%CI

23.7 – 29.8)wassigni ﬁ cantlylowerthan actualTLT(44.6seconds,95%CI

41.2 – 48.1).

Howdoesthisimprovepopulationhealth?

Theidenti ﬁ edtimedifferencesofferguidance foreducationalandproceduralinterventions withthegoalofimprovingclinicaloutcomes forpatients.

NationalRegistryofEmergencyMedicalTechnicians.The HCDFRSisacombinedcareer-volunteerdepartmentwith over900careerandvolunteerpersonnel.Thedepartment receivesover30,000EMScallsperyearandservesabout 325,000residentsinHowardCounty,MD.Thedepartment iscomprisedof14stations,allofwhicharestaffedwith careerpersonnelandsixaresupplementedbyvolunteer crews.ThedepartmentoperatesbothBasicLifeSupportand AdvancedLifeSupport(ALS)transportunitsstaffedwitha minimumoftwoEMT-Bpersonnelandatleastone paramedic,respectively.Threeparamedicdutyofﬁcers (MDO)operatingin ﬂycarsprovidedailyoperational supervisionofEMSoperations,incidentcommand,and additionalALSsupporttocrewsdispatchedonhighcomplexitycalls.

EachALSunitcarriesmedicalequipmentthatis standardizedacrossthedepartment.Forintubations,the departmentprovidesvideolaryngoscopes(UEScope2,UE MedicalDevices,Inc,Newton,MA)inadditiontoa standardcomplementofconventional,non-video laryngoscopesandrescueairwaydevicessuchasabougie andsupraglotticairwaydevice(i-gel,Intersurgical,Ltd, Rugby,UnitedKingdom).Airwaymanagementprocedures andprotocolsareoutlinedinadepartmentalgeneralorder. Thegeneralorderrecommendstheuseofvideolaryngoscopy asthepreferredmethodoflaryngoscopy.Ifvideo

laryngoscopeequipmentisnotavailableoriftheclinical circumstancesdictate,theintubationmaybeperformedwith directlaryngoscopy.Immediatelyfollowingacallduring whichvideolaryngoscopywasperformed,theMDOwill immediatelyconductadebrieﬁngoftheprocedurewiththe respondingcrewanddownloadthevideoforinternal departmentalqualityassurance.Insituationswhere oxygenationandventilationcannotbeadequately performed,anemergencyneedlecricothyroidotomy maybeperformed.

Paramedicintubationcompetencyisassessedduring yearlycontinuingeducation,whichincludesaone-hour airwaylectureledbyanEMSphysicianfollowedbyaskills assessment.Paramedicswhoareinternallycredentialedto performrapidsequenceintubation(RSI)arerequiredto attendatleastonecadaverlabeveryyear,aswellasmonthly RSIdebriefsledbyanEMSphysician.Thecadaverlaband debriefsareoptionalfornon-RSIcredentialedparamedics.

Weconductedourretrospectivechartreview,data collection,andanalysisfollowingbestpracticemethodologic standardsforhealthrecordreview.10 Followingeach intubation,theintubatormustcompletean “airwayform,” whichincludesaquestionaskingtheparamedictoestimate theintubationproceduretime.Iftheparamedicconducted multipleintubationattemptstosuccessfullyintubatethe patient,theparamedicwasaskedtoestimatetheprocedure timeforeachintubationattempt.TheperceivedTLTwas thenretrievedfromtheelectronichealthrecord.ActualTLT wasdeterminedbyconsensusfromatrainedpanelofexperts blindedtothestudyobjectiveswhoreviewedprehospital videolaryngoscopyrecordingsobtainedfromthevideo laryngoscope.Theexpertpanelconsistedoftwoboardcertifiedemergencyphysicianswithsubspecialtycertification inEMS,anEMSfellow,twoparamedic fireofficers,one paramedic fieldsupervisor,aqualityimprovementofficer, andtwo fieldparamedics.Ifthepatientwassuccessfully intubatedmultipletimesbytheparamedic,onlythe first intubationwasincludedinthedataset.Thepanelalso collectedinformationandcametoaconsensusonseveral variablesthatmayhaveaffectedtheairwayproceduretime. Wethencompiledalldataintoadataset.Patientsinwhich datawasincompletewereexcludedfromthedataset priortoanalysis.

Inclusioncriteriaconsistedofallpatients ≥18yearswho wereintubatedbyaparamedicwithvideolaryngoscopy.The primaryoutcomewasthedifferencebetweenactualTLTand perceivedTLT.Secondaryanalysisexaminedthe relationshipbetweenhightimedistortionandsecondary variablesincludingpatientage,paramedicyearsof experience,perceivedpresenceofdifﬁcultanatomy,excess secretions,andtheuseofRSI.Weusedthehighestquartileof theprimaryoutcomeasthecut-offpointtodeﬁnecaseswith hightimedistortion.Wecalculatedthemean,median,and interquartilerange(IQR)toprovideinitialdescriptive

analysisofthedata.Outliersweredeﬁnedasvaluesthatwere greaterthan150%oftheIQR.Weusedthepaired t -testto comparethedifferencebetweenactualandperceivedTLT, excludinganyidentiﬁedoutliers.Logisticregressionanalysis, chi-squaretests,andFisherexacttestswereusedwhen appropriatetoexaminetherelationshipbetweenhightime distortionandsecondaryvariables.Weconductedalldata analysisusingSTATAversion17,(StataCorpLLC,College Station,TX).

ThisstudywasapprovedbytheJohnsHopkinsMedicine InstitutionalReviewBoard(referencenumber IRB00319716).

RESULTS

Duringthedeﬁnedstudyperiod,atotalof122intubations wereconductedbythedepartment,andallattemptsinvolved theuseofvideolaryngoscopy.Noattemptsusedbackup airwaymethods.Amongtheseattempts,112metinclusion criteria.Tenintubationswereexcludedduetolackof availablevideorecording. Table1 demonstratescalllocation andultimatedispositionofthepatientattheendofthecall.

Patientswereintubatedduetocardiacarrestin84% (94/112)ofcases.Rapidsequenceintubationoccurredin15% (17/112)ofpatients.Timerangeofattemptswas19–300 seconds(s),with83%(93/112)taking60sorless.First-pass successwas83%(93/112)withanaveragetimeof47.5s (19–300).Oftheattemptsthattooklongerthanaminute,the averageTLTwas100.4s.Unsuccessfulattemptstookan averageof62.5s(24–120)(Table2).Paramedicsintubating hadanaverageof10.7yearsofexperienceinthedepartment andaverage2–3intubationsperyear.

ThemeanactualTLTwas50.0s(95%conﬁdenceinterval [CI]43.7–56.3),andthemeanperceivedTLTwas27.8s(95% CI24.6–31.0).Afterexcludingnineidentiﬁedoutliersthe meanactualTLTwas44.6s(95%CI41.2–48.1),andthe meanperceivedTLTwas26.8s(95%CI23.7–29.8).The differencesinmeansandmediansbetweenactualand

Table1. Demographicsandcharacteristicsofpatientsintubated.

CharacteristicsOverall(n = 112)

Age,mean(years)61.9

Malegender(%)62(55%)

Calllocation

Home/otherresidence(%)77(69%)

Public(%)21(19%)

Healthcarefacility(%)11(10%)

Other(%)3(2%)

Patientdisposition

Transferredtohospitalcare(%)95(85%)

Pronounceddeceasedonscene(%)17(15%)

Table2. Actualintubationaveragetimeandrangebrokendownbydifferentgroups.

perceivedTLTwere17.9s(95%CI14.5–21.2)and18.0s (IQR6–29),respectively(Table3).

Wecalculatedhightimedistortionashavingadifference greaterthan29sbetweenactualTLTandperceivedTLT. Patientage,paramedicyearsofexperience,theuseofRSI, presenceofexcesssecretionsordifﬁcultairwayanatomy,and multipleintubationattemptsshowednostatistically signiﬁcantassociationwithhightimedistortion(Table4).

DISCUSSION

Toourknowledge,thisisthe firststudytoinvestigate situationalawarenessofparamedicsduringprehospital intubations.Overall,ourdatashowsthatourparamedics hada first-passsuccessrateof83%whenusingvideo laryngoscopescomparedtoahistoric first-passrateof51% andoverallintubationsuccessrateof61%in2009,priorto theintroductionofvideolaryngoscopesinthedepartment.11

Ourreported ﬁrst-passsuccessrateishighercomparedto thatofothersystems,suchastheSeattleFireDepartment (63%),12 andfromlarge,multicenterstudiessuchasthe PragmaticAirwayResuscitationTrial(51%)13;however, accuratecomparisonof ﬁrst-passratesbetweenourcohort andthatofotherdepartmentsmaybecomplicatedbyour relativelysmallersamplesizeanddifferencesindepartmental protocolandtraining.

Ourdatashowsanaverageparamedic-perceivedTLTthat wassigniﬁcantlylowerthanthemeasuredTLT.Thisresultis similartothatofpreviousstudiesofstressfulsituations

conductedinahospitalsetting.Onestudy,followingintern physicians,residentphysicians,andnursesduringin-hospital cardiopulmonaryresuscitationsimulations,foundthat cliniciansunderestimatedcardiacarrestdurationby22.5s whenaskedduringthesimulation.14 Asimilar underestimationwasfoundinphysiciansandnursesduring neonatalresuscitationsimulationswhenaskedtoestimate timefrombirthtoseveralcheckpointinterventions.8 Finally, astudyofemergencyphysiciansexaminingtimeperception inactualemergencydepartmentRSIsfoundasigniﬁcant underestimationofproceduretime,23vs45.5s.Thisstudy alsofoundthataccuracyindeterminingthetimeelapsed worsenedasmoretimepassedduringintubation.9

Theclinicalimplicationofunderestimatingelapsedtime duringintubationispotentiallylethal.Evenwith preoxygenation,ittakesjust10minutesforthepulse oximetrytodropbelow80%inahealthy,non-obeseadult. However,acriticallyillpatientismorelikelytohavethe presenceofshunting,increasedmetabolicdemand,anemia, volumedepletion,anddecreasedcardiacoutput,allofwhich havebeenshowntoreducebothoxygenstorageinthelungs andsafeapneatime.15 Thiseffectwouldbereasonably ampliﬁedevenfurtherincardiacarrestpatientswitha prolongeddowntime.Ourresultsshowedamediantime underestimationof18scomparedtotheactualTLT.Whileit isnotclearwhetheranoveralldifferenceof18sissigniﬁcant, anytimedilationcouldresultinalongerthanexpectedapnea timeandapoorclinicaloutcome.

Table3. Comparisonofmeanandmedianactualvsperceivedtotallaryngoscopytimeamongallincludedintubations(n = 103),excluding 9outliers.

Excludingoutliers

TLT,totallaryngoscopytime; s,seconds; IQR,interquartilerange; CI,conﬁdenceinterval.

Table4. Univariatelogisticregressionofpatientandparamedic variablesassociatedwithhavinghightimedistortion.(excluding 9outliers).

IntubationvariableOR(95%CI) P-value

Patientage0.98(0.96–1.01)0.15

Paramedicyearsofexperience0.94(0.88–1.00)0.06

Difﬁcultanatomy0.39(0.04–3.25)0.38

Excesssecretions0.38(0.12–1.22)0.11

RSI1.24(0.35–4.31)0.74

Repeatattempts2.05(0.61–6.83)0.24

CI,conﬁdenceinterval; RSI,rapidsequenceintubation.

Wesoughttoexplorevariablesthatcouldaffect perceptionofintubationtimesuchaspresenceofadifficult airway,RSI,pastparamedicexperience,andrepeated intubationattempts.However,thesevariableswerenot associatedwithastatisticallysignificanthightimedifference. Futureresearchisrequiredtodeterminewhichfactors,if any,influenceaccuracyoftimeperception.

Currenteducationandthebodyofliteratureemphasize first-passsuccessasthebenchmarkofasuccessfulintubation. Multiplestudieshaveshownanassociationwithanincreased riskofadverseeventswitheachsuccessiveintubation attempt.However,overemphasison first-passsuccessmay leadtoa fixationonavoidingasecondintubationattemptat thecostofaprolongedproceduretimeandhypoxia. Monitoringforhypoxiaduringintubationofacriticallyill patientposesasignificantchallengeaspulseoximetryis unlikelytobereliablesecondarytopoorperfusion.To addressthis,weproposemodifyingthecurrentparadigmofa successfulintubationfromonethatemphasizes first-pass successtoonethatemphasizesoveralltimeawarenesswitha lowthresholdforrecognizingandabortingaprolonged intubationattempt.Currently,thegoalmaximumtimefora prehospitalintubationisnotestablished.Inourdataset,83% ofintubationattemptswereperformedwithinoneminute andattemptsthatlastedlongerthanaminuterequired another40sofproceduretime,onaverage.TheHCDFRS hasimplementedamaximumof60sforanintubation attemptgiventheseresultsandthesimplicityofremembering oneminuteperattempt.However,weacknowledgethat moreresearchisrequiredtoidentifyasafemaximum prehospitalintubationtimeandthatthetimethresholdmay varywithdifferentclinicalpresentations.

Weproposeintroducingandemphasizingtimeawareness inprehospitalintubationprotocolstoavoidtask fixation. ThismodificationwasincludedintheAmericanSocietyof AnesthesiologistsDifficultAirwayManagementGuideline in20225 andhasbeenincorporatedintothedepartment’ s mostrecentairwaymanagementprotocol.Interventions couldincludethosealreadyusedinaviationtoreducetask fixation,suchastheuseofchecklists,closed-loop

communication,andoptimizeddatapresentations.16,17 Additionalinterventionscanfocusonparamediceducation. Initialcertifyingclassesandcontinuingmedicaleducation canemphasizetimeawarenessduringintubationsthrough focuseddidacticsandfrequent,high-ﬁdelitysimulationsthat emphasizetheuseofanairwayalgorithmandpromotealow thresholdforabortinganintubationattemptandmovingtoa backupairwaymethod.Futureresearchisrequiredtoassess theefﬁcacyoftheseinterventionsintheprehospital environmentandestablishtheidealmaximumprocedural timeforETI.

LIMITATIONS

Ourstudyhassigniﬁcantlimitations.First,weuseda conveniencesampleofavailableprehospitalintubationsata singlesiteinwhichvideolaryngoscopydatawasreadily available.Assuch,oursamplesizeissmall,andwedidnot conductaformalsamplesizecalculationforthisstudy.The abilityofourconclusionstobegeneralizedtoothersystemsis limitedandwillwarrantanadditional,morerobuststudy withmorecomprehensivesampling.Second,thedatais reliantontheparamedicdocumentingtheirperceived intubationtimeduringcompletionoftheprehospitalcare report(PCR).Whilethedepartmentemphasizescompleting thePCRuponcompletionofthepatienttransport,the paramedichasupto24hourstocompletetheirit,whichmay affecttheparamedic’sabilitytoaccuraterememberthe perceivedproceduretime.

Additionally,thisstudyevaluatedonlyvideo laryngoscopy.Duetodifﬁcultiesinherentwithretrospective chartreview,itwasnotpossibletoevaluatepulseoximetryor clinicalstatusattimeofintubationattempt;thus,itisnot knownwhethertherewasanactualdifferenceinratesof hypoxiawithlongerintubationtimes,althoughprevious literaturewouldsupportthisassumption.Thiswillwarrant additionalstudiesincorporatingclinicaldataforpatients whoareintubated.Finally,notallpossiblesecondary variablesthatmayaffectperceptionofintubationtimewere capturedoranalyzedbythisstudy.Othervariablesthat possiblywarrantadditionalinvestigationincludepatient gender,indicationforintubation,andestimatedpatient weight,amongothers.

CONCLUSION

Inthissingle-sitestudy,thetotaltimeforvideo laryngoscopyintubationwassigniﬁcantlylongerthan perceivedbytheintubatingparamedic.Emphasisshouldbe placedonlimitingtheintubationtimetoavoidpotentially catastrophicdesaturationevents.

AddressforCorrespondence:EricGarﬁnkel,DO,JohnsHopkins Hospital,DepartmentofEmergencyMedicine,1800OrleansSt., Baltimore,MD21287.Email: egarﬁn2@jhu.edu

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

REFERENCES

1.CaseyJD,JanzDR,RussellDW,etal.Bag-maskventilationduring trachealintubationofcriticallyilladults. NEnglJMed. 2019;380(9):811–21.

2.GleasonJ,ChristianB,BartonE.Nasalcannulaapneicoxygenation preventsdesaturationduringendotrachealintubation:anintegrative literaturereview. WestJEmergMed. 2018;19(2):403–11.

3.RussottoV,MyatraSN,LaffeyJG,etal.intubationpracticesand adverseperi-intubationeventsincriticallyillpatientsfrom29countries. JAMA. 2021;325(12):1164.

4.HillC,FalveyD,McGillJ,etal.436:Timetosuccessfulintubationhasa similarcorrelationtohypoxiaasnumberofattemptsinrapidsequence intubation. AnnEmergMed. 2009;54(3):S137–8.

5.ApfelbaumJL,HagbergCA,ConnisRT,etal.2022AmericanSocietyof Anesthesiologistspracticeguidelinesformanagementofthedifﬁcult airway. Anesthesiology. 2021;136(1):31–81.

6.MarshallSDandChrimesN.Timeforabreathoffreshair:rethinking traininginairwaymanagement. Anaesthesia. 2016;71(11):1259–64.

7.NaftalovichR,McCueM,IskanderAJ,etal.Clinicians’ perceptionof time suggestedimprovementtothedifﬁcultairwayalgorithm. AnaesthCritCarePainMed. 2021;40(4):100899.

8.TrevisanutoD,DeBernardoG,ResG,etal.Timeperceptionduring neonatalresuscitation. JPediatr. 2016;177:103–7.

9.CemalovicN,ScoccimarroA,ArslanA,etal.Humanfactorsinthe emergencydepartment:isphysicianperceptionoftimeto intubationanddesaturationrateaccurate? EmergMedAustralas. 2016;28(3):295–9.

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

11.RothﬁeldKP,SeamanKG,DuellM,etal.Abstract33: videolaryngoscopyimprovesEMSintubationsuccessincardiacarrest patients. Circulation. 2011;124(suppl_21):A33.

12.MurphyDL,BulgerNE,HarringtonBM,etal.Fewertrachealintubation attemptsareassociatedwithimprovedneurologicallyintactsurvival followingout-of-hospitalcardiacarrest. Resuscitation. 2021;167:289–96.

13.LesnickJA,MooreJX,ZhangY,etal.Airwayinsertion ﬁrstpasssuccess andpatientoutcomesinadultout-of-hospitalcardiacarrest:the pragmaticairwayresuscitationtrial. Resuscitation. 2021;158:151–6.

14.BrabrandM,FolkestadL,HosbondS.Perceptionoftimebyprofessional healthcareworkersduringsimulatedcardiacarrest. AmJEmergMed. 2011;29(1):124–6.

15.BenumofJonathanL,DaggR,BenumofR.Criticalhemoglobin desaturationwilloccurbeforereturntoanunparalyzedstatefollowing 1mg/kgintravenoussuccinylcholine. Anesthesiology. 1997;87(4):979–82.

16.ChandranR.Humanfactorsinanaestheticcrisis. WorldJAnesthesiol. 2014;3(3):203–12.

17.NguyenT,LimCP,NguyenND,etal.Areviewofsituation awarenessassessmentapproachesinaviationenvironments. IEEE SystJ 2019;13(3):3590–603.

CompartmentSyndromeFollowingSnakeEnvenomationinthe UnitedStates:AScopingReviewoftheClinicalLiterature

JohnNewman,MD*†

ColinTherriault,MD‡

MiaS.White,MLIS§

DanielNogee,MD*∥

JosephE.Carpenter,MD*∥

SectionEditor:JeffreySuchard,MD

*EmoryUniversitySchoolofMedicine,DepartmentofEmergencyMedicine,Atlanta,Georgia

† VanderbiltUniversityMedicalCenter,DepartmentofPathology,Microbiologyand Immunology,Nashville,Tennessee

‡ UniversityofIllinoisCollegeofMedicine,DepartmentofEmergencyMedicine,Peoria,Illinois

§ WoodruffHealthSciencesCenterLibrary,EmoryUniversity,Atlanta,Georgia

∥ GeorgiaPoisonCenter,Atlanta,Georgia

Submissionhistory:SubmittedJuly13,2023;RevisionreceivedOctober31,2023;AcceptedJanuary23,2024

ElectronicallypublishedJune14,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.61539

Introduction: LocaltissuedestructionfollowingenvenomationfromNorthAmericansnakes,particularly thosewithintheCrotalinaesubfamily,hasthepotentialtoprogresstocompartmentsyndrome.The pathophysiologyofvenom-inducedcompartmentsyndrome(VICS)isadebatedtopicandisdistinctfrom trauma/reperfusion-inducedcompartmentsyndrome.Heterogeneityexistsinthetreatmentpracticesof VICS,particularlyregardingthedecisiontoprogresstofasciotomy.Associationswithfunctional outcomesandevolutioninclinicalpracticesincetheintroductionofCrotalidaepolyvalentimmuneFab (FabAV)havenotbeenwelldeﬁned.Ourgoalwastoidentifythepotentialgapsintheliteratureregarding thisphenomenon,aswellasilluminatesalientthemesintheclinicalcharacteristicsandtreatment practicesofVICS.

Methods: Weconductedthissystematicscoping-stylereviewusingthePreferredReportingItemsfor SystematicReviewsandMeta-Analyses(PRISMA)guidelines.Recordswereincludediftheycontained datasurroundingtheenvenomationandhospitalcourseofoneormorepatientswhowereenvenomated byasnakespeciesnativetoNorthAmericaandwerediagnosedwithcompartmentsyndrome from1980–2020.

Results: Weincluded19papers:10single-ortwo-patientcasereportsencompassing12patients,and ninechartreviewsprovidingsummarystatisticsoftheincludedpatients.Incasereports,themedian compartmentpressurewhenreportedwas60millimetersofmercury(interquartilerange55–68),66% underwentfasciotomy,andfunctionaloutcomesvaried.Useofantivenomappearedtobemoreliberal withFabAVthantheearlierantiveninCrotalidaepolyvalent.Rapidprogressionofswellingwasthemost commonlyreportedsymptom.Amongtheincludedretrospectivechartreviews,importantdatasuchas compartmentpressures,consistentlaboratoryvalues,andsnakespecieswasinconsistentlyreported.

Conclusions: Venom-inducedcompartmentsyndromeisrelativelyrare.Existingpapersgenerally describegoodoutcomesevenintheabsenceofsurgicalmanagement.Signiﬁcantgapsinthe literatureregardingantivenomdosingpractices,serialcompartmentpressuremeasurements,and functionaloutcomeshighlighttheneedforprospectivestudiesandconsistentstandardizedreporting. [WestJEmergMed.2024;25(4)651–660.]

INTRODUCTION

ThevenomoussnakesofNorthAmericacapableof causingsigniﬁcantsofttissuedamagefallunderthefamily ViperidaeandthesubfamilyCrotalinae(alsoreferredtoas crotalids).1 Snakesinthiscategoryconsistofthegenera Crotalus (rattlesnakes), Sistrurus (pygmyrattlesnakeand massasauga),and Agkistrodon (cottonmouthand copperheads).Thesegeneraareoftencolloquiallyreferredto aspitvipersduetothepresenceofheat-sensingpitsbehind theirnostrils.2 Crotalidvenomisacomplexmixtureofmore than100macromolecules,glycoproteins,andmetals. PhospholipaseA2,inﬂammatorymediatoranalogues,and metalloproteinasesdamageendotheliumanddisruptnormal coagulationcascades,primarilymanifestingaslocaltissue destructionandhematologictoxicity,althoughneurotoxicity candevelopafterenvenomationfromsomespecies.3,4 In severecases,tissuedestructionandswellingduetocrotalid envenomationhasthepotentialtoprogresstocompartment syndrome.Incontrast,elapidvenomfoundinNorth Americancoralsnakesresultsinlittletonolocal tissuedestruction.5,6

Thenatureofvenom-inducedcompartmentsyndrome (VICS)isadebatedtopic,aslocalsymptomscommonto crotalidenvenomationsuchaspallor,edema,paresthesia, andpainwithpassivemovementcanmimictraumaor reperfusion-associatedcompartmentsyndrome.However, truecompartmentsyndromeisthoughttoberareafter envenomation,astheassociatedsymptomsaremorelikely duetodirectmyonecrosisratherthanelevatedcompartment pressuresandassociatedtissueischemia.3,5–7 Asaresult, someadvocateagainstusingthetermcompartment syndrometodescribethecondition.Consequently,thereis heterogeneityinhowcliniciansapproachsuspectedcasesof VICS,includingtheroleoffasciotomy.

Thistreatmentinconsistencyalsostemsfromhistoric misguidanceofsuspectedcasesofcompartmentsyndrome followingenvenomation,whichreacheditsnadirinthe 1970s–1980swhenfasciotomywasconsideredthegold standardoftreatment.Numerousreviewsandanimalmodels suggestthatpromptantivenomadministrationprecludesthe needforfasciotomy,asantivenomtreatmentalonehasbeen showntoreduceintracompartmentalpressuresinanimal models.8,9 Ina2011review,Cumpstonconcludedthat currentevidencedidnotsupporttheuseoffasciotomyin Crotalinaeenvenomationwithelevatedcompartment pressuresandmightevenworsenoutcomes.7 Ofnote,the majorityofarticlesincludedinthatreviewdescribepatients treatedwithantiveninCrotalidaepolyvalent(ACP),priorto theintroductionofCrotalidaepolyvalentimmuneFab (FabAV),addingsigniﬁcancetoanadditionalreview.

Atourinstitution,wewererecentlyconsultedintwo copperheadenvenomationsinwhichlocaltissuedamage progressedtoallegedcompartmentsyndromewithelevated compartmentpressures;fasciotomywasperformedinboth

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Compartmentsyndromeisarare complicationofenvenomationbycertain snakespecies;clinicaldataregardingthis phenomenonispoorlydescribed.

Whatwastheresearchquestion?

Whataretheclinicalcharacteristics, treatmentparadigmsandfunctional outcomesofvenom-inducedcompartment syndrome(VICS)?

Whatwasthemajor ﬁndingofthestudy? For19papers,themediancompartment pressurewas60mmHg(IQR55 – 68)and 66%underwentfasciotomy.Functional outcomesvariedbutweregenerallygood.

Howdoesthisimprovepopulationhealth? (165charactersmax) Thisreviewdistillswhatisknownabout VICSandhighlightsimportantgapsin theliterature,includinglong-term functionaloutcomes.

cases.Thisledourteamtoquestionhowoftenthisclinical scenariooccursandwhatliteratureexiststoguide managementandinformprognosis.Therefore,we performedareviewofliteraturereportingcompartment syndromefollowingNorthAmericansnakeenvenomationto gatherdataregardingsymptomatology,laboratory/pressure abnormalities,interventions,andoutcomesandtoidentify gapsintheliteraturesurroundingthisphenomenon, particularlyconcerningfunctionaloutcomes.

METHODS

Weconductedasystematicreviewofpublishedstudies reportingcompartmentsyndromefollowingNorth AmericansnakeenvenomationfromJanuary1, 1980–November18,2020.Ourteamincludedthreemedical toxicologists,oneresidentphysician,andaninformation specialist(librarianMSW).WeusedthePreferredReporting ItemsforSystematicReviewsandMeta-Analyses (PRISMA)statementastheguidelineforconductingthis review.10 AccordingtotheguidelinesoftheEmory UniversityInstitutionalReviewBoard,thisstudywasnot humansubjectsresearchanddidnotrequirereview.

Afterconsultationwithotherteammembers,the informationspecialistdevelopedasearchstrategy;six

databasesweresearched.Wesearchedterms “compartment syndromes,”“snakebite,”“snakebites,” and “North America.” Thesystematicsearcheswereperformedin Agricola(Ebscohost),CochraneCentralRegisterof ControlledTrials(CENTRALviaCochraneLibrary), Embase(Elsevier),GlobalHealth(CABDirect),PubMed (NLM),andWebofScience(corecollectionsviaClarivate) databasesonNovember18,2020.Thecompletesearchterms andstrategiesareincludedassupplementalinformation.We filteredsearchresultsforEnglishlanguageandjournal articlesonly;editorialsandletterswereexcludedineach database.Inaddition,whereapplicable,wealsosought conferenceabstractsandreviewsifwefeltthattherewere sufficientdatapointswithintheabstract.Duringthesearch process,iftherewerefewerthan fiverecordsretrieved, filters suchasEnglishlanguageandarticletypewerenotapplied.

Allrecords(278)wereimportedintoCovidence (Melbourne,Australia),andduplicatecitationswere removedbyCovidencepriortothereview.Fifty-four duplicateswereremoved,and224recordsweresettobe screened.Recordswereeligibleforinclusionifthey containeddemographicandbite-relateddataregardingone ormorepatientswhowereenvenomatedbyasnakespecies nativetoNorthAmericaandwerediagnosedwith compartmentsyndrome.Oneresidentandtwomedical toxicologistsreviewedtherecords,andathirdmedical toxicologistresolvedrecordsindispute.Resultsare presentedindescriptiveandtabularformat.Noformal statisticalanalyseswereperformed.

RESULTS

Afterinitialscreeningofthe224recordsretrieved,161 studiesweredeemedirrelevant,usuallyduetobitesfrom animalsotherthansnakes,envenomationbyanon-native speciesofsnake,orbitesthattookplaceoutsidetheUnited States.Uponreviewofthecompletearticles,weexcludedan additional44duetoabsenceofsigniﬁcantdocumented outcomemeasures,leaving19studiesforstudyinclusion (Figure).Ofthe19studiesincluded,10weresingle-or two-patientcasereportsprovidingpatient-leveldata11–20 (Tables1–3)andninewerechartreviewsummariesproviding summarystatisticsoftheincludedpatients5,21–28 (Table4). AllspeciescausingVICSinthisreviewfallunderthe Crotalinaesubfamily(crotalids).Intotal,88caseswere extracted:12fromsingle-ortwo-patientcasereports,and76 casesfromretrospectivechartreviews.

Casereportsincludedatotalof12patientswithanage rangeof1–59years;9/12(75%)weremale(Table1).Species reportedwerethefollowing:copperhead(3/12,25%);western diamondbackrattlesnake(2/12,17%);greatbasin rattlesnake(2/12,17%);cottonmouth(1/12,8%);eastern diamondbackrattlesnake(1/12,8%);pygmyrattlesnake (1/12,8%);andblack-tailedrattlesnake(1/12,8%).Biteswere inﬂictedonthehands(4/12,33%),dorsalfoot(2/12,17%)and

identified from

54 duplicate records removed

224 abstracts screened

63 publications screened assessed for eligibility

19 publications included for review

161 excluded for irrelevancy (Bites from incorrect animal or non-native species of snake, or bites that took place in another country).

44 excluded (Inadequate patient data or experimental studies)

anteriorlowerextremity(2/12,17%).Allfemales(3/3) sufferedlowerextremitybites.

Signsandsymptomsreportedincludedthefollowing: rapidprogressionofswellingandedema(11/12,92%); ﬁrm compartments(10/12,83%);andpain(9/12,75%).Erythema wasnotascommonlyreported(3/1225%, Table2). Compartmentpressureswerereportedforall12patients, withamediancompartmentpressureof60millimetersof mercury(interquartilerange[IQR]55–68).Allpatients receivedantivenom.Insix(50%)casestheauthorsdidnot specifywhichantivenomwasused.Foranalyticpurposes,we assumedthatcasereportsfromthe1980sand1990s11–13 employedACPandthatanotherreportfrom201117 used FabAV.IncasesemployingACP,themediannumberof vialsemployedwas10(IQR7–15)andincasesemploying FabAVthemedianwas21(IQR15–32).Fasciotomywas performedin8/12(66%)cases:3/5ACPand4/6FabAV (Table3).Withbothantivenoms,patientsundergoing fasciotomyreceivedfewervialsthanthosewhodidnot receivesurgicalmanagement,keepinginmindthesmall numberofpatientsineachgroup.Twopatientswho underwentfasciotomyreportedmotordeﬁcits,comparedto zeropatientstreatedwithmedicaltherapyalone.

Chartreviewpublicationsincludeddatafrom947patients (Table4).Three(33%)studiesreportedthesnakespecies involved.Eight(89%)reportedthelocationofbite.Onlyone (11%)studyreportedphysicalexamination ﬁndings.Four (33%)studiesreportedspeciﬁccompartmentpressures.In total,49(5.2%)patientswerediagnosedwithcompartment syndrome,and44ofthosepatientsunderwentfasciotomy. Ofpatientswhoreceivedfasciotomies,onlysix(12%)had

Records

Agricola (Ebscohost), Cochrane Central Register of Controlled Trials (CENTRAL via Cochrane Library), Embase (Elsevier), Global Health (CAB Direct), PubMed (NLM), and Web of Science (Core collections via Clarivate)

Databases (n =6)

of studiesvia databases and registers

Figure. PRISMA ﬂowdiagram.

Table1. Demographicsforcasereports.

PublicationAge(y)GenderSnakespeciesBitelocation

Robertsetal,1985[13](patient1)14MPygmyrattlesnakeFinger (Patient2)39MCottonmouthVolarhand Seileretal,1994[14]8MNotspeciﬁedPosteriorlowerextremity PaddaandBowen,1995[15]5MCopperheadAnkle Rosenetal,2000[16]59MWesterndiamondbackDorsalfoot Goldetal,2003[17]43MWesterndiamondbackVolarhand Hardyetal,2006[18]35FBlack-tailedrattlesnakeAnteriorlowerextremity Thomasetal,2011[19] (Patient1) (Patient2)

8FGreatBasinrattlesnakeAnkle 2MGreatBasinrattlesnakeFinger

Mazer-Amirshahietal,2014[20]1FCopperheadDorsalfoot Brysetal,2015[21]9MCopperheadDorsalhand McBrideetal,2017[22]48MEasterndiamondbackAnteriorlowerextremity M,male; F,female.

Table2. Symptomsandcompartmentpressuresforcasereports.

Publication Pain (passive)EdemaErythema

Robertsetal,1985[13] (Patient1) YesYesNoYesYesParesthesia,numbness, diminishedpulses 60 (Patient2)YesYesNoYesYesParesthesia,diminished

Seileretal,1994[14]YesYesNoYesYesParalysis55 PaddaandBowen 1995[15] NoNoNoYesYesParesthesia35

Rosenetal,2000[16]YesYesNoYesYesNone46 Goldetal,2003[17]YesYesYesYesYesParesthesia55 Hardyetal,2006[18]YesYesNoYesNoParesthesia,paralysis68 Thomasetal,2011[19] (Patient1) YesYesYesYesYesNone68 (Patient2)NoYesNoYesYesPoikilothermia,weakpulses60

Mazer-Amirshahietal, 2014[20] YesYesYesYesNoNone85

Brysetal,2015[21]YesYesNoYesYesNone56 McBrideetal,2017[22]NoYesNoNoYesNone72 mmHg,millimetersofmercury.

objectivecompartmentpressuresreported.Althoughthe chartreviewsinconsistentlyreportedwhichantivenomwas used,itwasassumedthatpublicationsfrombefore2001 employedACP.Theincidenceofcompartmentsyndromein chartreviewsfromtheACPerawas8.3%(42compartment syndromediagnosesfrom508cases)comparedto1.6% (sevencompartmentsyndromediagnosesfrom439cases) after2001.Thenumberofvialsofantivenomadministered

andinformationregardingthetemporalassociationbetween antivenomadministrationandfasciotomywasnot consistentlyreported.

DISCUSSION

Afteranintensivescreeningprocess,weincluded19 articlesinthisreview.Mostoftheincludedretrospective cohortstudiesdidnotreportindividualpatient-leveldata.

Table3. Treatmentsandoutcomesforcasereports.

PublicationAntivenom#ofvials

Robertsetal,1985[13] (Patient1) Not speciﬁed* 7Yes4Complete resolution

(Patient2)Not speciﬁed* 10Yes5Complete

Seileretal,1994[14]Not speciﬁed*

PaddaandBowen 1995[15] Not speciﬁed* Not speciﬁed

Rosenetal,2000[16]ACP15No2Painwithwalking1week Goldetal,2003[17]ACP30No3Complete resolution 6days

Hardyetal,2006[18]FabAV12Yes12Abscess, motordeﬁcit 2months, 2years

Thomasetal,2011[19] (Patient1) Not speciﬁed# 32No6NotreportedN/A (Patient2)Not speciﬁed# 15Yes5NotreportedN/A

Mazer-Amirshahietal, 2014[20] FabAV26No4Notreported2weeks

Brysetal,2015[21]FabAV16YesNotspeciﬁedNotreported2weeks McBrideetal,2017[22]FabAV54Yes15NotreportedN/A

*AssumedtobeACPbasedonyearofpublication. #AssumedtobeFabAV. ACP,antiveninCrotalidaepolyvalent; FabAV,CrotalidaepolyvalentimmuneFab.

Venom-inducedcompartmentsyndromeisararelyreported diseaseprocess,asweidentiﬁedonly88casesconsistingof12 fromcasereportsand76casesfromlargerretrospective reviewsdespitereviewingmorethan40yearsofliterature. Whilethetrueprevalenceislikelytobehigherthanthe numberofpublishedreports,thisnonethelessrepresentsa smallnumberincomparisontotheapproximately6,000 snakeenvenomationsoccurringeachyearintheUS.29

AclinicallysalientthemeapparentinthedataisthatVICS portendsbetteroutcomesincomparisontotrauma-induced compartmentsyndrome.Inthisreview,onlytwopatients fromtheincludedcasereports(Table3)wererecordedto haveresidualmotordeﬁcitsfollowingVICStreatment,both ofwhomreceivedafasciotomy.Nocasesintheincluded publishedliteratureledtoamputationorwereassociated withdeath.Incontrast,followingdiagnosisandtreatmentof traumaorreperfusion-associatedcompartmentsyndrome, motordeﬁcitsrangefrom18–44%,30,31 andamputationrates rangefrom5.7–12.9%.31–34 Whilethepathologyunderlying venom-inducedvstraumaticcompartmentsyndromeisvery different,theexpectedclinicalcourseandfunctional outcomeareimportantpointstoaddresswhencounseling patientsatthebedside.Itshouldbenotedthatfollow-up timesreportedwerevariableandgenerallyquiteshort on

theorderofdaystoweeks;sopatients’ ﬁnalfunctional outcome(s)areunknown,identifyinganimportantgapinthe snakebiteliterature.

Oneinterestingjuxtapositionthatbecameapparent duringanalysiswashowthedatadiffersbetweenthearticles publishedduringtheACPandFabAVtimeperiods.FabAV wasapprovedforusein2000,andthemanufactureofACP wasdiscontinuedin2001.Lookingatthecasereports (Tables1–3),fourpatientswithcompartmentsyndrome underwentfasciotomyineachantivenom “ era ”:ACPand FabAV.Themediannumberofantivenomvialsemployedin theACP(pre-2001)reportswas10vials,whilethemedian numberofvialsinpatientsreceivingFabAVwas21.The manufacturerofACPrecommendedaninitialdoseforsevere envenomationof10–15vialswithadditionalantivenomas neededbasedupontheclinicalresponse.35 Consideringrealworldexperience,aretrospectivestudyof414patients treatedforpresumedrattlesnakeenvenomationreporteda meandoseof38vials.36 Theprescribinginformationfor FabAVrecommendsaninitialdoseof4–6vials,followedby anadditional4–6vialsifneededtogaininitialcontrolofthe envenomation,andanadditionaltwovialseverysixhours for18hours(totaldoseof14–18vials).37 Clinicalexperience suggeststhatmostpatientsachievecontrolofswellingwith

Table4. Summarystatisticsforcumulativedatastudies.

StudyMethods

Downey etal, 1991[23]

Cowin etal, 1998[24]

Single-center, retrospectivechart reviewusing orthopedicoperation logsandhospital admissionrecords overan11-year period.

Patient/bite characteristicsSignsandsymptomsTreatment(s)Outcome(s)

36patients,28(78%) male.Medianage 21years(range2–71). 5(14%)foot/ankle bites,7(19%)leg bites,20(56%)hand bites,2(6%)forearm and2(6%)upperarm bites.Snakespecies notrecorded.Most commonactivities beforebeingbitten includedalcoholuse, playingoutside,and handlingapetsnake.

Studyusedmodiﬁed Wood,Hoback,and Green(McCollough,N andGennaro,J etal1968) envenomationscale.5 (14%)grade1,27 (75%)grade2,and3 (8%)grade3bites.Of the25(69%)patients diagnosedwith compartment syndrome,7werein thedigit,9inthehand/ forearm,1inthearm, and8inthefoot/leg. 25diagnosedwith compartment syndrome.

Antivenomusedin22 (61%)ofallbitesand in11/15(73%)of patientsundertheage of18,withatotaldose rangingfrom1–15 vials.Serumsickness occurredin1patient receivingantivenom. All25patients diagnosedwith compartment syndromereceived fasciotomies;3 patientshadobjective compartment pressures.

4postoperative infectionsoccurred, including1 secondarytothe fasciotomyprocedure.

Tanen etal, 2001[7]

Single-center, retrospectivechart reviewusingdiagnosis codesforsnakebites overa3-yearperiod. Someupperextremity biteswereevaluatedin ahandsurgeryclinic orbytelephonefor outcomedata.

73patients,20(74%) male.27(37%)lower extremitybitesand46 (63%)upperextremity. 24pygmyrattlesnake bites,11diamondback rattlesnake,15 cottonmouth,9coral snake.

Nopatient-leveldata reported;3patients diagnosedwith compartment syndrome.

9/27(33%)lower extremityand22/46 (48%)upperextremity bitesreceived antivenom.All3 patientsdiagnosed withcompartment syndromereceived fasciotomy.

4/14(29%)patients seeninclinicreported residualpainand tissueatrophyatthe bitesite.Onepatient whounderwent fasciotomyhad numerousdeﬁcits notedonphysical exam.Patients contactedby telephone(n=10) reportedsubjective numbness(7/10),local tissueloss(2/10),and stiffness(2/10).

Single-center, retrospectivechart reviewofbitepatients admittedtoamedical toxicologyserviceover a6-yearperiod.

236patients,191 (81%)male;138(56%) overtheageof13; 142(60%)upper extremitybites,39% lowerextremitybites.It tookanaverageof1.7 hoursbetweenthe timeofthebiteand arrivalatahealthcare facility,and5.3hours onaveragefrombiteto antivenominfusion.

14%ofchildrenand 24%ofadults developed hemorrhagicbullae. Compartment syndromewas diagnosedin8(3.3%) patients.Compartment pressureswereonly reportedinonepatient (80mmHg).Diagnosis wasbasedonclinical signsincluded coldnesstothetouch andpulselessnessin theothercases.

ACPadministeredto 77%ofpatients.An averageof28.5vials weregiven. Fasciotomyperformed on3patients,digital dermotomyon5 patients

Meanhospitalstay was2.5days,nolongtermoutcomes reported.

(Continuedonnextpage)

Table4. Continued.

StudyMethods

Tokish etal, 2001[25]

Five-center, retrospectivechart reviewofhospital admissionsfollowing snakebiteovera5yearperiod

Patient/bite characteristicsSignsandsymptomsTreatment(s)Outcome(s)

163patients,89(55%) male.Meanage29 (range1–81).55%of bitesweretothelower extremities,withone torsobite.12%were intoxicatedwhen bitten,and29%were purposefullyhandlinga snake.98%ofbites werefrom rattlesnakes.10(6%) ofpatientswere treatedwiththe “cut andsuck” prehospital intervention,7(4%) usedaconstriction band,and6(4%)used atourniquet.

Shaw etal, 2002[26]

Campbell etal, 2007[27]

Single-center, retrospectivechart reviewofpediatricbite patientsovera10-year period.

24pediatricpatients, 18(75%)male.14 (58%)upperextremity bites,10(42%)lower extremitybites.

6(4%)patients developed compartment syndrome,and16 (11%)developed necrosisinthe inoculationsite.

90%ofpatients receivedantivenom, withanaverageof19 vials(range0–75).The 6patientswith compartment syndromereceiveda fasciotomy,1patient receiveda ﬁnger amputation,andthe16 patientswithnecrosis allreceivedsurgical debridement.Surgery wasmorecommonin thosereceiving prehospital interventionssuchas incisionandvenom suction.

Meanhospitalstayof 2.8days.

Correa etal, 2014[28]

Single-center, retrospectivechart reviewofbitepatients overa10-yearperiod

Single-center, retrospectivechart reviewofpediatric patientsenvenomated overa6-yearperiod.

114pediatricpatients, 68%male.Meanage 4.2years(range 1–17).71(62%)lower extremitybites.65 (57%)copperhead,9 (8%)rattlesnake,and 7(6%)cottonmouth bites.

151pediatricpatients, 150(66%)male.91 (60%)lowerextremity bites,58(38%)upper extremitybites,1(1%) groinbite,1(1%)face bite.65copperhead,5 cottonmouth,3coral snake,3pitviper,1

2patientsdeveloped necrosisofthetipsof thedigits.Onepatient developed compartment syndromeoftheleg whenantivenom administrationwas stoppedafter5vials duetoanurticarial reaction.Anteriorand posteriorcompartment pressureswere 45mmHg.

Compartment syndromediagnosed in2(1.8%)patients. Compartment pressuresinboth patientsexceeded 60mmHg.One patientwasbittenbya cottonmouth,andthe otherbyacopperhead.

Studyusedinternal bite-severityscale,but patient-leveldatanot reported.Atleast2 (1.3%)patients diagnosedwith compartment syndrome.

Patientsreceivedan averageof12.5vials ofACPantivenom exceptforonepatient whoreceived4vialsof FabAV,then5vialsof equineantivenom.The 2patientswith necrosisofthetipsof thedigitsunderwent limiteddebridement. Onepatientwith compartment syndromeoftheleg underwentfasciotomy.

7(6%)patients receivedFabAV antivenom,2patients withcompartment receivedfasciotomies.

Meanhospitalstayof 3days(range1–10).

52(34%)patients receivedantivenom (FabAV)withamedian doseof6vials(range 1–16).4patientshad surgery,andtherewas nosigniﬁcant differencebetween patientstreatedwith

Nopatientoutcomes reported.

Medianhospitalstay was2days.

(Continuedonnextpage)

Table4. Continued.

StudyMethods

Theilen etal, 2014[29]

Darracq etal, 2015[30]

Single-center, retrospectivechart reviewofsurgical outcomesofpatients afterasnakebiteinan academicreferral centerovera4-year period

Retrospectivecase seriesfroma statewide(California) poisoncenter databaseoveran 11-yearperiod.Bites wherefasciotomywas eitherdiscussedor performedwere reviewed.

Patient/bite characteristicsSignsandsymptomsTreatment(s)Outcome(s) pygmyrattlesnake,1 ferdelance,and1 timberrattlesnakebite. antivenomandthose nottreatedwith antivenom.The operationsincluded2 fasciotomiesfor compartment syndrome,1full thicknessskingraft, and1wound debridement.No mentionofpressures.

45patients,noother demographicdata reported.

105patients.28(27%) patientsunderwent fasciotomy,with79% beingmaleand68% beingupperextremity bites.Ofthe74cases wherefasciotomywas discussedbutnot performed,77%were maleand68%were upperextremitybites.

Nopatient-leveldata reported. 36(80%)received antivenom,with16 (35.6%)requiring additionaldosing.One caseinvolvedaminor dermotomyofthe ﬁnger.16/19adult patientsonlyrequired monitoringintheED.

Compartment pressureswereonly recordedin2patients receivingfasciotomy andwereelevatedin both(36and 70mmHg).

Inpatientsreceiving fasciotomy,amedian of4.5vialsofFabAV antivenomwas preoperativelyand 13.5vials postoperatively,vs.a medianof18vialsin thegroupthatdidnot receiveafasciotomy.

ACP,antiveninCrotalidaepolyvalent; FabAV,CrotalidaepolyvalentimmuneFab; mmHg,millimetersofmercury; ED,emergencydepartment.

thisregimen;additionaldosing,whenrequired,istypically directedtowardhematotoxicity.9,38

TherelativelylowmedianACPdoseandsomewhathigh medianFabAVdosenotedinourreviewmayreﬂectearly discontinuationofACPduetohypersensitivityreactionsor fearofserumsickness,bothofwhicharefarlesscommon withFabAV.36 ThispatternalignswithaNationalPoison DataSystemreviewthatrevealedincreasedclinicianuseof antivenom,especiallyfollowing Agkistrodon genus envenomation,aftertheyear2000.29 Alternately,thiscould indicateaprematuredecisiontoproceedwithsurgical management,priortoappropriatedosingofantivenom, duringtheACPera.Expandingonthistheme,analysisofthe chartreviewstudies(Table4)revealedthattheincidenceof compartmentsyndromeinpatientsreceivingACPwas8.3% comparedto1.6%inpatientsreceivingFabAV.Whilethis decreasecouldreﬂectdifferencesintheculpritsnakespecies, orpublicationbias,asreportsofVICSmaynolongerbe

Meanhospitalstayof lessthan2days.

Lengthofstaywas signiﬁcantlylongerin patientsreceiving fasciotomy(6.15vs 3.45days).

considerednovelorworthyofpublication,thestudiescitedin Table4 weregenerallycomprehensivereviewsofall snakebitepatientsevaluatedbyacenterorphysiciangroup, notjustthemostinterestingorseverelyenvenomated patients.Therefore,itisplausiblethattheincidenceofVICS mayindeedbelowerthanpriortotheintroductionof FabAV,reﬂectingadequatecontroloftissueinjurywith appropriatelydosedantivenomratherthanfasciotomy.

Lastly,therewasinconsistentreportingofdata, particularlyamongthelargerretrospectivechartreview studies.Laboratoryabnormalitieswerealsorarelyreported butwhentheywere,deﬁnitionsofcertainderangementssuch ascoagulopathyandhypoﬁbrinogenemiatendedtodiffer betweeninstitutionsprecludinganyanalysesofor conclusionsregardingthesevalues.Althoughobjective compartmentpressuremeasurementpriortosurgical managementistheexpert-recommendedpractice,39,40 many studiesdidnotrecordthesevalues.Basedonthedata

availabletouswecouldnotdeterminewhetherthesevalues werenotobtainedorsimplynotreportedinarticles.

LIMITATIONS

Asweconductedascopingreview,wedidnotperforma formalassessmentoftheincludedarticles’ methodologiesor riskofbias.41 Wehadaccessonlytopublishedarticlesand didnothaveaccesstooriginaldatasets.Withoutaccessto identifyinginformation,itispossiblethatsomeofthecase reportswerealsoincludedintheretrospectivechart-review studies.Althoughweemployedasystematicsearchstrategy, itispossiblethatwedidnotcastawideenoughnetandthat somestudiesmeetinginclusioncriteriaweremissed. Additionally,weonlysearchedforpublishedresearchthat includedcasesofdiagnosedcompartmentsyndromeanddid notanalyzetheclinicalcharacteristicsofpatientswhowere notdiagnosedwithcompartmentsyndrome.Whileobjective measurementofcompartmentpressuresisrecommended, compartmentsyndromeisultimatelyaclinicaldiagnosisthat mayvarybetweenphysicians,particularlythosefrom differentspecialties(eg,medicalandsurgical),anditis possiblethatthediagnosismaybeover-orunder-reported dependingontheauthorofeachpaper.

Manydatapointswerescarcelyreported,including laboratoryvalues,compartmentpressures,andvialsof antivenomadministered.Itwasalsosometimesdifﬁcultto discerntheorderofevents,particularlythetimingof evaluationsandinterventionsincludingantivenom administration,measurementofcompartmentpressures,and fasciotomy.Also,noneoftheincludedcasesusedtherecently introducedCrotalidaeimmuneF(ab')2antivenom,andwe areunabletocommentonitspossibleefﬁcacyinVICS. Theselimitationshighlighttheimportanceofrigorous, prospectivedatacollectionandreportingthrough centralized,enduringdatabasessuchastheNorthAmerican SnakebiteRegistry.

CONCLUSION

CompartmentsyndromefollowingNorthAmerican snakeenvenomationisararediseaseprocess,and heterogeneityexistsinitstreatmentdespiteglobalevidence discouragingfasciotomy.Theseeminglyincreased tolerabilityofFabAVcomparedtoACPandtherelatively positiveshort-termoutcomesfollowingsuspectedvenominducedcompartmentsyndromesupportsliberalantivenom usage,proceedingtofasciotomyonlyaftercareful clinicalassessmentwithcompartmentpressuremeasurement andtoxicologyconsult.Additionally,noamputationsor deathswerereportedinthereviewedarticles.Weilluminate severalsigniﬁcantgapsintheliterature,includingthe needforprospectivestudiesassessingdifferencesinlongtermoutcomesbetweentreatmentmodalities,aswell astheidealtimingofantivenomemploymentand subsequentfasciotomy.

AddressforCorrespondence:JosephCarpenter,MD,Emory UniversitySchoolofMedicine,50HurtPlazaSE,Suite600,Atlanta, GA30303.Email: joseph.edward.carpenter@emory.edu

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

REFERENCES

1.CorbettBandClarkRF.NorthAmericansnakeenvenomation. Emerg MedClinNorthAm.2017;35(2):339–54.

2.GoldBS,DartRC,BarishRA.Bitesofvenomoussnakes. NEnglJMed 2002;347(5):347–56.

3.HolstegeCP,MillerMB,WermuthM,etal.Crotalidsnake envenomation. CritCareClin.1997;13(4):889–921.

4.RuhaAMandCurrySC.RecombinantfactorVIIafortreatmentof gastrointestinalhemorrhagefollowingrattlesnakeenvenomation. WildernessEnvironMed.2009;20(2):156–60.

5.TanenDA,RuhaAM,GraemeKA,etal.Epidemiologyand hospitalcourseofrattlesnakeenvenomationscaredforatatertiary referralcenterinCentralArizona. AcadEmergMed 2001;8(2):177–82.

6.LavonasEJ,RuhaAM,BannerW,etal.Uniﬁedtreatmentalgorithm forthemanagementofcrotalinesnakebiteintheUnitedStates:results ofanevidence-informedconsensusworkshop. BMCEmergMed. 2011;11:2.

7.CumpstonKL.IstherearoleforfasciotomyinCrotalinae envenomationsinNorthAmerica? ClinToxicol(Phila) 2011;49(5):351–65.

8.TanenDA,DanishDC,GriceGA,etal.Fasciotomyworsenstheamount ofmyonecrosisinaporcinemodelofcrotalineenvenomation. Ann EmergMed.2004;44(2):99–104.

9.LavonasEJ,GerardoCJ,O’MalleyG,etal.Initialexperiencewith CrotalidaepolyvalentimmuneFab(ovine)antivenominthetreatmentof copperheadsnakebite. AnnEmergMed.2004;43(2):200–6.

10.PageMJ,McKenzieJE,BossuytPM,etal.ThePRISMA2020 statement:anupdatedguidelineforreportingsystematicreviews. IntJSurg.2021;88:105906.

11.RobertsRS,CsencsitzTA,HeardCWJr.Upperextremitycompartment syndromesfollowingpitviperenvenomation. ClinOrthopRelatRes 1985;(193):184–8.

12.SeilerIiiJG,SagermanSD,GellerRJ,etal.Venomoussnakebite: currentconceptsoftreatment. Orthopedics.1994;17(8):707–14.

13.PaddaGSandBowenCH.Anestheticimplicationofsnake-bite envenomation. AnesthAnalg.1995;81(3):649–51.

14.RosenPB,LeivaJI,RossCP.Delayedantivenomtreatmentfora patientafterenvenomationbyCrotalusatrox. AnnEmergMed 2000;35(1):86–8.

15.GoldBS,BarishRA,DartRC,etal.Resolutionofcompartment syndromeafterrattlesnakeenvenomationutilizingnon-invasive measures. JEmergMed.2003;24(3):285–8.

16.HardyDLSr.andZamudioKR.Compartmentsyndrome,fasciotomy, andneuropathyafterarattlesnakeenvenomation:aspectsofmonitoring anddiagnosis. WildernessEnvironMed.2006;17(1):36–40.

17.ThomasKC,CrouchBI,CaravatiEM.Elevatedcompartmentpressures intwopediatricrattlesnakeenvenomations. ClinToxicol(Phila) 2011;49(6):541.

18.Mazer-AmirshahiM,BoutsikarisA,ClancyC.Elevatedcompartment pressuresfromcopperheadenvenomationsuccessfullytreatedwith antivenin. JEmergMed.2014;46(1):34–7.

19.BrysAK,Gandolﬁ BM,LevinsonH,etal.Copperheadenvenomation resultinginararecaseofhandcompartmentsyndromeandsubsequent fasciotomy. PlastReconstrSurgGlobOpen.2015;3(5):e396.

20.McBrideKM,BrombergW,DunneJ.Thromboelastographyutilizationin delayedrecurrentcoagulopathyaftersevereeasterndiamondback rattlesnakeenvenomation. AmSurg.2017;83(4):332–6.

21.DowneyDJ,OmerGE,MoneimMS.NewMexicorattlesnakebites: demographicreviewandguidelinesfortreatment. JTrauma 1991;31(10):1380–6.

22.CowinDJ,WrightT,CowinJA.Long-termcomplicationsofsnakebites totheupperextremity. JSouthOrthopAssoc.1998;7(3):205–11.

23.TokishJT,BenjaminJ,WalterF.Crotalidenvenomation:theSouthern Arizonaexperience. JOrthopTrauma.2001;15(1):5–9.

24.ShawBAandHosalkarHS.Rattlesnakebitesinchildren:antivenin treatmentandsurgicalindications. JBoneJointSurgAm 2002;84(9):1624–9.

25.CampbellBT,CorsiJM,BonetiC,etal.Pediatricsnakebites:lessons learnedfrom114cases. JPediatrSurg.2008;43(7):1338–41.

26.CorreaJA,FallonSC,CruzAT,etal.Managementofpediatric snakebites:arewedoingtoomuch?JPediatrSurg 2014;49(6):1009–15.

27.TheilenAB,SchwarzE,PoirierR,etal.HowoftendoNorthAmerican crotalidbitesneedsurgicalmanagement? ClinToxicol(Phila) 2014;52(4):351–2.

28.DarracqMA,CantrellFL,KlaukB,etal.Achancetocutisnotalwaysa chancetocure–fasciotomyinthetreatmentofrattlesnake

envenomation:aretrospectivepoisoncenterstudy. Toxicon 2015;101:23–6.

29.SpillerHA,BosseGM,RyanML.Useofantivenomforsnakebites reportedtoUnitedStatespoisoncenters. AmJEmergMed 2010;28(7):780–5.

30.MithoeferK,LhoweDW,VrahasMS,etal.Functionaloutcomeafter acutecompartmentsyndromeofthethigh. JBoneJointSurgAm 2006;88(4):729–37.

31.LolloLandGrabinskyA.Clinicalandfunctionaloutcomesofacutelower extremitycompartmentsyndromeatamajortraumahospital. IntJCrit IllnInjSci.2016;6(3):133–42.

32.BadheS,BaijuD,ElliotR,etal.The ‘silent’ compartmentsyndrome. Injury.2009;40(2):220–2.

33.HeemskerkJandKitslaarP.Acutecompartmentsyndromeofthelower leg:retrospectivestudyonprevalence,technique,andoutcomeof fasciotomies. WorldJSurg.2003;27(6):744–7.

34.KirkupJ. AHistoryofLimbAmputation.London,England:SpringerVerlag,2007.

35.WyethLaboratories.PrescribingInformationforAntiveninPolyvalent. 2001.Availableat: https://theodora.com/drugs/ antivenin_polyvalent_wyeth.html.AccessedSeptember15,2022.

36.LoVecchioF,KlemensJ,RoundyEB,etal.Serumsicknessfollowing administrationofantivenin(Crotalidae)polyvalentin181casesof presumedrattlesnakeenvenomation. WildernessEnvironMed 2003;14(4):220–1.

37.BTGInternationalInc.PrescribinginformationforCROFAB.2018. Availableat: https://www.fda.gov/media/74683/download AccessedSeptember15,2022.

38.RuhaA-M,CurrySC,BeuhlerM,etal.Initialpostmarketingexperience withcrotalidaepolyvalentimmuneFabfortreatmentofrattlesnake envenomation. AnnEmergMed.2002;39(6):609–15.

39.ToschlogEA,BauerCR,HallEL,etal.Surgicalconsiderationsinthe managementofpitvipersnakeenvenomation. JAmCollSurg 2013;217(4):726–35.

40.HallEL.Roleofsurgicalinterventioninthemanagementofcrotaline snakeenvenomation. AnnEmergMed.2001;37(2):175–80.

41.MunnZ,PetersMDJ,SternC,etal.Systematicreviewor scopingreview?Guidanceforauthorswhenchoosingbetweena systematicorscopingreviewapproach. BMCMedResMethodol 2018;18(1):143.

BicarbonateandSerumLabMarkersasPredictorsofMortality

intheTraumaPatient

MatthewM.Talbott,DO*

AngelaN.Waguespack,BS*

PeytonA.Armstrong,BS* JohnW.Davis,BS*

KrishnaK.Paul,BS*

ShaniaM.Williams,BS* GeorgiyGolovko,PhD†

JoshuaPerson,MD‡ DietrichJehle,MD,RDMS*

SectionEditor:PierreBorczuk,MD

*UniversityofTexas,MedicalBranch,DepartmentofEmergencyMedicine, Galveston,Texas

† UniversityofTexas,MedicalBranch,DepartmentofPharmacology, Galveston,Texas

‡ UniversityofTexas,MedicalBranch,DepartmentofSurgery,Galveston,Texas

Submissionhistory:SubmittedJune9,2023;RevisionreceivedJanuary30,2024;AcceptedFebruary22,2024

ElectronicallypublishedMay20,2024

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

DOI: 10.5811/westjem.18363

Introduction: Severetrauma-inducedbloodlosscanleadtometabolicacidosis,shock,anddeath. Identiﬁcationofabnormalitiesinthebicarbonateandserummarkersmaybeseenbeforefrankchanges invitalsignsinthehemorrhagingtraumapatient,allowingforearlierlifesavinginterventions.Inthisstudy theauthoraimedtoevaluatetheusefulnessofserumbicarbonateandotherlabmarkersaspredictorsof mortalityintraumapatientswithin30daysafterinjury.

Methods: Thisretrospective,propensity-matchedcohortstudyusedtheTriNetXdatabase,covering approximately92millionpatientsfrom55healthcareorganizationsintheUnitedStates,including 3.8milliontraumapatientsinthelasttwodecades.Traumapatientswereincludediftheyhadlab measurementsavailablethedayoftheevent.Theanalysisfocusedonmortalitywithin30daysposttraumaincomparisontomeasuredlabmarkers.Cohortswereformedbasedonrangesofbicarbonate, lactate,andbaseexcesslevels.

Results: Beforepropensityscorematching,atotalof1,275,363traumapatientswithsame-day bicarbonate,lactate,orbaseexcesslabswereidentified.Asignificantdifferenceinmortalitywasfound acrossvariousserumbicarbonatelabrangescomparedtothestandardrangeof21–27milliequivalents perliter(mEq/L),post-propensityscorematching.Therelativeriskofdeathwas6.806forbicarbonate ≤5 mEq/L;8.651for6–10;6.746for11–15;2.822for16–20;and1.015forbicarbonate ≥28.Serumlactate alsodisplayedsignificantmortalityoutcomeswhencomparedtoanormallevelof ≤2millimolesperliter. Baseexcessshowedsimilarsignificantcorrelationatdifferentvaluescomparedtoanormalbaseexcess of 2to2mEq/L.

Conclusion: Thisstudy,approximately100timeslargerthanpriorstudies,associatedlower bicarbonatelevelswithincreasedmortalityinthetraumapatient.Whilelactateandbaseexcessoffer prognosticvalue,lowerbicarbonatevalueshaveahigherrelativeriskofdeath.Thegreaterpredictive valueofbicarbonateandaccessibilityduringresuscitationssuggeststhatitmaybethesuperior prognosticmarkerintrauma.[WestJEmergMed.2024;25(4)661–667.]

INTRODUCTION

Traumaisaleadingcauseofmortalityamongindividuals <45yearsofageandtheelderly.1 Hemorrhage-induced hypovolemiacanresultininadequateoxygendeliveryto tissues,leadingtometabolicacidosis.Earlyidentiﬁcationof shockintraumapatientsiscrucialasitcanfacilitate interventionsthatmitigateongoingtissuedamageand improvesurvival.Metabolicacidosisisasigniﬁcant prognosticindicatorfortheseverityofhemorrhagein traumacases.2

Bothvitalsignsandlaboratorymeasurementsprovide essentialguidanceforimprovingtheoutcomesof resuscitationincriticallyillpatients.3,4 Severalstudieshave attemptedtopredictmortalityinmajortraumapatients usingacid-basemeasures. 4,5 Manyofthesestudieshave revealedthatserumlactateisareliablepredictorof mortalityinseverelyinjuredpatients4,6 ,7 andmayeven outperformarterialbasede fi citasapredictivetool. 8, 9 Additionally,somesmallerstudieshaveindicatedthatboth arterialandvenousbicarbonatevaluescaneffectively predictmortalityincriticalcaresettings. 2,7 ,8 Serum bicarbonateandbasede fi cithavebeenfoundtobe approximatelyequivalentintheirpredictivecapacityin otherstudies.7 Giventhatlacticacidmeasurementsand arterialbasede fi citmaynotbeimmediatelyavailable atthetimeofapatient’ sinitialpresentation,9 further explorationofthepredictivevalueofbicarbonatemeasures becomescritical.

Theauthor’sprimaryobjectiveinthisstudywastoassess theutilityofserumbicarbonateandotheracid-basemarkers intheevaluationoftraumapatientswhopresenttothe emergencydepartment.Thisevaluationwasconducted usingacomprehensiveretrospectivehealthcaredatabase. Thespeciﬁcaimwastodeterminethepredictivevalueof serumbicarbonateandotherlaboratorymarkersin forecastingmortalityintraumapatientsupto30days aftertheirinjury.

METHODS

Design

Thiswasaretrospective,propensity-matchedcohort studyusingtheTriNetXdatabase.TriNetXisalarge,global researchnetworkthatprovidesde-identiﬁedmedical information.TheUnitedStatesCollaborativeNetworkin TriNetxrepresentsapproximately92millionpatientsand55 largehealthcareorganizations(HCO)withintheUS.The networkaccesseselectronichealthrecordinformationthat includesdiagnoses,procedures,medications,andlaboratory data.10 TheTriNetXdatabaseincludesadmittedand dischargedpatients,aswellasofﬁcevisits,incontrast totheNationalTraumaDataBank,whichonlyincludes admittedpatients.Forthisanalysis,theauthorincluded healthrecordsovera20-yearperiodfromNovember2, 2002–November2,2022.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Baseexcessandlactatelevelsare strongpredictorsofmortalityintrauma patients.Bicarbonatelevels,whilerelated, areamoreconvenientandpossibly superioralternative.

Whatwastheresearchquestion?

Isserumbicarbonatelevelthesuperior prognosticmarkerintrauma?

Whatwasthemajor ﬁndingofthestudy?

Lowerbicarbonatevalues(rangesfrom20to ≤ 5)werestronglyassociatedwithincreasing risksofmortality(P < 0.001).

Howdoesthisimprovepopulationhealth?

Thisstudysuggeststhatserumbicarbonateis superiortolactateandbaseexcessin predictingtraumamortality.

Participants

Cohortexposurewasdeﬁnedasserumbicarbonatelevelat baseline(bicarbonate[moles/volume]inserum,plasma,or blood,TMX:9021)withanytrauma-relatedInternational ClassiﬁcationofDiseases,Rev9or10(ICD-9orICD-10 code(ICD10CM:T14;ICD-9xxx).Approximately90%of thebicarbonatevalueswereobtainedfromvenoussamples, withtheremaining10%fromarterialsamples.Persons <18yearsoldorwithoutlabvaluesavailablefromthedayof eventwereexcluded.Themeasuredoutcomewasdeath within30daysoftheindexedtraumaticevent.Atleast94% oftheHCOsintheTriNetXdatabasearelinkedtotheUS NationalDeathRegistries.Patientswereexcludedifthe indexedtraumaticeventoccurredgreaterthan20yearsfrom dateofanalysis.

Thecontrolcohortwasdeﬁnedasallpersonswithtrauma whohadanormalbicarbonatelevel(21–27milliequivalents perliter[mEq/L])atbaseline.Therearevariabledeﬁnitions ofthenormalrangesforbicarbonate,lactate,andbaseexcess (BE)intheliterature;therefore,roundcutoffswerechosen forinterpretationpurposes.Thecontrolcohortwas comparedtoothercohortswithavaryingrangeof bicarbonatevalues.Theserangesofbicarbonateincluded ≤5,6–10,11–15,16–20,and ≥28mEq/L.Forcomparative effectivenessanalysis,theauthorthenrepeatedtheanalysis forlacticacidandBEastheyhavebeenstudiedinprevious research.Thecontrolcohortwasanormallacticacidof ≤2.0

millimolesperliter(mmol/L).Thecontrolcohortwas comparedtolacticacidlevelsatvaryingranges,at2mmol/L increments.ForBE,ourcontrolgroupwasanormalBE, between 2.0–2.0mmol/L.TheBEcontrolgroupwas matchedagainstcohortsatvaryingrangesofBE,at 2mmol/Lincrements.AllBEmeasurementswereobtained fromarterialsamples.

StatisticalAnalysis

Tocontrolforpotentialconfoundingdemographic factors,thepropensitymatchingtoolinTriNetXwasused. Usingthesematches,theresearchercanestimatethe differencebetweenbothgroupswithouttheinﬂuenceofthe confoundingvariables.10

Thecohortwasanalyzeddescriptivelyusingunivariate andbivariatefrequencieswithchisquareandt-testingto assessdifferences.Alleligiblepersonsinthecohortwere analyzedusingbothbinaryeventestimationwithriskratios (RR),95%confidenceintervals(CI),andprobabilityvalues. UsingtheTriNetXdatabase,theauthoremployeda1:1 propensitymatchusinglogisticregressionforage,gender, race,andethnicityformaximumgeneralizationtotheUS population.Greedynearest-neighbormatchingwasused withatoleranceof0.1anddifferencebetweenpropensity scores ≤0.1.Comparisonsweremadebetweencohortbefore andafterpropensitymatching.Thisstudymethodologyhas beenpreviouslyvalidatedintheTriNetXplatform.11 Statisticalsignificancewassetatatwo-sidedalpha <0.05. TriNetXprovidesdatathathasbeende-identified;therefore, IRBreviewwasnotrequiredforthisstudy.12 The final analysiswasrunonNovember2,2022.

RESULTS

Therewere92,529,034patientsintheUSCollaborative Networkfrom55HCOswithintheTriNetXdatabase.There wereatotalof3,892,737patientswithatraumatic mechanism,and28,967,134patientswithserumbicarbonate labvalues.Atotalof1,275,363traumapatientswere identiﬁedbeforepropensitymatching,whohadreceiveda bicarbonate,lactate,orBElabonthesamedayofatrauma incident(Table1).

Bicarbonate

Forthebicarbonategroup,atotalof1,275,363patients wereidentiﬁedbeforepropensitymatching:814,895patients withbicarbonate21–27mEq/L(control);2,643with bicarbonate ≤5mEq/L;5,949withbicarbonate6–10mEq/L; 25,882withbicarbonate11–15mEq/L;160,886with bicarbonate16–20mEq/L;and265,108withbicarbonate ≥28mEq/L.Afterpropensitymatching,patientswith bicarbonate6–10mEq/Lhadthehighestriskofdeathwhen comparedtocontrolat25.9%vs3.0%(RR8.65,95%CI 7.432–10.070, P < 0.001),anddecreasedasbicarbonate decreased,withthelowestbeing ≥ 28mEq/Lat3.5%vs3.4%

Table1. Cohortdemographics.

DemographicsMean ±SD Age55 ±22 Percentage

NotHispanicorLatino76% HispanicorLatino8%

UnknownEthnicity16% Race

White68% Black17%

AmericanIndianorAlaskan1% Asian1%

NativeHawaiianorotherPaciﬁcIslander0% Unknownrace12% Otherrace1%

Commoncomorbidities

Hypertensivediseases49% Otherformsofheartdiseases42% Otheranxietydisorders30% Overweightandobesity24% Diabetesmellitus23%

(RR:1.015,95%CI0.986–1.044, P = 0.32)whichwasnot statisticallysigniﬁcant.Whencomparedtocontrol,patients withbicarbonate ≤5mEq/L(19.8%,RR6.8)hadsimilar risksofmortalityas11–15mEq/L(20.0%,RR6.9). Mortalityfollowedasimilartrendbeforepropensity matching(Table2).

Lactate

Forthelactategroup,atotalof326,562patientswere identiﬁedbeforepropensitymatching:195,457patientswith lactate ≤ 2moles/volume(control);86,989withlactate 2.01–4moles/volume;23,120withlactate4.01–6moles/ volume9,540withlactate6.01–8moles/volume,and11,456 with ≥8.01moles/volume.Afterpropensitymatching, mortalitywasshowntoincreaseaslactatelevelsincreased. Whencomparedtothecontrol,thelowestRRsformortality werewithinthe2.01–4moles/volumerangeat9.2%vs5.1% (RR1.814,95%CI1.751–1.880, P < 0.001),and reachedthehighestriskswhen ≥8.01moles/volumeat31.7% vs4.9%(RR6.420,95%CI5.895–6.991, P < 0.001).

Mortalityfollowedasimilartrendbeforepropensity matching(Table3).

Table2. 30-daymortalitywhencomparedtonormalserumbicarbonate(21–27milliequivalentsperliter).

BeforepropensityscorematchingAfterpropensityscorematching Serumbicarbonate(mEq/L)MortalityRR(95%CI)

CI,conﬁdenceinterval; RR,riskratio; mEq/L,milliequivalentsperliter.

Table3. 30-daymortalitywhencomparedtonormallactate(≤2moles/volume)beforepropensityscorematching.

CI,conﬁdenceinterval; RR,riskratio.

Table4. 30-daymortalitywhencomparedtonormalbaseexcess( 2to2millimolesperliter).

CI,conﬁdenceinterval; RR,riskratio; mmol/L,millimolesperliter.

BaseExcess

FortheBEgroup,atotalof34,717patientswereidentiﬁed beforepropensitymatching:19,387patientswithBE 2to2 mmol/L(control);5,161withBE 4to 2.01mmol/L;3,525

withBE 6to 4.01mmol/L;2,359withBE 8to 6.01 mmol/L;1,585withBE 10to 8.01mmol/L;and2,700 with ≤−10.01mmol/L.Afterpropensitymatching, mortalitywasshowntoincreaseasBElevelsdecreased.

Whencomparedtothecontrolrange,BE 4to 2.01 mmol/Lshowedthelowestmortalityrisksat6.3%vs4.8% (RR1.308,95%CI1.113–1.538, P = 0.001),whichincreased tothehighestpointwhenBEwas ≤−10.01mmol/Lat21.8% vs5.1%(RR4.309,95%CI3.601–5.156, P < 0.001). Mortalityfollowedasimilartrendbeforepropensity matching,althoughRRwassomewhatlower(Table4).

DISCUSSION

Inthisstudytheauthorexploredthepossibilitythat serumbicarbonatewasamorepowerfulpredictorof mortalityat30daysfollowingapresentationfortraumain theemergencydepartmentthanlactateorBE.While arterialbasede fi citlikewisedemonstratedpredictiveutility, asinpreviousstudies,thismeasurerequiredanarterial bloodsample. 4, 8 Thisnovel fi ndingsuggestsserum bicarbonatecanprovidearapid,easilyobtainable assessmentofatraumapatientatinitialpresentation. Lowerserumbicarbonatelevelswereassociatedwitha greaterriskofmortalityat30daysthanthosewithnormal rangebicarbonatelevels.Manypreviousstudieshave demonstratedahighdegreeofcorrelationbetweenserum lactateandserumbicarbonateinthesettingoftrauma,8 but nonehavequantitativelyde finedthatriskinsuchadataset. Thisstudyisapproximately75timeslargerthananyother studyintheliteraturethathaslookedattherelationship betweenserumbicarbonatelevelsand30-daymortalityin patientspresentingfortrauma.

Shaneetalshowedthatalowerserumbicarbonatelevelis associatedwithasignificantincreaseinmortality,whichisin linewithourstudy.Theirstudyhadasmallersample populationof93.4 IntheShanestudy,theyproposedthatthe differenceinbicarbonatelevelsinthosewhosurvivedwas significantlydifferentvsthosewhoexpired,especiallywithin 24hoursoftraumasustained.Whiletheyalsosuggestedthat theunderdevelopedareaofUgandaandsmallsamplesize mayhaveplayedaroleinthedatacollected,thevenouslevels ofbicarbonatedoshowthatthosewithinanormalrangehad astatisticallysignificantsurvivaladvantage.

Husseinetalperformedasmallstudythatshowed elevatedlacticacidlevelswereassociatedwithanincreasein mortality.Theyalsodemonstratedthatbasedeficitcould predictmortalityinthetraumapatient.Theirstudyis somewhatlimitedasithadatotalof137patientswithonly36 beingtraumapatients.8 Husseinetalalsodemonstratedan increaseinmortalitywithsignificantdifferencesinbase deficitafter24hoursinpatientsinthesurgicalintensivecare unit,althoughtheinitialbasedeficitwasnotsignificantly different.Furthermore,theyproposedthattheinitialbase deficit(vsthe24-hourreading)didnotcorrelatewiththe lactatelevelsandwasnotareliablepredictorofmortality, exceptintheinstanceofdeathsduetotrauma(37of100total patients)furthershowingthatacid/basedifferencescanbea predictorofmortalityintrauma.8

FitzSullivanetalshowedacorrelationbetweenarterial basedeficitandserumbicarbonateandmaybeused interchangeablyintraumaresuscitation.Theirstudyhad 3,102patientswith50,311matchedlaboratorydatasets.7 FitzSullivanetalsetouttodrawalinearcorrelationbetween arterialbasedeficitandserumbicarbonate(HCO3)in relationtotheseverityofinjuryanddeath.Sincethebase deficitisacquiredthrougharterialpuncture,HCO3 could provideforasubstitutemarkerasitisnormallydrawnon admission.TheirdatashowedthepredictiveabilityofHCO3 intraumacaseswithregardtoitscomparisontobasedeficit inthesamecases.7 Inaddition,thebicarbonate outperformedlacticacidinpredictingmortality.Thisfurther showsthatbicarbonatecanaccuratelyandreliablybeusedas apredictorofmortalityintraumapatients.

Mutschleretalperformedastudywith16,305patients fromatraumaregistryandshowedasignificantcorrelation betweenworseningbasedeficitandmortality.(13) Caputoetal foundthatlactateandbasedeficitcorrelatedwellwitheach otherasindicatorsofthepresenceofoccultshockinagroupof 100traumapatients.(14) Callawayetalfoundthatlactateand basedeficitwereassociatedwithincreasedmortalityina groupof588elderlytraumapatients.2 Thesestudiesand others2–4,7,8,13–21 thathaveevaluatedlabmarkershavea smallerpatientpopulationcomparedtothecurrentstudyof overthreemilliontraumapatients.Becauseofthis,theauthor considershisstudytoholdmorepowerandpredictiveability inevaluatingtheserumlabmarkersintrauma.

Whilethispropensitymatchedstudyprovidespowerful, generalizableestimatesofmortalityriskwithbicarbonate levels,theauthoralsoperformednon-matchedestimationsas asensitivityanalysis.Theseestimatesdidnotmeaningfully differfromthosethatwerepropensitymatched,suggesting thatconfoundersattributabletothedemographicswerenot meaningfulinthisdatabase.

LIMITATIONS

Thereareanumberoflimitationstothisstudy.Aswithall observationalstudiesinelectronicdatabases,causaleffects cannotbeinferred.Therearemanyreasonswhyapatient withtraumamightpresentwithmetabolicacidosis,suchas age,increasedlikelihoodofcomorbidities(ie,heartfailure, chronicobstructivepulmonarydisease[COPD],diabetes mellitus),underlyinganemia,orlaterpresentationto emergencyservices.Clinicaldetailsabouteachpatient encountersuchasInjurySeverityScore(ISS),mechanismof injury,andotherresuscitativevariablesthatmayaffect mortalityendpointarenotallcapturedinthedatabase, whichcanlimitpredictabilityoflabresultsonmortality.The ISSscores,however,aretypicallyavailableatdischarge,and thisstudyevaluatedpatientsonarrival.

Propensityscorematchingwasemployedfor demographicssuchasage,race,ethnicity,andgender; despitethis,therecouldhavebeenothervariablesthatmay

haveaffectedoutcomesthatwerenotadjustedforinthe study.Additionally,covariateschosenforpropensity matchingwereconsistentbetweengroups.Variablesthat mayaffectonegroup(ie,renalfailure/COPDmightaffect bicarbbutnotlactates)werenotconsidered.Labswere gatheredonthesamedateasinitialtraumaandnot speciﬁcallythe ﬁrstlabvalue.Thereisalsoapossibilitythat patientscanbelongtomultiplelab-testinggroups.Asthis studycontainsalargenumberoftraumapatients,these limitationsshouldminimallyaffectthedata.

CONCLUSION

Metabolicacidosisisanominoussigninthesettingof initialtraumapresentationandhasbeenlongassociatedwith increasedmortalityrates.Inthisretrospective,propensitymatchedstudyofalargecohortofpatientspresentingtothe emergencydepartmentwithtrauma,wefoundanincreased mortalityriskwithlowerserumvenousbicarbonate measurements.Theserumbicarbonateoutperformedlactate andbaseexcesswithahigherriskratioofdeathforlower bicarbonatevalues.Becauseofthisgreaterprognosticvalue andavailability,werecommendroutinecollectionofserum bicarbonateratherthanlactateorarterialbasedeﬁcitat thepointofpresentationtoguidemanagementofthe traumapatient.

ACKNOWLEDGMENT

TheauthorwouldliketoacknowledgeDr.JohnBorderat theUniversityofBuffaloforrecognizingtheimportanceof anabnormalbicarbonatelevelasamarkerofoccult hemorrhageinthetraumapatient,whichindirectlyledtothis studybeingperformed.

AddressforCorrespondence:MatthewM,Talbott,DO,University ofTexas,MedicalBranch,DepartmentofEmergencyMedicine, 301UniversityBoulevard,Galveston,TX77555-1173. Email: mmtalbot@utmb.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsourcesand financialormanagementrelationshipsthatcouldbeperceivedas potentialsourcesofbias.Thisstudywasconductedwiththesupportof theInstituteforTranslationalSciencesattheUniversityofTexas MedicalBranch,supportedinpartbyaClinicalandTranslational ScienceAward(UL1TR001439)fromtheNationalCenterfor AdvancingTranslationalSciences,NationalInstitutesofHealth(NIH). Thecontentissolelytheresponsibilityoftheauthorsanddoesnot necessarilyrepresenttheofficialviewsoftheNIH.Therearenoother conflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.HeronM.Death:LeadingCausesfor2018. CDC,NationalVital StatisticsReport. 2021;70(4):1–114.

2.CallawayDW,ShapiroNI,DonninoMW,etal.Serumlactateandbase deﬁcitaspredictorsofmortalityinnormotensiveelderlyblunttrauma patients. JTrauma. 2009;66(4):1040–4.

3.MeregalliA,OliveiraRP,FriedmanG.Occulthypoperfusionis associatedwithincreasedmortalityinhemodynamicallystable,highrisk,surgicalpatients. CritCare. 2004;8(2):R60–5.

4.ShaneAI,RobertW,ArthurK,etal.Acid-basedisordersas predictorsofearlyoutcomesinmajortraumainaresource limitedsetting:anobservationalprospectivestudy. PanAfrMedJ. 2014;17:2.

5.MukherjeeK,BhattacharjeeD,ChoudhuryJR,etal.Associationof serumbiomarkerswiththemortalityoftraumavictimsinaLevel-1 traumacarecentreofEasternIndia. BullEmergTrauma. 2022;10(1):33–9.

6.WilsonRF,SpencerAR,TyburskiJG,etal.Bicarbonatetherapyin severelyacidotictraumapatientsincreasesmortality. JTraumaAcute CareSurg. 2013;74(1):45–50.

7.FitzSullivanE,SalimA,DemetriadesD,etal.Serumbicarbonatemay replacethearterialbasedeﬁcitinthetraumaintensivecareunit. AmJ Surg. 2005;190(6):941–6.

8.HusainFA,MartinMJ,MullenixPS,etal.Serumlactateand basedeﬁcitaspredictorsofmortalityandmorbidity. AmJSurg. 2003;185(5):485–91.

9.WeberB,LacknerI,BraunCK,etal.Laboratorymarkersinthe managementofpediatricpolytrauma:currentroleandareasoffuture research. FrontPediatr. 2021;9:622753.

10.TopalogluUandPalchukMB.Usingafederatednetworkofreal-world datatooptimizeclinicaltrialsoperations. JCOClinCancerInform. 2018;2:1–10.

11.HadiYB,LakhaniDA,NaqviSF,etal.OutcomesofSARS-CoV-2 infectioninpatientswithcystic ﬁbrosis:amulticenterretrospective researchnetworkstudy. RespirMed. 2021;188:106606.

12.MurphyLR,HillTP,PaulKK,etal.Tenecteplaseversusalteplasefor acutestroke:mortalityandbleedingcomplications. AnnEmergMed. 2023;82(6):720–8.

13.MutschlerM,NienaberU,BrockampT,etal.Renaissanceofbasedeficit fortheinitialassessmentoftraumapatients:abasedeficit-based classificationforhypovolemicshockdevelopedondatafrom 16,305patientsderivedfromtheTraumaRegisterDGU® CritCare. 2013;17(2):R42.

14.CaputoND,KanterM,FraserR,etal.Comparingbiomarkersof traumaticshock:theutilityofaniongap,baseexcess. AmJEmergMed. 2015;33(9):1134–9.

15.KunitakeRC,KornblithLZ,CohenMJ,etal.Traumaearlymortality predictiontool(TEMPT)forassessing28-daymortality. TraumaSurg AcuteCareOpen. 2018;3(1):e000131.

16.OuelletJF,RobertsDJ,TirutaC,etal.Admissionbasedeﬁcitandlactate levelsinCanadianpatientswithblunttrauma:Aretheyusefulmarkersof mortality? JTraumaAcuteCareSurg. 2012;72(6):1532–5.

17.RégnierMA,RauxM,LeManachY,etal.Prognosticsigniﬁcanceof bloodlactateandlactateclearanceintraumapatients. Anesthesiology. 2012;117(6):1276–88.

18.MoﬁdiM,HasaniA,KianmehrN.Determiningtheaccuracyofbase deﬁcitindiagnosisofintra-abdominalinjuryinpatientswithblunt abdominaltrauma. AmJEmergMed. 2010Oct;28(8):933–6.

19.RutherfordEJ,MorrisJAJr,ReedGW,etal.Basedeﬁcit stratiﬁesmortalityanddeterminestherapy. JTrauma. 1992;33(3):417–23.

20.FalconeRE,SantanelloSA,SchulzMA,etal.Correlationofmetabolic acidosiswithoutcomefollowinginjuryanditsvalueasascoringtool. WorldJSurg. 1993;17(5):575–9.

21.BaxterJ,CranﬁeldKR,ClarkG,etal.Dolactatelevelsintheemergency departmentpredictoutcomeinadulttraumapatients?Asystematic review. JTraumaAcuteCareSurg. 2016;81(3):555–66.