Volume 25 Issue 5 by Western Journal of Emergency Medicine

Volume 25, Number 5, September 2024

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

Indexed in MEDLINE

Behavioral Health

668 Methadone Initiation in the Emergency Department for Opioid Use Disorder

Daniel Wolfson, Roz King, Miles Lamberson, Jackson Lyttleton, Colin T. Waters, Samantha H. Schneider, Blake A. Porter, Kyle M. DeWitt, Peter Jackson, Martha W. Stevens, John Brooklyn, Richard Rawson, Elly Riser

Clinical Practice

675 Cross-Sectional Study of Thiamine Deficiency and Its Associated Risks in Emergency Care

Joseph Miller, Daniel Grahf, Hashem Nassereddine, Jimmy Nehme, Jo-Ann Rammal, Jacob Ross, Kaitlin Rose, Daniel Hrabec, Sam Tirgari, Christopher Lewandowski

680 Emergency Department Blood Pressure Treatment and Outcomes in Adults Presenting with Severe Hypertension

Farhan Chaudhry, Eliana Small, Steven J. Korzeniewski, Dana Benyas, Lydia Ross, Alex B. Hill, Amit Vahia, Candace McNaughton, Phillip Levy, Joseph Miller

Critical Care

690 Neutrophil-to-Lymphocyte Ratio Predicts Sepsis in Adult Patients Meeting Two or More Systemic Inﬂammatory Response Syndrome Criteria

Vamsi Balakrishnan, Anna Yang, Donald Jeanmonod, Harrison Courie, Spencer Thompson, Valerian Peterson, Rebecca Jeanmonod

697 The Nonlinear Relationship Between Temperature and Prognosis in Sepsis-induced Coagulopathy Patients: A Retrospective Cohort Study from MIMIC-IV Database

Guojun Chen, Tianen Zhou, Jingtao Xu, Qiaohua Hu, Jun Jiang, Weigan Xu

708 Scoping Review: Is Push-Dose Norepinephrine a Better Choice?

Michael Berkenbush, Lali Singh, Kelly Sessa, Raghad Saadi

Western Journal of Emergency Medicine:

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

R. 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

Medicine:

Western Journal of Emergency :

Western Journal of Emergency Medicine:

Integrating Emergency with Population Health

Integrating Emergency Care with Population Health

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

Editorial Board

Board

Editorial Board

MAAEM

Amin A. Kazzi, MD, MAAEM

Gayle Galleta, MD

Beirut,

The American University of Beirut, Lebanon

The American University of Beirut, Beirut, Lebanon

Brent King, MD, MMM University Texas, Houston

Brent King, MD, MMM University of Texas, Houston

Christopher E. San Miguel, MD

Ohio State University Wexner Medical Center

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

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

Daniel J. Dire, MD

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

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

Douglas Ander, Emory University

Douglas Ander, MD Emory University

Emory University

Edward Michelson, MD Texas Tech University

Edward Michelson, Texas Tech University

Edward Michelson, MD Texas Tech University

Edward Panacek, MD, MPH South

Edward 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

Elena Lopez-Gusman, JD

California ACEP

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

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog,

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Hjalti Björnsson, MD

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

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

Langdorf, MAAEM, FACEP

American of Emergency Physicians

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

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

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

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de

Bell,

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

Robert W. Derlet, MD 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

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

Singapore

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

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

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

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

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 Emergency Physicians UT Southwestern Medical Center

Robert Suter, DO, MHA American College of Osteopathic

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

Visha Bajaria, BS WestJEM Editorial Director

Cassandra Saucedo, MS Executive Publishing Director

American College of Osteopathic Emergency Physicians

UC Irvine Health School of Medicine

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

Kimberly Ang, MBA

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

UC Irvine Health School of Medicine

American College of Emergency Physicians Kaiser Permanente

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

J. American College of Emergency Physicians Kaiser Permanente

Jorge Fernandez, MD, FACEP

UC San Diego Health School of Medicine

Jorge Fernandez, MD, FACEP

UC San Diego Health School of Medicine

Emily Kane, MA WestJEM Editorial Director

Stephanie Burmeister, MLIS WestJEM Staff Liaison

Visha Bajaria, BS WestJEM Editorial Director WestJEM

Stephanie Burmeister, MLIS JEM Liaison

Nicole Valenzi, BA WestJEM Publishing Director

Cassandra Saucedo, MS 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

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

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

JOURNAL FOCUS

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

Education

715 Program Signaling in Emergency Medicine: The 2022–2023 Program Director Experience

Alexis E. Pelletier-Bui, Timothy Fallon, Liza Smith, Tania Strout, Michelle Fischer, Mark Olaf, Erin McDonough, Brian Barbas, Michael Cirone, Elizabeth Barrall Werley

725 Emergency Department Slit Lamp Interdisciplinary Training Via Longitudinal Assessment in Medical Practice

Samara Hamou, Shayan Ghiaee, Christine Chung, Maureen Lloyd, Kelly Khem, Xiao Chi Zhang

735 Emergency Medicine Milestones Final Ratings Are Often Subpar Diane L. Gorgas, Kevin B. Joldersma, Felix K. Ankel, Wallace A. Carter, Melissa A. Barton, Earl J. Reisdorff

739 Making A Difference: Launching a Multimodal, Resident-Run Social Emergency Medicine Program

Naomi P. Newton, Christopher Freeman, Patricia Panakos

Emergency Department Operations

748 Reduced Time to Admit Emergency Department Patients to Inpatient Beds Using Outﬂow Barrier Analysis and Process Improvement

Marjorie A. Erdmann, Ipe S. Paramel, Cari Marshall, Karissa LeHew, Abigail Kee, Sarah Soliman, Monica Vuong, Sydney Spillane, Joshua Baer, Shania Do, Tiffany Jones, Derek McGuire

758 Interfacility Patient Transfers During COVID-19 Pandemic: Mixed-Methods Study

Michael B. Henry, Emily Funsten, Marisa A. Michealson, Danielle Albright, Cameron S. Crandall, David P. Sklar, Naomi George, Margaret Greenwood-Ericksen

767 Impact of Medical Trainees on Efficiency and Productivity in the Emergency Department: Systematic Review and Narrative Synthesis

Jake Valentine, Jonathan Poulson, Jesus Tamayo, Amanda Valentine, Jacqueline Levesque, Shane Jenks

Emergency Medical Services

777 Telemedical Direction to Optimize Resource Utilization in a Rural Emergency Medical Services System

Ramesh Karra, Amber D. Rice, Aileen Hardcastle, Justin V. Lara, Adrienne Hollen, Melody Glenn, Rachel Munn, Philipp Hannan, Brittany Arcaris, Daniel Derksen, Daniel W. Spaite, Joshua B. Gaither

784 Impact of Prehospital Ultrasound Training on Simulated Paramedic Clinical Decision-Making

Andrea Roche, Evan Watkins, Andrew Pettit, Jacob Slagle, Isain Zapata, Andrew Seefeld, Nena Lundgreen Mason

793 Use of Long Spinal Board Post-Application of Protocol for Spinal Motion Restriction for Spinal Cord Injury

Amber D. Rice, Philipp L. Hannan, Memu-iye Kamara, Joshua B. Gaither, Robyn Blust, Vatsal Chikani, Franco Castro-Marin, Gail Bradley, Bentley J. Bobrow, Rachel Munn, Mary Knotts, Justin Lara

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. 5: September 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

800 Association of Gender and Personal Choices with Salaries of New Emergency Medicine Graduates

Fiona E. Gallahue, Louis J. Ling, Leo Quigley, Dian Dowling Evans, Edward Salsberg, Robert E. Suter, Catherine A. Marco

Health Equity

809 Equity in the Early Pain Management of Long Bone Fractures in Black vs White Patients: We Have Closed the Gap

Dietrich Jehle, Krishna K. Paul, Stanley Troung, Jackson M. Rogers, Blake Mireles, John J. Straub, Georgiy Golovko, Matthew M. Talbott, Ronald W. Lindsey, Charles P. Mouton

817 A Cross-Sectional Review of HIV Screening in High-Acuity Emergency Department Patients: A Missed Opportunity

Jacqueline J. Mahal, Fernando Gonzalez, Deirdre Kokasko, Ahava Muskat

Health Policy Analysis

823 Preventive Health Services Offered in a Sampling of US Emergency Departments, 2022–2023

Christopher L. Bennett, M. Kit Delgado, Melissa Pasao, Janice A. Espinola, Krislyn M. Boggs, Carlos A. Camargo Jr.

Medical Education

828 Exploring Medical Student Experiences of Trauma in the Emergency Department: Opportunities for Trauma-informed Medical Education

Giselle Appel, Ahmed T. Shahzad, Kestrel Reopelle, Stephen DiDonato, Frances Rusnack, Dimitrios Papanagnou

Pediatrics

838 Drowning Among Children 1–4 Years of Age in California, 2017–2021

Phyllis F. Agran, Diane G. Winn, Soheil Saadat, Jaya R. Bhalla, Van Nguyen Greco, Nakia C. Best, Shahram Lotfipour

Technology

845 ChatGPT’s Role in Improving Education Among Patients Seeking Emergency Medical Treatment

Faris F. Halaseh, Justin S. Yang, Clifford N. Danza, Rami Halaseh, Lindsey Spiegelman

Letters to the Editor

856 Comments on “A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke”

Gillian Cooper, Vainavi Gambhir, Zoe Gasparotti, Samantha Camp, William Gum, Robinson Okolo, Riya Raikar, Chad Schrier, Jessica Downing, Quincy K. Tran

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

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

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

Professional Society Sponsors

American College of Osteopathic Emergency Physicians

California American College of Emergency Physicians

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

Allegheny Health Network Pittsburgh, PA

American University of Beirut Beirut, Lebanon

AMITA Health Resurrection Medical Center Chicago, IL

Arrowhead Regional Medical Center Colton, CA

Baylor College of Medicine Houston, TX

Baystate Medical Center Springfield, MA

Bellevue Hospital Center New York, NY

Beth Israel Deaconess Medical Center Boston, MA

Boston Medical Center Boston, MA

Brigham and Women’s Hospital Boston, MA

Brown University Providence, RI

Carl R. Darnall Army Medical Center Fort Hood, TX

Cleveland Clinic Cleveland, OH

Columbia University Vagelos New York, NY

State Chapter Subscriber

Arizona Chapter Division of the American Academy of Emergency Medicine

California Chapter Division of the American Academy of Emergency Medicine

Florida Chapter Division of the American Academy of Emergency Medicine

International Society Partners

Conemaugh Memorial Medical Center Johnstown, PA

Crozer-Chester Medical Center Upland, PA

Desert Regional Medical Center Palm Springs, CA

Detroit Medical Center/ Wayne State University Detroit, MI

Eastern Virginia Medical School Norfolk, VA

Einstein Healthcare Network Philadelphia, PA

Eisenhower Medical Center Rancho Mirage, CA

Emory University Atlanta, GA

Franciscan Health Carmel, IN

Geisinger Medical Center Danville, PA

Grand State Medical Center Allendale, MI

Healthpartners Institute/ Regions Hospital Minneapolis, MN

Hennepin County Medical Center Minneapolis, MN

Henry Ford Medical Center Detroit, MI

Henry Ford Wyandotte Hospital Wyandotte, MI

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

California Chapter Division of American Academy of Emergency Medicine

INTEGRIS Health Oklahoma City, OK

Kaiser Permenante Medical Center San Diego, CA

Kaweah Delta Health Care District Visalia, CA

Kennedy University Hospitals Turnersville, NJ

Kent Hospital Warwick, RI

Kern Medical Bakersfield, CA

Lakeland HealthCare St. Joseph, MI

Lehigh Valley Hospital and Health Network Allentown, PA

Loma Linda University Medical Center Loma Linda, CA

Louisiana State University Health Sciences Center New Orleans, LA

Louisiana State University Shreveport Shereveport, LA

Madigan Army Medical Center Tacoma, WA

Maimonides Medical Center Brooklyn, NY

Maine Medical Center Portland, ME

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

Great Lakes Chapter Division of the American Academy of Emergency Medicine

Tennessee Chapter Division of the American Academy of Emergency Medicine

Norwegian Society for Emergency Medicine Sociedad Argentina de Emergencias

Mayo Clinic Jacksonville, FL

Mayo Clinic College of Medicine Rochester, MN

Mercy Health - Hackley Campus Muskegon, MI

Merit Health Wesley Hattiesburg, MS

Midwestern University Glendale, AZ

Mount Sinai School of Medicine New York, NY

New York University Langone Health New York, NY

North Shore University Hospital Manhasset, NY

Northwestern Medical Group Chicago, IL

NYC Health and Hospitals/ Jacobi New York, NY

Ohio State University Medical Center Columbus, OH

Ohio Valley Medical Center Wheeling, WV

Oregon Health and Science University Portland, OR

Penn State Milton S. Hershey Medical Center Hershey, PA

Uniformed Services Chapter Division of the American Academy of Emergency Medicine

Virginia Chapter Division of the American Academy of Emergency Medicine

Emergency Medicine

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

Stephanie Burmeister

WestJEM Staff Liaison

Phone: 1-800-884-2236

Email: sales@westjem.org

25, No. 5: September 2024

Sociedad Chileno Medicina Urgencia Thai Association for

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

Stephanie Burmeister

WestJEM Staff Liaison

Phone: 1-800-884-2236

Email: sales@westjem.org

Sociedad Chileno Medicina Urgencia Thai Association

BRIEF RESEARCH REPORT

MethadoneInitiationintheEmergencyDepartment forOpioidUseDisorder

DanielWolfson,MD* RozKing,MSN*

MilesLamberson,BA* JacksonLyttleton,BS*

ColinT.Waters,MD,PhD* SamanthaH.Schneider,MS† BlakeA.Porter,PharmD‡ KyleM.DeWitt,PharmD‡ PeterJackson,MD§∥

MarthaW.Stevens,MD,MSCE* JohnBrooklyn,MD§¶ RichardRawson,PhD∥# EllyRiser,MD,MPH**

SectionEditor:MarcMartel,MD

*UniversityofVermontLarnerCollegeofMedicine,DepartmentofEmergencyMedicine, Burlington,Vermont

† RushUniversityMedicalCenter,CollegeofMedicine,Chicago,Illinois

‡ TheUniversityofVermontMedicalCenter,DepartmentofPharmacy,Burlington,Vermont

§ UniversityofVermontLarnerCollegeofMedicine,DepartmentofPsychiatry, Burlington,Vermont

∥ UniversityofVermont,VermontCenterforBehaviorandHealth,CenteronRural Addiction,Burlington,Vermont

¶ UniversityofVermontLarnerCollegeofMedicine,DepartmentofFamilyMedicine, Burlington,Vermont

# UniversityofCaliforniaLosAngelesSchoolofMedicine,LosAngeles,California **UniversityofVermontLarnerCollegeofMedicine,DepartmentofMedicine, Burlington,Vermont

Submissionhistory:SubmittedOctober26,2023;RevisionreceivedApril23,2024;AcceptedApril29,2024

ElectronicallypublishedAugust1,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18530

Introduction: Overdosedeathsfromhigh-potencysyntheticopioids,includingfentanylanditsanalogs, continuetorisealongwithemergencydepartment(ED)visitsforcomplicationsofopioidusedisorder (OUD).Fentanylaccumulatesinadiposetissue;althoughrare,thisincreasestheriskofprecipitated withdrawalinpatientsuponbuprenorphineinitiation.ManyEDshaveimplementedmedicationforopioid usedisorder(MOUD)programsusingbuprenorphine.However,fewoffermethadone,aproventherapy withouttheriskofprecipitatedwithdrawalassociatedwithbuprenorphineinitiation.Wedescribethe additionofanED-initiatedmethadonetreatmentpathwayandcomparedits72-hourfollow-upoutpatient treatmentengagementratestoourexistingED-initiatedbuprenorphineMOUDprogram.

Methods: WeexpandedourEDMOUDprogramwithamethadonetreatmentpathway.FromFebruary 20–September19,2023,wescreened20,504EDarrivals;5.1%hadsignsofOUD.Weenrolled61 patients:28inthemethadone;and33inthebuprenorphinepathways.Forpatientswhoscreened positiveforopioiduse,shareddecision-makingwasemployedtodeterminewhetherbuprenorphineor methadonetherapywasmoreappropriate.Patientsinthemethadonepathwayreceivedtheir ﬁrstdoseof upto30milligrams(mg)ofmethadoneintheED.Twoadditionalmethadonedosesofupto40mgwere dispensedatthetimeoftheEDvisitandheldinthedepartment,allowingpatientstoreturneachdayfor observeddosinguntilintakeatanopioidtreatmentprogram(OTP).Wecompared72-hourratesof outpatientfollow-uptreatmentengagementattheOTP(forthoseonmethadone)orattheaddiction treatmentcenter(ATC)(forthoseonbuprenorphine)forthetwotreatmentpathways.

Results: Ofthe28patientsenrolledinthemethadonepathway,12(43%)successfullyengagedin follow-uptreatmentattheOTP.Ofthe33patientsenrolledinthebuprenorphinepathway,15(45%) successfullyengagedinfollow-uptreatmentattheATC(relativerisk1.06;95%conﬁdenceinterval 0.60–1.87).

Conclusion: MethadoneinitiationintheEDtotreatpatientswithOUDresultedinsimilar72-hourfollowupoutpatienttreatmentengagementratescomparedtoED-buprenorphineinitiation,providinganother viableoptionforMOUD.[WestJEmergMed.2024;25(5)668–674.]

BACKGROUND

TheopioidcrisisintheUnitedStatescontinuesunabated with106,699drug-involvedfatalitiesin2021,primarily involvingillicitlymanufacturedhigh-potencysynthetic opioids,andisfurthercomplicatedbyadulterantssuchas xylazineandgabapentin.1–6 Individualswithopioiduse disorder(OUD)facethehighestriskofdeathwithinthe first 48hoursfollowinganED(emergencydepartment)visitfora non-fataloverdose.7 TheEDidentificationofpatientswith OUDandinitiationofbuprenorphinetreatmenthasproven effectiveandissupportedbytheAmericanCollegeof EmergencyPhysiciansandtheCaliforniaBridgenetworkof hospitals.8–12 However,therisingprevalenceoffentanylin theillicitdrugsupplycomplicatestreatmentduetoits accumulationinadiposetissue,potentiallycausing precipitatedwithdrawaluponbuprenorphineinitiation.13–15 Additionally,abstainingfromfentanylfortherequiredpreinductionperiodmaybedifficultforsome,leadingthemto avoidfurtherbuprenorphineorfavormethadonefortheir medicationforOUD(MOUD).16–20 Methadone,asynthetic fullmu-opioidreceptoragonist,avoidsthesecomplications, asitdoesnotprecipitatewithdrawal.21,22 Inresponse,the UniversityofVermontMedicalCenter(UVM)enhancedits existingStartTreatmentandRecovery(STAR)program,an ED-basedinitiativetoinitiateMOUDinpatientswithOUD. Originallyfocusedonbuprenorphine,theprogramwas expandedtoincludemethadone,adaptingtotheshifting landscapeofopioiduseandpatientneeds.Wedescribethe implementationofanED-initiatedmethadonetreatment pathway,comparingits72-hourfollow-upoutpatient treatmentengagementratestoourexistingED-initiated buprenorphineMOUDprogram.

METHODS

WeperformedanopentrialcomparingtwoMOUD treatmentpathwayswherepatientsintheEDwhometOUD criteriaandagreedtotreatmentchosebetweeninitiation ontobuprenorphineormethadone.FromFebruary 20–September19,2023wescreenedchartsof20,504ED arrivals,with1,051(5.1%)havingsignsofOUD.Ofthese, 903weredeterminedineligible,43patientsdeclined treatment,andsixpatientseloped.Patientsdeclining participationduetotimeconstraintsordeemedunsuitable forthestudyatcliniciandiscretionwereexcluded. EnrollmenttoinitiateMOUDintheSTARprogramwas completedfor61patientswith28initiatedonmethadoneand 33onbuprenorphine.Notincludedinthisanalysiswerean additional38patientswhowereenrolledinSTARbut admittedtothehospital(Figure1).TheSTARprogram coordinatorsscreenedpatientchartsfrom9 AM to9 PM daily andremainedoncallforenrollments24/7.Theyapproached identiﬁedpatientstoconﬁrmopioiduse,eligibility,and interestinstartingMOUD.

Figure1. Flowchartofscreeningofemergencydepartmentpatients andenrollmentinaSTAR(starttreatmentandrecovery)program. February20–September19,2023.

ED,emergencydepartment; OUD,opioidusedisorder.

Anemergencyclinicianthenusedthe Diagnosticand StatisticalManualofMentalDisorder s,5th Ed,criteriato conﬁrmthediagnosisofOUDandassessreadinessfor treatment.Shareddecision-makingwasusedtodecideonthe mostappropriateMOUDtreatmentpathway:methadoneor buprenorphine/naloxone.Thisprocessinvolvedadiscussion betweentheclinicianandthepatientthatincludedareview oftherisksandbeneﬁtsofeachmedication,theseverityof OUD,thepatient’spriorexperience/preference,andclinical factorssuchasdruginteractionsorQTprolongation.We comparedratesof72-hourfollow-uptreatmentengagement attheopioidtreatmentprogram(OTP)(forthoseon methadone)orattheUVMAddictionTreatmentCenter (ATC)(forthoseonbuprenorphine)forthetwotreatment pathwaysusingachi-squaretestStata/SE18.0(StataCorp, CollegeStation,TX).

Patientssignedadisclosureagreementallowingaccessto theirelectronichealthrecord,whichwassenttotheOTP/ATC viasecureemail.Patientsreceiveddetailsabouttheiroutpatient treatmentappointmentandwereprovidedwithtransportation vouchersandacellphone,whennecessary.Patientswerelinked toanEDpeerrecoverycoachwhoengagedwiththemduring theirEDvisitandcontinuedsupportthroughphonecallsforup to10daysfollowingdischarge.

MethadoneTreatmentPathway: Patientsreceiving methadoneweregiventhestandardUSFoodandDrug Administration-recommendedstartingdoseof30milligrams (mg)orallywithsubsequentdosingof40mgonthefollowing daysifbridgingdoseswererequireduntiltheOTP appointment.23 Theinitialdosewasreducedto20mgfor patientswithknownopioiduseinthepriorfourhours,ifthey

werecurrentlyusingothersedatives,orwithrelevantdrug interactions.Methadonewasnotofferedifthepatienthada respiratoryrate <10breaths/minute,anallergyto methadone,end-stageliverdisease,medicalextremis,ora knownQTc ≥ 500milliseconds.Electrocardiogramswere notroutinelyrequiredbutwereobtainedforriskfactorsin patienthistoryormedications.Basiclabsandurinedrug screenwereobtained.Patientswereinstructedtofollowupat theOTPthenextbusinessday.Ifapatientwasinitiatedon methadoneonaweekendorholiday,theappropriatenumber ofadditionalmethadonedosesweredispensedandheldina lockboxintheEDforobserveddosing.Thepatientwas

instructedtoreturntotheEDtoreceivefollow-updoses. Patientsreturningforre-dosingwerenotrequiredtocheckin asanEDpatientbutweregiventheirmethadonedose, observed,anddocumentedbyanurseusingascripted template(Figure2).24

Buprenorphine/naloxoneTreatmentPathway: Forpatients receivingbuprenorphine,theClinicalOpioidWithdrawal Scale(COWS)guideddosingstrategies.PatientswithaCOWS score <8underwenthomeinitiation.Forscoresof8–11, initiationintheEDwith8mgbuprenorphine/naloxonewas provided,andforscores >12,a16mgdosewasadministered. Allpatientsreceivedatake-homestarterpackwithathree-day

Figure2. EmergencydepartmentinitiationofmethadoneandSTAR(starttreatmentandrecovery)pathway.

supplyofbuprenorphine/naloxoneandafollow-up appointmentattheATCwithin72hours(Figure3).25

InstitutionalReviewBoardReview: TheUniversityof VermontResearchProtectionsOfﬁcedeemedthisprojectto meetcriteriaforresearchnotrequiringreview.

RESULTS

Patientsenrolledinthemethadoneorbuprenorphine pathwayshadsimilardemographicswithnosigniﬁcant differencesbetweengroupsbygender,race,ethnicity,age, modeofEDarrival,orEDdisposition.Ofthe28patientsin themethadonepathway,12(43%)attendedtheOTPfor

ongoingmethadonetreatment.Ofthe33patientsenrolledin thebuprenorphinepathway,15(45%)attendedthe ATCforongoingbuprenorphine/naloxonetreatment. The72-hourratesofsuccessfulfollow-upoutpatient treatmentengagementforpatientsenrolledinthe methadonevsbuprenorphinepathwayswerenot signiﬁcantlydifferent(relativerisk1.06;95%conﬁdence intervalCI,0.60–1.87).

DISCUSSION

WeenhancedourED ’ sexistingbuprenorphine-based MOUDprogrambyincorporatingatreatmentpathway

Figure3. EmergencydepartmentinitiationofbuprenorphineSTAR(starttreatmentandrecovery)pathway.

forinitiatingmethadone.Our fi ndingsshowthatEDinitiationofmethadoneforOUDispracticalandachieves 72-hourfollow-upoutpatienttreatmentengagementrates comparabletothoseofbuprenorphine.Whileprevious casestudieshavedocumentedsuccessfulinitiationof methadoneintheED,weareoneofthe fi rstto systematicallyreportontheimplementationofaclinical practicepathwayformethadoneinitiationintheED followedbylinkagetoongoingcare. 22 , 26 Traditionally, methadonehasnotbeenusedintheEDduetothepotential tocausefatalrespiratorydepressionifgivenindoses exceedinganindividual ’ stolerance;however,theEDisan ideallocationtosafelymonitorpatientsduringmethadone initiation. 27 Previousfederalregulationshadrestrictedthe useofmethadonetotreatOUDtolicensedOTPsinthe outpatientsetting. 28 TheEasyMedicationAccessand TreatmentforOpioidAddictionActimprovedthe fl exibilityofMOUDbyallowingpractitionersto dispenseuptoathree-daysupplyofnarcotics,including methadone,forthepurposeofinitiatingmaintenanceor detoxi fi cationtreatment. 29 – 33

Patientspreferselectingtheoptimaltreatmentpathway throughshareddecision-making,whichinvolvesa thoroughcomparisonoftheadvantagesanddisadvantages ofbuprenorphinevsmethadone.Thisapproachfosters informedandcollaborativehealthcarechoicesand potentiallyleadstoimprovedoutcomesandadherence. 22, 34 Wefoundmostpatientswilldirectlysaywhichtreatment pathwaytheypreferduetopastexperiencesoftreatment andprecipitatedwithdrawal.Buprenorphineis advantageousandpreferredasitislogisticallyeasierto take:thereislessriskofrespiratorydepression;thepatient canreceivetake-homemedicationsandprescriptions;and carecanultimatelybemanagedbythepatient ’ sprimary carephysicianwithoutdailytripstothemethadoneclinic fordosing. 19 However,patientswhohaveexperienced buprenorphine-precipitatedwithdrawalorwhocannot toleratecessationoffentanylfortherequiredprebuprenorphineinductiontime(often72hoursorlonger) maybene ﬁ tfrommethadone. 35 Althoughsurveysfromotherinstitutionsindicate physicianshavemorecomfortinitiatingbuprenorphine overmethadone(88%vs45%),ourexperienceshows cliniciansreadilyadoptingthemethadonetreatment pathway. 36 TofosterclinicianacceptanceofEDMOUD, weimplementedseveralstrategies:sharingtestimonials fromourEDpeerrecoverycoaches;facilitatingone-on-one discussionsbetweenprojectchampionsandclinicians;and leveragingdirectclinicalexperience.Theseapproaches alignwithexistingresearch,whichdemonstratesincreased exposuretoimpactedpopulationseffectivelyreduces stigmatowardsthem. 37 Overcomingthesebarriers enhancedtreatmentoptionsthroughthesuccessful

implementationofamethadoneinitiationpathwayforED patientswithOUD.

LIMITATIONS

Limitationsofthisstudyincludeasmallsamplesizethat restrictsthegeneralizabilityofresultsandimpactsstatistical signiﬁcance.Additionally,theabsenceoflong-termoutcome data,suchassix-monthfollow-upmetrics,limitsinsightsinto theintervention’seffectiveness.Theexclusionofpatients concurrentlyenrolledinothertreatmentprograms introducedselectionbias,potentiallyaffectingthestudy’ s applicabilitytothewiderOUDpopulation.Finally, individualclinicianbiasesmayhaveinﬂuencedboth participantselectionandtreatmentchoice,potentially affectingstudyoutcomes.

CONCLUSION

EDinitiationofmethadoneforpatientswithopioiduse disorderispractical,achieves72-hourfollow-uptreatment engagementratescomparabletothoseofbuprenorphine treatment,andprovidesanotheroptionforMOUDthat beneﬁtssomepatients.

AddressforCorrespondence:DanielWolfson,MD,Universityof VermontLarnerCollegeofMedicine,DepartmentofEmergency Medicine,111ColchesterAve.,Burlington,VT05401.Email: Daniel. Wolfson@uvmhealth.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.ThisstudywasfundedbytheSubstance AbuseandMentalHealthServicesAdministration(SAMHSA) 1H79TI085330andthe2019UniversityofVermontHealthNetwork InnovationGrant.Therearenootherconflictsofinterestorsources offundingtodeclare.

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15.D’OnofrioG,HawkKF,PerroneJ,etal.Incidenceofprecipitated withdrawalduringamultisiteemergencydepartment-initiated buprenorphineclinicaltrialintheeraoffentanyl. JAMANetwOpen. 2023;6(3):e236108.

16.ShearerD,YoungS,FairbairnN,etal.Challengeswithbuprenorphine inductionsinthecontextofthefentanyloverdosecrisis:acaseseries. DrugAlcoholRev. 2022;41(2):444–8.

17.SpadaroA,FaudeS,PerroneJ,etal.Precipitatedopioidwithdrawal afterbuprenorphineadministrationinpatientspresentingtothe emergencydepartment:acaseseries. JAmCollEmergPhysicians Open. 2023;4(1):e12880.

18.SueKL,CohenS,TilleyJ,etal.Apleafrompeoplewhousedrugsto clinicians:newwaystoinitiatebuprenorphineareurgentlyneededinthe fentanylera. JAddictMed. 2022;16(4):389–91.

19.SchoenfeldEM,WestaferLM,BeckSA,etal. “Justgivethemachoice”: patients’ perspectivesonstartingmedicationsforopioidusedisorder intheED. AcadEmergMed. 2022;29(8):928–43.

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ORIGINAL RESEARCH

Cross-SectionalStudyofThiamineDe ﬁciencyandIts AssociatedRisksinEmergencyCare

JosephMiller,MD,MS*

DanielGrahf,MD†

HashemNassereddine,MD‡

JimmyNehme,MD§

Jo-AnnRammal,BS*

JacobRoss,DO§

KaitlinRose,MD∥

DanielHrabec,MD*

SamTirgari,MD*

ChristopherLewandowski,MD*

SectionEditor:PatrickMeloy,MD

*HenryFordHealthandMichiganStateHealthServices,Departmentof EmergencyMedicine,Detroit,Michigan

† AdvocateHealth,DivisionofCriticalCareMedicine,Chicago,Illinois ‡ CorewellHealthUniversityHospital,DepartmentofEmergencyMedicine, RoyalOak,Michigan

§ HenryFordHealthandMichiganStateHealthSciences,DepartmentofInternal Medicine,Detroit,Michigan

∥ UniversityofMichigan,DepartmentofEmergencyMedicine, AnnArbor,Michigan

Submissionhistory:SubmittedSeptember18,2023;RevisionreceivedJanuary30,2024;AcceptedApril4,2024

ElectronicallypublishedAugust1,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18472

Background: Growingdataindicatesthatthiaminedeﬁciencyoccursduringacuteillnessintheabsence ofalcoholusedisorder.Ourprimaryobjectivewastomeasureclinicalfactorsassociatedwiththiamine deﬁciencyinpatientswithsepsis,diabeticketoacidosis,andoncologicemergencies.

Methods: Thiswasananalysisofpooleddatafromcross-sectionalstudiesthatenrolledadult emergencydepartment(ED)patientsatasingleacademiccenterwithsuspectedsepsis,diabetic ketoacidosis,andoncologicemergencies.Weexcludedpatientswhohadknownalcoholusedisorderor whohadreceivedEDthiaminetreatmentpriortoenrollment.Investigatorscollectedwholeblood thiaminelevelsinadditiontodemographics,clinicalcharacteristics,andavailablebiomarkers.We deﬁnedthiaminedeﬁciencyasawholebloodthiaminelevelbelowthenormalreferencerangeand modeledtheadjustedassociationbetweenthisoutcomeandage.

Results: Therewere269patients,ofwhomtheaverageagewas57years;46%werefemale,and80% wereBlack.Fifty-five(20.5%)patientshadthiaminedeficiency.Inunivariateanalysis,age >60years (oddsratio[OR]2.5,95%confidenceinterval[CI],1.3–4.5),femalegender(OR1.9,95%CI1.0–3.4), leukopenia(OR4.9,95%CI2.3–10.3),moderateanemia(OR2.8,95%CI1.5–5.3),and hypoalbuminemia(OR2.2,95%CI1.2–4.1)wereassociatedwiththiaminedeficiency.Inadjusted analysis,thiaminedeficiencywassignificantlyhigherinfemales(OR2.1,95%CI1.1–4.1),patients >60years(OR2.0,95%CI1.0–3.8),andpatientswithleukopenia(OR5.1,95%CI2.3–11.3).

Conclusion: Inthisanalysis,thiaminedeﬁciencywascommonandwasassociatedwithadvancedage, femalegender,andleukopenia.[WestJEmergMed.2024;25(5)675–679.]

INTRODUCTION

Thiamine(vitaminB1)isacrucialcofactorfornumerous metabolicprocesses,especiallycarbohydratemetabolism.1 Itsdeficiencyisassociatedwithdiseaseswithsignificant morbidity,includingWernicke-Korsakoffsyndromeand beriberi.2 Dataincriticalillnessalsoshowsanassociation withincreasedmorbidityandmortalityindependentofthese specificsyndromes.3,4

Thiaminestoresareentirelydependentonregulardietary intakeorartiﬁcialsupplementation,andbodystorescan

becomedepletedwithinthreeweekswithoutadequate intake.5–7 Studiesindicatethatconditionsroutinelyseenin theemergencydepartment(ED)thatincreasemetabolic strainareassociatedwiththiaminedeficiency,including diabeticketoacidosis(DKA),sepsis,andcancer.3,4,8–13 In studiesofseveresepsisandsepticshock,upto35%ofpatients showthiaminedeficiency,withevidencethatlevelsimprove withrecoveryinchildren.3,8,9,14 CasereportsofWernicke’ s encephalopathyinpatientswithcancerarenumerous.15–19 In recentobservationalstudiesofgastrointestinaland hematologicalcancerpatients,thiaminedeficiencywas commonandassociatedwithneurologicalsymptoms.20 Studieshavealsodemonstratedthiaminedeficiencyinupto 35%ofchildrenandadultswithDKA.10,11

Althoughtheexistingliteraturedemonstratesan associationbetweensuchdiagnosesandthiaminedeficiency, furtherassessmentofclinicalriskfactorsfordeficiencycould definewhomaybenefitmostfromthiaminetreatment.Inthis study,wesoughttoexploretheassociationofclinicalrisk factorswiththiaminedeficiencyinEDpatients.Such informationcouldguidefuturetherapeuticandpreventative approachesinthemanagementofat-riskpatients.

MATERIALSANDMETHODS

DesignandSetting

Thisisananalysisofpooleddatafromtwocross-sectional studiesperformedatasingle-center,urbanacademicmedical center.Enrollmentoccurredinthecenter’sED,whichhas approximately92,000patientencounterseachyearand servesaprimarilyBlackpopulation.Thisresearchwas approvedbytheinstitutionalreviewboard,whichgranted waiverofinformedconsentforthestudy.

Population

Thisanalysiswasinclusiveofadultpatients(age ≥18years)intheEDfromtwostudies.The ﬁrststudy enrolledpatientswithdiabeticorinfectiousemergencies fromApril2015–February2018.Thesecondstudyenrolled patientswithactivemalignancybetweenMarch 2017–October2018.Forbothstudies,weexcludedpatients whohadknownalcoholusedisorderorreceivedthiamine treatmentintheEDorthroughhomesupplementationprior toenrollment.

BloodSamplesandDataCollection

Eligiblepatientsprovidedawholebloodsampleinthe ED,whichmeasuresthiamine-diphosphate.Thesamples wereprotectedfromlight,frozen,andsenttoanoffsite laboratory(WardeMedicalLaboratory,AnnArbor,MI)for thiamine-leveltestingusinggaschromatography–mass spectrometry.Wecollecteddemographics,clinical characteristics,andin-hospitalmortalitydataonallpatients. Wealsorecordedlaboratoryinformationobtainedduring routinecareintheED,includingchemistriesandblood

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencypatientswithhighmetabolic strain,suchasoccursincriticalillness,have signi ﬁ cantratesofthiaminede ﬁ ciencyinthe absenceofalcoholusedisorder.

Whatwastheresearchquestion?

Canclinicalfactorspredictpatientsmost likelytohavethiaminede ﬁ ciencyinthe absenceofalcoholusedisorder?

Whatwasthemajor ﬁndingofthestudy?

Factorssuchasage > 60years(OR2.0,95% CI1.0 – 3.8)andleukopenia(OR5.1,95%CI 2.3 – 11.3)areassociatedwithde ﬁ ciency.

Howdoesthisimprovepopulationhealth?

These ﬁ ndingspointtotheneedforfurther investigationintomicronutrientde ﬁ ciencyin populationsthatemergencyclinicians commonlyserve.

counts.Toaccountformissinglaboratorydataforserum albuminandhematologyresults,weperformedmultiple imputationpriorto ﬁnalanalysis.Becausepreclinicaldata suggeststhatmetforminmayinterferewithintestinal thiaminetransporters,dataspeciﬁctometforminusewas alsocollected.21 Finally,werecordedanyclinical documentationofabnormalgaitordiagnosisofdelirium throughoutapatient’sEDorhospitalstay.Wedidnot performstandardizedassessmentofgait,delirium,or nutritionalstatus.

StatisticalAnalysis

Weevaluatedclinicalcharacteristicsandoverall prevalenceofthiaminedeficiencyusingdescriptivestatistics. Discretedatawasreportedasfrequenciesandpercentages. Wereportedcontinuousdataasmeansormedianswhere appropriate.Analysisconsistedofunivariatecomparisons andmultivariablelogisticregressiontoassessriskfactorsfor theprimaryoutcomeofthiaminedeficiency,definedasa wholebloodlevelbelowthecentrallab’sreferencerange (38–122microgramsperliter).Basedoncommonclinically meaningfulcutoffs,wecreatedcategoricalvariablesforage >60years(primarycovariateofinterest)andlaboratory findingsofleukopenia(whitebloodcellcount <4 × 109/L), moderateanemia(hemoglobin <10gramsperdeciliter [g/dL]),andhypoalbuminemia(serumalbumin <3.4g/dL). Withstatisticallysignificantcategoricalvariables,we

performedstepwiselogisticregression(signiﬁcancelevelfor entry0.2andtostay0.1)toconstructa ﬁnalmodelthatwas inclusiveofage >60years,gender,presenceofleukopenia, andhypoalbuminemia.Analysisalsoincludedtestingforan interactionofgenderandage >60years.

Resultsarereportedasoddsratios(OR)witha95% conﬁdenceinterval(CI).A P -value <0.05(two-tailed)was consideredstatisticallysigniﬁcantforalltests.Duetothe exploratorynatureofthisanalysis,wedidnotperforma poweranalysisandusedthesamplesizeavailable. WeusedSAS9.4(SASInstitute,Inc,Cary,NC)for allanalyses.

RESULTS

Therewere269patientsenrolledfromMarch 2015–October2018.Theirmeanagewas57years,and46% werefemale.MostpatientsidentifiedasBlack(80%).There were55(20.5%)patientswhohadthiaminedeficiency.When comparedtopatientswithnormalthiaminelevels,thiaminedeficientpatientswereolder(P = 0.001)andmorecommonly female(P = 0.04).Wereportdemographicandclinical characteristicswithcomparisonsbythiaminestatus in Table1.

Significantlaboratory findingsassociatedwiththiamine deficiencyinthecohortincludedleukopenia,anemia,and hypoalbuminemia.Intheadjustedanalysis,femalegender, leukopenia,andage >60yearsweresignificantlyassociated withthiaminedeficiency. Table2 demonstratesthese unadjustedandadjustedassociations.Finally,unadjusted ratesofin-hospitalmortality,60-daymortality, findingsof abnormalgait,anddeliriuminpatientswithorwithout thiaminedeficiencyareshownin Table3.

DISCUSSION

Itiswellestablishedthatthiaminedeficiencycanresult fromalcoholusedisorderorseverenutritionaldeficiencies. However,thiaminedeficiencyisalsoprecipitatedbyacute illnesswithhighmetabolicdemand,anddataindicatesitmay becommoninconditionssuchasDKA,sepsis,andcancer. Determiningadditionalclinicalfactorsassociated withthiaminedeficiencyinsuchpopulationscould aidintailoringthiamineadministrationto appropriatepatients.

WithinthisanalysisofEDpatientswithsepsis,DKA,and cancer,wefoundthat20.5%ofpatientswerethiamine deficientbasedonEDbloodlevels.Weidentifiedadvanced age,femalegender,andleukopeniaashavinggreater adjustedoddsofthiaminedeficiency.Theseresultsongender andleukopeniaareunique.Priordataindicatesan associationbetweenadvancedageandthiaminedeficiency.22 Genderorthepresenceofleukopeniaarenotwell-described riskfactors.PriorresearchindicatesthatB12deficiencyis morecommoninmen,23 butwearenotawareofdata indicatingahigherriskofthiaminedeficiencybasedon

Table1. Demographicsandclinicalcharacteristicsofpatientsbased onpresenceorabsenceofthiaminedeﬁciency.

Normal thiamine N = 214 Thiamine deﬁciency N = 55 P-value

Demographics

Female,no.(%)91(42.5)32(58.2)0.04

Age,years,mean(SD)54.8(18.0)63.6(17.6)0.001

Age >60years, no.(%) 89(41.6)35(63.6)0.003

Blackrace,no.(%)169(79.0)47(85.5)0.28

Medicalhistory,no.(%)

Diabetesmellitus*123(57.5)22(40.0)0.02

Metforminuse33(15.4)11(20.0)0.41

Myocardialinfarction20(9.4)2(3.6)0.17

Chronickidneydisease57(26.6)16(29.1)0.72

Hypertension131(61.2)35(63.6)0.74

Stroke26(12.2)6(10.9)0.80

Cancer74(34.6)29(52.7)0.01

Congestiveheartfailure19(8.9)6(10.9)0.64

Laboratoryvalues

Whitebloodcell × 109/L, mean(SD)

Creatinine,mg/dL,mean (SD)

Serumalbumin,g/dL3.43(0.83)2.86(0.89) <0.001

Bodymassindex, kg/m2,mean(SD)

*Diabetesmellitusincludedanypatientwiththisclinical diagnosis(type1or2).Regardlessofbeingpartofthediabetic ketoacidosiscohort. g/dL,gramsperdeciliter; mg,milligrams; kg/m2,kilogramsper squaremeter.

femalegender.The findingthathypoalbuminemiamaybe associatedwiththiaminedeficiencyisalsonovel,although this findingdidnotreachstatisticalsignificanceinan adjustedanalysis.Itisalsonoteworthythatthisanalysis includedmostlyBlackpatients.Muchoftheexisting literatureonthiaminedeficiencyincriticalillnessisinclusive ofamainlyWhitepopulation.3,10,20,22 Nonetheless,wefound

Table2. Unadjustedandadjustedanalysisofpatientcharacteristicsandlaboratoryvaluesassociatedwiththiaminedeﬁciency. Unadjustedanalysis* Adjustedanalysis

Oddsratio(95%CI) P-valueOddsratio(95%CI) P-value

Femalegender1.88(1.03–3.43)0.0392.13(1.11–4.07)0.02

Age >60years2.46(1.33–4.54)0.0041.98(1.03–3.81)0.04

Cancer2.11(1.16–3.84)0.015

Diabetesmellitus2.03(1.11–3.71)0.022 WBC <4*109/L4.87(2.31–10.30) <0.0015.12(2.31–11.30) <0.001

Albumin <3.4g/dL2.20(1.19–4.08)0.0121.82(0.94–3.54)0.08

Hemoglobin <10g/dL2.81(1.49–5.32)0.002

*Categoricalvariablesincludedinstepwiselogisticregressionmodel.Adjustedanalysisdisplaysonlyresultsforretainedvariables. CI,conﬁdenceinterval; WBC,whitebloodcellcount.

Table3. Unadjustedclinicaloutcomesbasedonpresenceor absenceofthiaminedeﬁciency.

60-daymortality,no.(%)34(15.9)15(27.3)0.05

Abnormalgait,no.(%)58(27.1)25(45.5)0.009

Delirium,no.(%)64(30.1)22(40.0)0.16

overallcomparableratesofthiaminedeﬁciencywithina Blackcohort.

Nutritionaldeficiencymaybecontributorytoour findings.Whilewedidnotperformnutritionalsurveysin thesecohorts,otherresearchindicatesthatEDpatientshave significantratesofmalnutrition,approachingashighas60% intheelderly.24 Futureresearchinthisareacouldbenefit fromspecificmeasuresoffoodinsecurityandnutritional statusindiversepopulations.Whilewecouldpresumethat lowalbuminlevelsarereflectiveofpoornutritionalstatus,it ischallengingtodeterminewhetherhypoalbuminemiaisdue topoorproteinintakevsinflammatoryconditions orhighmetabolicdemandsthatsuppress albuminsynthesis.23

LIMITATIONS

Thecurrentstudyhasseveralnotablelimitations.First,we includedanarrowsubsetofdiagnoses,whichlimitsthe generalizabilityofthese ﬁndingstootherconditions.Overall patientenrollmentwaslowduetolimitedcoordinator coverage,whichmayhaveintroducedbiasinpatient selection.Asnoted,wedidnotperformstandardized nutritionalassessmentsorneurologicalassessmentsthat mighthaveteasedouttheclinicalimpactofthiamine deﬁciency.Ofnote,ourresultshighlighteddetectionofacute

deficiencyanddidnotmeasureglobalthiaminestores.We performedthisinanurbansettingwithsignificantratesof foodinsecurity.Such findingsmaynottranslateto suburbansettings.

Thestudywasalsounderpoweredtoassesscertaindrugs associatedwiththiaminedeficiencysuchasfurosemide.25 Nonetheless,theseresultsaddtoagrowingbodyofevidence onthiaminedeficiencyinEDpatientswithconditionssuchas DKA,sepsis,andcancerwhodonothavealcoholuse disorder.3,10,11,20 Furthertestinginbroaderpopulationsis neededtomeasurehowage,gender,nutritionalstatus,and otherclinicalfactorsinterrelatewiththiaminedeficiency.

CONCLUSION

InouruniquestudypopulationofEDpatientswithouta historyofalcoholusedisorderwhohadsepsis,canceror diabeticketoacidosis,independentriskfactorsforthiamine deficiencywereadvancedage,femalegender,and leukopenia.Furtherresearchisindicatedtodefinethe epidemiologyofthiaminedeficiencyinabroadcohortof adultswithacuteillness.

AddressforCorrespondence:JosephMiller,MD,MS,2799WGrand Blvd.,Detroit,MI48202.Email: jmiller6@hfhs.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Fundingfortheworkwasthrougha unrestrictedphysicianscientistawardgiventoJosephMillerby HenryFordHealth(grantnumberA20300).Therearenoother conflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

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9.RajKM,BaranwalAK,AttriSV,etal.Thiaminestatusinchildrenwith septicshockfromadevelopingcountry:aprospectivecase-control study. JTropPediatr. 2021;67(1):fmaa107.

10.MoskowitzA,GraverA,GibersonT,etal.Therelationshipbetween lactateandthiaminelevelsinpatientswithdiabeticketoacidosis. JCrit Care. 2014;29(1):182.e5–8.

11.RosnerEA,StrezleckiKD,ClarkJA,etal.Lowthiaminelevelsinchildren withtype1diabetesanddiabeticketoacidosis:apilotstudy. PediatrCrit CareMed. 2015;16(2):114–8.

12.AndersenLW,HolmbergMJ,BergKM,etal.Thiamineasanadjunctive therapyincardiacsurgery:arandomized,double-blind,placebocontrolled,phaseIItrial. CritCare. 2016;20:92.

13.DonninoMW,CocchiMN,SmithlineH,etal.Coronaryartery bypassgraftsurgerydepletesplasmathiaminelevels. Nutrition. 2010;26(1):133–6.

14.EqueyL,AgyemanPKA,VeraguthR,etal.Serumascorbicacidand thiamineconcentrationsinsepsis:secondaryanalysisoftheSwiss pediatricsepsisstudy. PediatrCritCareMed. 2022;23(5):390–4.

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ORIGINAL RESEARCH

EmergencyDepartmentBloodPressureTreatmentandOutcomes inAdultsPresentingwithSevereHypertension

FarhanChaudhry,MD,MS*†

ElianaSmall,DO‡

StevenJ.Korzeniewski,PhD†

DanaBenyas,MD*

LydiaRoss,MD§

AlexB.Hill,BS†

AmitVahia,MD,MPH∥

CandaceMcNaughton,MD,PhD¶

PhillipLevy,MD,MPH#

JosephMiller,MD,MS‡

SectionEditor:KennethScottWhitlow,DO

*DepartmentofSurgery,DetroitMedicalCenter/WayneStateUniversitySchool ofMedicine,Detroit,Michigan

† DepartmentofFamilyMedicineandPopulationHealthSciences,WayneState UniversitySchoolofMedicine,Detroit,Michigan

‡ DepartmentofEmergencyMedicine,HenryFordHealthandMichiganState UniversityHealthSciences,Detroit,Michigan

§ DepartmentofEmergencyMedicine,BaylorCollegeofMedicine, Houston,Texas

∥ AscensionSt.JohnHospital,Detroit,Michigan

¶ DepartmentofEmergencyMedicine,UniversityofToronto,Toronto,Canada

# DepartmentofEmergencyMedicine,WayneStateuniversity,Detroit,Michigan

Submissionhistory:SubmittedMay14,2023;RevisionreceivedApril13,2024;AcceptedApril16,2024

ElectronicallypublishedJuly17,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18126

Background: Patientswhopresenttotheemergencydepartment(ED)withseverehypertension deﬁnedasasystolicbloodpressure(SBP) ≥180millimetersofmercury(mmHg)ordiastolic(DBP) ≥120 (mmHg)withoutevidenceofacuteend-organdamageareoftendeemedhighriskandtreatedacutelyin theED.However,thereisadearthofevidencefromlargestudieswithlong-termfollow-upforthe assessmentofmajoradversecardiovascularevents(MACE).Weconductedthelargeststudytodateof patientspresentingwithseverehypertensiontoidentifypredictorsofMACEandexaminewhetherblood pressureatdischargeisassociatedwithheightenedrisk.

Methods: WeenrolledEDpatientswithaSBPof180–220mmHgbutwithoutsignsofend-organ damageandfollowedthemforoneyear.TheprimaryoutcomewasMACEwithinoneyearofdischarge. Secondarily,weperformedapropensity-matchedanalysistotestwhetherSBP ≤160mmHgat dischargewasassociatedwithreducedMACEat30days.

Results: Atotalof12,044patientswereenrolled.TheprevalenceofMACEwithinoneyearwas1,865 (15.5%).Olderage,malegender,historyofcardiovasculardisease,cerebrovasculardisease,diabetes, smoking,presentationwithchestpain,alteredmentalstatus,dyspnea,treatmentwithintravenousand oralhydralazine,andoralmetoprololwereindependentpredictorsforone-yearMACE.Additionally, dischargewithanSBP ≤160mmHgwasnotassociatedwith30-dayMACE-freesurvivalafterpropensity matching(hazardratio0.99,95%conﬁdenceinterval0.78–1.25, P = 0.92).

Conclusion: One-yearMACEwasrelativelycommoninourcohortofEDpatientswithsevere hypertensionwithoutacuteend-organdamage.However,dischargebloodpressurewasnotassociated with30-dayorone-yearMACE,suggestingthatBPreductioninandofitselfisnotbeneﬁcialinsuch patients.[WestJEmergMed.2024;25(5)680–689.]

INTRODUCTION

Background

Hypertensiveemergenciesareasignificantconcernwhen patientspresenttotheemergencydepartment(ED)with severelyelevatedbloodpressure(BP),definedas ≥180 millimetersofmercury(mmHg)systolicor ≥120mmHg diastolicpressure.1 Nevertheless,veryfewofthesepatients haveevidenceofacuteend-organdamage.(EOD)andoften haveonlyseverelyuncontrolledchronichypertension (HTN).2,3 SeverelyelevatedBP,butwithoutEOD,isoften called “hypertensiveurgency.” Thereissignificantlong-term evidenceregardingcharacteristicsassociatedwithincreased majoradversecardiovascularevents(MACE)forpatients withchronicallyelevatedBP,butthereisalackoflong-term evidenceregardingcharacteristicsassociatedwithincreased MACEinthosepresentingwithhypertensiveurgencyinthe ED.2 Evenwithoutthislong-termevidence,thereis temptationandexpectationtoacutelylowerBP.Recent retrospectiveEDstudiessuggestthattheremaybeno immediatebenefitfromacutelyreducingBPinthesettingof severehypertensionwithoutEOD.4,5 Thiscouldbebecause thereisevidencetosuggestagreaterriskforsevereadverse effectswithantihypertensivesinthesettingofseverely elevatedBPwithoutEOD.5,6 However,largeroutcomedata forreachingalowertargetBPforthispopulationpriorto dischargeislacking.

Rationale

Giventhattherearesigniﬁcantlymorepatientspresenting totheEDwithsevereHTNwithoutEOD,identifying characteristicsassociatedwithMACEinthiscohorthas becomeincreasinglymoreimportant.1,3,7 Likewise,thereis uncertaintyregardingthevalueofreachingasigniﬁcantly lowertargetpressurepriortodischargefromtheEDforthis cohort.AssessingtheimpactofreachingatargetBPon MACEwouldalsoprovideclinicalutilityfor emergencyphysicians.

Objective

Toaddresstheseuncertainties,weconductedthelargest observationalcohortstudytodatetoidentifyriskfactorsfor MACEatoneyearamongpatientsdischargedhomefromthe EDwhopresentedwithseverelyelevatedBPwithoutEOD. Wealsotestedwhethertargetingalowersystolicblood pressure(SBP)priortodischargewasassociatedwithreduced MACEat30daysinthiscohort.Ourhypothesisforour primaryanalysiswasthatpatientswithSBPbetween 180–220mmHgwithoutdocumentedEODandtreatedwith anti-hypertensiveswouldhavelessMACEatoneyear.We usedanSBPgreaterthan180mmHgasthisisthecutofffor hypertensivecrisisaccordingtotheAmericanHeart Association(AHA).8 Oursecondaryhypothesiswasthat propensity-matchedpatientswithaninitialSBPbetween 180–220mmHgwithoutdocumentedevidenceofEOD,but

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Patientswithworseninglevelsofuncontrolled bloodpressurehaveincreasingriskoflongtermcardiovascularevents.

Whatwastheresearchquestion?

Howcommonaremajoradverse cardiovascularevents(MACE)withinone yearforpatientsdischargedfromtheEDwith severehypertension?

Whatwasthemajor ﬁndingofthestudy?

While15.5%hadacardiovascularevent withinayear,wefoundnoassociationwith initialEDencounterforso-called “ hypertensiveurgency. ”

Howdoesthisimprovepopulationhealth?

Severehypertensionintheabsenceof hypertensiveemergencyidenti fi espatientsat signi fi cantriskofMACE,butacuteBP reductionintheEDmaynotbe immediatelybene fi cial.

whoweredischargedwithalowertargetSBP(≤160mmHg), wouldhavelessMACEat30days.WeusedaSBP ≤160mm Hg,as >160mmHgisthecutoffforGrade2hypertensionand hasbeenshowntobeassociatedwithahighriskofEOD.8

METHODS

StudySettingandPopulation

Subjectsincludedpatientsbetween18–90yearsofagewho presentedtooneofeightEDsinanintegratedhealthsystem (HenryFordHealthSystem,Detroit,MI)fortreatmentof anymedicalconditionbetweenJanuary2014–July2015. TheseEDsconsistedofonetertiary-careacademicteaching hospital,threecommunityteachinghospitals,andfour freestandingEDs.TheEDlocationsservedurban communitieswithlowsocioeconomicstatusaswellas suburban,moreafﬂuentcommunities.WeincludedED encountersthatresultedindischargefromtheEDanddid notresultinadmissionorbeingplacedinobservation.Adult patientencounterswereabstractedfromtheelectronichealth record(EHR)sharedbyallEDsincludedinthestudy(Epic SystemsCorporation,Verona,WI).WeincorporatedallED encountersforadultsforinitialabstraction.Ofthese encounters,weexcludedpatientencounterswithSBP >220mmHgorbelow <180mmHgandencounterswith missingorincorrectlycodedpatientvariables.Forthisstudy

wedeﬁnedacuteEODasanenteredclinicaldiagnosisat presentationofacutecoronarysyndrome,stroke,heart failureexacerbation,oracutekidneyinjuryintheEHR.

StudyDesign

Thestudywasapprovedbytheinternationalreviewboard (IRB)atHenryFordHospitalSystem.Datacollection includedthepatient’ s firstEDBPanddischargeBP, demographicinformation,comorbidities,insurancestatus, tobaccouse,andclinicalpresentation.Weusedchief complaintastheprimarysymptomfortheirvisit.Wealso recordedwhethertheywerereferredtotheEDprimarilyfor hypertension(HTN).Comorbiditiesincludedhistoryof cardiovasculardisease,stroke,diabetes,andchronickidney disease.Weclassifiedinsurancestatusintoinsured (Medicare,Medicaid,commercial)ornotinsured.Wealso collectedthemedianincomefortheZIPcodewhereeach patientresided.ThemedianincomesforeachZIPcodewere groupedintoquartilesforsubsequentanalysis.Thepatient’ s antihypertensivetherapiesduringthevisitwererecorded. WeusedamethodcriteriondescribedbyWorsteretal.9 1)Twodataabstractorsweretrainedwiththestudycriteria describedabove;.2)Theinclusionandexclusioncriteriaused wereasstatedabove.3)Variablesweredefinedpriorto analysis.4)Weusedastandardabstractionform.

5)Abstractorperformancewasbasedonthenumberof recordsscreenedandverifiedbasedonaccuracyof incorporatingthecriteriainrecordselection.6)Abstractors duringabstractionofrecordswereblindedtothehypothesis. 7)Interobserverreliabilitywasdiscussed,8)butitwaswas notmeasuredduetolownumberofobserverstoperforma statisticaltest.9)Thehealthrecorddatabasewasidentified. 10)Methodofsamplingwasdescribedpreviously.11)Any missingvariabledataofpreidentifiedvariablesofinterest resultedinremovaloftheentirepatientrecordfromthe study.12)TheIRBdidreviewthestudy.

PrimaryandSecondaryOutcomes

Eachpatientwastrackedinthehealthsystem’sEHRupto oneyearfollowingthedateofthepatient’ s ﬁrstED encounter.Weconsideredpatientstohavetheprimary outcome,MACE,iftheyhadadocumenteddiagnosisof acuteheartfailure,acutestroke(hemorrhagicorischemic), acutecoronarysyndrome,ordeathwithinoneyearfollowing theirEDvisit.Weselectedaone-yearfollow-upperiodto increasethenumberofeventsandtherebyimprovestatistical powergiventhesamplesize.

Ifapatienthadmorethanonecardiovasculareventinthe 12-monthperiod,weonlycountedtheir ﬁrsteventforthe purposeoftheprimarystudyoutcome.DocumentedMACE fromEpic’sCareEverywherenetworkwasalsoincluded,so thatwewouldnotmissanyMACEifthepatientpresentedto anoutsidehealthcaresystemwithinthestateofMichigan usingthesameEHR.Thisincorporatesdeathsidentiﬁedby

thestateofMichigan;however,ifaneventoccurredoutside thestate,thenthiscouldnotbeincorporated.TheCare EverywherenetworkincorporatestheEHRsofmultiplecare systemsinthestateofMichigan,andrecordscreatedwithin thesecaresystemsareautomaticallyuploadedandvalidated inCareEverywhere.However,outsiderecordsmayhave beenmissedand,thus,maybealimitationtothestudy.

Thesecondaryoutcomewastime-to-MACEwithin 30daysfromdischarge:a)becauseeventsthatoccurnear dischargearemoreplausiblycausallyrelatedthanareevents thatoccurlongafterdischarge;andb)totestfordifferences ininstantaneousriskvelocity(ie,hazardratio[HR]) conditionalonsurvival(ie,toidentifyfactorsthatare associatedwithshorterintervals-to-MACEat30days).

PrimaryAnalysisandSecondaryStatisticalAnalyses

Weuseddescriptivestatisticstoassessbaseline demographicandclinicalcharacteristicsofthecohort. Continuousvariableswereexpressedasmedianinterquartile range(IQR),whilecategoricaldatawereexpressedas frequenciesandproportions(ie,%).TheMann-Whitney U-testandthechi-squaretestwereusedtoexamine differencesindistributionsandproportions,respectively.In theprimaryregressionanalysis,weusedlogisticregressionto estimatemagnitudesofassociationbetweenpatient characteristicsandMACEatoneyear.Wechoselogistic regressionbecausethesymmetricnatureoftheoddsratio (OR)enablesinferencesaboutassociationsbetween antecedentsandoutcomesorviceversa,unlikerelative risk.10 Symmetryisidealgiventhepotentialforconfounding byindicationinnon-randomizedclinicalstudies;thatis,only ORsallowinferencesabouttreatmentgivenoutcomeand viceversa.10,11 Potentialconfoundersweredeﬁnedapriorias factorsthatareassociatedwithbothanexposureand outcomewhoseadjustmentalterstheestimatedmagnitudeof associationby >10%.Weemployedatwo-stagemodel selectionstrategy.Firstly,weselectedallfactorsthatwere associatedwithdischargeSBPandMACEbothinourstudy andbasedonpriorknowledge(ie,fullmodel).Next,to reducethenumberofcovariablesandpotentialimpactof multicollinearity,weusedanagnosticstrategythat optimizedmodelaccuracymeasuredbypartialareaunder thecurveata10% ﬁxed-false-positiverateacross1,000 bootstrapreplicatesoftraining(70%)andtestingdatasets (30%).WhenconsideringZIPcodecharacteristics,we includedarandomintercepttoaccountforsimilarities amongpatientsnestedinthesamegeographicarea.

Inthesecondaryregressionanalysis,weusedtheCox proportionalhazardsmodeltoestimatethemagnitudeof associationbetweenpatientfactorsatEDdischargeand time-to-MACEat30days.Giventhepotentialfor confoundingbyindication,andbecausewewantedto examinetheclinicalrelevanceofdischargeSBP,we performedapropensity-matchedanalysistobalancethe

distributionofpotentialconfoundersbetweenstudygroups thathadSBP ≤160mmHgor >160mmHg.12 Weusedthe MatchItR-packageto findpairsofobservationswithsimilar propensityscoresbutthatdifferintreatmentstatus.13 That is,theprimarylogisticregressionmodelwasusedtoderive propensity-matchedgroups;factorsthatnevertheless differedbetweenpropensity-matchedgroupswereincluded inthe finalmultivariableCoxmodelaspotential confounders.Inboththeprimaryandsecondaryanalyses, magnitudesofassociation(ie,ORandHR)with95% confidenceintervals(CI)thatdonotincludethenullestimate (ie, ‘1.0’)arestatisticallysignificant.Allanalysiswas performedusingRversion4.0.3(RFoundationfor StatisticalComputing,Vienna,Austria).

RESULTS

DemographicsandClinicalCharacteristics

Of222,028EDencountersreviewedduringthestudy period,13,042(5.8%)patientsmetinclusioncriteria.There were12,044(92.4%)whohadcompleterecordsandwere usedforsubsequentanalysis.Theoverallnumberofpatients thathadMACEwithinoneyearwas1,865(15.5%),inclusive of176deaths(9.5%).

Table1 demonstratestheoveralldemographicand clinicalcharacteristicsofthecohort.Univariateanalysis foundthatpatientswithMACEwithinoneyearfollowing EDdischargeweresigniﬁcantlymorelikelytobeolder(ages 65–90,OR6.66[95%CI5.44–8.24] P < 0.001),andmale (779/1,865[41.8%]vs3,719/10,179[36.5%];OR1.25 [1.13–1.38], P < 0.001),butlesslikelytobeBlack(646/1.865 [34.6%]vs3,814/10,179[37.5%];OR0.89[0.80–0.98], P < 0.05).AlsosigniﬁcantlyassociatedwithMACEwithin oneyearwerehistoryofcardiovasculardisease(495/1,865 [26.5%]vs251/10,179[2.47%],OR14.3[13.2–16.8], P < 0.001);cerebrovasculardisease(202/1,865[10.8%]vs 136/10,179[1.33%],OR8.97[7.18–11.2], P < 0.001); diabetesmellitus(607/1,865[32.5%]vs1,092/10,179[10.7%], OR4.02[3.58–4.51], P < 0.001);andchronickidneydisease (352/1,865[18.9%]vs337/10,179[3.31%],OR6.80 [5.80–7.97], P < 0.001).Patientswhousedtobacco,had insurance,andthosewholivedinaZIPcodewithamedian annualincomeof$54,973–$70,439US(75%quartile)were morelikelytohaveMACEwithinoneyearincomparisonto thosewithlessthan$44,583(25%quartile)(OR2.59 [2.24–2.87], P < 0.001,3.81[2.78–5.39], P < 0.001,and1.17 [1.02–1.34], P < 0.05, respectively).

Table1. Patientcharacteristicsandunivariatelogisticregressioncomparisonsforoutcomes.

Demographic

Age rangeinyears,n(%)

18–45

46–65

65–90

Male,n(%)

2,243/12,044(18.6%)2,139/10,179(21.0%)104/1,865(5.58%)

4,995/12,044(41.5%)4,409/10,179(43.3%)586/1,865(31.4%)2.74(2.22–3.41) P < 0.001

4,806/12,044(39.9%)3,631/10,179(35.7%)1,175/1,865(63.0%)6.66(5.44–8.24) P < 0.001

4,498/12,044(37.3%)3,719/10,179(36.5%)779/1,865(41.8%)1.25(1.13–1.38) P < 0.001

Black,n(%) 4,460/12,044(37.0%)3,814/10,179(37.5%)646/1,865(34.6%)0.89(0.80–0.98) P < 0.05

Medicalhistory

Cardiovasculardisease,n(%)746/12,044(6.19%)251/10,179(2.47%)495/1,865(26.5%)14.3(12.2-16.8) P < 0.001

Cerebrovasculardisease, n(%) 338/12,044(2.81%)136/10,179(1.33%)202/1,865(10.8%)8.97(7.18–11.2) P < 0.001

Diabetesmellitus,n(%)1,699/12,044(14.1%)1,092/10,179(10.7%)607/1,865(32.5%)4.02(3.58–4.51) P < 0.001

Chronickidneydisease,n(%)689/12,044(5.72%)337/10,179(3.31%)352/1,865(18.9%)6.80(5.80–7.97) P < 0.001

Socialhistory

Tobaccosmoker,n(%)3,176/12,044(26.3%)2,358/10,179(23.1%)818/1,865(43.8%)2.59(2.24–2.87) P < 0.001

Hasinsurance,n(%) 11,258/12,044(93.5%)9,431/10,179(92.7%)1,827/1,865(98.0%)3.81(2.78–5.39) P < 0.001

ZIPcodemedianannualincomerangein$US

Lessthan44,583,n(%)4,663/12,044(38.7%)3,979/10,179(39.1%)684/1,865(36.7%) 44,584–54,972,n(%)1,857/12,044(15.4%)1,549/10,179(15.2%)308/1,865(16.5%)1.16(1.00–1.34)0.05 54,973–70,439,n(%)2,634/12,044(21.9%)2,192/10,179(21.5%)442/1,865(23.7%)1.17(1.02–1.34) P < 0.05 (Continued onnextpage)

Table1. Continued.

VariableTotalNo1-yearMACE1-yearMACEOR(95%CI)

Over70,440,n(%) 2,889/12,044(24.0%)2,459/10,179(24.2%)431/1,865(23.1%)1.02(0.89–1.16) 0.77

Presentation

Headache,n(%) 398/12,044(3.31%)346/10,179(3.41%)52/1,865(2.79%)0.81(0.60–1.08)0.70

Chestpain(%) 990/12,044(8.22%)799/10,179(7.86%)191/1,865(10.2%)1.34(1.13–1.58) P < 0.001

Alteredmentalstatus(%)92/12,044(0.772%)53/10,179(0.530%)39/1,865(2.09%)4.01(2.63–6.05) P < 0.001

Dyspnea(%) 465/12,044(3.86%)329/10,179(3.23%)136/1,865(7.29%)2.36(1.91–2.89) P <

Referralforhypertension(%)781/12,044(6.48%)675/10,179(6.63%)106/1,865(6.02%)0.85(0.68–1.04)0.13

Systolicbloodpressurerange inmmHg(%)

180–200 9,572/12,044(79.5%)8,158/10,179(80.1%)1,414/1,865(75.8%)

201–220

Diastolicbloodpressurerange inmmHg(%)

Lessthan80

80–100

2,472/12,044(20.5%)2,021/10,179(19.9%)451/1,865(24.2%)1.288 (1.15–1.45)

1,530/12,044(12.7%)1,182/10,179(11.6%)348/1,865(18.6%)

6,600/12,044(54.8%)5,577/10,179(54.8%)1,023/1,865(54.9%)0.62(0.54

Greaterthan101 3,914/12,044(32.5%)3,420/10,179(33.6%)494/1,865(26.5%)0.49(0.42–0.57)

Treatment 3,528/12,044(29.3%)2,345/10,179(23.0%)1,183/1,865(63.3%)5.80(5.22–6.44) P < 0.001

Clonidineoral(%) 1,220/12,044(10.1%)897/10,179(8.81%)323/1,865(17.3%)2.17(1.89–2.49)

EnalaprilatIV(%) 114/12,044(0.946%)74/10,179(0.727%)40/1,865(2.14%)2.99(2.01–

Labetaloloral(%) 241/12,044(2.00%)159/10,179(1.56%)82/1,865(4.40%)2.90(2.20–3.79)

827/12,044(6.87%)559/10,179(5.49%)268/1,865(14.4%)2.89(2.47–3.37)

Metoprololoral(%) 1,603/12,044(13.3%)809/10,179(7.95%)794/1,865(42.6%)8.59(7.64–9.65)

316/12,044(2.62%)174/10,179(1.71%)142/1,865(7.61%)4.74(3.77

655/12,044(5.44%)319/10,179(3.13%)336/1,865(18.0%)6.79(5.78–7.99)

Hydralazine IV(%) 1,086/12,044(9.01%)656/10,179(6.4%)430/1,865(23.1%)4.35(3.81

Outcome

DischargesystolicbloodpressurerangesinmmHg(%)

90–160 4,356/12,044(36.2%)3,641/10,179(35.8%)715/1,865(38.3%)

160–220 7,688/12,044(63.8%)6,538/10,179(64.2%)1,150/1,865(61.6%)0.90(0.81–0.99) P < 0.05

Acutecoronarysyndrome(%)1,190/12,044(9.88%)

1,190/1,865(63.8%)

Heartfailureadmission(%)705/12,044(5.85%) 705/1,865(37.8%)

Stroke(%) 488/12,044(4.05%) 488/1,865(26.2%)

Death(%) 176/12,044(1.46%) 176/1,865(9.47%)

MACE, majoradversecardiacevent; OR,oddsratio; CI,conﬁdenceinterval; mmHG,millimetersofmercury; IV,intravenous.

SymptomsandPresentingBP

Patientspresentingwithchestpain,alteredmentalstatus, dyspneaandaSBPof201–220insteadof180–200mmHg weresigniﬁcantlymorelikelytosufferMACE(OR1.34 [1.13–1.58], P < 0.001,4.01[2.63–6.05], P < 0.001,2.36 [1.91–2.89], P < 0.001,and1.29[1.15–1.45], P < 0.001), respectively.Achiefcomplaintofheadacheorreferralfor HTNwasnotsigniﬁcantlyassociatedwithMACE(OR0.81 [0.60–1.08], P = 0.17andOR0.85[0.68–1.04], P = 0.13).

Patientswithapresentingdiastolicbloodpressureranging

from80–100mmHgor101mmHgandgreaterwereless likelytosufferMACE(OR0.62[0.54–0.72], P < 0.001;0.49 [0.42–0.57], P < 0.001).

TreatmentandOutcomes

Therewere3,528/12,044(29.3%)patientswhohadany antihypertensivetreatmentduringtheirEDvisit,andthis treatmentwassigniﬁcantlyassociatedwithahigherrateof MACEwithinoneyearcomparedtothosewhodidnot receiveantihypertensivetreatment(OR5.80,95%CI

5.22–6.44).Univariateanalysisforeachtypeof antihypertensivemedicationdemonstratedthateachwas associatedwithMACEatoneyear.Furthermore,patients whoweredischargedwithaSBPabove160–220mmHgwere lesslikelytosufferMACEatoneyear(OR0.90,95%CI 0.81–0.99, Table1).

PrimaryAnalysis

Tocreateaparsimoniousmultivariablelogisticregression model,thebootstrapreceiveroperatingcurvemodelretained age,gender,historyofcardiovasculardisease, cerebrovasculardisease,diabetesmellitus,chronickidney, smokingstatus,presentationwithchestpain,alteredmental status,dyspnea,treatmentwithhydralazine(oralandIV), oralmetoprolol,anddischargeSBPasvariables(Supplement S1).Thebefore-variableselectionAUCwas0.842,andthe after-variableselectionAUC0.839.Giventhattheestimated variancefromtherandomeffectofpatientZIPcodeswaslow (0.0759,SD0.275),thisrandomeffectwasnotincludedin our ﬁnalanalysis.Intheadjustedmodel,olderagerange, malegender,historyofcardiovasculardisease, cerebrovasculardisease,diabetesmellitus,smoking,

Table2. Multivariablelogisticregressionofpatientcharacteristics withamajoradversecardiacevent(MACE)atone-yearvsthose withoutaMACE. OR(95%CI) P-value

Agerangeinyears

18–45

46–65

1.90(1.53–2.39) P < 0.001

65–90 4.04(3.27–5.04) P < 0.001

Male 1.35(1.19–1.52) P < 0.001

Historyofcardiovasculardisease4.62(3.78–5.66) P < 0.001

Historyofcerebrovasculardisease4.62(3.48–6.15) P < 0.001

Historyofdiabetesmellitus1.64(1.41–1.91) P < 0.001

Historyofchronickidneydisease1.19(0.96–1.48)0.11

Tobaccosmoker 1.35(1.19–1.54) P < 0.001

Chestpain 1.38(1.13–1.68) P < 0.01

Alteredmentalstatus 3.27(1.92–5.49) P < 0.001

Dyspnea 1.47(1.11–1.93) P < 0.001

TreatedwithhydralazineIV1.98(1.67–2.35) P < 0.001

Treatedwithhydralazineoral2.15(1.74–2.65) P < 0.001

Treatedwithmetoprololoral4.88(4.26–5.59) P < 0.001

DischargesystolicbloodrangesinmmHg

90–160

161–220 0.94(0.83–1.06)0.295

Multivariatelogisticregressionresultsafterachievingparsimonywith ROC-bootstrap method.

CI,conﬁdenceinterval; IV,intravenous; mmHg,millimeters ofmercury.

presentationwithchestpain,alteredmentalstatus,treatment withIVandoralhydralazine,andoralmetoprololwere signiﬁcantindependentpredictorsforMACEatoneyear (Table2).Themodelhadapseudo-R2 of0.260. RetrospectivepoweranalysisperformedwithGPower3 (https://www.psychologie.hhu.de/arbeitsgruppen/ allgemeine-psychologie-und-arbeitspsychologie/gpower. html)showedastatisticalpowerofthisstudyover90%.14

SecondaryAnalysis

Wecomparedshort-termoutcome(30-dayMACE-free survival)forpatientswhoweredischargedwithaSBP ≤160mmHgvsthosewithSBP >160mmHg.Therewere signiﬁcantgroupdifferencesforage,gender,historyof cerebrovasculardisease,smoking,presentationofheadache, chestpain,presentingSBP,andreceptionofantihypertensive treatmentsbetweenthosewhoweredischargedwithaSBP ≤160mmHgcomparedtothosewithaSBP >160mm Hg(Table3).

Afterpropensity-scorematching,4,356controlswithSBP >160mmHgand4,356patientswithSBP ≤160mmHgwere matched.Chestpainwastheonlyvariablethatremained significantlydifferentbetweenpatientswithSBP >160mm HgvsthosewithSBP <160mmHg.Thiswasincludedasa variableforadjustmentforthefollowingCoxregression analysisfor30-dayMACE(Table4).Inthepropensity-score matchedanalysisachiefcomplaintofchestpainwas independentlyassociatedwithanincreasedriskof30-day MACE(HR1.76,95%CI1.30–2.37, P < 0.001, Table4). However,dischargewithanSBP ≤160mmHgwasnot associatedwith30-dayMACE-freesurvivalafteradjusting forcovariates(HR0.99,95%CI0.78–1.25, P = 0.92). Survivalcurveshowsnosignificantsurvivalbenefitfor patientswhoweredischargedwithaSBP ≤160mmHgvs thosedischargedwithSBP >160mmHg(Figure1).

DISCUSSION

ThisstudyrepresentsalargecohortofEDpatientswith severelyelevatedBPwithoutEOD.TherewerehighMACE ratesatoneyear(15.5%)inourcohort.Independentrisk factorsforMACEatoneyearafteranEDvisitwhere severelyelevatedBPwasnotedincludedadvancedage,male gender,historyofcardiovasculardisease,cerebrovascular disease,diabetesmellitus,andsmoking.Presentingsignsof chestpainandalteredmentalstatus,butnotheadache,were alsofoundtobeindependentriskfactorsforMACE. Treatmentwithhydralazineormetoprololwasassociated withhigherratesofMACEatoneyearaswell.Similarto ﬁndingsbyPateletal,wefoundthatreferraltotheEDforBP managementbyaclinicwasnotassociatedwithanincreased riskofMACEatoneyear.4

Weusedpropensity-matchedanalysistomeasurethe associationbetweenreducingSBPintheEDandmore immediate,30-dayMACE-freesurvival.Inthisanalysis,

Table3. Pre-vspost-propensityscorematchingpatientcharacteristicsbetweenpatientsdischargedwithasystolicblood pressure ≤160vs >160.

Historyofcardiovascular disease(%)

477/7,688(6.2%)269/4,356(6.18%)0.949277/4,356(6.29%)269/4,356(6.18%)0.72

Historyofcerebrovascular disease(%) 198/7,688(2.58%)140/4,356(3.21%)

Historyofdiabetes mellitus(%) 1,086/7,688 (14.1%) 614/4,356(14.1%)0.979597/4,356(13.4%)614/4,356(14.1%)0.60

Historyofchronickidney disease(%)

458/7,688(5.97%)231/4,356(5.30%)0.132209/4,356(5.07%)231/4,356(5.30%)0.28 Tobaccosmoker(%)1,972/7,688 (25.7%) 1,204/4,356 (27.6%)

Headache(%) 223/7,688(2.90%)176/4,356(4.03%) P < 0.01212/4,356(4.82%)176/4,356(4.04%)0.06

Chestpain(%) 422/7,688(5.48%)569/4,356(13.0%) P < 0.001421/4,356(9.69%)569/4,356(13.1%) P < 0.001

Alteredmentalstatus(%)56/7,688(0.73%)37/4,356(0.85%)0.47645/4,356(0.90%)37/4,356(0.85%)0.38

Dyspnea(%) 229/7,688(2.98%)236/4,356(5.41%) P < 0.001228/4,356(5.23%)236/4,356(5.42%)0.70

PresentingmedianSBP inmmHg(IQR) 190(184–199)190(184–198)

antihypertensive treatment(%)

0.001189(184–198)190(184–198)0.45

Pre-vspost-propensitydemographics,presentationcharacteristicsandoutcomes. T-test comparisonsareshown. SBP,systolicbloodpressure; mmHg,millimetersofmercury; IQR,interquartilerange,

therewasnosigniﬁcantassociationbetweenareductionin SBP ≤160mmHguponEDdischargeand30-dayMACE. Thiswasfoundevenafterpropensitymatchingforreception ofantihypertensiveagents.Thisdataaddstoprior observationalstudiesshowingnoassociatedbeneﬁtwitha targetBPpriortodischargefromtheED.5

Table4. Coxregressionanalysisfor30-dayMACE*-freesurvival afterpropensitymatching.

Variable30day-MACEHR(95%CI) P-value

Chestpain 1.76(1.30–2.37) P < 0.001

Discharge SBP ≤1600.99(0.78–1.25)0.92

Coxregressionanalysisfor30-dayMACE-freesurvival;discharge SBP≤160 variableisadjustedforchestpainaspresentingclinical symptomafterpropensityscorematching.

*MACE,majoradversecardiacevent; HR,hazardratio; CI, conﬁdenceinterval; SBP,systolicbloodpressure.

Therewasanassociationwithcertainantihypertensive treatmentsintheEDandhigherone-yearMACE.Whileitis unlikelythatthisantihypertensivetreatmentledtohigher ratesofMACEuptooneyearfollowingtreatment,itis plausiblethatcliniciansperceiveaclinicalneedtotreatBPor heartrateimmediatelyinpatientswithhigherriskfor MACE.This ﬁndingcoincideswithourpreviouswork illustratingthatseverelyhypertensivepatientswhowereat higherriskforMACEweremorelikelytobegiven medicationsthatquicklylowerBPintheED,suchas nitrates,clonidine,hydralazine,metoprolol,labetalol, enalapril,andnicardipine,inadditiontocontinuingtheir chronicHTNmedications.5 Asrecentdatashowsan associationwithinpatientantihypertensivetreatmentand higherratesofacutekidneyinjuryat30days,futurework mayconsiderthisoutcomeinassessingthepracticeofacute BPloweringintheED.15

Ofnote,wefoundnoassociationbetweenBlackraceand one-yearMACEinpatientswithsevereHTNonadjusted

Figure1. 30-dayMACE*-freesurvivalcurvefordischargingpatientwithanSBP ≤160afterpropensityscorematchingandadjustingforchest painaspresentingclinicalsymptom.

*MACE, majoradversecardiacevent; HR,hazardratio; SBP, systolicbloodpressure; mmHg,millimetersofmercury.

analyses.Studieshavepreviouslydemonstratedsigniﬁcant associationbetweenBlackraceandincreasedincidenceof MACE,attributingcausationtohigherprevalenceof cardiovascularcomorbidities,genetics,lowersocioeconomic status,anddifferenttreatmentreceivedduring hospitalization.16,17 SevereHTNismorecommoninBlacks andispresentatayoungerageincomparisontootherraces; therefore,theremaybeaprotectivebiasamongthis population.Itisimportanttonote,however,thatchronic HTNisdifferentfromanacutepresentationofsevereHTN, inwhichitiswellestablishedthatBlackshavesigniﬁcantly worseoutcomes.18

Inourcohort,chestpain,alteredmentalstatus,and dyspneawerethreechiefcomplaintsindependently associatedwithone-yearMACE.Priordatahasindicated thatpatientswhopresenttotheEDwithchestpain,withor withoutelevatedBP,haveabouta5%chanceofdeveloping MACEatoneyear.19 Ofthe990patientsinthisstudywho presentedwithachiefcomplaintofchestpainandhad severelyelevatedBP,191(19.3%)developedMACEatone year.Ofthe92patientswhopresentedwithalteredmental status,39(42.4%)developedMACE.Additionally,ofthe 465patientswhopresentedwithdyspnea,136(29.2%) developedMACE.Thecombinationofseverelyelevated BPandthesecomplaintsmayindicatepoorcontrolof comorbidconditions,whichcontributestovascular endothelialdysfunctionandacuteend-organinjury.While headacheinthesettingofseverelyelevatedBPisconsidered bysometobeindicativeofahypertensiveemergency,itis notablethatwefoundnoassociationbetweenthisand MACEinourstudy.

ClinicalPerspectives

Whilehypertensiveemergenciesrequireemergent treatment,bestpracticesremaincontroversialwhenpatients

haveseverelyelevatedBPandlackacuteEOD.1 Often termed “hypertensiveurgency,” amisnomerthatimplies sometypeofurgentinterventionisneeded,currentguidance formanagementofsuchpatientsislargelybasedonexpert opinionandvariessignificantly.20 Observationaldatashows noassociatedbenefitforoutpatientclinicreferraltotheED forasymptomaticsevereHTN.4,21 Guidancefromthe AmericanCollegeofEmergencyPhysiciansrecommends againstantihypertensivetherapyintheEDforpatientswith asymptomaticsevereBPelevation.22 Whilesomehave advocatedthatthepotentialfordevelopingEODis concerningenoughwithseverelyelevatedBPtojustify urgentmanagementintheED,particularlyinpopulations withpoorEDfollow-upcare,thereisnodefinitiveevidence thatinterveninginsuchamannerimprovesshort-orlongtermoutcomes.20 Infact,ourstudyprovidesnewevidence suggestingthattheincreaseinlong-termriskofMACEin thiscohortismostlyduetoestablishedcardiovascularrisk factors.ReachingalowertargetSBPdoesnotappeartobe beneficial.Whileobservationalstudiessupportthis conclusion,arandomizedclinicalstudyiswarrantedtohelp confirmthisstatement.ManagementofseverelyelevatedBP shouldbereservedfortheoutpatientsetting.Weidentified keypredictorsformortalityinthispopulation,andefforts shouldconcentrateonbetteroutpatientmanagementof patientswiththesecharacteristics.

LIMITATIONS

Animportantlimitationtothisstudyisthepotentialfor unmeasuredconfoundersthatmayhaveaffectedoutcomes. Neitherdidweaccountforpriormedicationadherenceor newlydiagnosedHTN,factorsthatmayimpactaclinician’ s approachtotreatmentintheED.5,21 Anotherlimitationis thelackoflongitudinalfollow-upBPandantihypertensive medicationuseoveroneyearfollowingtheEDvisit.While

otherpublishedreportsindicatethatEDpatientswith severelyelevatedBPoftencontinuetohaveuncontrolledBP, wedidnotcollectsuchlongitudinaldata.4 Furthermore,we failedtocollectpotentiallyrelevantbiomarkerssuchas troponinandB-typenatriureticpeptidetomoreaccurately deﬁnepatientswithEOD.Thus,itispossiblethatclinicians mayhavemisseddiagnosingpatientswhomayhavebeen sufferingfromEOD.Eventsthatoccurredoutsidethishealth system,whichwerenotdocumentedintheCareEverywhere network,werenotcaptured,andpatientsmayhavesuffered subclinicalorunreportedevents.Itisunknownhowmany hospitalsareregisteredintheCareEverywherenetwork. Together,theseconsiderationsmayhaveledtoan underestimationofthetotalnumberofevents.

CONCLUSION

Ourstudyshowsthattheriskofsubsequentmajoradverse cardiovasculareventsinEDpatientswithseverelyelevated bloodpressurewithoutend-organdamageishigh.Patientsat higherriskofMACEoftensufferfromwell-established cardiovascularriskfactors.Whilethesepatientsstandto beneﬁtfromcarefullycoordinatedfollow-upfor cardiovascularriskreduction,reachingatargetBPin theEDisnotassociatedwithimprovedoutcomes.This dataaddstomountingevidenceagainsttheutilityof havingatargetBPpriortodischargefromtheEDand suggestthattheterm “hypertensiveurgency” beavoided todescribesuchindividuals,asthereisnoneedfor urgentintervention.

AddressforCorrespondence:JosephMiller,MD,MS,HenryFord Hospital,DepartmentofEmergencyMedicine,2799WGrandBlvd., Detroit,MI48202.Email: jmiller6@hfhs.org

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

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ORIGINAL RESEARCH

Neutrophil-to-LymphocyteRatioPredictsSepsisinAdultPatients

MeetingTwoorMoreSystemicInﬂammatoryResponse SyndromeCriteria

VamsiBalakrishnan,MD*

AnnaYang,MD†

DonaldJeanmonod,MD*

HarrisonCourie,MD*

SpencerThompson,MD‡

ValerianPeterson,MD§

RebeccaJeanmonod,MD*

SectionEditor:PatrickMeloy,MD

*St.Luke’sUniversityHealthNetwork,Bethlehem,Pennsylvania † RegionalOneHealth,Memphis,Tennessee ‡ LinnCountyEmergencyMedicinePC,CedarRapids,Iowa § MedicalCollegeofWisconsin,DepartmentofEmergencyMedicine, GrandRapids,Michigan

Submissionhistory:SubmittedSeptember14,2023;RevisionreceivedMarch28,2024;AcceptedApril4,2024

ElectronicallypublishedJune28,2024

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

DOI: 10.5811/westjem.18466

Introduction: Determiningwhichpatientswhomeetsystemicinﬂammatoryresponsesyndrome(SIRS) criteriahavebacterialsepsisisadifﬁcultchallengeforemergencyphysicians.Wesoughttodetermine whethertheneutrophil-to-lymphocyteratio(NLR)couldbeusedtoexcludebacterialsepsisinadult patientswhomeet ≥2SIRScriteriaandarebeingevaluatedforsepsis.

Methods: Consentingadultpatientsmeeting ≥2SIRScriteriaandundergoingevaluationforsepsiswere enrolled.Werecordedpatientage,gender,vitalsigns,andlaboratoryresults.Wethenlaterreviewed healthrecordsforcultureresults,endorgandysfunction,survivaltodischarge,and finaldiagnoses. Patientswereclassifiedashavingsepsisiftheymet ≥2SIRScriteriaandwereultimatelydiagnosed withabacterialsource.Weanalyzeddatausingdescriptivestatisticsandsensitivityand specificityanalyses.Areceiveroperatingcharacteristiccurve(ROC)wascreatedtodetermine testcharacteristics.

Results: Atotalof231patientshadcompletedatasets.Patients’ medianagewas69(interquartilerange [IQR]54–81),and49.6%weremale.Therewere154patients(66.7%)ultimatelydiagnosedwithsepsis withanidentifiedbacterialsource,while77patientswith ≥2SIRScriteriahadnon-infectiousreasonsfor theirpresentations(33.3%).SepticpatientshadamedianNLR12.36(IQR[interquartilerange] 7.29–21.69),comparedtothosewithoutsepsis(medianNLR5.62,IQR3.89–9.11, P < 0.001).TheNLR valueof3appliedasacutoffforsepsishadasensitivityof96.8(95%confidenceinterval[CI]92.2–98.8), andaspecificityof18.2(95%CI10.6–29.0).TheROCforNLRhadanareaunderthe curveof0.74.

Conclusion: Theneutrophil-to-lymphocyteratioisasensitivetooltohelpdeterminewhichpatientswith abnormalSIRSscreenshavebacterialsepsis.[WestJEmergMed.2024;25(5)690–696.]

INTRODUCTION

Theclinicalprogressionofsystemicinﬂammatory responsesyndrome(SIRS)fromaseriousinfectiontosepsis tosepticshockisamajorcauseofpatientmorbidityand

mortality.Sepsisaffects1.7millionadultsintheUnited Stateseachyear,resultinginatleast350,000deaths.1 Worldwide,sepsisistheleadingcauseofdeath,passing cardiovasculardiseaseandcancer.2

Thehealthcarecostsassociatedwithsepsisarealsohigh, withanestimatedannualeconomicburdenof$57billionin theUSin2019.3 Notsurprisingly,thecostincurredfromany individualcaseofsepsisincreaseswithincreasingdisease severity,anddiseaseseverityincreasesovertime.4,5 Therefore,rapididentiﬁcationandtreatmentofsepsishas beenahighprioritywithinthehospitalsettingfordecades, andperformanceimprovementprogramswith standardizationandprotocolizationofsepsismanagement havedemonstratedimprovementinoutcomes.6–8 Since87% ofcasesofsepsisarepresentuponarrivaltothehospital(as opposedtobeinghospitalacquired),emergencyphysicians playacrucialroleinpromptlyrecognizingandintervening withthesehigh-riskpatients.1,9 Emergencyphysiciansare alsotaskedwithlimitingunnecessaryuseofbroad-spectrum antibioticsaspartoftheantibioticstewardshipgoals outlinedbytheInfectiousDiseaseSocietyofAmerica,the SocietyforHealthcareEpidemiologyofAmerica,andthe PediatricInfectiousDiseaseSociety.10

Identiﬁcationofsepsiscontinuestobeachallenge. Screeningtoolsbasedonclinicaland/orlaboratorycriteria, suchasQuickSequentialOrganFailureAssessment (q-SOFA)andSIRS,arecommonlyusedtoidentifypatients withsepsis,but15–60%ofpatientswhomeetthosecriteria donotgoontohaveanactualdiagnosisofsepsis.11–13

Cardiacdysrhythmias,primarylungdisease,viralillness, trauma,endocrinedisease,andnumerousotherprocesses canresultinapositiveSIRSorq-SOFAscreen;more importantly,forrisk-stratificationtools,highsensitivityis criticallyimportanttoavoidmissingcasesofsepsis.In multipletrials,SIRSwithsuspicionforinfectionoutperforms qSOFAintermsofsensitivitybutisinferiorfor specificity.14–18 Lactateisanothertoolcommonlyused primarilyforprognosticationandassessmentofresponseto treatmentinpatientswithdiagnosesofsepsis.19,20 Althoughspecificlactatevaluesareusedasdefiningcriteria inthediagnosesofseveresepsisandsepticshock, lactateisneithersensitivenorspecificduring earlysepsis.

Theneutrophil-to-lymphocyteratio(NLR)hasbeen demonstratedtobeareliableandeasy-to-obtainmeasureof patientimmuneresponsetoavarietyofdifferentinfectious andnon-infectiousconditions.21 AnormalNLRisgenerally considered <3,althoughneonatalliteratureusesmore conservativecutoffs.21 TheNLRhasbeenassociatedwith thepresenceofbacteremiaandappearstoberelevantto prognosisandprogressioninsepsis.22–25 Inneonates, researchdemonstratesthattheNLRcanbepredictiveof bothearlyandlatesepsis.26–28 Inthisstudy,wesoughtto determinewhethertheNLRcouldbeusedtoexcludesepsis inadultpatientswhomettwoormoreSIRScriteria orhadapositiveq-SOFAscreenwhowerebeingevaluated forsepsis.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Currentscreeningforbacterialsourcesof sepsisisneithersensitivenorspeci ﬁ c.

Whatwastheresearchquestion?

Cantheneutrophillymphocyteratio(NLR) beusedtoexcludebacterialsepsisinpatients meeting ≥ 2SIRScriteriaforsystemic in ﬂ ammatoryresponsesyndrome?

Whatwasthemajor ﬁndingofthestudy?

AnNLRvalueof3hadasensitivityof96.8% (CI92.2 – 98.8),andaspeci ﬁ cityof18.2% (10.6 – 29.0).TheROCforNLRhadanarea underthecurveof0.74.

Howdoesthisimprovepopulationhealth?

Bacterialsepsisisamajorcauseofmorbidity andmortality.TheNLRisasensitiveand inexpensivetoolthatcanhelpdetermine whichpatientshavebacterialsepsis.

MATERIALSANDMETHODS

StudyDesign

Thiswasaprospectivecohortstudyofadult(≥18years) emergencydepartment(ED)patientswhowerebeing evaluatedforsepsis.Allpatientscompletedwritteninformed consentorhadsurrogateinformedconsent.Thestudywas reviewedandapprovedbytheinstitutionalreviewboard.

StudySettingandPopulation

ThestudytookplaceatasingleacademicEDwithan annualcensusof50,000patients.Patientswereenrolledfrom April2019–March2020.Adultpatientswereeligiblefor enrollmentiftheywerepositiveonSIRSscreening(≥2values present)oronq-SOFAscreeningonarrivaltotheEDand wereundergoingevaluationforsepsis.TheSIRScriteriaare temperature >100.4°Fortemperature <96.8°F;heartrate >90beatsperminute;respiratoryrate(RR) >20orpCO2 < 32millimetersofmercury(mmHg);andwhitebloodcell count >12,000or <4,000,orbandcount >10%.AqSOFA scoreiscalculatedbygivingthepatientapointforaltered mentalstatus,systolicbloodpressurelessthan100mmHg, orRR ≥22,with ≥2pointsconsideredindicativeofhighrisk. Patientswereidentiﬁedthroughtheelectronichealthrecord (EHR)(EpicSystemsCorporation,Verona,WA),which generatesanautomaticcomputeralertforpatientswith positiveqSOFAandSIRSscreens.Afteridentiﬁcationof

potentialpatientsthroughthecomputeralert,eligibility formswerecompletedbyclinicians.

Patientswererequiredtoprovidewritteninformed consent.Incaseswherepatientsweretooill,cognitively impaired,orintubatedandcouldnotconsent,consentwas soughtfromtheirhealthcareproxy,ifavailable.Weexcluded non-English-speakingpatientsandpatientsforwhomtheir evaluationscouldnotbedelayedtoaccommodatethe consentprocess.Pregnantpatientsandpatientstriagedtothe traumabaywerealsoexcluded.Traumabaytriagecriteria arelistedin Appendix1

StudyProtocolandMeasurements

Aftereligibilityformswerecompletedbyclinicians involvedinthepatients’ care,theformswerescreenedby studyinvestigatorswhothenapproachedthepatientsto obtainconsent.Onceconsentwascompleted,werecorded clinicaldataforeachSIRS-positiveandqSOFApatient enrolled,includingage,gender,vitalsigns,completeblood count(CBC)andlactatelevels.Welaterreviewedhealth recordsoutto90daysforcultureresults;endorgan dysfunction(includingrenalfailure,shockliver,pulmonary failure,cardiacfailure,delirium);survivaltodischarge; disposition(home,rehab,nursingfacility,ordeathwithin 90days);and ﬁnaldiagnoses.Wecollecteddataina standardizedExcelspreadsheet(MicrosoftCorp,Redmond, WA)onapassword-protectedcomputerbelongingtoastudy investigator.Alldatawasenteredfromaprepopulatedpulldownmenutoreducedataentryerrors.Onceallclinicaldata collectionwascomplete,thedatabasewaspurgedofpatient identiﬁerspriortoanalysis.

Patientswereclassifiedashavingsepsisiftheymet ≥2 SIRScriteriaor2+ qSOFAcriteriaandwereultimately diagnosedwithabacterialsource.Patientswereclassifiedas nothavingsepsisiftheymetSIRS/qSOFAcriteriabut werediagnosedwithanalternativesourceforthose abnormalitiesandhadnobacterialsourceidentified. Bacterialsourcesofsepsiswereclassifiedasurinary, pulmonary,centralnervoussystem,intra-abdominal,skin andsofttissue,hematogenous,orother.Cutoffvaluesfor analysisofNLRwere3,whichisacommonlyreported numberintheliteratureasbeingabnormallyhigh, and10,whichisavaluereportedtohavenegative prognosticimplications.

InvestigatorandEnrolleeTraining

OnlyphysicianswhohadcompletedmandatoryCITI trainingandgoodclinicalpracticetrainingconsentedand enrolledpatientsinthisstudy.Althoughallclinicians workingintheEDwereinformedandremindedofthestudy duringweeklyeducationaltimeandwerepermittedto completeeligibilityforms,onlytrainedinvestigatorswere permittedtoenrollpatients.Inadditiontomandatory researchtraining,investigatorsmetwiththeprincipal

investigator(AY)whodesignedthedatacollectiontooland weretrainedinitsuse.

DataAnalysis

Weanalyzeddatausingdescriptivestatistics.Sensitivity andspeciﬁcitycalculationswereperformedusingMedCalc (MedCalcSoftwareLtd,Ostend,Belgium)andVassarStats (RichardLowry1998–2023).Wecreatedreceiveroperating characteristic(ROC)curvestodeterminetestcharacteristics.

RESULTS

Weenrolled233patients.Twohadincompletedatasets, leaving231patientsfordataanalysis.Thepatients’ median agewas69,withaninterquartilerangeof54–81;49.6%were male.Twenty-ﬁvepatients(10.7%)wereadmittedtothe intensivecareunit,18patients(7.7%)diedinthehospital duringtheindexvisitorweredischargedtohospice,and32 (13.7%)diedwithin90daysoffollow-up.Fivepatientswere enrolleddespitenotmeetingSIRSorqSOFAcriteriaon initialpresentation.Theywereincludedinthisanalysisonan intent-to-treatbasis.Furtherpatientcharacteristicsare showninthe Table.

Ofthe231eligiblepatients,154patients(66.7%)were ultimatelydiagnosedwithsepsiswithanidentifiedbacterial source(Figure1).Seventy-sevenhadnon-infectioussources identified(33.3%).Themostcommonlyidentifiedsources werepulmonaryandurinarytract,followedbybacteremia andsofttissueinfections(Figure2).Somepatientshadmore thanoneidentifiedsource.Themostcommonlyidentified reasonsforpatientsmeetingSIRScriteriawithoutbacterial sourceofsepsiswereviralsyndromes(28patients); congestiveheartfailure(10);asthma/chronicobstructive pulmonarydiseaseexacerbations(5);medication/drugs(5); malignancyrelated(5);pneumonitis(5);andcomplications ofendocrinedisease(3).Patientswithsepsiswithan identifiedbacterialsourcehadamedianNLRof12.36 (interquartilerange[IQR]7.29–21.69),comparedtoa medianNLRof5.62(IQR3.89–9.11)inthosethatdidnot haveabacterialsource(P < 0.001)(Figure3).

TheNLRvalueof3appliedasacutoffforsepsishada sensitivityof96.8(95%confidenceinterval[CI]92.2–98.8), andaspecificityof18.2(CI10.6–29.0).Inthispopulation withahighprevalenceofdisease,thepositivepredictive valueofNLRwas70.3(CI63.6–76.2),withanegative predictivevalueof73.7(CI48.6–89.9),withaperformance oddsratioof6.86(CI2.37–19.89)forhavingdisease.When anNLRcutoffof10wasused,thespecificityincreased significantlyto73%,althoughwithamarkedsacrificeof sensitivitydownto60.5%.TheROCforNLRyieldedan areaunderthecurveof0.74(Figure4).

DISCUSSION

Mosthospitalsusesomevariationofscreeningforsepsis asrequiredtomeetcoresepsismetricsimplementedbythe

Table. Characteristicsofpatientsundergoingevaluationfor bacterialsourceofsepsis.

Total(N = 231)

Medianage(IQR)69(54–81)

Gender(%)

Male114(49.4)

Female117(50.6)

Dispositionfromindexvisit(%)

Home156(67.5)

Assistedlivingandnursinghome55(23.8)

Hospice14(6.1)

Death5(2.2)

Unknown1(0.4)

NumberofSIRScriteria(%) 00(0) 16(2.6) 2102(44.2) 393(40.3) 426(11.3) 54(1.7)

NumberofqSOFAcriteria(%)

094(40.7) 1113(48.9) 223(10)

31(0.4)

IQR,interquartilerange; SIRS,systemicinﬂammatoryresponse syndrome; qSOFA,quickSequentialOrganFailureAssessment.

CentersforMedicareandMedicaidServices.Theseare typicallybasedonSIRSand/orqSOFAcriteriawith suspicionforinfection.Manyhospitalshavebestpractice advisorywarningsautomaticallyimplementedintotheEHR basedonthesestratificationtoolstohelpcliniciansearlier identifypotentiallyillpatientswhomaybenefitfrom escalationofcare.Thisinitialrecognitionofahigherrisk cohortofpatientsisanimportant firststep.Becausethese initialscreensarehistoricallyinsensitive(bothwith sensitivitiesofabout50%)butalsonotadequatelyspecific,a secondaryscreenwouldbeusefultohelpdeterminewhich patientsmighthavesepsisasthereasonfortheir presentation.13,29 ANLRisasimplecalculation requiringonlyacompletebloodcount(CBC)with differentialtoberesultedandcouldbeusedasa secondaryscreen.

Althoughvirtuallyeverypatientwithsuspectedsepsishas theirCBCanalyzed,thegoalofthisbloodtestistraditionally todetermineabsolutewhitebloodcellcountandpercentage ofbands,astheseareexistingcriteriawithinSIRS.TheNLR hasnotbeenpositedasbeingusefulinthedeterminationto initiateantibioticsorasapotentialscreenforsepsis.Fora computer-generatedalert,usingaNLRiseasytoimplement andcouldprovideusefulguidanceinprescreened high-riskpatients.

Inourstudy,patients allofwhomwereprospectively beingevaluatedforsepsis aNLR >3gaveanoddsratioof 6.9ofsepsis,withasensitivityof96.8%.Thissuggeststhatit maybereasonabletoinitiatebroad-spectrumantibioticsin high-riskpatientswithanelevatedNLR.SinceaCBChasa rapidlabturnaroundtime,thismayhastentreatmentin

,againstmedicaladvice; ICU,intensivecareunit.

Figure1. Patient ﬂowdiagram. ED,emergencydepartment; AMA

Figure3. Neutrophil-to-lymphocyteratioinpatientswith ≥2 SIRS*criteria.

*SIRS,systemicinﬂammatoryresponsesyndrome; NLR,neutrophilto-lymphocyteratio.

Figure4. Receiveroperatingcurvefortestcharacteristicsof neutrophil-to-lymphocyteratioinpredictingbacterialsourcein patientsmeeting ≥2SIRS*criteria.

ROC,receiveroperatorcurve;*SIRS,systemicinﬂammatory responsesyndrome.

patientsforwhomthephysicianis “onthefence” regarding antibioticadministration.

WhetherNLRwouldbeusefulinacutepresentationsof sepsiswithnegativeSIRSandqSOFAscreensisdifficultto assess.Wechosetoincludeonlypatientswithpositive clinicalexamfeaturesforsepsis,whichrepresentsworkup biaswithinourstudy.Thiswasdonesothatwecouldhavea standardizedprotocolbywhichtoenrollpatients,rather thansimplyenrollingeverypatientwhohadaCBCdrawn. Therearemanyclinicalpresentationsinwhichpatients “screennegative” forsepsisusingqSOFAandSIRScriteria, butthephysicianhasahighindexofsuspicionforother reasonsthatarelesseasilyquantified,orinwhomsepsisis stillonthedifferentialdiagnosis.These “screennegative” patientswithsepsisarebydefinitionthehardesttorecognize, andNLRmayhavethepotentialtorisk-stratifythem. FurtherstudymayhelptoidentifytherolethatNLRcould haveinscreeningpatients.

Itisimportanttoacknowledgetheperformanceof qSOFAandSIRSwithinthecontextofourstudy.Veryfew ofourenrolledpatientswhowentontohaveadiagnosesof sepsiswithbacterialsourceshadpositiveqSOFAscreens, whichisnotinkeepingwiththeexistingliteratureonqSOFA scores.Only11%ofourbacterialsepsispatientshadpositive qSOFAscores,and29%ofourpositiveqSOFAscreenswere notseptic.Becauseofthis,itisdifﬁculttospeaktoNLR’ s beneﬁtinpatientswithpositiveqSOFAscreens,asthis representedtheminorityofourpatientpopulation,mostof whomwereenrolledonthebasisofvitalsignabnormalities consistentwithSIRS.Thiswouldbeanareafor furtherstudy.

LIMITATIONS

Becausethiswasarelativelysmallstudyperformedata singleinstitutionandweenrolledpatientsasaconvenience sample,itsgeneralizabilityislimited.Theincidenceof diseasewasveryhighinourcohort,whichisimportantto

Figure2. Sourcesofsepsis.

considerwheninterpretingourresults.Weenrolleda relativelyhigh-riskcohort,whichmeansthatourdatamay notbeapplicabletopatientswithnegativeqSOFA/SIRS screens.Toeffectivelymirrorreal-worldapplicationofthe NLRinpatients,weattemptedtoidentifypatientsina prospectivemannertoincludepatientswithphysiologic processesthatcausevitalsignabnormalitieswhereinfection mighthavebeenaconsiderationinthedifferentialdiagnosis, butultimatelythediagnosiswasnotsepsis.Further,this studyisalsolimitedbythestudyprotocolinclusioncriteria. Sincethiswasaprospectivestudywithwrittenconsentand patientswithalteredmentalstatuscouldnotconsent,and surrogateconsentwasnotalwaysavailable,thiscouldhave affectedtheyieldofNLRasascreeningtool,eitherpositively ornegatively.

SinceourstudyrequiredqSOFAandSIRSscreeningfor studyentry,itislimitedbytheaccuracywithwhichthose screenswereperformed.Atourinstitution,thesevaluesare inputbyatriagenurseandmaybesubjecttoindividual variabilityandskillset.Examplesofhowthiscouldhave affectedthestudyincludeinaccuraciesintemperature measurementsbasedonmethodorinaccuraciesincounting respiratoryrates.Additionally,ourqSOFAdatalikelywas affectedbythelackofemphasisonit;historically,and currently,ourinstitutionstressestheimportanceof considerationforSIRSwithsuspicionofsourceofinfection, withqSOFAofsecondaryimport.Itispossiblethatwemay nothaveemphasizedthedocumentationofitasmuchas SIRSgivensomewhatlessfamiliarity,resultinginmissed opportunitiesforenrollmentinpatientswhowereSIRS negativebutqSOFApositive.

Additionallimitationsincludethelackofinclusionof patientswhowereexcludedfromenrollmentbystudydesign. Non-Englishspeakerswereexcludedbecauseofinabilityto appropriatelytranslatetheinformedconsentforallcomers. Althoughthedrawingofbloodisofminimalrisktothefetus, pregnantpatientswereexcludedfromthecurrentstudy becauseduringpregnancytheneutrophilcountnaturally increasesduringthesecondandthirdtrimesters. Additionally,physiologicchangesofpregnancyincluding increasedheartrateandrespiratoryratemightmakethe patientSIRSpositive,despitetheabsenceofasevere infection.Patientstriagedtothetraumabaywereexcluded becauseofdifﬁcultieswithconsentingpatientsanddictating diagnostictestingduringtheirtraumaevaluation.

ThisstudywasperformedinaperiodpriortotheCOVID19pandemic.Becauseofissueswithquarantiningpatients earlyinthepandemic,patientenrollmentwasstoppedatthe beginningofthepandemic.TheutilityofNLRasascreening testmaynotbeapplicableinapost-pandemicenvironment.

CONCLUSION

Theneutrophil-to-lymphocyteratioisasensitivetoolto helpidentifypatientswhomayhaveabacterialsourcefor

sepsis.Itisfasttouseandwithoutadditionalcosttothe patient.Inourstudy,acceptableperformancewas demonstratedwithacutoffof3.Furtherstudiesshouldfocus onvalidationofthese ﬁndingsinbroaderpopulations.

AddressforCorrespondence:RebeccaJeanmonod,MD,St.Luke’s UniversityHealthNetwork,businessaddress,801OstrumSt., Bethlehem,PA18015.Email: rebeccajeanmonod@yahoo.com

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

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ORIGINAL RESEARCH

TheNonlinearRelationshipBetweenTemperatureandPrognosis inSepsis-inducedCoagulopathyPatients:ARetrospective CohortStudyfromMIMIC-IVDatabase

GuojunChen,MD*†∘

TianenZhou,PhD*†∘

JingtaoXu,MD*†

QiaohuaHu,MD*†

JunJiang,PhD*†

WeiganXu,MD*†

*FirstPeople’sHospitalofFoshan,DepartmentofEmergency,Foshan,Guangdong,China † FirstPeople’sHospitalofFoshan,ThePoisonTreatmentCentreofFoshan,Foshan, Guangdong,China

∘ GuojunChenandTianenZhouareco-ﬁrstauthorsandcontributedequallytothiswork

SectionEditor:QuincyK.Tran,MD,PhD

Submissionhistory:SubmittedNovember19,2023;RevisionreceivedApril24,2024;AcceptedApril26,2023

ElectronicallypublishedAugust16,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18589

Background: Theprognosticvalueofbodytemperatureinsepsis-inducedcoagulopathy(SIC)remains unclear.Inthisstudyweaimedtoinvestigatetheassociationbetweentemperatureandmortalityamong SICpatients.

Methods: Weanalyzeddatafor9,860SICpatientsfromanintensivecaredatabase.Patientswere categorizedbymaximumtemperatureinthe ﬁrst24hoursintothefollowing: ≤36.0°C;36.0–37.0°C; 37.0–38.0°C;38.0–39.0°C;and ≥39.0°C.Theprimaryoutcomewas28-daymortality.Weused multivariateregressiontoanalyzethetemperature-mortalityassociation.

Results: The37.0–38.0°C,38.0–39.0°Cand ≥39.0°Cgroupscorrelatedwithlower28-daymortality (adjustedHR0.70,0.76and0.72,respectively),whilethe <36.0°Cgroupcorrelatedwithhighermortality comparedtothe36.0–37.0°Cgroup(adjustedHR2.60).Anonlinearrelationshipwasobserved betweentemperatureandmortality.Subgroupanalysisfoundnoeffectmodiﬁcationexceptin cerebrovasculardisease.

Conclusion: Abodytemperatureintherangeof37.0–38.0°Cwasassociatedwithasignificantlylower mortalitycomparedtothenormaltemperature(36.0–37.0°C)group.Additionally,agradualbut statisticallyinsignificantincreaseinmortalityriskwasobservedwhenbodytemperatureexceeded 38.0°C.Furtherresearchshouldvalidatethese findingsandelucidateinvolvedmechanisms,especially incerebrovasculardiseasesubgroups.[WestJEmergMed.2024;25(5)697–707.]

INTRODUCTION

Sepsis,deﬁnedaslife-threateningorgandysfunctiondue todysregulatedhostresponsetoinfection,1 frequentlyleads toderangementsincoagulationrangingfromsubtle activationtoovert,disseminatedintravascularcoagulation (DIC).2,3 Thisconditioninsepsisisassociatedwithmultiple organfailureandhighmortality.4,5 In2017theInternational SocietyonThrombosisandHaemostasis(ISTH)proposed “sepsis-inducedcoagulopathy” (SIC)criteriatoidentify

earlycoagulopathyinsepsis,deﬁnedbysepsisplus thrombocytopeniaandprolongedprothrombintime.4 SeveralstudieshavevalidatedSICasanearlyidentiﬁerof impendingovertDICinsepsis.6,7 Sepsis-induced coagulopathycorrelateswithmortality,withratesexceeding 30%atascore ≥4.4 ComparedtoovertDICcriteria,SIC demonstratesgreatersensitivityinpredictingmortality.7

Insummary,SICrepresentsanearlyphaseofcoagulation dysfunctioninsepsisthatoftenprogressestoovertDIC.The

highmorbidityandmortalityassociatedwithSIChighlights theneedforearlyidentiﬁcationusingsimplecriteriasuchas theSICscore,allowingrapidinitiationofinterventionsthat mayimproveoutcomesinthishigh-riskpopulation. Monitoringbodytemperaturechangesisvitalinevaluating septicpatientprognosis,asfeverisacommonsymptom.8 Bothhypothermiaandhyperthermiainsepsisreﬂectimmune responsetoinfection.However,theirimplicationsfor prognosisremaindebated.9–13

Previousstudieshaveassociatedhypothermiawithpoor outcomes.14–19 Theprognosticvalueofhyperthermiaisless clear,withconﬂictingreports.11,13,20 Thishighlightstheneed toclarifytheroleofbodytemperatureinsepsis.

ConsideringthatSICsignificantlyinfluencessepsis prognosisbyalteringcoagulation,4,21,22 anexplorationofthe relationshipbetweentemperatureandSICwillenhanceour comprehensionofsepsispathophysiologyandfacilitatemore preciseprognosticationandmanagementstrategies. Nonetheless,theprognosticvalueofbodytemperature abnormalitiesspecificallywithinSIChasnotbeen comprehensivelyestablished.Therefore,weaimedto investigatetheassociationbetweenbodytemperatureand theshorttermmortalityofsepticpatientswithcoagulopathy. The findingsareexpectedtobridgeacriticalknowledgegap concerningtheintricateinterplaybetweentemperature regulationandcoagulationinsepsis.

MATERIALSANDMETHODS

DataSource

Thedatautilizedinthisstudywasextractedfromthe MedicalInformationMartforIntensiveCare-IV(MIMICIV)databasethroughtheemploymentofNavicatPremium 15software.MIMIC-IV,acollaborativeeffortbetweenBeth IsraelDeaconessMedicalCenter(BIDMC)and MassachusettsInstituteofTechnology(MIT),isa comprehensiverepositoryencompassingdatafromover 60,000adultintensivecareunit(ICU)admissionsatBeth IsraelDeaconessMedicalCenterspanningfrom2008to 2019.23 Thedata,collectedduringroutineclinicalcareat BIDMC,werede-identiﬁed,transformed,andmade accessibletoresearcherswhohavecompletedrequisite traininginhumanresearchethicsandenteredintoadatause agreement.Accesstothedatabasewassecuredbyour correspondingauthor,bearingcertiﬁcationNo.46450588. TheInstitutionalReviewBoardatBIDMCgrantedan exemptionfromobtaininginformedconsentandapproved thesharingoftheresearchresource.

StudyPopulation

Patientdataconformingtosepsis-inducedcoagulopathy criteriawereextractedfromtheMIMIC-IVdatabase’sICU records.Thepatientselectionprocessforthisstudyadhered tothefollowinginclusioncriteria:(1)hospitalstayduration of ≥24hours;(2)age ≥18years.Exclusioncriteria

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Bodytemperatureisacriticalvitalsign, butitsprognosticvalueinsepsis-induced coagulopathy(SIC)remainsunclear, withcon ﬂ ictingevidenceonideal temperatureranges.

Whatwastheresearchquestion?

Weaimedtoinvestigatetheassociation betweenbodytemperatureand28-day mortalityamongSICpatients.

Whatwasthemajor ﬁndingofthestudy?

Comparedto36.0 – 37.0 ° C,37.0 – 38.0 ° Cwas associatedwithlowermortality(adjustedHR 0.70,95%CI0.62 – 0.79,P < 0.001).

Howdoesthisimprovepopulationhealth?

Identifyingtheoptimaltemperaturerange inSICcouldguidebetterthermoregulation management,potentiallyreducingmortality andimprovingoutcomesinthis high-riskpopulation.

encompassed:(1)presenceofgreaterthan10%missing individualdata;(2)outliers,indicatedbyvaluesexceeding themean ± 3StandardDeviation(SD).Incasesofmultiple ICUadmissions,solelydatafromthe ﬁrstICUadmissionof theinitialhospitalstaywereconsidered.

DataExtraction

StructuredQueryLanguage(SQL)washarnessedto extractdatarecordedonthe ﬁrstdayofadmission.Extracted dataincludeddemographicdetails,fundamentalvitalsigns, comorbidities,basiclaboratoryparameters,andpretreatmentscoringsystems.Demographicdataencompassed race,gender,andage.Vitalsignsincorporatedheartrate, respiratoryrate,andbodytemperature.Bodytemperature wasroutinelymeasuredbynursesatbedside,primarily throughtheaxillaryandoralroute,at4–8hourintervals.For someICUpatients,occasionalcoretemperaturesfrom esophagealandrectalprobeswerealsoavailable.We extractedthemaximumtemperatureondayoneforeach patient.Comorbiditieswerecategorizedasmyocardial infarction,congestiveheartfailure,cerebrovasculardisease, chronicpulmonarydisease,renaldisease,anddiabetes. Laboratoryparametersencompassedhemoglobin,platelet count,whitebloodcellcount,bicarbonate,creatinine,urea nitrogen,glucose,ProthrombinTime(PT),Partial

ThromboplastinTime(PTT),andInternationalNormalized Ratio(INR).Additionally,theCharlsonComorbidityIndex (CMI),SequentialOrganFailureAssessment(SOFA)score, SimpliﬁedAcutePhysiologyScoreII(SAPSII),Renal ReplacementTherapy(RRT), ﬁrst-dayventilationuse,and vasopressorusewereincluded.Variableswithmissingvalues ≥40%wereexcludedduringvariableselection.Forsomeof thecontinuousvariablesincludedwithmissingdata(seethe SupplementaryTableS1 formissingdata),weusethesimple substitutionmethodtodealwiththem.Missingvaluesare replacedwithmeansiftheyfollowanormalor approximatelynormaldistribution,andwithmediansifthey followaskeweddistribution.

PrimaryandSecondaryOutcomes

Theprimaryoutcomemeasurewas28-daymortality, whilesecondaryoutcomesincluded90-daymortality, lengthofstay(LOS)inboththeIntensiveCareUnit(ICU), andhospital.

StatisticalAnalysis

Allparticipantswerecategorizedinto ﬁvegroupsbasedon theirmaximumbodytemperaturewithinthe ﬁrst24hoursof hospitaladmission: ≤36.0°C,36.0–

C.Thereferencegroupwasdeﬁnedas thetemperaturecategoryof36.0–37.0°C.Normallydistributed continuousvariableswerepresentedasmean ± standard deviation,whilenon-normallydistributeddataweredisplayed asmedian[interquartilerange(IQR)].Normalitydistribution wasassessedusingtheShapiro-Wilktest.Categoricaldata werepresentedascounts(percentages).Tocomparethe differencesacrossgroups,one-wayanalysesofvariance (normaldistribution),Kruskal–Wallistests(skewed distribution),andchi-squaretests(categoricalvariables) wereundertaken.

Univariatelogisticregressionanalyseswereperformedto exploretheassociationsbetweeneachvariableandtherisks of28-dayand90-daymortality,withtheresultspresentedin SupplementaryTablesS2andS3,respectively.

Theassociationbetweenbodytemperatureand28-day mortalitywasexaminedviaCoxproportionalhazard regression,withresultsexpressedasHazardRatios(HR) alongwith95%ConﬁdenceIntervals(CI).Foreach endpoint,fourmultivariateanalyticmodelsweredeveloped: Model1,unadjustedcovariates;Model2,covariates includinggender,age,race,heartrate,andrespiratoryrate; Model3,furtheradjustedforhemoglobin,plateletcount, INR,whitebloodcellcount,aniongap,bicarbonate,blood ureanitrogen,creatinine,glucose,PT,andPTT;and Model4,encompassingallcovariates.Lineartrendtests acrosstemperaturecategorieswereperformedusingthe mediantemperaturevalueineachgroup.

Wealsoexaminedthelinearityofthebodytemperaturemortalityassociationusingcurve ﬁtting.Forthisanalysis,we

modeledtemperatureasacontinuousvariable,ratherthan usingthepre-deﬁnedtemperaturecategories.AtwopiecewiseCoxmodelwithsmoothingsplinewasusedto determinethethresholdrelationshipbetweenbody temperatureandmortality,withthethresholdpoint identiﬁedthroughlikelihoodratiotestingand bootstrapresampling.

Furthermore,potentialmodiﬁcationsoftherelationship betweenbodytemperatureandmortalitywereassessed, includingthefollowingvariables:age(<70vs. ≥70years), gender,SOFAscore(<4vs. ≥4),SAPSII(<42vs. ≥42), myocardialinfarct(yesvs.no),cerebrovasculardisease (yesvs.no),chronicpulmonarydisease(yesvs.no),diabetes mellitus(yesvs.no)andrenaldisease(yesvs.no).

Heterogeneityamongsubgroupswasassessedby multivariatecoxregression,andinteractionsbetween subgroupsandbodytemperaturewereexaminedby likelihoodratiotesting.Toadjustformultiplecomparisons inthesesubgroupanalyses,weappliedtheBonferroni correction.Specifically,wedividedthepredetermined significancelevelof α = 0.05bythenumberofsubgroup comparisons(9),resultinginaBonferroni-adjusted significancelevelof0.0056.Wethenevaluatedwhetherthe associationbetweentemperatureandSICmortalitydiffered significantlyineachsubgroup,usingthiscorrected significancethreshold.

Finally,Kaplan-Meiercurveswereconstructedtovisually examinetheassociationbetweentemperaturecategories andmortality.

AnalyseswereconductedusingRsoftware(http://www. R-project.org,TheRFoundation)andFreeStatistics software(version1.7),withtwo-sided p < 0.05considered statisticallysigniﬁcant.

WeusedClaudeAI,anartiﬁcialintelligencewriting assistantdevelopedbyAnthropic,toaidin ﬁnalpolishingof themanuscript.ClaudeAIprovidedsuggestivecontent whichwethenreviewed,edited,andapprovedbefore inclusion.Wetakefullresponsibilityforthecontentand conclusionsofthemanuscript.

RESULT

BaselineCharacteristicsandPatientOutcome

Atotalof9,860patientsdiagnosedwithsepsis-induced coagulopathy(SIC)wereincludedinthiscomprehensivestudy (Figure1).Thedemographicdetails,vitalsigns,laboratory parameters,andcomorbiditiesofthesepatientsatbaselineare meticulouslypresentedin Table1.Notably,comparedto patientswithabodytemperaturebetween38.0–39.0°C,the mortalityratewasslightlyhigherinthegroupwithbody temperaturesabove39°C.However,thehighestmortalityrate wasobservedinthegroupwithbodytemperaturesbelow 36.0°C,suggestingabimodalrelationshipbetweenbody temperatureandmortalityinSICpatients.

Figure1. Flowchartofthescreeningandenrollmentofstudy participants.MIMIC:MedicalInformationMartforIntensiveCare. ICU,IntensiveCareUnit; LOS,lengthofstay; PLT,platelet; INR, InternationalNormalizedRatio; SIC,sepsis-inducedcoagulopathy.

RelationshipsBetweenBodyTemperatureandOutcomes

Table2 offersacomprehensiveoverviewoftheoutcomes’ associationwithvaryingbodytemperatures.Inthe unadjustedmodel(Model1),thehazardratios(HRs)and 95%conﬁdenceintervals(CIs)for28-dayall-causemortality were2.82(2.17,3.66)fortemperatures <36.0;°C,0.62(0.56, 0.69)for37.0–38.0°C,0.63(0.55,0.72)for38.0–39.0°C,and 0.75(0.62,0.90)for ≥39.0°C,allcomparedtothereference groupof36.0–37.0°C.

InthefullyadjustedModel4,whichaccountedforgender, age,race,vitalsigns,laboratoryparameters,comorbidities, andseverityscores,theassociationbetweentemperatureand 28-daymortalityremainedstatisticallysigniﬁcant.This suggestsarobustinverserelationshipbetweenbody temperatureandshort-termmortalityriskinthis patientpopulation.

Theresultsfromtheadditionalregressionmodels(Models 2and3)wereprovidedin SupplementaryTableS4.These modelsshowedconsistent ﬁndings,withhighertemperatures beingassociatedwithlowermortalityrisk.

Whentemperaturewasexaminedasacontinuousvariable, thefullyadjustedModel4showedthatforevery1°Cincrease inbodytemperature,therewasan18%(HR0.82,95%CI 0.78–0.87)reductionintheriskof28-daymortality.

Thenon-linearrelationshipbetweentemperatureand 28-dayall-causemortalitywasfurtherdemonstratedbythe smoothcurve ﬁttinganalysisdepictedin Figure2 (p for non-linearity <0.001).Asimilarprotectiveassociation wasalsoobservedfor90-dayall-causemortality (SupplementaryFigureS1).

Furthermore,ourmultivariatelinearregressionmodels revealedthatforevery1°Cincreaseinbodytemperature, therewasacorrespondingincreaseinICUlengthofstayby

0.40days(95%CI:0.24–0.55days)andtotalhospitallength ofstayby0.82days(95%CI:0.48–1.15days)inthefully adjustedanalysis.

ThresholdEffectAnalysisofBodyTemperatureonSIC Patients’ Mortality

Weconductedasmoothingfunctionanalysistoassessthe potentialnon-linearrelationshipbetweenbodytemperature and28-daymortalityinSICpatients.Afteradjustingfor potentialconfoundersincludingage,gender,laboratory resultsandcomorbidities,weobservedanon-linear associationbetweenbodytemperatureandriskof28-day mortality(Figure2).Thisnon-linearrelationshipwas alsoobservedwhenanalyzing90-daymortality (SupplementaryFigureS1).

Furthersplineanalysisrevealedathresholdeffect, withriskdecreasingasbodytemperatureincreasedupto 38.0°C(adjustedHR0.640;95%CI0.589–0.696),after whichriskslightlyincreasedbutwasnolonger statisticallysigniﬁcant(adjustedHR1.192;95%CI 0.984–1.444).(Table3)

Thethresholdeffectat38.0°Cisillustratedbythespline curvein Figure2,whichdepictstheestimatedadjusted hazardratios(solidline)andpointwise95%conﬁdence intervals(shadedarea)fortherelationshipbetweenbody temperatureand28-daymortalityrisk.Ouranalysesindicate acomplexnon-linearassociationbetweenbodytemperature andmortalityriskinSICpatients,withhypothermia conferringthehighestrisk.

SubgroupAnalysis

Toidentifyfactorsimpactingtheeffectofbody temperatureon28-daymortality,comprehensivesubgroup analyseswereconducted,asdepictedin Figure3.Interaction p -valueswerelargelynon-signi ﬁcantacrossage,gender, severityscores,comorbidities,andothersubgroups. Notably,anexceptionwasobservedforthecerebrovascular diseasesubgroup(p < 0.001),wherepatientswithout cerebrovasculardiseaseexhibitedalower28-daymortality risk(adjustedHR:0.78,95%CI0.73~0.83).Analogous ﬁndingsarediscernibleinthe90-daysubgroupanalysis (SupplementaryFigureS2).

SurvivalAnalysis

TheKaplan–Meiersurvivalanalysisin Figure4 highlights theimpactofvaryingbodytemperatureson 28-daysurvival.Mortalityrateswerenotablyhigherinthe <36.0groupandcomparativelylowerinthe37.0–38.0group whencontrastedwiththereferencegroup(36.0–37.0).This trendisreafﬁrmedwithadjustedHRsof2.6(95%CI1.99~ 3.42)and0.7(95%CI0.63~0.78),respectively(Table2). Consistentoutcomesareobservedinthe90-daysurvival analysis(SupplementaryFigureS3).

Table1. Baselineclinicalandlaboratorycharacteristicsofthestudypatients.

Characteristicn

Race,n(%)

White6,730(68.3)62(56.4)1,605(71)3,546(68.6)1,149(68.5)368(57.2)

Other3,130(31.7)48(43.6)656(29)1,622(31.4)529(31.5)275(42.8)

Gender,n(%)

Male6,049(61.3)66(60)1,291(57.1)3,192(61.8)1,089(64.9)411(63.9) Female3,811(38.7)44(40)970(42.9)1,976(38.2)589(35.1)232(36.1)

Vitalsign

Laboratorydata

HGB(g/dL),median(IQR)9.2(7.9,10.7)9.2(8.2,11.5)9.1(7.8,10.5)9.1(7.9,10.6)9.4(8.0,10.9)9.6(8.0,11.1)

PLT( × 10 9 /L),median(IQR)117.0(80.0,164.0)133.0(100.0,181.0)118.0(81.0,175.0)115.0(80.0,159.0)118.0(83.0,165.0)116.0(67.0,164.0)0.001 Glucose(mg/dL),median(IQR)143.0(117.0,190.0)203.0(141.0,323.8)142.0(115.0,188.0)141.0(116.0,187.0)147.5(120.0,194.0)154.0(122.0 ,199.0) < 0.001

BUN(mg/dL),median(IQR)24.0(16.0,41.0)29.5(19.2,55.2)29.0(18.0,51.0)24.0(16.0,39.0)22.0(15.0,35.0)22.0(14.5,37.0) < 0.001

Scr(mg/dL),median(IQR)1.2(0.9,2.0)1.6(1.1,3.4)1.3(0.9,2.2)1.2(0.8,1.8)1.2(0.9,1.8)1.2(0.9,2.0) < 0.001

INR,median(IQR)1.6(1.4,2.0)1.7(1.5,2.6)1.7(1.4,2.3)1.6(1.4,2.0)1.6(1.4,2.0)1.6(1.4,1.9) < 0.001

PT(s),median(IQR)17.5(15.5,22.1)18.9(16.1,27.6)18.1(15.8,24.3)17.3(15.4,21.7)17.2(15.3,21.1)17.5(15.6,20.9) < 0.001

PTT(s),median(IQR)36.7(31.1,49.9)47.8(36.8,85.4)38.7(32.1,54.5)36.2(30.9,48.8)36.0(30.9,47.4)35.9(30.8,48.0) < 0.001

Medicalhistory

Myocardialinfarct,n(%)1,712(17.4)31(28.2)456(20.2)865(16.7)274(16.3)86(13.4) < 0.001

Congestiveheartfailure,n(%)2,994(30.4)43(39.1)842(37.2)1,510(29.2)444(26.5)155(24.1) < 0.001

Cerebrovasculardisease,n(%)1,138(11.5)13(11.8)221(9.8)598(11.6)223(13.3)83(12.9)0.011

Chronicpulmonarydisease,n(%)2,379(24.1)30(27.3)578(25.6)1,269(24.6)373(22.2)129(20.1)0.012

Diabetes,n(%)2,901(29.4)22(20)705(31.2)1,533(29.7)469(27.9)172(26.7)0.016

Renaldisease,n(%)2,161(21.9)31(28.2)647(28.6)1,093(21.1)297(17.7)93(14.5) < 0.001

Diseaseseverityscore Charlsoncomorbidityindex,mean

Procedure

RRTuse,n(%)605(6.1)19(17.3)157(6.9)292(5.7)88(5.2)49(7.6) < 0.001

Table1. Continued.

Characteristicn = 9,860n =

Ventilatoruse,n(%)5,065(51.4)87(79.1)879(38.9)2,667(51.6)1,063(63.3)369(57.4) < 0.001

Vasopressoruse,n(%)5,341(54.2)78(70.9)1,193(52.8)2,796(54.1)917(54.6)357(55.5)0.005

Outcomes

< 0.001

Loshospital(days),median(IQR)days9.0(5.6,16.0)6.8(3.9,14.2)8.5(5.3,15.1)8.7(5.4,15.0)10.0(6.0,18.2)11.2(6.8,21.4)

LosICU(days),median(IQR)days3.1(1.8,6.2)4.4(2.6,7.4)2.9(1.7,5.3)2.9(1.7,5.6)3.8(2.0,7.7)4.8(2.5,9.3)

28-daymortality,n(%)2,062(20.9)61(55.5)622(27.5)938(18.2)305(18.2)136(21.2)

90-daymortality,n(%)2,754(27.9)68(61.8)811(35.9)1,292(25)408(24.3)175(27.2)

HR ,heartrate; RR ,respiratoryrate; WBC ,whitebloodcell; HGB ,hemoglobin; PLT ,platelets; AG ,aniongap; CO 2 , bicarbonate; BUN ,bloodureanitrogen; Scr ,serumcreatinine; INR ,InternationalNormalizedRatio; PT ,prothrombintime; PTT ,partialthromboplastintime; SOFA ,sequentialorganfailureassessment; SAPSII, simpli ﬁ edacutephysiology scoreII; RRT, renalreplacementtherapy; LOS, lengthofstay.

DISCUSSION

Inourstudy,asignificantrevelationemergesfromthe analysis.Specifically,SICpatientswithinthe37.0–38°C temperaturerangeexhibitedthemostfavorableprognosis, characterizedbythelowestmortality.Conversely,lowbody temperature(<36.0°C)wasassociatedwithhighermortality intheSICpopulationsimilartothatobservedinotherseptic cohorts.Subgroupanalyses,asidefromcerebrovascular disease,demonstratednosubstantialeffectmodificationby age,gender,orcomorbidities.

Ourresultscontributenovelinsightsintotheimplications ofbodytemperatureinSIC,markingapioneeringattemptat investigatingthisassociation.Sepsis-inducedcoagulopathy holdsapivotalplaceinthespectrumofsepsis-related coagulationdisorders,intimatelyconnectedwith disseminatedintravascularcoagulation(DIC).24 Recognized foritsroleinthepathogenesisofsepsis, SICactsasabridgebetweenearlysystemicinﬂammationand full-blownDIC.Byhighlightingthepotential valueofSICasamarkerandapossibletherapeutictarget, ourstudyunderscoresitssigniﬁcanceinguidingclinical decisionsandfurtheringourunderstandingof sepsispathogenesis.

Theobserveddifferencesinmortalityandhospitalstay durationbasedontemperaturegroupsunderscorethe clinicalsignificanceoftemperaturemanagementinSIC. Patientsinthehypothermicgroup(<36.0°C)displayedthe highest28-daymortalityrisk,suggestiveofsevere physiologicaldistressandcompromisedorganfunction.25 Correspondingly,maintaininganormothermicrange (37.0–38.0°C)wasassociatedwithimprovedsurvival outcomes,highlightingthepotentialimportanceof normothermiainenhancingpatientprognosis.26 Ourstudy echoespreviousreportsassociatinglowertemperatureswith heightenedmortalityriskinsepticpatients.13,19 Notably,our definitionofhypothermia(<36.0°C)withintheSICcohort yieldeda2.6-foldincreaseinmortalityafteradjustingfor confoundingfactors,reaffirmingthesignificanceof thisobservation.

Theunderlyingmechanismslinkingtemperaturewith mortalityinsepsisaremultifaceted.Hypothermiacan contributetoimmunesuppression,impaired thermoregulation,anddisruptedcoagulationpathwaysby causingplateletdysfunctionandamilddecreaseinplatelet countorotherstepsinthecoagulationcascade,thereby exacerbatingmortalityrisk.27 Conversely,feverhasbeen linkedtoimprovedsurvivalduetoenhancedbacterial clearance,optimizedantibioticefficacy,andcontrolled inflammatoryresponses.11,28 Incontrasttoprior studiesinsepsispopulations,our findingsinthesepsisinducedcoagulopathy(SIC)cohortdidnotindicatethatan earlypeaktemperatureabove39.5°Cwasassociated withworseoutcomes.11,29 Infact,patientswith temperaturesinthe37.0–38.0°Crangeexhibitedthe

Table2. Resultsofmultivariateregressionanalysisbetweentemperatureandoutcomes.

Primaryoutcomes

28-daymortalitya

Temperature0.78(0.74~0.83)

Bodytemperature

<36.02.82(2.17~3.66)

<0.0010.82(0.78~0.87)0.001

<0.0012.6(1.99~3.42) <0.001

36.0–37.01(Ref)1(Ref)

37.0–38.00.62(0.56~0.69) <0.0010.7(0.63~0.78) <0.001

38.0~ 39.00.63(0.55~0.72) <0.0010.76(0.66~0.88)0.001

≥39.00.75(0.62~0.9)0.0020.72(0.59~0.87)0.001

Secondaryoutcomes

Bodytemperature

36.02.52(1.97~3.23)

36.0–37.01(Ref)1(Ref)

37.0–38.00.64(0.59~0.7) <0.0010.73(0.67~0.8) <0.001

38.0–39.00.63(0.56~0.71) <0.0010.79(0.69~0.89)

Note: ModelIadjustedfornothing.ModelIVadjustedforgender,age,race,HR,RR,hemoglobin,platelets,INR,WBC,aniongap, bicarbonate,bun,creatinine,glucose,PT,PTT,myocardialinfarction,congestiveheartfailure,cerebrovasculardisease,chronic pulmonarydisease,renaldisease,Charlsoncomorbidityindex,SOFAscore,SAPSII,RRT, ﬁrstdayventilationuseandvasopressoruse. aLogisticregressionanalysis. bLinearregressionanalysis.

*Regressioncoefﬁcient(β). HR,hazardratio; CI,conﬁdenceinterval; LOS,lengthofstay.

lowestmortality,similartothosewithtemperatures above39.0°C.

Wefoundthatnormothermia(37.0–38.0°C,definedasa mildfeverinsomecountries)wasassociatedwithreduced mortalitycomparedto36.0–37.0°C.Thisisconsistentwith previous findings.AmulticenterRCTbySchortgenetal. reportedexternalcoolingtoachievenormothermia (36.5–37.0°C)couldreduce14-daymortalitycomparedto externalheatingtoachievefevercontrol.8 However,aRCT byYoungetal.didnot findasignificantdifferencein90-day mortalitybetweenfevercontrolandnofevercontrol.30 Thediscrepancymaybeexplainedbythedifferenttarget temperatureranges.Overall,maintainingnormothermia ormildfeverappearstobebeneficialbasedon currentevidence.

Feveriscommoninsepsispatients.However,studieson theassociationbetweenhighfever(>39.0°C)andsepsis mortalityremaincontroversial.16,31 Ourstudyshowed slightlyincreasedmortalityinhighfeverpatientswithSIC thaninmildfeverpatients,butdidnotreachstatistically signiﬁcanceFutureresearchiswarrantedtoclarifythis relationshipinSICpatients.

Moreover,ourresultsdemonstratedanonlinear relationshipbetweenbodytemperatureandboth28-dayand 90-dayall-causemortality.EachCelsiusdegreeincreasein temperaturecorrelatedwithan18%reductionin28-day mortality,underscoringthepotentialbeneﬁtsofmaintaining normothermiaduringSICtreatment.However,the relationshipshiftedbeyondatemperaturethresholdof 38.0°C,whereconsistentlyincreasedtemperaturescorrelated

Figure2. Smoothcurve ﬁttingfortemperatureand28-day mortalityinpatientswithsepsis-inducedcoagulopathy.

withgradual,albeitstatisticallyinsigniﬁcant,increases inmortality.

Notably,subgroupanalysisrevealednosigniﬁcant interactionon28-daymortalityinmostsubgroups, suggestingthatbodytemperaturemightindependently

Table3. Thresholdeffectanalysisoftheassociationbetweenthe bodytemperatureandthe28-daymortalityinSICpatients.

ThresholdofbodytemperatureHR(95%CI) <38.0950.640(0.589,0.696) ≥38.0951.192(0.984,1.444)

Note:Thedatahavebeenadjustedforallofthefactorsincludedin ModelIVin Table2 HR, hazardratio; CI, conﬁdenceinterval; SIC, sepsisinducedcoagulopathy.

influencetheprognosisofSICpatientsregardlessoffactors likeage,gender,orothercomorbidities.However,a significantinteractionwasobservedincerebrovascular diseasepatients,indicatingthatthisspecificsubgroupmay haveuniquethermoregulationcharacteristicswarranting furtherinvestigation.32 Thephenomenonthatpatientswith sepsiscomplicatedbycerebrovasculardiseasedisplayed differentpatternsoffeverandoutcomeassociationsmerits closerinvestigation.Severalpossiblemechanismsmay underpinthisinteraction.First,thermoregulationin cerebrovasculardiseaseisimpaired.Central thermoregulationinvolvescomplexneuralcircuitrylikethe preopticanteriorhypothalamus.33 Ischemicorhemorrhagic strokecaninterrupttheinvolvedpathways,compromising thermoregulatorycapacity.34 Thismaycontributetoaltered feverresponsesinoursubgroupofpatients.Second,cerebral inflammationisexacerbatedbyfever.Animalstudiesshowed

Figure3. Subgroupanalysisofassociationbetweentemperatureand28-daymortality.

hyperthermiacanworsenischemicinjuriesviaincreased neutrophilinﬁltration,blood-brainbarrierdysfunction, edemaformationandneuronalloss.35,36 Therefore,febrile responsesinsepsispatientswithpreexistingcerebrovascular lesionsmayworsensecondaryinsultsthrough neuroinﬂammation.Third,cerebralperfusionisimpairedby fever.Feverescalatesmetabolicdemandswhilesepticshock reducescerebralperfusion.37–39 Thecombinedeffectsmay createmismatchesinoxygensupplyanddemand,settingthe stageforischemicdamage.Strictfevercontrolmighthelp conserveneuronalviability.

Ourstudyholdsseveralnotablestrengths.Byexclusively focusingonSICpatients,weaddressacrucialgapinthe literature.Ourcomprehensiveanalysisbolstersthereliability andgeneralizabilityofour ﬁndings,whilealsouncovering novelcorrelationsandtheirimplications.Theobservednonlineartemperature-mortalityrelationshipaddsanewlayerof understandingtoSICmanagement,highlightingpotential harmatbothtemperatureextremes.

However,certainlimitationsshouldbeacknowledged. Ourstudy’sretrospectivenatureandrelianceondatafroma singlecenterintroducepotentialbiasesandlimitexternal validity.Inclusionofpatientsreceivingantipyreticsor temperaturemanagementcouldinﬂuenceobserved temperatures.Additionally,theuseofthehighestbody temperatureatICUadmissionmaynotcapturedynamic temperaturechanges.Itisalsoimportanttonotethatour analysiswaslimitedto9,860patientsoutoftheinitialcohort of23,828patientsduetothelackofavailableSICscores,

whichwasourprimaryindependentvariableofinterest.The exclusionofpatientswithoutSICscoresmayhave introducedpotentialselectionbias,asthesepatientscould havedifferedsystematicallyfromthoseincludedinthe analysis.However,thelargesamplesizeof9,860patients withcompletedatastillprovidesarobustbasisforour ﬁndings.Futurestudieswithmorecomprehensivedata collectionwouldbevaluabletofurthervalidateand generalizeourresults.

CONCLUSION

Inconclusion,ourstudyidentifiesanassociationthat meritsattentioninthecontextofSICpatientmanagementin ICUsettings.WefoundthatamongSICpatientsontheir first dayintheICU,abodytemperaturefrom37.0–38.0°Cwas associatedwithasignificantlyimprovedprognosis,marked bythelowestoverallmortalityrisk,whilethegroupwithlow bodytemperature(<36.0°C)exhibitedthehighestmortality risk.Additionally,agradualbutstatisticallynon-significant increaseinmortalityriskwasobservedwhenbody temperatureexceeded38.0°C.Futureresearchontheimpact ofrigoroustemperaturemanagementonSICpatient outcomes,andprospectivevalidationofourassociation betweentemperatureandsepsismortality,isneededto provideamorecomprehensiveunderstandingofthis complexrelationship.

AVAILABILITYOFDATAANDMATERIAL

AlldatainthearticlecanbeobtainedfromMIMIC-IV database(https://mimic.physionet.org/).

ETHICSDECLARATIONS

Theresearchprotocolforthisretrospectivestudyusinga de-identiﬁeddatabasewasreviewedandapprovedbythe InstitutionalReviewBoard(IRB)oftheMassachusetts InstituteofTechnologyandBethIsraelDeaconessMedical Center.Therequirementforinformedconsentwaswaivedin accordancewiththeUSCodeofFederalRegulationsand institutionalguidelines.

AddressforCorrespondence:WeiganXu,MD,FirstPeople’s HospitalofFoshan,DepartmentofEmergency,No.81LingnanAve. North,ChanchengDistrict,Foshan,Guangdong,China.Email: 113101993@qq.com.JunJiang,PhD,FirstPeople’sHospitalof Foshan,DepartmentofEmergency,No.81LingnanAve.North, ChanchengDistrict,Foshan,Guangdong,China.

Email: jiangjungd2@163.com

Figure4. Kaplan–Meiercurveof28-daymortalityforpatientswith sepsis-inducedcoagulopathy.

GuangdongMedicalScienceandTechnologyResearchFund Project(grantno.A2023178toZTE),theBasicandAppliedBasic ResearchFundofGuangdong(RegionalCooperationFundProject, 2022)(grantno.2022A1515140033toJJ),the14thFive-YearHighLevelMedicalKeySpecialtyProjectofFoshan,andtheFoshan ScienceandTechnologyInnovationProjects(2022)(grantno. 2220001004172toGJC).Thefundershadnoroleinstudydesign, datacollectionandanalysis,decisiontopublish,orpreparationofthe manuscript.Therearenootherconﬂictsofinterestorsourcesof fundingtodeclare.

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ScopingReview:IsPush-DoseNorepinephrineaBetterChoice?

MichaelBerkenbush,MD,NRP

LaliSingh,DO

KellySessa,PharmD

RaghadSaadi,PharmD

SectionEditor:DavidPage,MD

MorristownMedicalCenter,SamethEmergencyDepartment, Morristown,NewJersey

Submissionhistory:SubmittedNovember16,2023;RevisionreceivedApril11,2024;AcceptedApril16,2024

ElectronicallypublishedJuly17,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18584

Introduction: Theuseofpush-dosevasopressorstotreatanesthesia-inducedhypotensionisa commonevidence-basedpracticeamonganesthesiologists.Inmorerecentyears,theuseofpush-dose vasopressorshastransitionedtotheemergencydepartment(ED)andcriticalcaresetting.Thereis debateonthebestchoiceofapush-dosevasopressor,withpush-doseepinephrineorphenylephrine beingmorecommonlyused.Thisscopingreviewevaluatedpublicationsregardingtheclinicaluseof push-dosenorepinephrine.

Methods: WequeriedresearchstudiesinbothPubMedandGoogleScholarontheuseofpush-dose norepinephrineinhumansubjects,withnumerousrandomizedcontrolledtrialsthatcompare norepinephrinetoothervasopressorsincludingphenylephrine,ephedrine,andepinephrine.

Results: Alargemajorityofthestudieswereperformedinthesettingofspinalanesthesiapriorto cesareansection,whileseveralinvolvedtheadministrationofgeneralanesthesia,withlimited-to-no literatureintheemergencyandcriticalcaresetting.Ofthe27studiesthatweincludedinthereview, 17wererandomizedcontrolledtrials.Thesestudiesdemonstratedthatnorepinephrinewassafe andeffective.

Conclusion: Priorresearchhasdemonstratedthesuperiorityofnorepinephrineasapressorofchoice forvariousshockstates.Inthisreview,thesafetyandefficacyofpush-dosenorepinephrineis demonstrated,andfavorablehemodynamicmarkersareshownincomparisontootheragents.In addition,therearesomesafetyandef ficiencybenefitstousingpush-dosenorepinephrinefroman administrationstandpoint,aswellasclinicallyindecreasedneedforrepeatdoses.Furtherhigh-quality studiesintheemergencyandcriticalcarerealmwouldbebeneficialtoconfirmthese findings.[WestJ EmergMed.2024;25(5)708–714.]

Keywords: push-dosevasopressors;norepinephrine;anesthesia-inducedhypotension;criticalcare.

INTRODUCTION

Theuseofpush-dosevasopressorstotreatanesthesia induced-hypotensionisacommon,evidence-basedpractice amonganesthesiologists,1 whichhastransitionedtothe emergencydepartment(ED)andcriticalcaresetting.Pushdosevasopressorsallowclinicianstourgentlystabilize patients’ hemodynamicsandprovideadditionaltimefor procedures(eg,intubations)andbridgingtocontinuous

infusions.Norepinephrine(NE)isthevasopressor ofchoiceinmostshockstatesdueinparttoadecreased incidenceofsideeffects,2 superiorhemodynamicproﬁle,3 andbettercontroloftheshockstate.4 Ourmainpurposein thisscopingreviewwastodeterminetheevidence forpush-doseNEcomparedtoothervasopressorswhile addressingthesafety,effectiveness,andefﬁciency ofthedrug.

METHODS

Inthisstudyweevaluatedfull-textpublicationsinthe Englishlanguageregardingtheclinicaluseofpush-doseNE inhumansubjectsinaccordancewithPRISA-ScR guidelines.UsingPubMedandGoogleScholarinOctober 2022,literaturewasreviewedbasedonthefollowing keywords: “bolusnorepinephrine,”“push-dose norepinephrine,” andvariousformulationsof “norepinephrine/administrationanddosage” [Mesh]AND (pushbolusORbolusdose)Filters:English,Humans.Using ORincludingvariousothernamesfornorepinephrine includingDroxidop,Nordefrin,Normetanephrine, Levonorepinephrine,Noradrenaline,Levarterenol, Levonor,Levophed,LevophedBitartrate,orNoradrénaline tartraterenaudin.

Weidentified88articlesusingthesesearchterms(Figure). Thesearticleswerereviewedtodeterminewhetherthe administrationofNEwasstudiedasapushorbolusdose. WeexcludedthosewhichonlyincludedNEinfusions.One reviewerreviewedthestudiesforeligibility,whichwasthen confirmedindependentlybyasecondreviewer.Non-human studies,casereports,andletterstotheeditorswereexcluded. WealsoexcludedstudiesoncirculatingplasmalevelsofNE, aswellasarticleswhoseprimaryoutcomewasnot hemodynamics.OneexcludedarticlefocusedonNEuseto avoidpost-reperfusionsyndromeinlivertransplant,and anotherfocusedonumbilicalarterialpHinneonatesafter theirmothersreceivedNEduringtheircesareansection.Of theseincludedarticles,27studiesthatincludedpush-doseNE wereincludedinthefollowingreview.Thearticlesobtained werepublishedinorafter2015exceptforonestudy.5 Seventeenwererandomizedcontrolledtrials(RCT),and fourweredose-findingtrials.Therewerethreeprospective observationalstudiesandthreeliteraturereviews.

RESULTS

ThereweresevenRCTsthatcomparedNEwith phenylephrine,encompassingatotalof626patients,allin thesettingofmaternalpatientsreceivingspinalanesthesia forcesareansection.6–12 Norepinephrineshowedlessriskof bradycardiacomparedtophenylephrine.TheuseofNE requiredfewerbolusesthanphenylephrinetocorrect hypotensionandmaintainedhighercardiacoutputand strokevolumeincomparisontophenylephrine.Therewere nosafetyconcernswithNEusedperipherally.Therelative potencyratiousedonaveragewasnorepinephrine: phenylephrine1microgram(μg):12.5 μg.

Twodouble-blindedRCTscomparedNEwithboth phenylephrineandephedrine.13,14 Thesetwostudies involvedatotalof211patientsreceivingspinalanesthesiafor cesareansection.Norepinephrinehadfewerepisodesof bradycardiacomparedtophenylephrineandfewerepisodes oftachycardiacomparedtoephedrine.Inonestudy14 NE

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Push-dosevasopressorsarecommonlyusedin emergencyandcriticalcaresettings. Norepinephrineinfusionshavebeenshownto besuperiortoothervasopressors.

Whatwastheresearchquestion?

Wesoughttodeterminetheevidencefor push-dosenorepinephrinecomparedto othervasopressors.

Whatwasthemajor ﬁndingofthestudy?

Thesafetyandef ﬁ cacyofpush-dose norepinephrineat4 – 16mcgisdemonstrated comparedtootheragents.

Howdoesthisimprovepopulationhealth?

Push-dosevasopressorsareacrucialpartof emergencyandcriticalcareandareusedfor hemodynamicstabilizationduringtimesensitivepatientemergencies.

maintainedahighermeanarterialpressure(MAP)compared totheothertwoagents.

Barakaetallookedatthehemodynamiceffectsin phenylephrine,NE,andepinephrineforintubatedpatients undergoingcoronaryarterybypassgrafting5.Phenylephrine andNEhadsimilarchangesinsystemicvascularresistance withoutsigniﬁcantchangeincardiacoutput.Allagents increasedMAPsimilarlyinthisstudy.Ofnote,thiswasthe onlystudywefoundthatcomparedpush-doseepinephrine withNE.

Threedouble-blindedRCTscomparedNEwithephedrine with276totalpatients.15–17 Ineachstudy,NEwasfoundto bemoreefﬁcaciousthanephedrineinmaintainingMAPand wasalsoassociatedwithlesstachycardiaandfewertotal dosesgiven.Onestudyusedradialarterycathetersfor monitoringbothMAPandheartrate,whiletheothersused non-invasivemonitoringatstandardintervals.Thesestudies alsoincludedhypertensivepatientsundergoingspinal surgeryandpatientswithcoronaryarterydiseaseundergoing kneearthroscopy.

FourRCTscompareddifferentNEboluses/infusions,two ofwhichweredouble-blinded.18–21 Eachofthesestudieswas relatedtospinal-inducedhypotensionduringcesarean section,andprimarilyfocusedonpreventionofhypotension byadministrationofprophylacticNE.Infusionswere successfulinpreventinghypotension,andhigherboluses

(6 μgor0.10 μg/kg)performedbettercomparedtolower boluses(4mcgor0.05 μg/kg).

Therewerefourdose-ﬁndingtrialsincludingatotalof342 patientsundergoingspinalanesthesiaduringcesarean delivery.22–25 Differentmethodswereusedtodetermine efﬁcacy,withtheprimarygoalofmaintainingsystolicblood pressureat80%oftheinitialreading.Foradouble-blind sequentialallocationstudywithbiasedcoinupanddown design,theED90 was5.8 μg.Usingrandomallocationgraded doseresponse,theED50 forNEwas10 μg.Anotherstudy comparingprophylacticversusrescuebolusofNEhasan ED90 of10.85 μgforprophylacticdoseand12.3 μgfor rescuedose.

Therewerethreeprospective,observationalstudies regardingpush-doseNE,oneduringgeneralanesthesiaand twoduringspinalanesthesiaforcesareansections.26–28 Two ofthesestudiescomparedNEagainstphenylephrine.27,29 Norepinephrineresultedinincreasedstrokevolume comparedtophenylephrine.Otherhemodynamiceffects weresimilarbetweenthetwoagents.Anotherstudyreviewed

theuseofNEcomparedtoephedrine,withNEshowing higherMAPsandlesstachycardiacomparedtoephedrine, alsolowernumberofbolusesneededfortreatmentof hypotension.28

Therewerethreepriorliteraturereviewsidentified.29–31 The firstperformedin2018identifiedninefull-textarticles regardingtheuseofnorepinephrine.30 Atthattime,itwas determinedthattheefficacyofNEissimilartophenylephrine withoutadverseoutcomes,showsimprovementincardiac outputanddecreasedriskofbradycardia.Asecondreview focusedonthepharmacologyofvariousvasopressorsand theirdiverseclinicalscenariosforuse(intraoperative, periprocedural,bridgetovasopressorinfusions,post-cardiac arrest,andanaphylaxis).31 Thisarticlealsocoveredthe safetyandcompoundingconcernswiththebedsidemixingof vasopressors.Dilutedconcentrationshavebeenshown tobesafeperipherally,althoughcentralaccessispreferred.A thirdreviewfocusedonanesthesiauseofvasopressors andaddressingthepharmacologyofcommonagents indetail.32

Figure. SearchStrategyandResults. NE,norepinephrine; PE,phenylephrine; EPH,ephedrine; EPI,epinephrine.

DISCUSSION

Push-doseepinephrineorphenylephrinearecommonly usedvasopressorsinthecriticalcaresettingforthetreatment ofhypotension.32 Epinephrinehasbothalphaandbeta effects,thusactingasaninopressor.Atlowerdoses(0.01to 0.1 μg/kg/min),epinephrinestimulatesbeta-1andbeta-2 receptorsandfunctionsasaninotrope,andathigherdoses (>0.1 μg/kg/min)italsostimulatesalpha-1causing vasoconstriction,thusincreasingbloodpressure. Phenylephrineisapurealpha-1agonistthatincreasesarterial andvenoustone,thusincreasingbloodpressure.Ephedrine hasbothalpha-1andbeta-1receptoractivity.Itisapopular choiceintheoperatingroomduetoitsrapidonset(one minute)andlongerdurationofaction(60minutes).

Norepinephrineisanalpha-1receptoragonistwith moderatebeta-1activityandminimalbeta-2activity.Itisan attractiveagentbecauseitshemodynamiceffectsare dominatedbyitsalpha-1activity,whileitsbeta-1activity providesjustenoughinotropytomaintaincardiacoutput. Thereareadvantagestousingpush-doseNEcomparedto othervasopressorsincludingsafety,effectiveness,efﬁciency, andcost.

Safety

Thepreparationofpush-dosevasopressorsisassociated withahighriskformedicationerrorsbecausethese medicationsareusuallymixedatthepatient’sbedsidefor immediateuseinstressfulsituations.33,34 Becauseofthishigh risk,itisrecommendedthatthesepreparationsbedouble checkedbyanotherhealthcareprofessionalpriorto administration.Immediatelyafterpreparation,allsyringes andbagsthatareusedintheprocessshouldbelabeledwith theappropriateconcentrationandmedicationnameto furtherpreventanymedicationerrors.

Comparedtocompoundingotherpush-dose vasopressors,anadvantagetopush-doseNEisthatitcan allowforlimitedpreparationdependingonpremixedbag availability.Ifusingapremixedbag4milligrams(mg)/250 milliliters(mL)tomakepush-doseNE,itwouldrequireno mixing,andtheoreticallylesschanceforcompounding errors.ForinstitutionsthatdonothavepremixNE4mg/ 250mL,thepreparationofpush-doseNEcanbemixedby withdrawingthe4mLofNEfromthe4mg/4mLvialand injectingitintoa250mLbagofnormalsaline.Fromthebag, withdraw10mLofNE-containing ﬂuidintoa10mL syringe.The ﬁnalconcentrationwouldbe16 μg/mL ofnorepinephrine.

Allthedose-ﬁndingstudiesreviewedareinpregnant womenundergoingelectivecesareansectionsreceivingspinal anesthesia.However,thisdatacouldbeextrapolatedtothe criticalcaresettingwiththeunderstandingthatpatients mightrequirehigherempiricdoses.Basedonseveralstudies assessingpush-doseNE,dosesrangingfrom4–16 μgwere reportedtobesafeandeffectiveintreatingorpreventing

hypotensionduetospinalanesthesia.Aninitialpush-doseof NE4–16 μg(0.25–1mL)seemstobereasonableinthecritical caresetting.

Effectiveness

Norepinephrineisthe ﬁrst-linevasopressorforalmostall formsofshock,includingundifferentiatedshock, vasodilatory/septicshock,andcardiogenicshock.The2021 SurvivingSepsisCampaignrecommendsNEasthe ﬁrst choiceinpatientswithsepticshock(Evans2021).35 Inthe CENSERtrial,patientswhoreceivedearlyNEhadbetter controloftheirshockstatebythesix-hourmark.4 Notonly doesNEimprovebloodpressure,butitalsoimproves cardiacoutput.36 ItwaspreviouslythoughtthatNEmight worsenorganhypoperfusioncomparedtoother vasopressors.However,ithassincebeenshownthatin patientswithseveresepticshock,thosewhoreceivedNEhad highersplanchniccirculationcomparedtothosewho receivedepinephrine.37

AstudydonebyMartinetalshowedthatpatientstreated withNEhadsignificantlylowerhospitalmortalitycompared tothosetreatedwithhigh-dosedopamineand/or epinephrine.38 Forcardiogenicshock,onestudyshowedthat NEhasalowerincidenceofrefractoryshockcomparedto epinephrine.39 Norepinephrinehasalsobeenshowntohavea decreasedriskofcausingarrhythmiascomparedto dopamine,whichmakesitpreferredoverothervasopressors, especiallyinacardiogenicshockstate.40 Inthesettingof hypovolemicorhemorrhageshock,thereisaconcernthat vasopressorsmaycompromisemicrocirculationandcause tissueischemiaduetoexcessivearteriolarvasoconstriction. However,arecentstudybyHarroisetalobservedthatNE preservedintestinalmicrocirculationduringhemorrhagic shockinmice.41 Additionally,therewasastudycompleted byPoloujadoffetalinrats,whichshowedthatwhenusing eitherahypotensiveornormotensivetargetfor fluid resuscitationinhemorrhagicshock,ratsthatreceivedNE infusionshadimprovedsurvivalcomparedtothosewho received fluidsonly.42

Theuseofpush-doseNEcanbeextendedtosettings beyondthatofshockstates,suchaspriortoorduring proceduresthatrequirehemodynamicoptimization,suchas endotrachealintubationortheinductionofgeneral anesthesia.BarakaetalcomparedtheeffectsofNE, phenylephrine,andepinephrineonpatientswhowere endotracheallyintubatedbeforeundergoingelective coronaryarterybypassgrafting.5 TheyfoundthattheNE grouphadthehighestincreaseinMAP(42.9%vs35%and 32.6%).Inaddition,thePrePAREtrialhasshownthata ﬂuid bolusmaynotbeenoughtopreventcardiovascular collapse.43 Push-doseepinephrinehasgainedpopularityin theemergencyandcriticalcarerealmforthispurpose. However,randomizedtrialscomparingepinephrinetoNEin thissettinghavenotbeenperformed.

EfﬁciencyandCost

Usingasingleagentforbothpush-doseandcontinuous infusionrequiresoveralllessmedications/materialsthan compoundingtwodifferentagents,whichinturnimproves efﬁciencyincriticalcaresettingswhereeveryminutematters. Comparedtophenylephrine10mgvialsandepinephrine 1mgvials,theaveragewholesalepriceofNE4mgvialsis slightlymoreexpensivefortherequireddoseneededto preparepush-doseNE.44 However,incriticalcaresettings push-dosevasopressorsarecommonlyusedasabridgetoan infusion;therefore,theNEcostwouldbenegated,asthe samebagusedtomakeupthepush-doseNEcanbeusedfor theinfusion.

LIMITATIONS

Thisreviewofpush-doseNEdemonstratedasignificant numberofdouble-blindedRCTs.However,nearlyallthe studieswereperformedintheoperatingtheater,withlimited dataintheEDorcriticalcaresetting.Patientsmaybeless optimized,andlikelywouldbeconsiderablyolderandhave morecomorbidities,thanthepopulationsofpregnant femalesprimarilystudiedinthisreviewundergoingspinal anesthesia.Inaddition,theoptimaldosingofNEmaynotbe accuratelyreflectedforthecriticalcaresetting.However,the lackofadverseeventsisreassuringforitssafetyprofile.Itis unclearwhethertheshorterhalf-lifeofNEwouldimpactits utilityforperiproceduraluse;however,theeffectofpushdoseNEremainedeitherequivalentorbetterthanother vasopressorsinthestudiesreviewed.Norepinephrine appearstobethevasopressorofchoicecomparedto phenylephrineandephedrine.Comparisonstopush-dose epinephrine,whichismorecommonlyusedinthecritical caresetting,arealsolacking.

CONCLUSION

Priorresearchhasdemonstratedthesuperiorityof norepinephrineasapressorofchoiceforvariousshock states,althoughitisrecognizedthattheclinicalsituationmay dictatewhichvasopressorisused.Inthisreview,thesafety andefficacyofpush-doseNEaredemonstrated,and favorablehemodynamicmarkersareshownincomparison tootheragents.Inaddition,therearesomesafetyand efficiencybenefitstousingpush-doseNE,frombothan administrationstandpointandclinicallyinadecreasedneed forrepeatdoses.Furtherhigh-qualitystudiesinthe emergencyandcriticalcarerealmwouldbebeneficialto confirmthese findings.

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

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EDUCATION SPECIAL ISSUE-ORIGINAL RESEARCH

ProgramSignalinginEmergencyMedicine:The2022–2023 ProgramDirectorExperience

AlexisE.Pelletier-Bui,MD*

TimothyFallon,MD†

LizaSmith,MD‡

TaniaStrout,PhD,MS†

MichelleFischer,MD,MPH§

MarkOlaf,DO∥

ErinMcDonough,MD¶

BrianBarbas,MD#

MichaelCirone,MD**

ElizabethBarrallWerley,MD§

*CooperUniversityHospital/CooperMedicalSchoolofRowanUniversity, DepartmentofEmergencyMedicine,Camden,NewJersey

† MaineMedicalCenter,TuftsUniversitySchoolofMedicine,Departmentof EmergencyMedicine,Portland,Maine

‡ UniversityofMassachusettsChanSchoolofMedicine,BaystateMedicalCenter, DepartmentofEmergencyMedicine,Springﬁeld,Massachusetts

§ PennStateCollegeofMedicine/PennStateHealthMiltonS.HersheyMedical Center,DepartmentofEmergencyMedicine,Hershey,Pennsylvania

∥ GeisingerCommonwealthSchoolofMedicine,DepartmentofEmergency Medicine,Scranton,Pennsylvania

¶ UniversityofCincinnatiCollegeofMedicine,DepartmentofEmergencyMedicine, Cincinnati,Ohio

# LoyolaUniversityChicago,StritchSchoolofMedicine,LoyolaUniversityMedical Center,DepartmentofEmergencyMedicine,Maywood,Illinois

**UniversityofIllinois,DepartmentofEmergencyMedicine,Chicago,Illinois

SectionEditors:PaulLoganWeygandt,MD,andChrisMerritt,MD

Submissionhistory:SubmittedFebruary2,2024;RevisionreceivedApril22,2024;AcceptedJune3,2024

ElectronicallypublishedAugust27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.19392

Introduction: Programsignaling(PS),whichenablesresidencyapplicantstosignaltheirpreferencefora speciﬁcprogram,wasintroducedinemergencymedicine(EM)inthe2022–2023residencyapplicationcycle. InthisstudyweevaluatedEMprogramdirectors’ (PD)utilizationofPSinapplicationreviewandranking.This studyalsoexplorestherelationshipbetweenprogramcharacteristicsandnumberofsignalsreceivedaswell astherelativeimportanceandutilizationofsignalsrelatedtothenumberofsignalsreceived.

Methods: Thisisaninstitutionalreviewboard-approved,cross-sectionalstudyofPDsatAccreditation CouncilforGraduateMedicalEducation-accreditedEMresidencyprograms.Weuseddescriptive statisticstodescribethecharacteristicsofresidencyprogramsandpracticesaroundPS.Measuresof centraltendencyanddispersionsummarizedcontinuousvariables.Weusedchi-squareanalysisorthe Fisherexacttestforcomparisonsbetweengroupsforcategoricalvariables.Comparisonsforcontinuous variablesweremadeusingthe t-testforindependentsamplesoranalysisofvariance.

Results: Theresponseratewas41%(n = 113/277EMprograms).MostprogramsparticipatedinPS (n = 261/277EMprograms,94.2%).Meannumberofsignalsreceivedwas60(range2–203).Signals receivedvariedbasedonprogramcharacteristicsincludinggeographiclocationandprogramtype,duration, environment,andlongevity.MostusedPSinholisticreview(52.2%),butotherusesvariedbyproportionof applicationsthatweresignaled.TheimportanceofPSinapplicationreview(mean2.9;1–5scale,1 = not important,5 = extremelyimportant)andranklistpreparation(2.1)wasrelativelylowcomparedtoother applicationelementssuchasstandardizedlettersofevaluation(4.97forreview,4.90forranking).

Conclusion: ThestudyprovidesinsightsintoPSutilizationinEM’sinauguralyear.Wehaveidentiﬁed patternsofsignalusebasedonprogramcharacteristicsandnumberofsignalsreceivedthatcaninformsignal allocationandutilizationonanindividualapplicantandprogramlevel.Amorenuancedunderstandingof signalusecanprovidevaluableinsightasthespecialtyofEMgrappleswith ﬂuctuationsinitsapplicant numbersandshiftingdemographicsofitsapplicantpool.[WestJEmergMed.2024;25(5)715–724.]

INTRODUCTION

Programsignaling(PS)wasintroducedintotheresidency applicationprocessinresponsetotheincreasingnumberof applicationsreceivedbyprograms,exacerbatingthe challengeofcomprehensiveholisticreview.1 Subsequently, EMhasexperienceddrastic fluctuationsinthenumberof applicantspursuingEMandspecialtyMatchrates,aswellas unprecedentedchangestothedemographicsofits applicationpooloverthelastseveralyears.2 Evenwith variabilityinthenumberofapplicationstoemergency medicine(EM)inrecentyears,EMapplicationnumbers remainsignificantlyabovewhattheywere10yearsago.2,3 Programsignalingallowsapplicantstoassignsignalsto theirmostdesiredtrainingprograms,sothatprograms mayfocustheirholisticeffortstowardhigh-yieldinterview candidates,potentiallybenefitingbothapplicants andprograms.

ProgramsignalingwasimplementedinEMviathe ElectronicResidencyApplicationService(ERAS)inthe 2022–2023residencyapplicationcycle,allowingapplicants tosend fivesignalsatthetimeoftheirresidencyapplication submissionwithinstructiontonotsignaltheirhomeorawayrotationinstitutions.4 TheAssociationofAmericanMedical Colleges(AAMC)publishedgenericguidanceforprograms regardingtheuseofPSonlyduringtheinterview-offerphase andprogramsattestedtoacodeofconductregardingsignal usagewhenoptingintotheprocess,includingguidancenotto usePSinrankorderlist(ROL)decisions.5 Whiledatawas evaluatedbyERASacrossallparticipatingspecialties,and otherspecialtieshavereportedtheirownspecialty-specific data,opportunitiesremainedtofurtherinvestigatequestions specifictoPSwithinEM.6–18 Theuniquechallengesfacing EMcreatedanappetiteandunderscoredtheneedfor specialty-speci ficguidance.

Toprovideevidence-basedguidance,theERAS ApplicationWorkingGroup,asubsetoftheCouncilof ResidencyDirectorsinEM(CORDEM)Application ProcessImprovementCommittee,createdasurveyto addressmorenuancedEM-speciﬁcquestionsnotaskedor answeredbytheAAMCsurvey.Ourobjectiveinthisstudy wastodeterminehowEMprogramdirectors(PD)usedPSin theirapplicationreviewandrankingpracticesduringthe 2022–2023applicationcycle,particularlyinrelationtothe proportionofsignaledapplicationsreceived.Toour knowledge,nootherspecialtiesparticipatinginPShave reportedPSutilizationdatainthismanner.Wealsoexplored therelationshipbetweenprogramcharacteristicsandthe numberofsignalsreceived,includingcharacteristicsnot previouslystudiedbytheAAMCsuchasgeographic location,programlengthoftraining,programenvironment, andprogramlongevity.Lastly,weinvestigatedtherelative importanceandutilizationofsignalsincomparisontoother residencyapplicationelementsandinrelationtothenumber ofsignalsreceived.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Programsignaling(PS)wasintroducedinto theemergencymedicine(EM)residency applicationprocessin2022 – 2023viathe ElectronicResidencyApplicationService.

Whatwastheresearchquestion?

HowdidEMprogramdirectorsusePSin applicationreviewandranking?

Whatwasthemajor ﬁndingofthestudy?

52.2%ofprogramdirectorsusedPSin holisticreview.Otherusesvariedby proportionofsignaledapplications.

Howdoesthisimprovepopulationhealth? UnderstandingPSusagepatternshelps informPSallocationandusageonan individualapplicantandprogramlevel.

METHODS StudyDesign

Weusedacross-sectionalstudydesign.Participantswere PDsinAccreditationCouncilforGraduationMedical Education(ACGME)-accreditedEMresidencyprograms participatinginthe2023NationalResidentMatching ProgramMatch.TheCORDmemberdirectory,crossreferencedwiththeACGMEAccreditationDataSystem publicsearchwebsite,wasusedtocompiletheemail distributionlist.WeeditedthelisttoreﬂectnewPDswhen possible(277).Thesurveywascreatedfollowingathorough literaturereviewandsynthesisofbackgroundinformation. QuestionswereiterativelyreviewedbyexpertsinEM medicaleducation.Thesurveywasfurtherreﬁnedafter conductingtwocognitiveinterviewswithEMresidency programleadersandthenpilotedbyseveralEMeducatorsto assessforclarityofthequestions.Datawasprimarily quantitative.Noidentifyinginformationwascollected.The studywasdesignedtotakeabout10minutestocomplete. Oursurveytoolisincludedin Appendix1.Thisstudywas approvedbytheinstitutionalreviewboardattheinstitution ofauthorsTFandTS.

DataCollection

Thesurveylinkwasdistributedviaemail.Wecollected datausingaconﬁdentialandsecureweb-based(Qualtrics, Provo,UT)surveyofEMresidencyPDsortheirdesignees. Anonymouslinkswerecreatedforeachpotentialrespondent anddistributedviaQualtrics.AsdescribedbyDillmanand

colleagues,oneweekpriortodistributionofthesurveylink, PDsreceivedabriefemailintroducingthestudyand informingthemthattheywouldreceivethestudylinkinthe comingweek.19 Participantsthenreceivedamessage containingthesurveylink.Non-respondersreceivedupto threeremindermessagesover ﬁveweeks.

DataAnalysis

DatawasdownloadedfromREDCap,hostedatMaine MedicalCenter,directlyintoSPSSforWindowsv27(IBM SPSSStatisticsforWindows,IBMCorp.,Armonk,NY) statisticalsoftwareforanalysis.Weuseddescriptivestatistics todescribethecharacteristicsofstudyparticipants’ residency trainingprograms.Programpracticesandexperiences aroundPSweredescribedusingnumbersandpercentagesfor eachcategoricalvariable.Wesummarizedcontinuous variablesusingmeasuresofcentraltendency(meanor median)anddispersion(standarddeviation,interquartile range[IQR]).Comparisonsbetweengroupsforcategorical variablesweremadeusingchi-squareanalysisortheFisher exacttest.Comparisonsforcontinuousvariablesweremade usingthe t -testforindependentsamplesoranalysisof variance.Weaccepteda P -valueof <0.05assigniﬁcant.We alsocomputeddifferencesbetweengroupsandtheir associated95%conﬁdenceintervals(CI)andcreatedvisual datadisplaystoaidininterpretation.

RESULTS

ProgramCharacteristics

Wereceived113/277surveys(responserate41%). Participantsrepresenteddiversegeographicregions,withthe largestnumbersfromtheMiddleAtlantic,EastNorth CentralMidwest,andSouthAtlanticregions(Table1). Programsrepresentedweremostcommonlyurban, university-based,andthreeyearslengthofresidency training.Facultyatparticipatingprogramswerelargely universityorhospitalemployees,andmostprograms reportingbeingfoundedmorethan15years.

ProgramSignalingParticipationandApplicationsReceived

ThemajorityofrespondentsparticipatedinthePS componentoftheERASsupplementalapplicationduring the2022–2023residencyapplicationcycle(106,94%). Reasonsfornon-participationincludednotsigningupin time(three,2.7%),feelingthatitwouldnotcontributeto applicantrevieworinterviewofferdecisions(two,1.8%),and beinganewlyapprovedprogram(1,0.9%).Programs interviewedto ﬁllameanandmedianof12postgraduate year(PGY)-1spots(range6–26spots,IQR8–15).The numberofsignalsreceivedbyparticipatingprogramsranged from2–203,withameanof60andmedianof50(IQR 23–86).Programsreportedreceiptofbetween283–1,400 applications(mean768,median772,IQR600–926).The proportionofapplicationsthatweresignaledranged

from0.7%to26.5%(mean7.3%,median6.5%, IQR3.9–10.1%).

Therewasamoderate,positivecorrelationbetweenthe numberofsignalsandthenumberofapplicationsreceived (r = 0.581, P < 0.001)andtheproportionofsignalsreceived increasedbaseduponthenumberofapplicationsreceived (P < 0.001)aswellastheproportionofapplicationsthat weresignaled(P < 0.001).Thenumberofsignalsreceived increasedasthenumberofPGY-1positionsincreased (P < 0.001).Fourquartilesweredeterminedforthenumber ofprogramsignalsreceived,thenumberofapplications received,andtheproportionofapplicationssignaled (SupplementalTable1)toallowforfurthercomparisonof dataassubsequentlydetailed.

SignalsReceivedbyProgramCharacteristics

Thenumberofsignalsreceiveddifferedsigniﬁcantlybased onseveralkeycharacteristics:geographiclocation,with greaternumbersofsignalsreceivedincoastalregions (P < 0.01);programduration,withfour-yearreceivingmore thanthree-yearprograms(P < 0.01);programtype,with urbanprogramsreceivingthemost(P < 0.01);program environment,withuniversity-basedprogramsreceivingthe most(P < 0.01);andlongevityofprogramswithprogramsin existence >15yearsreceivingthemost(P < 0.01). Additionaldetailisprovidedin Figures1 and 2 and SupplementalFigure1.

SignalUtilization

ProgramsmostcommonlyendorsedusingPSasone componentofholisticreview(59,52.2%).Additionalspeciﬁc waysthatsignalswereusedincludethefollowing:asa tiebreakerbetweentwoequallyqualiﬁedcandidates (45,39.8%);asascreeningtool(44,38.9%);tohelpprioritize theprogram’swaitlistorwaitlistorder(31,27.4%);andto sendaninterviewinvitationtoeveryapplicantwhosignaled theprogram(19,16.8%).Theproportionofapplicationsthat weresignaledappearedtoaffectthefrequencywithwhich programsendorsedusingsignalstoprioritizethewaitlist (P < 0.001),serveasatiebreaker(P < 0.001),andtosend interviewinvitationstoeverysignalingapplicant(P = 0.03) (Figure3).ParticipantsanticipatedusingPSinthe 2023–2024cyclesimilarlytotheirreporteduseinthe 2022–2023cycle,andsimilardifferenceswerealsonotedfor anticipatedusebasedontheproportionofapplicationsthat weresignaled.

SignalImportance

Participantsratedtheimportanceofvariousapplication elementswhenconsideringinterviewinvitationsand preparingtheirprogram’srankorderlist(ROL)usinga 5-pointscale(1 = notimportantatall,5 = extremely important)(Table2).Participantsratedthestandardized letterofevaluation(SLOE)asthemostimportantelement

Table1. Characteristicsofparticipatingresidencyprogramsandsurveyrespondents.

Characteristic%(n)Comparisontoexistingprogramdata(percentageofprograms)

Professionalrole

*Programdirector100(113)

Geographicregion

MiddleAtlantic24.8(28)23.7a EastNorthCentralMidwest20.4(23)20.5a SouthAtlantic17.7(20)19.1a PaciﬁcWest11.5(13)10.6a WestSouthCentral11.5(13)9.9a NewEngland5.3(6)4.2a MountainWest4.4(5)3.9a WestNorthCentralMidwest2.7(3)3.9a EastSouthCentral1.8(2)4.2a Programlength

Threeyears77.0(87)80.6b

Fouryears23.0(26)19.4b Programenvironment

Urban63.7(72)Notavailable

Suburban30.1(34)Notavailable Rural6.2(7)Notavailable Programtype

University-based47.8(54)35.4a Community-based,university-afﬁliated36.3(41)46.2a Community-based15.9(18)18.4a Facultyemploymentmodel

Universityorhospital73.5(83)Notavailable Contractmanagementgroup18.6(21)Notavailable Democraticphysician-ledgroup8.0(9)Notavailable Programlongevity

<5years17.7(20)Notavailable 5–10years8.0(9)Notavailable 10–15years10.6(12)Notavailable >15years63.7(72)Notavailable *261/277EMprogramsparticipatedinPSfor2022–2023.All277programssurveyed. MiddleAtlantic = NJ,NY,PA;EastNorthCentralMidwest = IL,IN,MI,OH,WI;SouthAtlantic = DC,DE,GA,FL,MD,NC,SC,VA,WV,PR; PaciﬁcWest = AK,CA,HI,OR,WA;WestSouthCentral = AR,LA,OK,TX;NewEngland = CT,MA,ME,NH,RI,VT;MountainWest = AZ, CO,ID,MT,NM,NV,UT,WY;WestNorthCentralMidwest = IA,KS,MN,MO,ND,NE,SD;EastSouthCentral = AL,MS,KY,TN. aFellowshipandResidencyElectronicInteractiveDatabase(FREIDA), https://freida.ama-assn.org bEmergencyMedicineResidents’ Association(EMRA)MatchDatabase, https://match.emra.org/

whenreviewingapplications(mean4.97,95%CI4.93–5.00). TheSLOEs(mean4.90,95%CI4.83–4.97)andinterviewday performance(mean4.81,95%CI4.72–4.89)weremost importantwhenpreparingtheROL.Importanceofthe presenceorabsenceofaprogramsignalwhenreviewing applicationswasameanof2.9(95%CI2.67–3.13)and medianof3(2,4).Importanceofthepresenceorabsenceofa

programsignalwhenpreparingaROLwasameanof2.1 (95%CI1.87–2.32)andmedianof2(1–3).About30%of participants(28)endorsedthepresenceorabsence ofaprogramsignalasveryorextremelyimportant whenreviewingapplicationswhile11%(10)rated programsignalsasbeingequallyimportantto ROLdevelopment.

Figure1. (A)Meannumberofsignalsreceivedbygeographicregion.(B)Mediannumberofsignalsreceivedbygeographicregion. Geographicregionsinclude:EastNorthCentralMidwest(IL,IN,MI,OH,WI),EastSouthCentral(AL,MS,KY,TN),MiddleAtlantic(NJ,NY, PA),MountainWest(AZ,CO,ID,MT,NM,NV,UT,WY),NewEngland(CT,MA,ME,NH,RI,VT),Paci ﬁcWest(AK,CA,HI,OR,WA),South Atlantic(DC,DE,GA,FL,MD,NC,SC,VA,WV,PR),WestNorthCentralMidwest(IA,KS,MN,MO,ND,NE,SD),andWestSouthCentral (AR,LA,OK,TX).

WeassessedfordifferencesinPDs’ relativeassessmentsof variousapplicationelementsbasedontheproportionof applicationsthatweresignaled(SupplementalFigure2).As theproportionofapplicationssignaledincreased,the

proportionofprogramsendorsingboardscoresas “extremelyimportant” decreased(P < 0.01).Asthe proportionofapplicationssignaledincreased,theproportion ofprogramsendorsingcommunicationbeforetheinterview

Volume25,No.5:September2024WesternJournal

Figure2. Meannumberofsignalsreceivedbyprogramcharacteristics.(A)Meannumberofsignalsreceivedbyprogramduration.(B)Mean numberofsignalsreceivedbyenvironmenttype.(C)Meannumberofsignalsreceivedbyprogramtype.(D)Meannumberofsignalsreceived byprogramlongevity.

(A) Programs with 03.81% (Quartile 1) of applications signaled.

(B) Programs with 3.82-6.48% (Quartile 2) of applications signaled.

(D) Programs with 10.13-26.46% (Quartile 4) of applications signaled.

Figure3. Programsignaluseinthe2022–2023academicyearbytheproportionofapplicantssignaled.* *TheAAMCCodeofConduct,whichprogramsattesttowhensigninguptoparticipateinprogramsignaling(PS),speciﬁcallyprohibitstheuse ofPSinrank-orderlistdiscussionandpreparation.

Table2. Importanceofapplicationelements.

ApplicationelementImportancewhenreviewingapplicationsImportancewhenpreparingrankorderlist

Mean(95%CI)Mean(95%CI)

SLOEs4.97(4.93–5.00)4.90(4.83–4.97)

InterviewdayinteractionsN/A4.81(4.72–4.89)

Priorworkorlifeexperiences3.61(3.42–3.80)3.52(3.32–3.72)

Boardscores3.47(3.27–3.66)3.14(2.93–3.35)

MSPE3.44(3.24–3.65)3.32(3.12–3.53)

Extracurricularinvolvement3.36(3.17–3.54)3.25(3.05–3.45)

Presenceorabsenceofaprogramsignal2.90(2.67–3.13)2.10(1.87–2.32)

Communicationbeforeinterview2.64(2.42–2.87)2.89(2.65–3.13)

Researchexperience2.46(2.27–2.64)2.43(2.24–2.62)

Lettersofrecommendation2.40(2.22–2.58)2.33(2.15–2.52)

*5pointscalewhere5 = extremelyimportantand1 = notimportantatall. CI,conﬁdenceinterval; SLOE,standardizedletterofevaluation; MSPE,medicalstudentperformanceevaluation.

as “notimportantatall” increasedwhiletheproportion ratingthisfactor “veryimportant” decreased(P < 0.01). Extracurricularinvolvementincreasedinimportanceasthe numberofapplicationssignaledincreased,withalarger proportionofparticipantsratingthisaspectofthe application “extremelyimportant” astheproportionof applicationssignaledincreased(P = 0.04).Programswith thelowestproportionofsignalingapplicantsweremore likelytorateresearchexperienceas “notimportantatall” thanthosewhohadalargerproportionofapplications signaled(P = 0.02).

DISCUSSION

Responsestooursurveyappeartobeappropriately representativeofprogramsnationwidewithregardto geographicdistribution,programlength,andprogramtype (Table1).20,21 Rangesandmediannumbersforapplications andPSdataaresimilartoERASdata,againdemonstrating thatoursurveyrespondentsreﬂectedarepresentativesample ofEMprogramsthatparticipatedinPSduringthestudied applicationcycle.6

Fordataanalysis,weusedquartilesbasedonthe percentageofsignalingapplicationsaprogramreceivedto correctforthedifferencesinrawnumbersbasedonprogram size.WiththenumberofsignalsallocatedtoeachEM applicantincreasingfrom ﬁvetosevenforthe2023–2024 academicyear,itisreasonabletopresumethattheraw numberandpercentageofsignalingapplicantsprograms receivewillalsoproportionallyincrease.Thisdiscrepancy maymakeitmoredifﬁcultforaprogramtoaccurately identifywithagivenquartilebasedonthisyear’sapplication data,butthesedatashouldstillserveasaroughguideby whichprogramscanassessthemselves.

Understandingtherelationshipbetweenprogram characteristicsandthenumberofreceivedprogramsignals canbehelpfulforbothprogramsandapplicants.Programs candeterminetheircompetitivenesswithinthecontextof similarprograms,whichcanbeparticularlyhelpfulinthe currentEMmatchenvironmentwithachangingapplicant demographicpoolandmanyprogramsgoingunmatched overthepastfewyears.2 Providingprogramswitha barometeragainstwhichtomeasuretheirowndemographics andproportionofsignaledapplicantsearlyintheapplication cyclecanhelpguidehowtheyincorporateprogramsignals intotheirapproachandmoreeffectivelyselectapplicants whowillbehighestyieldfortheirprograms.By understandingsignalingtrendsasrelatedtoprogram characteristics,advisorsandapplicantsmaybeableto strategicallydeterminethebestapproachforallocating signalstomaximizeeachsignal’simpact.

Inourstudy,wenotedthatthePaci fi cWestandNew Englandregionsdemonstratedthehighestmeanand mediansignalnumbers.Incontrast,programsintheEast SouthCentral,Mid-Atlantic,WestSouthCentral,and WestNorthCentralMidwestreceivedfewersignals.Itis reasonabletospeculatethatmanyofthesepatternsre fl ect overallpopulationdensitypatterns,suggestinglocal preferencesthatmirrortheUSpopulation.Thishypothesis alignswithourdata,whichshowedthatmoreurban(likely morepopulation-dense)programsreceivedahigher proportionofsignals.Theonlyregionthatdoesnot fi tthis hypothesisistheMid-Atlanticregion,whichisthemost denselypopulatedinthecountry,butwesuspectthevery highEMprogramdensityinthisregionlikelycontributed toprogramsignaldilution,leadingtolowersignals perprogram.

Onaverage,four-yearprogramsreceivedahigher proportionofsignalingapplicantsthanthree-yearprograms. Whileprogramlengthitselfmaybeadriverofthis,itmay alsobeduetootherconfoundingfeaturesmorecommonly associatedwithfour-yearprograms,includingurban location,universityafﬁliation,andprogramdurationand stability.Ultimately,ourdatawasunabletodiscernthis difference.Programswiththelowestproportionofsignaling applicantsweremorelikelytobesmaller,rural,andnot academicallyafﬁliated.Theseprogramsweremorelikelyto rateresearchexperienceas “notimportantatall.” We suspectthatthesesmaller,morecommunity-oriented programsmaybelessresearch-focusedintheir missionsand,therefore,emphasizeresearchlessintheir applicantselection.Applicantsmaybeabletousethis informationtotargettheirsignalsdependingon theirinterests.

Itseemsintuitivethattheproportionofsignaling applicantsaprogramreceiveswouldaffecthowthat programvaluesandusesthesignal,buttoourknowledge thisisthe ﬁrstdatatodemonstratethateffect.When examiningsignalinguseamongprogramsseparatedinto quartilesbasedontheproportionofsignalingapplicants, signiﬁcantdifferencesemerged.Programsthatreceived lowerproportionsofsignalingapplicantsweremorelikely toreportofferinginterviewstoallsignalingapplicants whilethosewiththehighestproportionofsignaling applicantsweremorelikelytoincorporatesignalsasa screeningtoolortohelpprioritizetheprogram’swaitlistor wait-listorder.

Byaskingprogramstoratetheimportanceofvarious applicationelements,wehopedtogainanunderstandingof therelativeimportanceofPSinrelationtointerviewoffers andROLcreation.Receivingaprogramsignalin orthopedicswasrankedamongthemostimportantfactorsin residentselectionforinterview.13 WhileasuccessfulsubinternshipatthePD’sinstitutionandlettersof recommendationwerethehighest-rankedcriteriafor residentselectionforinterviewaturologyprograms,81%of urologyPDsreportedthatalackofasignalwouldnegatively impactinterviewofferchancesforanapplicant.18 Inour study,programsignalswerenotshowntoholdasmuch weightasinorthopedicsorurology.Programsignalswere onlyratedasmoreimportantthannarrativelettersof recommendation,pre-interviewcommunication,and researchexperience.

Howanapplicantperformsclinically(SLOEs,Medical StudentPerformanceEvaluation)isunderstandablymost important,withPSintendedtobeonlyonesmallpartofthe holisticapplicationreview.22 Studentscanbereassuredthat thetraditionallyvaluedportionsoftheEMapplication retaintheirimportancewellabovethevalueofaprogram signal,andprogramsacrossallquartilesareinterviewingand rankingstudentswhodidnotsendthemasignal.

Analyzingthisdatainamoregranularfashion,wedid observesomesignificantdifferencesintherelativeimportance ofresidencyapplicationelementsbetweenquartiles.Asthe proportionofsignalingapplicantsincreased,theproportionof participantsendorsingboardscoresas “extremelyimportant” decreased.Thisdiscrepancymayspeaktotheintendedability ofPStomitigatetheuseof filteringbehavior.Programswith smallerproportionsofsignalingapplicantsmaycontinueto seekoutstrategiestostratifytheirapplicantpooltobetter allocatetheirholisticreviewefforts,suchasusingboardscore filters.Programswithahigherproportionofsignaling applicants,ontheotherhand,maynotfeelthissamepressure. Alternatively,itispossiblethathavingbeenpromptedbythe introductionofPStoinvestigateprogramsbeforeapplying, applicantsmaystrategicallyhavechosentotargettheirsignals toprogramsthatadvertisedalackofboardscorecutoffs becausetheirscorefellbelowstatedcutoffsatotherprograms orbecausetheyvaluedprogramsthatdonotemphasize standardizedtestscores.

Ourdataalsodemonstratesthatastheproportionof signalingapplicantsincreased,theproportionofrespondents ratingpre-interviewcommunicationas “extremely important” decreasedandtheproportionofrespondents ratingpre-interviewcommunicationas “notimportantat all” increased.Thistrendsuggeststhatthesignalisserving itsintendedpurposeofallowingtheapplicantto meaningfullyexpressinterest,obviatingtheneedfor additional,extra-applicationcommunication,lesseningthe burdenforbothapplicantsandprograms.Italsosuggests thatPSreducestheimpactofothercommunication fromapplicants.

TheAAMCguidancewasconsistentinitsmessagingthat programsignalswereonlytobeusedduringtheapplication reviewandinterview-offerportionoftheapplicationcycle.It isworthnotingthatdespiteallprogramshavingattestedin thecodeofconductnottousePSintheconsiderationof ROLplacement,11%ofprogramsreportedprogramsignals tobeveryimportanttotheROLdevelopmentprocess.The 2022–23AAMCPDsurveyfoundsimilarresultsamongPD respondentsfromallspecialties.6 Programdirectorsmaybe extrapolatingthatastudentwhosignaledislikelytobea higherprobabilitymatchthanastudentwhodidnotsenda signal.Thisusepresumesthatstudentpreferencewillnotbe signiﬁcantlyaffectedbytheirexperiencesengagingwith programsthroughouttheinterviewseasonandisatriskof being ﬂawedlogic.However,itisimportantthatapplicants beawarethatsignalsmaybeusedbyPDsinthismannerand shouldtakethisintoconsiderationwhenchoosingwhere tosignal.

ParticipationofEMprogramsinPSremainedrobust forthe2023–2024cycle,with278of279programs participatingand97.5%ofapplicantsparticipating(email communicationfromAAMCERASPilotAdministration Director,JaymeBograd,January2024).24 Wehopethat

thisdatahelpsinformprogramsandapplicantsona morenuancedapproachtoPSintheEMresidency applicationprocess.

LIMITATIONS

Respondents(113)comparedtothetotalnumberof ACGME-accreditedEMresidencyprograms(277)was limited.ThePDswhochosetorespondmaydifferfrom thosewhodidnotconcerningtheirPSexperience.Forty-six percentofEMprogramsdidnot fi llinthe2023Main ResidencyMatch. 25 Oursurveywasdistributedintheweeks thatfollowed.ThePDsexperiencingadif fi cultMatchcycle mayhavebeenmoreorlessinclinedto fi lloutasurvey regardingtheresidencyapplicationprocess.Universitybasedprogramswereover-represented.Community-based, university-af fi liatedprogramswereunder-represented. The11%ofprogramsthatreportedusingsignalsaspartof theirROLdiscussionsmaybeanunderestimateasother programsmaynothavebeencomfortabledisclosing behaviorthatwasknowinglyinviolationofthecode ofconduct.

CONCLUSION

Thisstudyprovidesdetaileddataandpatternsofsignaluse yieldinginsightsintoprogramsignalinginEM’sinaugural yearforbothprogramsandapplicants.Ourdataprovidesa morenuancedunderstandingofsignalutilizationacrossa spectrumofEMprogramsinawaythatallowsindividual programstogobeyondthegeneralAAMCrecommendations andcomparetheirapproachtothatofprogramswithsimilar characteristics.Identifyingpatternsofsignalusebasedon programcharacteristicscanalsoinformadvisingfor studentsdecidingonhowtobestallocatetheirsignals. AsEMcontinuestonavigate fluctuationsinitsapplicant numbersandshiftingdemographicsofitsapplicantpool, providinginsighttoguidesignaluseandutilization canhelppaveapathforwardforthespecialtytowardthegoal ofmoreefficiently findingtherightapplicantforthe rightprogram.

REFERENCES

1.Pelletier-BuiAE,SchnappBH,SmithLG,etal.Makingourpreference known:preferencesignalingintheemergencymedicineresidency application. WestJEmergMed. 2021;23(1):72–5.

2.AssociationofAmericanMedicalColleges.ERASpreliminarydataasof January3eachseason.2024.Availableat: https://www.aamc.org/ media/6231/download?attachment.AccessedApril20,2024.

3.RamsayN.EMmatch2020bythenumbers.2020.Availableat: https:// www.emra.org/students/newsletter-articles/em-match-2020-bythe-numbers/.AccessedApril20,2024.

4.Pelletier-BuiA,WerleyE,CamejoM.EMRAhangouts-preference signaling101.2022.Availableat: https://www.emra.org/be-involved/ events–activities/emra-hangouts/20220721-preference-signaling AccessedApril20,2024.

5.AssociationofAmericanMedicalColleges.SupplementalERAS® application:guideforresidencyprograms.2022.Availableat: https://www.aamc.org/media/56451/download/ AccessedApril20,2024.

6.AssociationofAmericanMedicalColleges.SupplementalERAS® 2022–2023applicationcycle:evaluationofprogramsignaling.2023. Availableat: https://www.aamc.org/media/64591/download AccessedApril20,2024.

7.AssociationofAmericanMedicalColleges.SupplementalERAS® 2022–2023applicationcycle:resultsoftheprogramdirectorreaction survey.2023.Availableat: https://www.aamc.org/media/64996/ download.AccessedApril20,2024.

8.LaFeminaJ,RosmanIS,WallachSL,etal.Therelationshipbetween programandapplicantcharacteristicswithapplicantprogramsignalsin the2022residencyrecruitmentcycle: ﬁndingsfrom3specialties. AcadMed. 2024;99(4):430–6.

9.RosenblattAE,LaFeminaJ,SoodL,etal.Impactofpreferencesignals oninterviewselectionacrossmultipleresidencyspecialtiesand programs. JGradMedEduc. 2023;15(6):702–10.

10.BanksE,WinkelAF,MorganHK,etal.Programsignalinginobstetrics andgynecologyresidencyapplications. ObstetGynecol. 2024;143(2):281–3.

AddressforCorrespondence:AlexisPelletier-Bui,MD,Cooper MedicalSchoolofRowanUniversity/CooperUniversityHospital, DepartmentofEmergencyMedicine,401HaddonAve.,Education& ResearchBuilding,2ndFloor,CamdenNJ08103. Email: pelletier-bui-alexis@cooperhealth.edu

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

11.BenjaminWJ,LenzeNR,BohmLA,etal.Impactofapplicants’ characteristicsandgeographicconnectionstoresidencyprogramson preferencesignalingoutcomesinthematch. AcadMed. 2024;99(4):437–44.

12.SergesketterAR,SongE,ShammasRL,etal.Preferencesignaling andtheintegratedplasticsurgerymatch:anationalsurveystudy. JSurgEduc. 2024;81(5):662–70.

13.SureshKV,CovarrubiasO,MunF,etal.Preferencesignalingsurvey ofprogramdirectors-afterthematch. JAmAcadOrthopSurg. 2024;32(5):220–7.

14.KotlierJL,MihalicAP,PetriglianoFA,etal.Understanding thematch:theeffectofsignaling,demographics,andapplicant characteristicsonmatchsuccessintheorthopaedic residencyapplicationprocess. JAmAcadOrthopSurg. 2024;32(5):e231–9.

15.CaiF,SouthworthE,SantiagoS,etal.Thegoldentickets:impactof preferencesignalingonobstetricsandgynecologyresidency applicants. AmJObstetGynecol. 2024;230(2):262.e1–9.

16.GrauerR,RantiD,GreeneK,etal.Characterizationofapplicant preferencesignals,invitationsforinterviews,andinclusiononmatch listsforresidencypositionsinurology[publishedcorrectionappears inJAMANetwOpen.2023;6(2):e233305]. JAMANetwOpen. 2023;6(1):e2250974.

17.ChangCWD,ThorneMC,MalekzadehS,etal.Two-yearinterviewand matchoutcomesofotolaryngologypreferencesignaling. Otolaryngol HeadNeckSurg. 2023;168(3):377–83.

18.Rodriguez-AlvarezJS,Munoz-LopezC,HarwoodSJr.,etal.Urology residencyapplicantselection:programdirectors’ newcriteria. Urology. 2024;S0090–4295(24):00141–9.

19.DillmanDA. MailandInternetusrveys:TheTailoredDesignMethod: 2007withNewInternet,VisualandMixed-ModeGuide.2nded. Hoboken,NJ:JohnWiley&Sons,2007.

20.AmericanMedicalAssociation.Fellowshipandresidencyelectronic interactivedatabase(FREIDA™).Availableat: https://freida.ama-assn. org.AccessedApril20,2024.

21.EmergencyMedicineResidents’ Association(EMRA).EMRAmatch database.Availableat: https://match.emra.org/ AccessedApril20,2024.

22.NationalResidentMatchingProgram.Resultsofthe2021NRMP programdirectorsurvey.2021.Availableat: https://www.nrmp.org/ wp-content/uploads/2021/11/2021-PD-Survey-Report-for-WWW.pdf AccessedApril20,2024.

23.AssociationofAmericanMedicalColleges.Residencyprograms participatinginprogramsignaling.2023.Availableat: https:// students-residents.aamc.org/applying-residencies-eras/residencyprograms-participating-program-signaling.AccessedApril20,2024.

24.AssociationofAmericanMedicalColleges.Exploringtherelationship betweenprogramsignaling&interviewinvitationsacrossspecialties: 2024ERASpreliminaryanalysis.2024.Availableat: https://www.aamc. org/media/74811/download?attachment.AccessedApril20,2024.

25.NationalResidentMatchingProgram.Resultsanddata:2023main residencymatch.2023.Availableat: https://www.nrmp.org/wp-content/ uploads/2023/05/2023-Main-Match-Results-and-Data-Book-FINAL. pdf.AccessedApril20,2024.

EDUCATION SPECIAL ISSUE-ORIGINAL RESEARCH

EmergencyDepartmentSlitLampInterdisciplinaryTrainingVia LongitudinalAssessmentinMedicalPractice

SamaraHamou,BA*

ShayanGhiaee,MD,MS†

ChristineChung,MD‡

MaureenLloyd,MD‡

KellyKhem,MD§

XiaoChiZhang,MD,MS§

*SidneyKimmelMedicalCollege,Philadelphia,Pennsylvania † DepartmentofEmergencyMedicine,EmoryUniversity,Atlanta,Georgia ‡ DepartmentofOphthalmology,WillsEyeHospital,Philadelphia,Pennsylvania § DepartmentofEmergencyMedicine,ThomasJeffersonUniversity,Philadelphia, Pennsylvania

SectionEditors:JulesJung,MDandAndrewKetterer,MD

Submissionhistory:SubmittedOctober20,2023;RevisionreceivedMarch21,2024;AcceptedJune7,2024

ElectronicallypublishedAugust16,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18514

Introduction: Eyeemergenciesmakeupnearly3%ofUSemergencydepartment(ED)visits.While emergencyphysicians(EP)shoulddiagnoseandtreattheseophthalmologicemergencies,many traineesreportlimitedocularexposureandinsufﬁcienttrainingthroughouttheirresidencytoconﬁdently conductathoroughslit-lampexam.

Methods: Wecreatedaninterdisciplinary,simulation-basedmasterylearning(SBML)curriculumto teachemergencyattendingphysicianshowtooperatetheslitlampwithmultimodallearning methodologyatatertiaryacademiccenter.TheEPs ﬁrstdemonstratetheirinitialslit-lampcompetency witha20-itemchecklist,andtheythenreviewthenecessarycurricularcontenttopasstheirindependent readinesstestbeforecompletingtheirin-personteachinganddemonstrationsessionwithan ophthalmologyattendingtodemonstrateproceduralmastery(minimalpassingscore >90%).

Results: FifteenEPswereenrolled;allcompletedthe ﬁnalexamofthecurriculum.Thepre-andpostcurriculumchecklistscoresincreasedbyanaverageofsevenpoints(P = .002);86.7%ofEPsfelt conﬁdentincompletingaslit-lampexamafterthecurriculum,comparedto20%atthebeginning.Fiveof 15reportedteachinglearnerswithinthetwo-monthpost-curricularperiod,rangingfrom5–30students. Thehands-onteachingwasthemostpositivelyreviewedelementofthecurriculum.

Conclusion: TheSBMLprogramsuccessfullytrainedEPsonperformingacomprehensiveslit-lamp examwithpromisingresultsofdownstreameducationtojuniorlearners.Weencourageotherinstitutions toleverageSBMLasateachingmodalityforprocedural-basedtrainingandadvocatecross-discipline educationinitiatives.[WestJEmergMed.2024;25(5)725–734.]

INTRODUCTION

Theslit-lamp1 (Figure1A)isamicroscopethatallowsfor adetailedexaminationoftheanterioreyesegmentusinglight beammanipulation.Theslit-lampenablesphysiciansto diagnoseanteriorophthalmicpathologiessuchascorneal injuries,iritis,hyphema,hypopyon,andforeignbodies2; furthermore,itisessentialforperformingdetailed ophthalmologicexamtechniquessuchaslideversion, ﬂuoresceinexamination,andforeignbodyremoval.3 The

Wood’slamp4 (Figure1B),incontrast,isahandhelddevice oftenusedtocharacterizeskinpigmentation,dermal infections,andmacroscopicinfectionswithabuilt-in magnifyinglensandultraviolet(UV)light.TheUV capabilitiescanhighlight ﬂuoresceinstainingduringexternal ocularexamstoassesscornealpathologiesatlower magniﬁcation.WhiletheWood’slampoffersalessdetailed examinationthantheslitlamp,itisamoreportable diagnostictoolforlargerocularlesions,foreignbodies,or

speciﬁcreactionto ﬂuoresceinstainingandmeetstheneedsof theemergencyphysician(EP)undercertainsituations.

Eyeemergenciesmakeupnearly3%ofUSemergency department(ED)visits,themostcommonofwhichare traumatic.5,6 Themostcommoneyeinjuryevaluatedinthe EDiscornealabrasion(superficialinjurytothecornea)and eyelidlaceration.Suchinjuriesarebestviewedunderhighfieldmagnifiedviewingusingtheslitlamptoassessfor concomitantinjuriesorco-infectionssuchascornealulcers, hypopyon/endophthalmitis,retainedforeignbody,full thicknesscorneallaceration,globeruptures,andseidel testing.7 Ocularemergenciessuchastraumaticgloberupture, ocularforeignbody,closed-angleglaucoma,and endophthalmitisarevisibleonlyusingtheslitlamp,andfall withintheEP’sscopeofpracticefordiagnosis,triaging,and management.8 Mismanagedophthalmicemergenciescan resultininappropriateconsultation,excessivetesting, financialburden,andevenirreversiblevisionloss.9 Despite thesignificanceandfrequencyofocularemergenciesacross theUS,manyEPsarenotconfidentperformingadetailed ophthalmicexam.10

PreviousliteraturehasfoundEPsreceivefewerthan10 hoursofophthalmiceducationduringresidencywithlow confidenceinperformingacomprehensiveophthalmicslitlampexam.11 Ophthalmiceducationthroughclerkshipsand didacticsinmedicalschoolisalsoindecline,leadingtothe unpreparednessofincomingresidentsbeforeanyformal residencytraining.11,12 However,itisimportantthatEPsbe confidentinusingtheslitlamptoappropriatelytriageand manageocularemergenciesaspartoftheAccreditation CouncilforGraduateMedicalEducation(ACGME) EmergencyMedicine(EM)MilestonesPatientCaredomain (PC8) – GeneralApproachtoProcedures,whichdesignatesa setofsequentialmilestonesforoverallprocedural competency,notfocusingonaspecificlistofprocedures.13

Theoptimallearningenvironmentforadultlearnersto performatechnicallychallengingprocedureshould incorporateelementsfromboththemasterylearningmodel andrapidcycledeliberatepractice(RCDP).Themastery

learningmodelensuresthatstudentscanmasteratopicif theyreceiveunlimitedtimeandsupportinlearningand reviewingmaterialuntilmasteryproficiencyisreached. Meanwhile,theRCDPmodelensureslearnerscanpractice skillsrepetitivelywhilereceivingbrief,interspersedfeedback toachieveadesignatedproficiencylevelbeforeproceedingto thenexttask.14,15–17 Withinmedicaleducation,simulationbasedmasterylearning(SBML)modelshavebeen successfullyimplementedacrossvariousspecialties,suchas emergencymedicine,generalsurgery,criticalcare,and gastroenterology.18,19,20 Inlightofsuccessful,smallerscaled studiesontheeffectivenessofslit-lamptrainingwithin undergraduatemedicaleducation,weproposeaSBML proceduraltrainingcurriculumthatcanenableadultlearners toconductdeliberateperformancesofintendedcognitiveor psychomotorskillsinsequentialorderwitharepetitiveskills assessment.15,21,22 Specific,informativefeedbackwillenable sustainedperformanceimprovementtoachieveslit-lamp mastery.23 Ourgoalwastodesignapilotinterdisciplinary coursethatcouldteachEPstocompleteacomprehensiveslitlampexamindiagnosingcommonanterioreyepathology.

METHODS

Ourstudy,EmergencyDepartmentSlitLamp InterdisciplinaryTrainingviaLongitudinalAssessmentin MedicalPractice(EDSLITLAMP),isamulticentered, collaborativeprojectthatleveragestheconceptual frameworksofthemasterylearningmodelandRCDPto ensureproﬁciencyinconductingacomprehensiveslitlamp exam.Italsoservesasascaffoldfordeconstructingbarriers intraditionalsiloedmedicalpracticesandleadstoimproved patientcare,knowledgesynthesis,andresourceutilizationof ourconsultingservices.ThestudywasconductedatThomas JeffersonUniversity(TJUH)andtheWillsEyeHospital (WEH)from2021– 2023.Thehospitalswiththeirrespective EDs,are0.2milesapart,withstafffromeachinstitution workingasconsultantsattheother;WEHresidentsfunction asophthalmologyconsultationfortheTJUHED,while TJUHEPsfunctionasovernightmedicalemergency

Figure1. Slitlamp(A)andWood’slamp(B).

consultantsattheWEHED.Thegeographicand relationshipproximitycreatedidealconditionstodevelop andpilotaproceduralskillcompetenceSBMLcurriculum.

Emergencyphysicianswereselectedasideallearnersdue totheirleveloftraininganduniqueteachingresponsibilities. UsingtheTJUHEDlistservwerecruitedeligible participantsandofferedstaggered financialincentives.For thispilotstudy,werequiredaminimumof12participantsto meet5%type1errorand80%powerbasedonscore improvementfrombaselinetestingtopost-testing,as referencedbyMilleratal.24 TheEDSLITLAMPstudy leveragedtalentsfromcontentandeducationexpertsfrom bothinstitutionstocreateaninterdisciplinaryprocedural teachingcurriculum.ThesuccessofatraditionalSBML curriculumislinkedtothelearners’ skillacquisition.Our studyexpandsthismeasuretoincludeinterdisciplinary collaboration,demonstratingthesuccessfulalignment betweeneducationalandpatient-centeredgoalsthatbenefit bothdepartments.Toevaluatethecurriculum,weemployed allfourlevelsoftheKirkpatrickmodel.Usingpre-andposttestLikertscalequestionnaires,ourmeasurementofsuccess includedimprovedlearnerconfidence(level1),knowledge acquisition(level2),willingnessoflearnerstoincorporate theirskillsetinclinicalpractice(level3),anddisseminationof thisknowledgetojuniorlearners(level4).Anycurricular feedbackandimprovementswereextractedforfuture curriculariterations.

Aneeds-basedanalysisconductedatTJUHEDrevealed EPsdesiredhands-onslit-lampeducationandtrainingon identifyinganteriorsegmentophthalmiccomplaints.Since ophthalmologyisarecognizedcomponentoftheAmerican BoardofEmergencyMedicineexamcontent,weconstructed thepre-testclinicalcontentbasedoncriticalandcommon oculardiagnoses,themostcommonWEHED ophthalmologydischargediagnoses,andclinical identiﬁcationsdeemed “ can ’tmiss” bytheEDand ophthalmologydepartment.

Allcurricularcontents(lecturematerials,videorecording, pre-post-postassessments,studysurveys,masterylearning checklist)werecreatedbytheprincipalinvestigator[XCZ] withophthalmologyco-investigatorsconsultation[CC, MEL]basedontargetedneedsassessment.Thesematerials underwentsequentialreviewbyselectexpertsatWEHand weremodiﬁedsequentiallyuntilaconsensuswasreached. Theminimalpassingchecklistscorewasdeterminedtobe 90%,basedoncombineddeterminationfrom ophthalmologistexpertsatWEHandsimilarthreshold determinedbyMilleretal.24 Eachcurriculumassessment (AppendixA)wasconstructedtomirrorthenatural knowledge,skills,andattitudeprogressionfromthe ACGMEEMMilestonesPatientCareDomain(PC8).Due tothemultifacetednatureofEM,thereisnospeciﬁc proceduralmilestoneforperformingaslit-lampexam,as describedindetailintheACGMEOphthalmologyPC1:

DataAcquisition-BasicOphthalmologyExamandTesting (Level1).13 However,theEMPC8milestonesprovide structuredlanguageapplicabletomanyEDproceduresand advanceddevice-assistedmedicalexaminations(ie,slit-lamp exam).Pleasesee Table1 forthecorrelationbetweentheEM milestoneandEDSLITLAMPassessments.

Thelongitudinalcurriculumincludedfouruniquetime points(Time0–3)ofinterventionstaggeredoversixmonths (AppendixA, AppendixB).AtTime0,participants completedanin-personbaselineslit-lampexamthatwas video-recordedandreviewedbytwoindependent investigators[XCZ][MEL].AtTime1,theparticipants gainedaccesstoanasynchronouslearningpacketthat consistedofaPowerPointpresentationoncommonEDeye complaints,digitallibrarylinkstotheWEHManual,slitlampchecklist,andavideorecordingofacomprehensiveslitlampexamination.25 Theparticipantsalsogainedaccessto anindependentreadinessassessment(IRAT),whichwas requiredtobecompletedwithin30dayswithaminimum scoreof90%beforeproceedingtothenextin-personphaseof thestudy(AppendixA).

UponachievingthepassingIRATscore,theywereinvited toparticipateintheTime2(in-person)SBMLportionofthe studywheretheyweretocompleteanin-person demonstrationofacomprehensiveslit-lampexambya board-certifiedophthalmologist[CC]onastandardized patientvolunteer.Followingthedemonstration,participants weregivenunlimitedtimeforRCDPwithbrief,interspersed feedbackundertheobservationandteachingfromthe ophthalmologist.Participantswererequiredtocompletea minimum18of20checklistitemstoachievemastery (AppendixB).Uponcompletingthe finalchecklist,the participantswereaskedtocompleteacourseevaluationand learnerconfidencesurvey(AppendixC)withLikertscaling, subjectivecommentary,andavalidated5-itemCritical IncidenceQuestionnaire(CIQ)forcurricularimprovement. Giventheunpredictabilitynatureofthe “unlimited attempts” atTime2,allparticipantswerescheduledattwohourintervalstoallowfordevicepreparation,onetotworeattempts,debriefing,surveycompletion,andgeneral troubleshooting.AtTime3,participantscompleteda60-day post-examinationsurvey,assessingtheirocularknowledge, slit-lampconfidence,clinicalteachingopportunities,and relevantinterprofessionalrelationships.

WeusedaWilcoxonsigned-ranktesttodifferentiatethe checklistscoresbetweenthecurricularinterventionby incorporatingcollectedpaireddatabeforeandafterthe training,medianandinterquartilerangevaluesofsubtotal scoresattwo-timepoints.26 WeusedMcNemar’stestto comparingeachcategoricalsub-score(Yes/No)bytime pointsandcorresponding P -valuewithinthesame population.27 Thedescriptivesummariesofsurveyquestions atTime0,Time2,andthree-monthfollow-upwereanalyzed usingBonferroniadjusted P -values(multiplying P -value

Table1. Correspondingemergencydepartmentslit-lampassessmentstoACGMEEM*milestonegeneralapproachtoprocedures. ACGME

EMmilestonePC8BoldedPC8elementsrelatabletoperformingaslitlampexam CorrelatingEDSLITLAMP assessments

Level1 Identiﬁes indicationsforaprocedureandpertinentanatomyand physiology.Performsbasictherapeuticprocedures (eg,suturing,splinting)

Level2Assessesindications,risks,beneﬁts,andalternativesandobtains informedconsentinlow-tomoderate-risksituations.Performsand interpretsbasicprocedures,withassistance.Recognizes commoncomplications

Level3Assessesindications,risks,andbeneﬁtsandweighsalternativesin high-risksituations.Performsandinterpretsadvancedprocedures, withguidance.Managescommoncomplications

Level4Actstomitigatemodiﬁableriskfactorsinhigh-risksituations. Independentlyperformsandinterpretsadvancedprocedures. Independentlyrecognizesandmanagescomplexand uncommoncomplications

Level5Teachesadvancedproceduresandindependentlyperformsrare, time-sensitiveprocedures. Performsproceduralpeerreview

AppendixA–Part II(clinical imageexamination)

AppendixB–Part I(slitlamp technical) AppendixB (ﬁnal checklist)

AppendixA–Part III(ophthalmology exammix-n-match

AppendixB (ﬁnal checklist)

AppendixC–ED SLITLAMP surveys

*ACGME EM,AccreditationCouncilforGraduateMedicalEducationEmergencyMedicine; PC,patientcare; EDSLITLAMP,Emergency DepartmentSlitLampInterdisciplinaryTraining.

fromWilcoxonsigned-ranktestbythenumberofmultiple tests,doublingthe P -values),whichwasdirectlycomparedto thepre-speciﬁed5%signiﬁcancelevel.Allstatisticalanalyses wereperformedusingR4.1.2(RFoundationforStatistical Computing,Vienna,Austria).28

Thisstudywasapprovedbytheinstitutionalreviewboard atThomasJeffersonUniversityHospital(TJUH)in Philadelphia,PA.Informedconsentwasobtainedfrom participatingphysicians.Thisstudywasfundedbythe CenterforFacultyDevelopmentandNexusLearning PedagogyGrantatThomasJeffersonUniversity.

RESULTS

FifteenEPs(sixfemalesandninemales)wereenrolledin EDSLITLAMPduringthetwo-yearperiod;nonewerelost tofollow-up.Allparticipantswereboard-certiﬁedEPswith anaverageclinicalexperienceof7.8yearspost-residency graduation.AllEPscompletedthe ﬁnalexamofthe curriculuminoneattemptandallunder60minutes.

Table2 liststhe20stepsoftheslit-lampexamcurriculum checklist,comparingparticipantresultsfromrecordedslitlampattempts(Time0)tothe ﬁnalin-personassessment (Time2).Theintra-classcorrelationintestscoresbetween EPsandophthalmologistsatTime0(2raters)was0.98.We foundasigniﬁcantincreasebetweenthechecklist scoresbeforeandaftertheeducationinitiative, 12.0to19.0, P = 0.002.

Themostnotabledifferencesbetweenthepre-andpostcurricularinterventionwereasfollows:1)instructingthe patienttoclosetheireyeswhilepoweringupandpositioning

thepatientintheslitlampwiththeforeheadtouchingthe horizontalbarandchininthechinrest(P < 0.001); 2)adjustingthemicroscope90degreestofacialplanewith illuminationsetata45-degreeangle(P = 0.008); 3)performingananteriorchamberevaluation(P = 0.002); 4)lookingforcellsand flare(P = 0.021);and5)placing fluoresceinintheinferiorfornixoftheeye(P = 0.031).The mostmissedstepsatthebaselineexamwere:1)applyinga transparentfaceshield(26.7%);2)instructingpatientsto closetheireyeswhenthemachinewasturnedon(26.7%); 3)lookingforcellsand flare(26.7%).

Figures2 and 3 illustratelearners’ confidencein performingandteachingtheslit-lampexamatthebeginning ofthestudy(Time0),immediatelyafterachievingprocedural mastery(Time2),andtwomonthslater(Time3). Figure4 illustratesthelearners’ likelihoodinteachingtheslit-lamp examatTime0andTime2.Beforeparticipatingintheslitlampcurriculum,73%ofEPsalsoreportedrarelyornever performingaslit-lampexam,while80%ofEPsreported sometimesoroftenusingaWood’slampforocular complaints.Only20%ofEPsreportedfeelingconfidentin performingandteachingacomprehensiveslit-lampexam, while67%ofEPsreportedfeelingconfidentinusingand teachingWood’slampforocularexamination.

Aftercompletingtheslit-lampcurriculum(Time2),86.7% ofEPsreportedfeelingconﬁdentperforminga comprehensiveslit-lampexamforocularcomplaints,and 73.3%weremoreconﬁdentinteachingresidentshowto performaslit-lampexam.MostEPsstronglyagreedthatthe EDSLITLAMPcurriculumhelpedthemperforman

Table2. Descriptivesummaryofchecklistevaluationatpre-andpost-curricularandcomparisonbetweentimepoints.

ChecklistitemPerformed

1-Identifyslitlampanatomy.

2 -Applytransparentfaceshieldovertheslitlamp(COVID).

3-Sanitizeforeheadandchinrestforthepatient.

4-Applytopicaltetracaine/proparacaineonpatient’seyes.

5-Unlockinstrumentbaseandshiftbypullingtowardyou.

6-Adjusteyepiecesforyourinterpupillarydistanceand refractiveerror.

7-Adjusttableheightand/orchair(s)-neitherpatientnorexaminer shouldbehunchedover.

Time0,N(%) (N = 15)

Time2,N(%) (N = 15)

P-valuefrom exactMcNemar’s test

Yes13(86.7%)15(100%)0.50

Yes4(26.7%)15(100%) <0.001

Yes5(33.3%)14(93.3%)0.004

Yes8(53.3%)12(80.0%)0.22

Yes15(100%)15(100%) NA

Yes10(66.7%)14(93.3%)0.22

Yes12(80.0%)14(93.3%)0.50

8-Instructpatienttocloseeyeswhileyoupowerupbyturningon thelightsourceatlowvoltagesettingandfocusonrighteyelid. Positionpatientinslitlampwithforeheadtouchingthehorizontal barandchininthechinrest. Yes4(26.7%)15(100%) <0.001

9-Setmagniﬁcationonlowestsettings(10xto12x),illuminationat largestapertureandwidestslitbeam.

Yes12(80.0%)15(100%)0.25

10-Adjustchinrestsothepatientissittingcomfortablywiththeir chinonthechinrestandtheirforeheadagainsttheheadrest. Yes12(80.0%)15(100%)0.25

11-Practicemacroandmicroadjustmentsoftheslidingbase withjoystick.

12-Adjustmicroscope90° tofacialplanewithilluminationset at45° angle(angleleftforpatient’srighteye,andrightfor lefteye).

13-Performouterstructureevaluation.

14-Performanteriorchamberevaluation.

15-Lookforcellsand ﬂare.

16-Placeadropoftetracaine/proparacaineonasterile ﬂuoresceinstrip.

17-Placethe ﬂuoresceinintheinferiorfornixoftheeyebypulling downonthelowerlidandgentlytouchingthebulbar conjunctivawiththe ﬂuoresceinstrip.

18-Adjustcobaltblue ﬁlterondiaphragmwheelatmaximumbeam heightandmediumwidthslitsettingfor ﬂuoresceinevaluation.

19-Focustheslitbeamat9:00positiononlimbus.Moveacross thecorneatothe3:00positionbytiltingjoysticklaterally.

20-Pullinstrumentbasetowardyouwhen ﬁnishedandlockin position.Turnoff.

Yes14(93.3%)15(100%)1.00

Yes7(46.7%)15(100%)0.008

Yes14(93.3%)15(100%)1.00

Yes5(33.3%)15(100%)0.002

Yes4(26.7%)12(80.0%)0.02

Yes15(100%)15(100%) NA

Yes9(60.0%)15(100%)0.03

Yes14(93.3%)15(100%)1.00

Yes12(80.0%)15(100%)0.25

Yes4(26.7%)13(86.7%)0.004

Time0, median[IQR]

Time2, median[IQR] P-valuefrom Wilcoxonsigned ranktest

Subtotalscore 12.0[10,16]19.0[19,20]0.002

IQR, interquartilerange.

independentslit-lampexamandidentifycritical ﬁndingsfor commonocularcomplaints(80%),enhancingtheirlearning morethantraditionallecturesandreadingalone(86.7%).Of theasynchronousmaterials,thevideodemonstrationwasthe mostused(53%usedit “alot” ora “greatdeal”);the

PowerPointlectureandWEHManualweretheleastused.At twomonthspost-EDSLITLAMP(Time3),73%and67%of participantsexpressedextremeconﬁdenceinperformingand teachingaresidenthowtoperformaslit-lampexam.Fivetof 15EPsreportedteachinglearnerswithinthetwo-month

Figure2. Learnerconﬁdenceinperformingtheslit-lampexamatTime0(pre-curricular),Time2(immediatepost-SBMLcurriculum),and Time3(2-monthpost-SBMLcurriculum).

Figure3. Learnerconﬁdenceinteachingtheslit-lampexamatTime0(pre-curricular),Time2(immediatepost-SBMLcurriculum),Time3 (2-monthspost-SBMLcurriculum).

post-curricularperiod,rangingfrom5–30studentsper EPparticipant.

Table4summarizesthestatisticallysignificant findings fromthesurveyresponsesbasedonthethreetimeframes. Therewasastatisticallysignificantincreaseinself-reported confidencein1)performingacomprehensiveslitlampexam and2)teachingresidentstoperformthisexambetweenTime 0toTime2andTime0toTime3(P < 0.001).Therewasno differenceinrelianceonophthalmologyconsultationto modifyorreinforceatreatmentplanforocularcomplaints whencomparingTime0toTime3(P = 0.70, P = 0.814). Therewasalsonostatisticaldifferenceinthenumberof patientswithocularcomplaintsevaluatedbythestudy

participantsattheTJUHEDandWEHEDthroughoutthe study(P = 0.14, P = 1.00).

DISCUSSION

TheEDSLITLAMPcurriculumallowedEPstoincrease theiruseandconfidenceinperformingslit-lampexamsinthe ED.TheimpetusfortheprojectarosefromEPs’ intrinsic motivationtoprovidebetterpatientcare.Ourparticipant populationconsistedprimarilyofjuniorfacultywhowere initiallyuncomfortableperformingorteachingslit-lamp examsandpreferredusingtheWood’slamp.Upon completingthecurriculum,theEPsnotedasignificant increaseinself-reportedconfidenceinusingslit-lamps

Learnerlikelihoodinteachingtheslit-lampexamatTime0(pre-curriculuar)andTime2(immediatepost-SBMLcurriculum).

andwereteachingmultiplejuniorlearnersduringtheir studyenrollment.

Theimprovementbetweenthepre-andpost-curricular proceduralcompetencyalsodemonstratestheimportanceof understandingthetechnicalnuancesoftheslit-lampexam andpracticingcriticaldevicemovement,suchascareful patientpositioning,adjustingofthechinstraps,changingthe microscopeangulation,andadjustingvaryingslit-lamp beamlengthsandwidthsfordiagnosingawiderangeof anteriorophthalmicpathologies.Theseskillsaredrastically differentthanthoserequiredtooperateaWood’slamp, whichactsprimarilyasamagnifyingglasswith UVcapabilities.

OurcurriculumachievedthreeofthefourKirkpatrick goals.Themajorityoftheparticipants(over80%)reported positivereactiontothecurriculum(thecurriculumhelped themperformaslit-lampexam,evaluateforcommon pathologies,andofferedmorethantraditionallectures) (Level1);alloftheparticipantsdemonstratedprocedural masteryatTime2(Level2);upwardsof50learnersreceived instructionsfromthestudyparticipantsonhowtousetheslit lampatTime3(Level3).Whiletherelianceon ophthalmologyconsultationdidnotrevealstatistically signiﬁcantchanges,wepositthatimprovedprocedural acumenresultedinmoretargetedconsultationquestioning andimprovedrapportbetweenthemedicaldisciplines.

Sinceourparticipantswereboard-certifiedEPswith limitedavailabilities,themostvaluedcomponentofthe curriculumwasthein-personRCDPsessionwiththe ophthalmologist(Time2).Thiswasreflectedinalmostevery CIQitem,withspecificmentionofdirectguidancein positioningthebeamtolookforcellsand flare.Themost surprisingelementtomanyparticipantswashowmany oculardiagnosesrequiredtheslit-lampexamandthat learningtheprocedurewasnotascomplicatedastheyhad

initiallyanticipated.Incontrast,manyoftheparticipantsfelt mostdistancedorremovedfromthecurriculuminreviewing theasynchronouslearningmaterials.

Wewereunsurprisedtoseetheconfidencelevelsinusing Wood’slampunchangedbetweenthethreedifferenttime frames.Whiletheslitlampoffersasuperiorandin-depth evaluationoftheanteriorsegmentoftheeye,we acknowledgethatacomprehensiveslit-lampexamistimeandresource-consumingandmaynotaffecttheclinician’ s managementifthesuspectedpathologyinvolveslarger lesions,foreignbodies,orspecificreactionto fluorescein staining.TheWood’slampremainsaneasierand moreportablediagnostictoolforsomeocularpathologies, anditsuseintheclinicalarenaisstillacceptablein certainsituations.

LIMITATIONS

Thisstudywasconductedatasingle,large,tertiary academiccenterwithanaffiliatedophthalmologyhospital andsupportedwithinternalgrantfunding.Whiletheresults werepositive,multiplefactorsciykdpreventthisstudyfrom beingreplicated,especiallyatcommunitysiteswithouta closerelationshipwithophthalmology.Oneofthemost significantchallengesisschedulingin-personevaluationsin thepre-curricularsession,aswellasthe finalin-person trainingandexamination.Weencounteredsignificant logisticalchallengesincreatingaschedulethatwasamenable totheophthalmologists,EPs(withunpredictableshift schedules),andresearchinvestigators,aswellas findinga consistentspaceintheWEHandWEHEDthathadaccess toanattached-observerscopetoensuretheparticipantswere focusingonthecorrectanatomicstructureduringtheir proceduraldemonstration.Thiswasfurtherexacerbated whenaccountingforthe “unlimitedattempts” forRCDP. Asthiswasourpilotstudywithadvancedlearners,we

Figure4.

Table3. Statisticalanalysisofsurveyquestionsbetweenthethreedifferentstudytimeframes.

Surveyquestion

Slitlamp

Based onyourcurrentpracticepatterns:how conﬁdentareyouin:performingacomprehensiveslit lampexamforocularcomplaints?

Basedonyourcurrentpracticepatterns,how conﬁdentareyouin:teachingresidentstoperforma comprehensiveslitlampexamforocularcomplaints

Howoftendoyou:performanindependentslit lampexamforocularcomplaints?

Wood’slamp

Basedonyourcurrentpracticepatterns,how conﬁdentareyouin:performingacomprehensive Wood’slampexamforocularcomplaints?

Basedonyourcurrentpracticepatterns,how conﬁdentareyouin:teachingresidentstoperforma comprehensiveWood’slampexam(withaccesstoa slitlamp)forocularcomplaints?

Howoftendoyou:useawoodlamp(withaccess toaslitlamp)forocularcomplaints?

Ophthalmologyconsultationhabits

Howconﬁdentareyouinidentifyingcommon ocularpathologyseeninyourmainworksite(CC, MHD,UrgentCare)?

Onaverage,howmanyeyepathologiesdoyou seeatthemainworksite? 10[4,15]n/a*5[3,12.5]n/a*

Onaverage,howmanyeyepathologiesdoyou seeatotherfacilities?

Howoftendoyourelyonophthalmology consultationto:helpmodifyyourtreatmentplanfor ocularcomplaints? 3[3,3]n/a*3[2.5,3]

Howoftendoyourelyonophthalmology consultationto:reinforceyourtreatmentandplanfor ocularcomplaints? 3[2,3]n/a*3[2,3]

Howoftendoyourelyonophthalmology consultationto:provideadditionalinformationand guidancetoyourtreatmentandplanforocular complaints?

3[3,4]n/a*3[3,3.5] n/a* 1.00

Confidence levels:1 = Notatallconfident,5 = Extremelyconfident

Frequencylevels:1 = Never,5 = Always

aTime0 = pre-curricularevaluation.

bTime2 = immediatepostSBMLexam.FrequencyofslitlampandWood’slampusewereintentionallyomittedforTime2duetotheclose proximitybetweenTime0andTime2,thusresultingin ‘n/a’ forsomecalculations.

cTime3 = threemonthsafterSBMLexam.

CC,JeffersonHospitalinCenterCityPhiladelphia; MHD,JeffersonMethodistHospital; IQR,interquartilerange.

over-budgetedatwo-hourtemplateforeachlearner,which drasticallylimitedthenumberofparticipantswecould scheduleforthe ﬁnalin-personexam.

Duetothelongitudinalnatureofthisstudyandseveralinpersoncomponents,maintainingparticipantrecruitment andengagementwasalsodifﬁcult.Ofthe50eligibleboardcertiﬁedTJUHEPs,only15EPsvolunteeredtoparticipate. Theprimarydeterrence,whendiscussedwithnonparticipants,wastimerestraintsandcommutingintothecity forin-personevaluationsandexaminations.Wesuggest implementingdedicatedteachingdays(ie,conferencedaysor facultymeetings)forlargerparticipantrecruitmentand subsequentfollow-upandexamination.

Thisstudywasfundedbyaninternalgrantthatprovided minor financialincentivesfortheparticipantsand standardizedpatientvolunteers.Whileourneeds-based analysisrevealedparticipantsweremorefocusedon promotingbetterpatientcare,manyoftheparticipants expressedappreciationforthestaggeredgiftcards,which alsoincentivizedthemtocompleteeachtimeline-specific survey.Allotherinvestigators’ efforts,incontrast,wereinkindandrequireddedicatednon-academicandnon-clinical timetoenrollparticipants,recordalltheinteractions,and provideunrestrictedtimeavailabilitiesforthe finalmastery assessment.Thisstudywasalsounanimouslysupportedby bothdepartmentalleadershipstopromoteabettercollegial relationshipandinterdisciplinaryeducationopportunity betweenorganizationswiththetwoprincipalinvestigators holdinguniqueleadershippositions,ophthalmology consultingdirector[CC]andEMclerkshipdirector[XCZ]. Wesuspectthatalsopositivelyaffectedourrecruitment processandthesuccessofthisinterdisciplinarytraining curriculum.Asthisstudywasconductedatanacademic hospitalinanurbansetting,ithasbeensuggestedthat academiccenterslikelyoverestimateEPcomfortand confidenceinthediagnosisandmanagementofophthalmic emergencies.9 Furthermore,theproximitybetweenbothEDs mayskewthedata,astheseEPsarelikelyexposedtofewer ophthalmicemergenciesthanhospitalswithoutanearbyeyefocusedED.

Ultimately,thebiggestlimitationtothispilotstudywas thelackofin-personskillassessmentatthe60-dayfollow-up duetolimitedstaffingandschedulingchallenges.Inlieuofan objectivecompetencyscore,weleveragedself-reported confidenceatthe60-daymarkasanapproximate measurementoftheskillretention.Werecognizethat learnersarepooratgaugingtheirownabilities,bothoverandunderestimatingtheirskillsbasedonavarietyoffactors. Itisnotablethat80%ofourlearnerswereinitially “not confident” incompletingacomprehensiveslit-lampexam priortotheSBMLcurriculumandscoredanaverage checklistscoreof60%.AtTime2,almost87%ofresponders were “ confident” incompletingacomprehensiveslit-lamp examafterreceivinganaveragechecklistscoreof95%.

Unfortunately,thereisnoassociationbetweenlearners’ conﬁdenceandpassingrate(score >18)atTime0(Pearson chi-square3.46, P = 0.17)andTime2(Pearsonchi-square 0.833, P = 0.66),respectively.Whileweareunabletopredict howtheselearnerswouldhaveperformedontheirslit-lamp examtestatday60,weareencouragedtoseethenumberof studyparticipantswhocontinuedtoteachslit-lampexamfor juniorlearners.Weposittheseparticipantswilllikelyhave improvedsustainedcompetenceanddecreasedskilldecayby activelyteachingothers.Futurestudiesshouldbeconsidered toadda ﬁnalexamination(procedureormultiple-choice question)tovalidateourresults.

CONCLUSION

Emergencyphysiciansareexpectedtodiagnoseand manageocularcomplaintsaspartoftheirtrainingand clinicalpractice.Ourprimaryfocuswastocreatearigorous methodologictrainingcurriculum(slit-lampexam)fora specialty-focusedskillsetthatcouldresultindownstream teaching.Thisprojecthighlightedasigniﬁcantneedforslitlampexamtrainingwithinourinstitutionthatledtoa successfultransdisciplinarysimulation-basedmastery learningcurriculumandimprovedourEPs’ conﬁdencein performingandteachingslit-lampexamstofutureclinicians. Furthermore,thisstudydemonstratesthatadultlearners, especiallyattendingphysicianvaluedirectinteractionwith clinicalinstructorswhenlearninganewskillsetandare intrinsicallymotivatedtohonetheirskillsetandteachitto futurelearnerswhentheyhaveachievedthismastery. WeencourageotherinstitutionstoleverageSBMLasa teachingmodalityforprocedural-basedtrainingand advocatecross-disciplineeducationinitiatives.Future investigationcouldincludecreatingamulticenterstudyto implementthiscurriculumatotheracademicinstitutionsand potentiallyincludeitinEMresidencytraining.

ACKNOWLEDGMENTS

WewanttothanktheThomasJeffersonUniversityCenter forFacultyDevelopmentandNexusLearning(CFDNL)for theirgeneroussupportandgrantfundingincompleting thisstudy.

AddressforCorrespondence:XiaoChiZhang,MD,Thomas JeffersonUniversity,DepartmentofEmergencyMedicine,1020 SansomSt.,ThompsonBldg,Suite239,Philadelphia,PA19107. Email: Xiaochi.zhang@jefferson.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisstudyreceivedgrantfundingfrom theCenterforFacultyDevelopmentandNexusLearning(CFDNL) Pedagogy,ThomasJeffersonUniversity.Therearenoother conflictsofinterestorsourcesoffundingtodeclare.

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16.LemkeDS,FielderEK,HsuDC,etal.Improvedteamperformance duringpediatricresuscitationsafterrapidcycledeliberatepractice comparedwithtraditionaldebrieﬁng:apilotstudy. Pediatr EmergCare. 2019;35(7):480–6.

17.MavisSC,KreofskyBL,OukMY,etal.Trainingfellowsinneonatalteleresuscitationusingasimulation-basedmasterylearningmodel. ResuscitationPlus. 2021;8:100172.

18.ZendejasB,CookDA,BingenerJ,etal.Simulation-basedmastery learningimprovespatientoutcomesinlaparoscopicinguinalhernia repair:arandomizedcontrolledtrial. AnnSurg. 2011;254(3):502–9; discussion509–11.

19.FranklinBR,PlacekSB,GardnerAK,etal.PreparingfortheAmerican BoardofSurgery ﬂexibleendoscopycurriculum:developmentofmultiinstitutionalproﬁciency-basedtrainingstandardsandpilottestingofa simulation-basedmasterylearningcurriculumfortheendoscopy trainingsystem. AmJSurg. 2018;216(1):167–73.

20.BarsukJH,McGaghieWC,CohenER,etal.Useofsimulation-based masterylearningtoimprovethequalityofcentralvenouscatheter placementinamedicalintensivecareunit. JHospMed. 2009;4(7):397–403.

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28.R:TheRProjectforStatisticalComputing.June11,2023.Accessed August8,2023. https://www.r-project.org/

EDUCATION

EmergencyMedicineMilestonesFinalRatingsAreOftenSubpar

DianeL.Gorgas,MD*

KevinB.Joldersma,PhD†

FelixK.Ankel,MD‡

WallaceA.Carter,MD§

MelissaA.Barton,MD†

EarlJ.Reisdorff,MD†

*OhioStateUniversityWexnerMedicalCenter,DepartmentofEmergencyMedicine, Columbus,Ohio † AmericanBoardofEmergencyMedicine,EastLansing,Michigan ‡ RegionsHospital,DepartmentofEmergencyMedicine,St.Paul,Minnesota

§ WeillCornellMedicine,DepartmentofEmergencyMedicine,NewYork,NewYork

SectionEditors: KendraParekh,MD,andAbraFant,MD

Submissionhistory:SubmittedJanuary16,2024;RevisionreceivedJune14,2024;AcceptedJuly8,2024

ElectronicallypublishedAugust16,2024

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

DOI: 10.5811/westjem.18703

Background: Theemergencymedicine(EM)milestonesareobjectivebehaviorsthatarecategorized intothematicdomainscalled “subcompetencies” (eg,emergencystabilization).Thescaleforrating milestonesispredicatedontheassumptionthatarating(level)of1.0correspondstoanincomingEM-1 residentandaratingof4.0isthe “targetrating” (albeitnotanexpectation)foragraduatingresident.Our aiminthisstudywastodeterminethefrequencywithwhichgraduatingresidentsreceivedthetarget milestoneratings.

Methods: Thisretrospective,cross-sectionalstudywasasecondaryanalysisofadatasetusedinaprior studybutwasnotreportedpreviously.WeanalyzedmilestonesubcompetencyratingsfromApril 25–June24,2022forcategoricalEMresidentsintheir ﬁnalyearoftraining.Ratingsweredichotomized asmeetingtheexpectedlevelatthetimeofprogramcompletion(ratingsof ≥3.5)andnotmeetingthe expectedlevelatthetimeofprogramcompletion(ratingsof ≤3.0).Wecalculatedthenumberofresidents whodidnotachievetargetratingsforeachofthesubcompetencies.

Results: InSpring2022,ofthe2,637residentsinthespringoftheirlastyearoftraining,1,613(61.2%) achievedaratingof ≥3.5oneverysubcompetencyand1,024(38.8%)failedtoachievethatratingonat leastonesubcompetency.Therewere250residents(9.5%)whofailedtoachievehalfoftheirexpected subcompetencyratingsand105(4.0%)whofailedtoachievetheexpectedrating(ie,ratingwas ≤3.0)on everysubcompetency.

Conclusion: WhenusinganEMmilestoneratingthresholdof3.5,only61.2%ofphysiciansachievedthe targetratingsforprogramgraduation;4.0%ofphysiciansfailedtoachievetargetratingsforany milestonesubcompetency;and9.5%ofphysiciansfailedtoachievethetargetratingsforgraduating residentsinhalfofthesubcompetencies.[WestJEmergMed.2024;25(5)735–738.]

INTRODUCTION

WiththeadventoftheNextAccreditationSystem(NAS), theAccreditationCouncilforGraduateMedicalEducation (ACGME)introducedanewassessmentprocesscalledthe “milestones.”1 Themilestonesareobjectivebehaviorsthat reﬂectelementsofthemajorcompetencies(eg,patientcare, systems-basedpractice)inthematicdomainscalled “subcompetencies” (eg,emergencystabilization,patientandfamily-centeredcommunication).Themilestonescale

usesnineratingsfrom1.0,1.5,2.0,2.5,etc,to5.0.Thescaleis predicatedontheassumptionthatarating(level)of1.0 correspondstoanincomingemergencymedicine(EM)-1 residentandaratingof4.0isthegraduation “target,” albeit notagraduationexpectationorrequirement.Accordingto theACGME: “Level4isdesignedasagraduation goal but doesnot representagraduation requirement . ”2 TheEM milestoneshavebeenusedexclusivelyasaformative assessmentbytheACGME.Likewise,aphysician’sEM

milestoneratingsarenotconsideredwhendetermining theeligibilityofaphysiciantotaketheAmerican BoardofEmergencyMedicine(ABEM)written qualifyingexamination.

TheEMmilestoneswereintroducedin2012,andthe ﬁrst ratingswerereportedin2013.3 TheEMmilestoneswere revisedin2021,resultingin22subcompetencies.Since2012, substantialvalidityevidencefortheEMmilestoneshasbeen accumulated.4–10 Aresident’smilestoneratingsareusually assignedbyclinicalcompetencycommittees(CCCs).Some subcompetencyratingsarebelowtargetlevels.Often,the subcompetencyratingsassignedbytheCCCsarelowerthan theratingsthatresidentsgivethemselves.11 Themilestones wereinitiallydesignedtohavearatingof4.0asthetargetfor aresidentcompletinganEMresidency.9 AggregateEM milestonesarereportedannuallybytheACGME.12 These dataandotherreportssuggestthatasubstantialnumberof graduatingresidentsarenotachievingalevel4ratingin manymilestonesubcompetencies.

Weundertookthisstudytodeterminethefrequency withwhichgraduatingresidentsreceivedthetarget milestonerating.

METHODS

StudyDesign

Thisretrospectivecross-sectionalstudywasasecondary analysisofanalreadyde-identiﬁeddatasetusedinaprior study.13 Ourcurrentstudywasdeemedexemptfromhuman subjectresearchbytheWestern-CopernicusGroup InstitutionalReviewBoard.Thedatasetavailabletothe investigatorsdidnotincludephysicianorprogram characteristicsthatwouldallowamoredetailedanalysis.

StudySettingandPopulation

Weanalyzedmilestonesubcompetencyratingsfrom Spring2022forcategoricalEMresidentsintheir ﬁnalyearof training.Thesemilestoneratingsweresubmittedbetween April25–June24.ThisratingsreportusedEMMilestones 2.0,whichincluded22subcompetencies.Thedatasethad beenprovidedearliertoABEMbytheACGMEaspartof theroutineEMmilestonessecuredata-sharingprocess.

MeasurementsorKeyOutcomeMeasures

Theprimarymeasurewasthenumberofsubcompetencies forwhichphysiciansfailedtoachieveatargetratingof3.5at thetimethattheSpringmilestoneratingsweresubmittedto theACGME.Becausetheratingsweresubmittedbetween AprilandJunepriortoresidencycompletion,andtheCCC couldhavedeterminedtheratingsevenearlierthanthat,an expectedratingforpurposesofthestudywasmodiﬁedtobe 3.5ratherthan4.0.Doingsoassumedthattheresidentwould achievearatingof4.0overtheremainingweekstomonthsof residencytraining.Wedeterminedthenumberofphysicians

whodidnotachievethetargetratingforthesubcompetencies (from0subcompetenciestoall22subcompetencies).

DataAnalysis

Ratingsweredichotomizedasmeetingthetargetlevelat thetimeofprogramcompletion(≥3.5)andnotmeetingthe targetlevelatthetimeofprogramcompletion(≤3.0).We calculatedthenumberofcompetenciesforwhichatarget ratingwasnotachieved.

RESULTS

InSpring2022,thereweremilestoneratingsfor2,637 residentsintheSpringoftheirlastyearoftrainingin279EM residencies.Therewere1,613residents(61.2%)whoachieved aratingof ≥3.5oneverysubcompetencyand1,024residents (38.8%)whofailedtoachievearatingof ≥ 3.5onatleastone subcompetency.Therewere250physicians(9.5%)whofailed tomeethalfoftheirtargetsubcompetencyratings.There were105residents(4.0%)whofailedtomeetthetargetrating (ie,ratingwas ≤3.0)oneverysubcompetency(Table).

Table. Thefrequencyofemergencymedicineresidentsreceiving targetmilestonesratingslowerthat3.5inSpring2022(n = 2,637).

LIMITATIONS

First,theactuallevelofsubcompetencyachievementat graduationwasimpreciselyknown.Wechosearatingof ≥3.5torepresenttheperformancetarget,giventhatthe milestoneratingswereprovidedpriortothecompletionof theprogram.Usingaratingof4.0tobeassignedtwomonths priortograduationwouldlikelyunderestimate subcompetencyachievementandascoreof3.5attwo monthspriortoprogramcompletionwouldlikely overestimatesubcompetencyachievement.Anticipatingthat allresidentswitharatingof3.5wouldachievearatingof4.0 withinweekswasabenevolentassumption.Second, demographicdataonresidents(eg,gender)andprogram characteristics(eg,durationoftraining)wereunavailableto theinvestigators.Althoughthislackofadditional informationlimitedourabilitytodeterminefactors associatedwiththeratings,webelievethatthe findings aresufficientlysignificantontheirmeritandwarrant additionalinvestigation.

Third,wedidnotcorrelatepoorsubcompetencyratings withprogramextensionorremediation,thuslimitingthe opportunitytogatheranyevidenceofpredictiveor consequentialvalidity.Itispossiblethatnearlyevery physicianwhodidnotachievearatingof ≥3.5onnearlyhalf ofthemilestonesubcompetenciesunderwentremediation. Fourth,theratingsareassignedbyCCCs.Thestructuresof, andinformationusedbyCCCs,varybyEMresidency.14,15 Wedidnotattempttodeterminethereliabilityoraccuracyof theindividualratings.Moreover,wedidnotexaminethe potentialimpactofbiasintheratings.Priorstudiessuggested thatwomenwereassignedlowerperformanceratings.16,17 Sixth,theratingsusedforthisstudywerefromthe ﬁrstyear oftheEMMilestones2.0.Althoughtherewasadegreeof acclimationindevelopingfacilitywiththeEMMilestones 1.0,itislikelythatthesamedegreeofunfamiliaritywouldbe lesswiththemostrecentversion.Thedegreetowhichthe continueduseofEMMilestones2.0willchangeratingtrends isunknown.

DISCUSSION

Thisstudyisthe ﬁrstinEMtodemonstratethedegreeto whichphysicianscompletingEMresidenciesarenot achievingtargetsubcompetencyratings.Thesedatashowed thatofthe2,637residentsintheirlastyearoftraining,nearly oneintenfailedtomeettargetratingsforhalfoftheEM subcompetencies.Asimilar ﬁndingwasreportedfor physicianscompletingpediatricEMfellowships.18 However, thatreportusedatargetratingof4.0,not3.5asinourstudy. Consequently,67%ofpediatricEMfellowsdidnotattaina ratingofatleast4.0foratleastonesubcompetency.

Aphysicianshouldbeabletograduatefromresidency withoutscoring4.0onall22subcompetencies.Infact,all4.0 ratings(astraight-linescore)wouldbehighlyimprobable.19 Considerthehypotheticalsituationthatwouldresultfrom

themilestonesbeingusedinasummativemannerto determineABEMboardeligibility.Ifresidentswererequired tohavenomorethansixsubpar(ie, <3.5)milestoneratings (morethanone-fourthofthesubcompetencies),then353 residents(13.4%)intheir ﬁnalyearoftrainingwouldnotbe eligibletotaketheABEMwrittenqualifyingexamination. Giventheintentofthemilestonesasaformativeinstrument, ABEMmaintainsthepositionthatthemilestonesshouldnot beusedasasummativedeterminantofboardeligibility.

Therateofprogramextensionbyphysiciansbeyonda scheduledgraduationdatehasbeenreportedtobe approximately8.5%.13 Theseextensionsincludephysicians undergoingacademicremediation,aswellasprogram extensionsduetoapersonalleaveofabsence.Theprevalence ofphysiciansnotmeetinghalfofthetargetsubcompetency ratingswas9.5%.Basedonthese ﬁndings,therewere physicianswhofailedtomeetatleasthalfoftheEM milestonesubcompetenciesyetweredeemedcompetentto practiceautonomouslyasattestedbytheprogramdirector. Thislikelihooddoesnotchallengetheconstructvalidityof themilestones,nordoesitsuggestthatthetargetistoohigh. Inafact,apriorvaliditystudybyKorteetalusedprogram directorsurveydatatoverifytheappropriatenessofthe targetratings.9

Inthisstudywedidnotanalyzetheimpactoftraining length(EM1-3vsEM1-4).However,areviewofmeanscores wasundertakeninapriorinvestigationthatusedthesame studyperiod.13 ThescoressuggestthatresidentsinEM1-3 programstendedtohavehigherscoresthroughthe postgraduateyears(PGY)1–3.Forexample,inthePGY3year,residentsfromEM1-3programshadameanratingof 3.51(95%conﬁdenceinterval[CI]3.50–3.53)andresidents fromEM1-4programshadameanratingof3.07(95%CI 3.05–3.09),whileEM4residentshadameanratingof3.67 (95%CI3.65–3.69).

Thisanalysisisaninitialexplorationintoamorethorough investigationofthe finalmilestonesratingthatanEM residentreceives.Thecurrentstudydoesnotidentifyvariable impactwithindemographicgroups,nordoesitprovideany indicesofpredictivevalidity.Giventhe findingsofthis analysis,amorethoroughanalysisofthemilestonesshould beundertakentodeterminetheirpsychometricqualitiesand subsequentutilityinthe field.Giventheuseofthemilestones asaformativeevaluationsystem,itshouldnotbeusedto makesummativedecisionssuchasthedeterminationof ABEMboardeligibility.Amorestructured,valid,and reliableprocessformakingthesummativedetermination thataphysicianhasdemonstratedthenecessary competenciestopracticesafelyandindependentlyis advisable.Moreover,suchadetailedsummativeprocess couldalsobeusedtomakeaconfidentdeterminationthata physicianiseligibleforboardcertification.Thisprocess wouldbeeasilyaccommodatedinamodelofcompetencybasedmedicaleducation.

CONCLUSIONS

ManyphysicianscompleteanEMresidencywithout meetingatargetratingforagraduatingresidentinuptohalf oftheEMmilestones.Someresidents(4%)didnotmeeta targetratinginanymilestone.These ﬁndingssupportthe continueduseofthemilestonesasaformativeinstrument, ratherthanatooltodetermineboardeligibility.

AddressforCorrespondence:DianeL.Gorgas,MD,American BoardofEmergencyMedicine,3000CoolidgeRoad,EastLansing, MI48823.Email: diane.gorgas@osumc.edu

REFERENCES

1.NascaTJ,PhilibertI,BrighamT,etal.ThenextGMEaccreditation system–rationaleandbeneﬁts. NEnglJMed. 2012;366(11):1051–6.

2.EmergencyMedicineMilestones.TheAccreditationCouncilfor GraduateMedicalEducation.2021.Availableat: https://www.acgme. org/globalassets/PDFs/milestones/emergencymedicinemilestones.pdf AccessedAugust4,2023.

3.BeesonMS,CarterWA,ChristopherTA,etal.Emergencymedicine milestones. JGradMedEduc. 2013;5(1Suppl1):5–13.

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

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6.HamstraSJ,CuddyMM,JurichD,etal.Exploringtheassociation betweenUSMLEscoresandACGMEmilestoneratings:avalidity studyusingnationaldatafromemergencymedicine. AcadMed. 2021;96(9):1324–31.

7.HamstraSJ,YamazakiK,BartonMA,etal.Anationalstudyof longitudinalconsistencyinACGMEmilestoneratingsbyclinical competencycommittees:exploringanaspectofvalidityinthe assessmentofresidents’ competence. AcadMed. 2019;94(10):1522–31.

8.HolmboeES,YamazakiK,NascaTJ,etal.Usinglongitudinal milestonesdataandlearninganalyticstofacilitatetheprofessional developmentofresidents:earlylessonsfromthreespecialties. AcadMed. 2020;95(1):97–103.

9.KorteRC,BeesonMS,RussCM,etal.Theemergencymedicine milestones:avalidationstudy. AcadEmergMed. 2013;20(7):730–5.

10.PeckTC,DuboshN,RosenC,etal.Practicingemergencyphysicians reportperformingwellonmostemergencymedicinemilestones. JEmergMed. 2014;47(4):432–40.

11.GoldﬂamK,BodJ,Della-GiustinaD,etal.Emergencymedicine residentsconsistentlyratethemselveshigherthanattending assessmentsonACGMEmilestones. WestJEmergMed. 2015;16(6):931–5.

12.EdgarLaura,HoganSO,HolmboeES,etal.Milestones:National Report.2022. https://www.acgme.org/globalassets/pdfs/milestones/ 1160-ACGME-Milestones-Report-2022-R22.pdf AccessedAugust4,2023.

13.BeesonMS,BartonMA,ReisdorffEJ,etal.Comparisonofperformance databetweenemergencymedicine1–3and1–4programformats. JAmCollEmergPhysicians.Open 2023;4(3):e12991.

14.DotyCI,RoppoloLP,AsherS,etal.Howdoemergencymedicine residencyprogramsstructuretheirclinicalcompetencycommittees? Asurvey. AcadEmergMed. 2015;22(11):1351–4.

15.GoyalN,FoltJ,JaskulkaB,etal.Assessmentmethodsandresource requirementsformilestonereportingbyanemergencymedicineclinical competencycommittee. Med EducOnline. 2018;23(1):1538925.

16.SantenSA,YamazakiK,HolmboeES,etal.Comparisonofmaleand femaleresidentmilestoneassessmentsduringemergencymedicine residencytraining:Anationalstudy. AcadMed. 2020;95(2):263–8.

17.DayalA,O’ConnorDM,QadriU,etal.Comparisonofmalevsfemale residentmilestoneevaluationsbyfacultyduringemergencymedicine residencytraining. JAMAInternMed. 2017;177(5):651–7.

18.RoskindCG,LeonardK,BaghdassarianA,etal.Pediatricemergency medicinefellows’ milestoneevaluations:dotheyallmeetthetargetsfor graduation? AEMEducTrain. 2021;5(3):e10620.

19.BeesonMS,HamstraSJ,BartonMA,etal.Straightlinescoringby clinicalcompetencycommitteesusingemergencymedicinemilestones. JGradMedEduc. 2017;9(6):716–20.

EDUCATION SPECIAL ISSUE-BEST PRACTICES

MakingADifference:LaunchingaMultimodal,Resident-Run SocialEmergencyMedicineProgram

NaomiP.Newton,MD* ChristopherFreeman,MD†

PatriciaPanakos,MD†

SectionEditor:PaulLoganWeygandt,MD

*EmoryUniversitySchoolofMedicine,DepartmentofEmergencyMedicine, Atlanta,Georgia

† JacksonHealthSystem,DepartmentofEmergencyMedicine,Miami,Florida

Submissionhistory:SubmittedOctober17,2023;RevisionreceivedApril28,2024;AcceptedMay30,2024

ElectronicallypublishedAugust16,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18509

Introduction: Socialmedicineseekstoincorporatepatients’ socialcontextsintotheirmedicalcare. Emergencyphysiciansareuniquelypositionedtoaddresssocialdeterminantsofhealth(SDoH)onthe frontlinesofthehealthcaresystem.Miami-DadeCounty(MDC)isadiverseandsociallyvulnerablearea. In2020,theUniversityofMiami-JacksonHealthSystem(UM-JHS)emergencymedicine(EM)residency programlaunchedamultimodal,resident-ledSocialEMprogramtoidentifyandaddressSDoHinthe emergencydepartment(ED).

Methods: Weuseafour-pillarapproachtoSDoHintheED:CurriculumIntegration;Community Outreach;AccesstoCare;andSocialJustice.ResidentsgraduatewithaknowledgeofSocialEM principlesthroughan18-monthcurriculum,anelective,andalongitudinaltrack.Wedeveloped sustainableinitiativesthroughinterdepartmentalandcommunity-basedpartnerships,includingaNarcan distributioninitiative,anED-basedprogramlinkinguninsuredpatientstofollow-upcare,ahuman trafﬁckingeducationinitiative,andaqualityimprovementinitiativeforincarceratedpatients.

Results: Giventhatthe18-monthcurriculumwaslaunchedin2022,afullrotationofthecurriculumhad notbeencompletedasofthiswriting,anddatacollectionandanalysisisanongoingprocess.Theinitial pretestandpost-testsurveydatashowimprovementinknowledgeandconﬁdenceinmanagingSocial EMtopics.TheNarcaninitiativehasscreened1,188patients,ofwhom144havereceivedNarcan.The ED-basedpatientnavigationprogramhasenrolled31patientstodate,18ofwhomobtainedoutpatient care.Analysisoftheimpact/effectivenessoftheprogram’sotherinitiativesisongoing.

Conclusion: Toourknowledge,thisisoneofthemostrobustsocialEMprogramstodate,asmanyother programsprimarilyfocusonserviceopportunities.RootedintherevisedprinciplesofBloom’staxonomy ofcognitivelearning,thisprogrammovesbeyondunderstandingSocialEMtenetstogenerating solutionstoaddressSDoHinandoutsidetheED.[WestJEmergMed.2024;25(5)739–747.]

BACKGROUND

Socialmedicine,ortheincorporationofpatients’ social contextsintotheirmedicalcare,hasbecomeavibrant, interdisciplinarymovementthathasgainedtractionin medicalschools,residencies,andatthenationallevel.Social medicineemphasizestheimportanceofsocialdeterminants ofhealth(SDoH),or “theconditionsintheenvironments wherepeopleareborn,live,learn,work,play,worship,and agethataffectawiderangeofhealth,functioning,and

quality-of-lifeoutcomesandrisks.”1 TheUSDepartmentof HealthandHumanServiceslists ﬁvecoreSDoHtoconsider duringpatientcare:economicstability;educationaccessand quality;healthcareaccessandquality;neighborhoodand builtenvironment;andsocialandcommunitycontext.1

AlthoughSDoHcanbeappliedtoallspecialties,theyare perhapsmostrelevanttoemergencymedicine(EM).Passage oftheEmergencyMedicalTreatmentandLaborAct (EMTALA)in19862 wasacknowledgmentthatemergency

physiciansareoftentheonlylinktothehealthcaresystemfor patientswith ﬁnanciallimitations.Emergencyphysiciansare estimatedtoprovidetwo-thirdsofacutecareforall uninsuredpatientsandhalfofacutecareforallMedicaid patients.3 WhethertheyarerushingapatienttoCT,leading theirteamduringaresuscitation,orevaluatingpatientsina crowdedhallway,emergencyphysiciansareimmersedin longstanding,complexsocialissues:trauma;poverty; homelessness;mentalhealthdisorders;etc.Therefore, recognizingtheeffectsofSDoHonpatientcareiscriticalin theED.

JacksonMemorialHospital(JMH)istheprimarytraining sitefortheUniversityofMiami-JacksonHealthSystem (UM-JHS)EMresidencyprogram.Itisalsothethirdlargest publichospitalinthecountry.TheUM-JHSocialEM programwaslaunchedin2020toimprovetheincorporation ofpatients’ socialcontextsintotheircare.

NeedsAssessment

WhendesigningaSocialEMprogram,keepingthe residency’slocationandpatientpopulationinmindis important.LikemostEDsacrossthenation,theJMHEDis aplaceofrefugeforpatientswhoseSDoHmaypreventthem fromobtainingcareelsewhere.Asasafety-nethospitalinthe seventhmostpopulouscountyinthenation,4 JMHservesa particularlydiversepatientpopulationwithstriking socioeconomicneeds.TheUMhealthsystemconducted formalneedsassessmentsofMiami-DadeCounty(MDC) from2019–2022,andtheUM-JHSSocialEMprogramwas designedtoreﬂecttheseneeds.4,5

TheUM-JHSSocialEMprogramwasdesignedtoensure thatallresidentsgraduatewiththeabilitytoincorporate theirpatients’ SDoHintoEDcareregardlessoftheir ultimatepracticelocations.However,certainaspectsofthis programweredesignedtoaddresstheuniqueneedsof MDC a “minority-majority” communitythatexperiences challengeswithEnglishproﬁciency,andinwhich20%ofthe populationlivesbelowthepovertylevel.4,5

PROGRAMGOALS

Bloom’staxonomyofcognitivelearningobjectives outlinessixlevelsinthecognitivedomain:knowledge; comprehension;application;analysis;synthesis;and evaluation.6 Overtime,scholarshavesoughttorevisethis frameworkand,whentakenasawhole,theserevisionsplace lessemphasisonalinearprogressionthrougheachlevel.6 Instead,thereisanincreasedfocusongeneratingnew hypothesesanddevelopingprojectsthatuseandexpand upontheacquiredknowledge.6 Therefore,theUM-JHS SocialEMprogramseekstoshiftitsparticipantsfrompurely understandingSDoHastheypertaintoEM,togenerating effectivesolutionsforaddressingtheseSDoHinandoutside theED.TheSocialEMprogramoutlinessixgoalsforits residents,whoarethentaskedwithgeneratingeffective

solutionsanddesigningtheirownmeasurableoutcomesfor eachgoal.Uponsuccessfulcompletionofthisprogram, residentsshouldbeableto:

1.DeﬁneandidentifySDoHintheEDandapplythese principlestobedsidecare.

2.EngagewithMDCoutsidetheEDandaddressits socialandmedicalneedsthroughlongitudinal involvementinlocaloutreachinitiatives.

3.Solidifyandshareacquiredknowledgethroughan 18-month,multimodalcurriculum.

4.Identifyandseektoaddressbarrierstomedicalcare experiencedbypatientswhousetheEDastheirmain sourceofhealthcare.

5.Identifyandseektoaddressrecurrentsocialjustice issuesencounteredintheED.

6.Enactpositivechangethroughadvocacyandquality improvementinitiativesathospital-wide,local,and/or nationallevels.

PROGRAMPARTICIPATION

Sinceitslaunchin2020,theprogramhasbeendividedinto fourpillarsthataddresscoreareaswithinSocialEM: CurriculumIntegration;CommunityOutreach;Accessto Care;andSocialJustice(Figure1).Initiativeswithineach pillarwillbediscussedinaseparatesection.Anyone afﬁliatedwiththeUM-JHSEDcanparticipateininitiatives acrossallfourpillars.Manyoftheseinitiativesare longitudinal,allowingforvaryinglevelsofparticipation throughoutresidency.Additionally,thisprogramalsooffers leadership,peerteaching,andscholarlyopportunitiesthat maycounttowardexistingresidencyrequirements.

TheUM-JHShasathree-yearEMresidencyprogram, andeachofitsclasses(postgraduateyears[PGY]1–3)is comprisedof14–15residents.EMresidentsarenotrequired toparticipateintheSocialEMprogrambutareencouraged todoso.Theymaychoosetoserveasprogramleaders (Figure1),participateinthelongitudinaltrackand/ortwoweekelective(discussedindetailinsubsequentsections below),ortoparticipateinindividualinitiativesastheir schedulesallow.However,SocialEMprogramleadership developedaformalcurriculumtoensurethatallresidents graduatewithasolidunderstandingofcoreSocialEM principles,regardlessoftheirlevelofinvolvementwiththe program;thiswillbediscussedinaseparatesection.

CORELEADERSHIPHIERARCHY

Thisprogramwasdesignedtobeexecutedbyresidentsin collaborationwithfaculty,medicalstudents,andstaff.The programwasstructuredintoacoreleadershiphierarchyto appropriatelydividethelaborofdesigningandlaunching initiativesthatpertaintoeachpillar,whileensuringthat residentscompletetheirexistingclinicalandacademic

Figure1. Socialemergencymedicineprogramorganizationanddivisionoflabor.Programdirectorsconsistofonefacultydirectorand1–4 residentdirectors(EMresidentsselectedviaaformalapplicationprocess).Programdirectorsoverseeinitiativesacrossallfourpillarsbut spendadditionaltimeleadingCurriculumIntegrationinitiativestoensureaseamlessincorporationofSocialEMprinciplesintoresidency training.PillarleadersareEMresidentswhoareselectedbyprogramdirectorsviaaformalapplicationprocess;theydesignandoversee initiativesintheirassignedpillars.FacultymentorsaregenerallycorefacultyintheEMdepartmentwithexpertiseintheirassignedpillar. However,facultyinotherspecialtiesatUM-JHSmayalsoserveasmentorsiftheycurrentlyoverseeacommunityorhospital-basedinitiative thatcollaborateswiththeSocialEMprogram.(Forexample,afacultymentorfromthefamilymedicinedepartmentoverseestheIDEANeedle ExchangeClinic.)AnyoneafﬁliatedwiththeEMdepartmentmayserveasateammember.Teammembersworkdirectlywiththeirassigned residentleadersanddividethetasksrequiredtolaunchandpublicizeinitiatives.

requirements(Figure1).Thisleadershiphierarchyorganizes, executes,andpublicizestheprogramanditsinitiatives.

Directors

Afacultydirectorandatleastoneresidentdirector overseetheprogramtogether(Figure1).Theoriginal directors,PatriciaPanakos,MD,andNaomiNewton,MD, authoredthispaperandconceptualizedtheprogram togetherinFall2020.ThecollaborationbetweenDrs. PanakosandNewtonwasbornefromasharedpassionfor socialmedicineandadesiretoimplementanEMresidencybasedprogramtoaddresstheSDoHofpatientsinMDC.Dr. PanakosistheassociateprogramdirectorfortheUM-JHS EMresidencyandhasundergoneformaltrainingin curriculumdevelopment.ShehasalsodevelopedED-based publichealthinitiativesatJHS,suchasauniversalscreening programforcommunicablediseases,includingHIV, hepatitisC,andsyphilis.Dr.Panakoscontinuesherroleas facultydirectorforthesocialEMprogram.Dr.Newtonisan alumnaoftheUM-JHSEMresidencyandservedaschief residentduringher ﬁnalyearoftraining.Sheassumedthe roleofthesocialEMprogram’sresidentdirectorasaPGY-1 andtransitionedherpositionuponhergraduationin2023. ShehasalsocollaboratedwithDr.Panakosonpublichealth

initiatives,includingauniversalHIVscreeninginitiativein JHS’spediatricED.Dr.Newtoniscurrentlypursuing atwo-yearfellowshipinhealthpolicyandadvocacyat EmoryUniversity.

Giventhattherewasnoprecedenceforsuchaprogramat UM-JHS,Drs.PanakosandNewtonworkedalmostdailyto createtheprogramandmaintainitssustainability,whilealso completingtheirexistingclinicalandacademic responsibilities.Drs.PanakosandNewtondesignedthe program ’soverallstructure,createdaformalselection processforpillarleaders,andidentiﬁedcommunitypartners andfacultymentorswithexpertiseinSocialEM.They presentedaformalproposalthatwasapprovedbyboththe chairoftheEDatJMHandtheUM-JHSEMresidency programdirectorinOctober2020.Theyalsodesignedand launchedthe18-monthcurriculum,two-weekelective,and longitudinaltrack,whicharedescribedinsubsequent sectionsofthispaper.Toaccountforcontinuedprogram growth,theoriginaldirectorsselectedfournewresident directorsforthe2023–2024academicyearviaaformal applicationprocess(Figure1).

Directorsapproveproposedinitiativesacrossallpillars andworkdirectlywithpillarleaderstotrackprogressand troubleshootchallenges.Theycheckinremotelywithpillar

leadersatleastbi-monthlytoensuretimelyproject completion.Theyalsopromotetheprogramata departmentalandhospital-widelevelandhelppillarleaders identifyfacultyandcommunitypartners(Figure1).Resident directorsarerecognizedwithaSocialEMleadershipaward upontheirgraduation.

ResidentLeaders

AnaverageoftwoPGY-1orPGY-2EMresidentslead eachpillar.Interestedresidentsapplyforthispositionviaa briefelectronicapplication(GoogleSurvey)atthestartofthe academicyearandareselectedbythedirectors.Residents generallydonotserveasleadersofmorethanonepillar,as thispositionmustbebalancedwithexistingresidency obligations.Residentleadersreportdirectlytothedirectors anddedicateanaverageoftwotofourhoursperweekto theirroles.Asleadersprogressthroughtraining,theymay eitherremainintheirleadershiprolesortransitiontheirroles toincomingPGY-1sandPGY-2s.Allresidentleaderswho haveservedforatleastoneyeararerecognizedwithaspecial awardupongraduationfromresidency.

Leadersfocusondesigninginitiativesthatpertaintothe goalsoftheirassignedpillar.Theyidentifyappropriate partnerswithinJHSandMDCtoaidindevelopingand launchingtheseinitiatives(Figure1).PartnersincludeJHS faculty(includingthoseinnon-EMspecialties),local outreachorganizations(manyofwhichalreadyhad establishedrelationshipswithUM-JHSthroughmedical studentinvolvement),andotherJHS-afﬁliatedresidency programs(eg,pediatrics,internalmedicine,family medicine).Interdisciplinarycollaborationpreventsthe SocialEMprogramfrom “re-inventingthewheel” andhelps initiativesachievesuccesswithfewerfunding,resource,and logisticalrestrictions.Residentleadersdelegateday-to-day taskstoaninterdisciplinaryteamtodividethelaborof executingtheseinitiatives.Leadersarerequiredtocheckin remotelywiththeirteammembersatleastmonthlytodiscuss progressonpillarinitiatives.

InterdisciplinaryTeams

Teammembersdividethetasksrequiredtolaunch initiativeswithintheirassignedpillar.Theyarerequiredto dedicateaminimumofonetotwohoursperweekonthese tasksandcheckinregularlywiththeirpillarleadersas previouslydiscussed.Thosewhodesiretodosomay participateinmorethanonepillarteam.Participationina pillarteamisopentoanyoneintheUM-JHSED.However, duringthe ﬁrstthreeyearsoftheprogram,teamswere primarilycomprisedofEM-boundUMmedicaland pharmacystudents,JHSclinicalpharmacyresidents,and hospitalstaff(eg,nursesandsocialworkers).

PROGRAMDESIGN:THE4-PILLARAPPROACH

Inthefollowingsection,weprovideabroadoverviewof eachpillar’sobjectivesandhighlightseveralkeyinitiatives withineachpillar.Whenrelevant,pleaseseethe correspondingappendicesforadditionaldetails.

CurriculumIntegration

ThispillarincorporatesthetenetsofSocialEMinto residencytrainingtoempowerfuturegenerationsof emergencyphysicianstoapplySocialEMprinciplestotheir care.ThisistheonlypillarthatrequiresallEMresidentsto participatebecauseitsinitiativeshavebeenincorporatedinto theexistingresidencycurriculum.Doingsoensuresthatall EMresidentsgraduatewithanunderstandingofSDoHand theprinciplesofSocialEM,regardlessoftheirlevelof involvementinotherpillars.Ofnote,approvalfromthe institutionalreviewboardwasnotrequiredforthe developmentofthiscurriculum.

Wedevelopedandlaunchedamultimodal,18-month SocialEMcurriculumthathasbeenincorporatedintothe existing18-monthresidencydidacticschedule(AppendixA). Thecurriculumcovers18coresocialEMtopics(Table1)and includesjournalclubs,simulationcases,lectures,problembasedlearning,andinteractivegroupdiscussions.The curriculumisledbyfacultyandresidentswithexpertiseor

Table1. 18coreareasofstudywerechosentobecoveredmonthlyduringthe18-monthSocialEMcurriculum.Thiscurriculumisintegrated intostandardresidencydidacticschedule,whichrepeatsevery18months.Usingamultimodallearningformat,topicscanbepresentedas traditionallectures,case-baseddiscussionsandjournalclubs(“Cases”),orsimulations.Theinitialmodalitiesforeachtopicarelistedbelow; themodalitiesusedforeachtopicwillchangeevery18months(eg,thepediatrichealthlecturewouldbepresentedaseitheracaseor simulation18monthslater).Additionaldetailsregardinglogisticsandimplementationcanbefoundin AppendixA

LecturesCasesSimulations

1.Socialdeterminantsofhealth7.Implicitbias/racism13.Humantrafﬁckinganddomesticviolence

2.Healthcarecoverageandaccess8.Homelessness14.Substanceabuseandharmreduction

3.Financialstability9.Healthliteracy15.Caringforincarceratedpatients

4.FrequentEDutilizers10.Immigration16.Highlycommunicablediseases/STIepidemics

5.Women’shealth11.Resourceinsecurity17.Languageandculturalbarrierstohealthcare

6.Pediatrichealth12.Trauma-informedcare18.Genderidentity

ED,emergencydepartment; STI,sexuallytransmittedinfection.

interestinthecoretopics.SocialEMleadershipassists presentersinidentifyinglearningobjectivesforeachsession, selectingtopics,anddevelopingcontent.Allconference attendeesparticipateinpre-andpost-surveystoassesstheir baselineknowledgeandtheeffectivenessofeachdidactic session.ResidentsarealsoaskedtoevaluatetheSocialEM curriculumduringtheannualresidencyprogramevaluation. SurveysandresultsarediscussedfurtherintheImpact/ Effectivenesssectionofthismanuscript.

In2022,welaunchedthetwo-weekSocialEMelectivefor residentswhodesireamorein-depthexperiencewiththe program(AppendixB).ThiselectiveisopentoPGY-2EM residentsduringtheirelectiveblockandiscomprisedof serviceopportunities,self-directedstudy,peerteaching,and initiativeparticipationacrossallpillars.ThePGY-2rotation scheduleisdesignedsothatonlyoneresidentcompletesan electiveinanygivenmonth.Therefore,theexperienceis personalizedforeachparticipatingresident.SocialEM directorsworkwiththeresidentaheadoftimetodesignan electiveschedulethatensuresparticipationacrossallpillars butallowsthemtoengagemoredeeplywithintheirpillar(s) ofinterest(AppendixB).

Wealsodesignedalongitudinaltrackthatwaslaunched the2023–2024academicyear.Trackparticipantsengageina

setnumberofoutreachevents,qualityimprovement initiatives,peerteaching,andself-directedstudyover18 months.Therequirementsarebasedonapointsystemthat ensuresengagementwithallpillarsbutallowsfordeeper explorationinareasofindividualinterest.Residentsmust reachaminimumof30pointstocompletethetrack (Figure2).Requirementsincludealongitudinalscholarly activitythatculminatesinapresentationatthelocal, regional,ornationallevels(eg,developingaprojectto addressfoodinsecurity).Theymustalsoparticipateinthe SocialEMdidacticcurriculumthroughpeerteaching, developingnewelementstothecurriculum,andmentoring medicalstudents.Participantslogtheirprogressviaanonline formandmustattendaminimumofninemonthlytrack meetingswiththeSocialEMdirectorsoveran18-month period.Upongraduation,residentswhocompletethetrack willreceiveaDistinctioninSocialEM.

CommunityOutreach

Thispillarwasdesignedtoestablishameaningfulpresence inMDCbeyondbedsidecareandtoaddresssocialissues throughpartnershipswithlocalorganizations.Forexample, throughapartnershipwithMiamiStreetMedicine, participantsjoinaninterdisciplinaryteaminproviding

Figure2. Pointsystemforthe18-monthlongitudinaltrack.Notethatopportunitiesineachpillarmayvaryovertime.This ﬁgurelists opportunitiesfromthefallof2023.

regularmedicalcareatlocationscommonlyoccupiedby Miami’shomelesspopulation.Throughapartnershipwith theStoptheBleedCampaign,participantsundergoformal trainingtoserveaslocalinstructors.Participantsthenlead workshopsthatteachnon-medicalcommunitymembersto performbystandercardiopulmonaryresuscitationand stabilizevictimsofviolenceuntil ﬁrstrespondersarrive. ParticipantsmayserveasinstructorsforStoptheBleed eventsthroughoutMDC,astheirschedulesallow.

ThispillarlaunchedaNarcanprograminJuly2022,in partnershipwiththeUMIDEA(InfectiousDisease EliminationAct)NeedleExchangeClinicandtheUM MichaelWolfsonDepartmentofCommunityService (DOCS).ThisprogramseekstoaddressSouthFlorida’ s opioidepidemicandisinkeepingwiththestatewide EmergencyTreatmentforSuspectedOpioidOverdoseAct.7 Atcommunityhealthfairs,participantsprovidefreeopioid usedisorder(OUD)screening,basedonDiagnosticand StatisticalManualofMentalDisorders,5th ed,criteria.8 Narcanissubsequentlydistributedtothoseidentiﬁedtobeat highriskforlife-threateningoverdoses,andadditionalOUD counselingandtrainingonsafelyadministeringNarcan areprovided.9

AccesstoCare

Thispillarlinkschronicallyillpatients,highEDutilizers, andtheuninsuredtooutpatientcare.Italsoseeksto centralizeexistingsocialsupportresourceswithinUM-JHS andefﬁcientlyaddressSDoHatthebedside.Througha partnershipwithDOCS,uninsuredpatientspresentingtothe EDwithchroniccomplaintsarepairedwithlong-term patientnavigators,whohelpthemsecureaffordable outpatientcareupondischarge.

TheHighUtilizersInitiativeaimstostreamlinethecareof patientswhofrequentlyvisittheED.Participantsconduct chartreviewsofindividuals ﬂaggedasfrequentutilizersinthe electronichealthrecordandcreatepatientcarebriefsthat auto-populateintheircharts.Thesepatientsoftenpresentto theEDnumeroustimesaweekandreceivecarefrom differentclinicianseachtime.Byconsolidatingtheir pertinentmedicalinformation,thesebriefsallowforbetter, morestreamlinedpatientcarewithlessrepetitionoftestsand procedures.Thebriefsalsolessenthecognitiveloadofthe clinician,decreasingthetimespentonchartreviewsand helpingguidefuturecare.

ManypatientspresenttotheEDwithconditionsthatare exacerbatedbyalackofbasicresources.Itischallengingto addressthesecomplexSDoHamidstthetimeconstraintsof EDcare,andEDscannolongerrelyheavilyonsocial workersforassistance,duetothenationwidesocialworker shortage.10 ThispillarpartneredwithMiamiStreetMedicine andtheJMHPharmacyDepartmenttocreateresource guidesforpatientsandcliniciansinresponsetothisneed. Communityresourceguides(inEnglish,Spanish,and

HaitianCreole)provideinformationforaffordable outpatientclinics,prescriptions,mentalhealthservices, temporaryhousing,mealprograms,andsubstanceuse treatmentcenters,aswellasresourcesforpregnantpatients andvictimsofdomesticviolence.Clinicianresourcesinclude referralinformationforresident-runsubspecialtyclinics, instructionsforinitiatingbuprenorphineintheEDand referringpatientstomedication-assistedtreatmentclinics, andalgorithmsforhumantrafﬁckingscreening.

SocialJustice

Thispillartackleshealthinequityandinjusticeissues throughinterdisciplinaryeducationandquality improvementinitiatives.TheHumanTraffickingEducation Ambassadorprogram,inpartnershipwithJMH’sRape TreatmentCenter,teachesclinicianstoscreenforandtreat victimsofhumantrafficking.Floridahasthethirdhighest numberofhumantraffickingcasesinthenation,andMDC is,sadly,aknowntraffickinghub.11 Trainedresidentslead interactiveseminars,sharingHIPAA-complianttrafficking casesandteachingclinicianstoidentifyandaddressred flags fortrafficking.

Thispillaralsoseekstoimprovecareforincarcerated patientsintheED,particularlyconcerningpatientprivacy andexaminationsinthepresenceoflawenforcement. Initiativesincludearecentlypublishedreviewonthebarriers tocaringforthispopulationandrecommendationsto improvetheirdeliveryofcare.12 Wealsoimplementeda simulationsessiononcaringforincarceratedpatientsinto residencydidactics.

IMPACT/EFFECTIVENESS

CurriculumIntegration

SocialEMleadershipisintheprocessofcompletinga formalimpactassessmentofthecurriculumintegrationpillar oftheprogramviaasingle-group,pretest-posttestdesign.6 Briefpre-andpost-didacticsessionsurveysaredesignedfor eachSocialEMtopicinthe18-monthcurriculum.Surveys aredesignedtoassessbaselineknowledgeofthetopicandthe changesinthisbaselineknowledgeafterthesession.Survey questionsalsoaddressrelevantepidemiologicalstatisticsand usefulcommunityresourcesforaddressingthetopicin MDC.Eachpost-surveyendswithablanksectionfor participantstowriteinanyadditionalfeedback,which SocialEMprogramleadershipusesforsubsequent didacticsessions.

Forconvenience,thesesurveysareadministeredvia electronicforms;conferenceattendeesscanQRcodestothe formsbeforeandafterthesession.Allresidents,faculty, students,andstaffinattendanceareeligibleforparticipation inthesurveys.However,thusfar,surveyparticipationhas generallybeenlimitedtoresidentattendees,asfaculty,staff, andstudentattendanceislessconsistent.Hospitalbadge

numbersareusedtocompareindividuals’ changesinpreandpost-sessionresponses.

Sincethe18-monthcurriculumwaslaunchedin2022,a fullrotationofthecurriculumhasnotbeencompletedasof thiswriting,anddatacollectionandanalysisisongoing. However,thusfar,thecurriculumtopicshavebeenwellreceived,withresidentsindicatinganimprovedconfidencein theirabilitytorecognizeandaddresstheseSocialEMissues atthebedside.Forexample, Figure3 showskeyresultsfrom thepre-andpost-surveysadministeredduringthe first sessionoftheformalcurriculumin2022 asimulation sessiononhighlycommunicablediseases/sexuallytransmittedinfection(STI)epidemics(Table1).Theseresults suggestefficacyinimprovingbaselineknowledgeand confidencewiththetopicofacuteHIVintheED,including epidemiology,communityresources,andinitiatingeither highlyactiveantiretroviraltherapyorpre-exposure prophylaxiswhenindicated.

Animpactassessmentofthetwo-weekelectiveispending, asonlyonePGY-2residenthadcompletedatthetimeofthis manuscript’sdevelopment.

CommunityOutreach

Itischallengingtoconcretelyassesstheimpactofthe CommunityOutreachpillar,asitsservice-driveninitiatives aregenerallyqualitativeinnature.However,initialdata

fromtheNarcanInitiativehighlightsitsimpactonMDC.As ofMay2023,theprogramscreened1,188patientsacross MDC,ofwhom144receivedNarcan.Inrecognitionofthe NarcanInitiative’scurrentimpactandcontinuedgrowth, JMH’sDepartmentofEmergencyMedicinereceivedthe 2023UniversityofMiamiMitchellWolfsonSr.Department ofCommunityServiceaward.

AccesstoCare

Wearecurrentlyintheearlystagesofdatacollectionto analyzethesuccessoftheAccesstoCareinitiatives.Thusfar, thepatientnavigationprogramhasenrolled31EDpatients. Ofthesepatients,18wereabletosuccessfullycompletetheir navigationgoalsandobtainoutpatientcare.Thisprogram hasparticularlybenefittednon-English-speakingpatients, whoselanguagebarrierscanhindertheirabilitytonavigatea complexsystem.Forexample,navigatorswereable tolinkaSpanish-speakingpatienttooutpatientoncologic careforheruntreatedgynecologiccancer.Recently,a homeless,uninsuredpatientlivingattheMiamiRescue Mission(MRM)wastreatedforanacuteulcerative colitis flareintheED.Afterhewasdischarged,the navigatorsensuredthatheobtainedtimelyfollow-upatan MRM-affiliatedgastroenterologyclinic,astudent-runclinic staffedbyUMfaculty.Wearecontinuingtopublicize thisprogramandencourageemergencyclinicians

Figure3. Comparisonofkeypre-andpost-surveyresultsafterasimulationsessiononhighlycommunicablediseases/STIepidemics;30 residentscompletedthesurveys.Afterthesession,residentsindicatedanincreasedconﬁdenceintheirabilitytorecognizeacuteHIVand initiateHighlyActiveAntiretroviralTherapy(HAART)orPre-ExposureProphylaxis(PrEP)treatmentwhenindicated.Mostresidentsfound thesessionbeneﬁcialinlearningaboutcommunityresourcesforEDpatientswithHIV,aswellasprescribingHAARTandPrEP.

toenrolltheirpatientsduringtheirshifts.Weare stillinthedatacollectionphaseoftheHigh Utilizersinitiative.

SocialJustice

TheSocialJusticepillarinitiativesexperiencedseveral launchdelaysduetoCOVID-19pandemicrestrictionsand facultyturnover.Initiativeswereofficiallylaunched inthe2022–2023academicyear,anddataregardingtheir impactandeffectivenessispending.Thusfar,human traffickingeducationambassadorshavegiven well-receivedlecturestoJHS-affiliatedclinicsand toJMH’sfamilymedicine,pediatrics,andinternal medicineresidencies.

OverallProgramFeedbackandSupport

Sincetheprogramisunderthedirectguidanceofacurrent residencyassociateprogramdirector,thereiscontinual communicationbetweenSocialEMdirectorsandEM residencyleadership.Residencyleadershipactivelyengages withandprovidesinsightsintopillarinitiatives,leadingto timelychangestotheprogramwhendeemednecessary.For example,previousfeedbackledtothedevelopmentofthe electiveandlongitudinaltracks.ResidentsinthecoreSocial EMleadershipteamalsoobtainregularqualitativefeedback fromtheirpeersandsharethisfeedbackwiththeSocialEM directors.Thisprogramisalsoreviewedduringtheannual residencyprogramevaluationcommitteemeeting.This programhasfullEMdepartmentalsupport.

AdditionalRecognition/Awards

Overall,thisrobust,multimodal,resident-ledSocialEM programhasrapidlygrownoverthelastthreeyears,despite theCOVID-19pandemic.In2023,sixofthe14PGY-3 residentsgraduatedwithaSocialEMdistinction.The program ’sinterdisciplinarynatureensureditssuccess,as multipleinitiativeswerelaunchedwithoutsigniﬁcant fundingoradministrativerestrictions.Theprogramis receivingincreasingrecognition.Inadditiontothe previouslymentionedcommunityserviceawardforthe NarcanInitiative,theMDCchapteroftheStoptheBleed Campaignreceiveda2021awardfromthemayorforits educationinitiativesinlocalhighschools.In2023,wewere alsohonoredtoreceivethe2023ACEPSocialEMSection DistinguishedProgramAward.

LIMITATIONS

Residents’ availabilityoftenlimitsconsistentparticipation inSocialEM.Residentshavemultipleclinicalandacademic responsibilities,andastheyprogressthroughtraining,their timeisfurtherlimitedbysearchingforjobsandapplyingfor fellowships.Inresponsetothislimitation,theelectiveand longitudinaltrackweredevelopedtoallowfor ﬂexiblebut regularparticipation,asmanyrequirementscanbe

completedduringlighterrotations.Thedidacticcurriculum alsoensuresthatallresidentswillgraduatewiththesame baselineknowledgeofSocialEMtenets.Additionally,the SocialEMleadershipwilltransitioneverytwoyears, allowingjuniorresidentswithleadershiprolestopasson theirdutiestoincomingresidentsastheybecome seniorresidents.

Certainaspectsofthisprogramweredesignedtoaddress someofthesocialissuesthatareparticularlyprevalentin MDCandmaynotbegeneralizabletootherEMresidency programsintheUnitedStates.Otherresidencyprograms seekingtodeveloptheirownSocialEMinitiativesshould considertheuniqueneedsoftheirpatientpopulationswhen doingso.

Theprogram’ s ﬁrstthreeyearswerededicatedtooverall development,garneringparticipants, ﬁndingcommunity partners,andlaunchinginitiativesineachpillar.Therefore, datacollectiontoformallyassesstheprogram’simpactand effectivenessisstillinprocessandiscurrentlylimitedto initialdata(unblindedpre-andpost-testscompletedby residentparticipants)fromthelaunchofthe18-month didacticcurriculum.Thisdatamayalsobesubjectto selectionbias,asmostresidents,faculty,students,andstaff areexcitedabouttheSocialEMprogramandwant ittosucceed.

CONCLUSION

TheUniversityofMiami-JacksonHealthSystemSocial EMprogramwaslaunchedin2020toaddresstheSDoHof patientsinMiami-DadeCounty anareaofsigni ﬁ cant medicalandsocialneed.Ittargetscriticalsocialissues throughfourpillars:CurriculumIntegration;Community Outreach;AccesstoCare;andSocialJustice.This multimodal,resident-runprogramachievedrapidsuccess inthreeyearsbydevelopingsustainableinitiativesin partnershipwithlocalorganizationsand otherUM-JHSdepartments.Ratherthanfocusing solelyonserviceopportunities,thisprogramenhances residents ’ knowledgeofSDoH,fostersthedevelopmentof qualityimprovementinitiatives,andprovides opportunitiestocreatemeaningfulchangeintheED andthecommunity.Thisprogramalsoprovidesresidents withleadershipandscholarlyopportunities.Wehope thatthisarticlewillinspireotherresidenciestodevelop similarprograms.

ACKNOWLEDGMENTS

TheUniversityofMiami-JacksonHealthSystemSocial EmergencyMedicineprogramwouldnothavebeenpossible withouttheingenuity,dedication,andpassionofthe followingindividualsandorganizations.Thankyoufor everythingthatyouhavedoneandcontinuetodotocreate

positivechange:RachelArmstrong,MD;TatianaBarriga, MD;KelleyBenck;DanielBergholtz,MD;EmilyBrauer, MD;SandraCabrera,MD;DanielleCohen,MD;Emily Dawra,MD;LuisDeLaRosa,RN;ShaheenEmami; JoshuaGoldstein,MD;JamieHarris;Kristopher Hendershot,MD;ArmenHenderson,MD,MBA;Brooke Hensley,MD;SarahJabre,MD;JacksonHealthSystem ClinicalPharmacyResidency;JohnnatanMarin,MD;Julia Martinez,MD;ElizabethMay-Smith,MD;KellyMedwid, MD;MiamiStreetMedicine;VictoriaMcKee;Samantha Mosle;LienMorcate;KalebMorris;JudithOriental-Pierre, MD;RoxcyBoltonRapeTreatmentCenter;StoptheBleed; UniversityofMiamiIDEANeedleExchangeClinic; UniversityofMiami,MichaelWolfsonDepartmentof CommunityService;andMelissaVelasquez,MD.

AddressforCorrespondence:NaomiP.Newton,MD,Emory UniversityHospital,531AsburyCircle,AnnexSuiteN340,Atlanta,GA 30322.Email: naomi.newton@emory.edu

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

REFERENCES

1.U.S.DepartmentofHealthandHumanServices.Healthypeople2030socialdeterminantsofhealth.Availableat: https://health.gov/ healthypeople/priority-areas/social-determinants-health AccessedMay2,2023.

2.ZibulewskyJ.TheEmergencyMedicalTreatmentandActiveLaborAct (EMTALA):whatitisandwhatitmeansforphysicians. Proc(BaylUniv MedCent). 2001;14(4):339–46.

3.AmericanCollegeofEmergencyPhysicians.UnderstandingEMTALA. Availableat: https://www.acep.org/life-as-a-physician/ethics–legal/ emtala/emtala-fact-sheet/.AccessedMay30,2023.

4.U-Health-UniversityofMiamiHealthSystem.Communityhealthneeds assessment2019–2021.Availableat: https://umiamihealth.org/-/media/ uhealth/chna/umhc-2019-community-health-needs-assessment.ashx AccessedMay15,2023.

5.FloridaDepartmentofHealthinMiami-DadeCounty.2022Community healthassessment.2022.Availableat: https://www.ﬂoridahealth.gov/ _media/miami-dade/community-reports/miamidade-cha.pdf AccessedMay15,2023.

6.ThomasPA,KernDE,HughesMT,etal.(Eds.),(2016).Goalsand objectives.In: CurriculumDevelopmentforMedicalEducation (53–56;130–133).3rded.Baltimore,MD:JohnsHopkinsUniversity Press,2016.

7.EmergencyTreatmentforSuspectedOpioidOverdose. Chapter381 Section887–2021FloridaStatutes,StateofFlorida2021Legislative Statutes,1Jan.2021.

8.AmericanPsychiatricAssociation.(2013). DiagnosticandStatistical ManualofMentalDisorders,5thed.(541–542).Washington,DC: AmericanPsychiatricAssociation.

9.BenkKN,GoldsteinJ,NewtonN,etal.Socialemergencymedicine: naloxoneoutoftheED&intothecommunity.2022.Availableat: https:// fcep.org/social-emergency-medicine-naloxone-out-of-the-ed-andinto-the-community/.AccessedFebruary3,2022.

10.LinVW,LinJ,ZhangX.USsocialworkerworkforcereportcard: forecastingnationwideshortages. SocWork. 2016;61(1):7–15.

11.Miami-DadeStateAttorney’sOffice.Floridafactsregardinghuman trafficking.Availableat: https://humantrafficking.miamisao.com/ human-trafficking.AccessedJune3,2023.

12.ArmstrongRE,HendershotKA,NewtonNP,etal.Addressing emergencydepartmentcareforpatientsexperiencingincarceration:a narrativereview. WestJEmergMed. 2023;24(4):654–61.

ORIGINAL RESEARCH

ReducedTimetoAdmitEmergencyDepartmentPatientsto InpatientBedsUsingOutﬂowBarrierAnalysis andProcessImprovement

MarjorieA.Erdmann,MS,PhD*

IpeS.Paramel,MHA*

CariMarshall*

KarissaLeHew,BS†

AbigailKee,BS†

SarahSoliman,BS†

Authorscontinuedatendofpaper

SectionEditor:TehreemRehman,MD,MPH

*OklahomaStateUniversity,SpearsSchoolofBusiness,CenterforHealth SystemsInnovation,Stillwater,Oklahoma † OklahomaStateUniversityCenterforHealthSciences,Collegeof OsteopathicMedicine,Tulsa,Oklahoma

Submissionhistory:SubmittedDecember12,2023;RevisionreceivedMay22,2024;AcceptedMay24,2024

ElectronicallypublishedAugust1,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18626

Objective: Becauseadmittedemergencydepartment(ED)patientswaitingforaninpatientbed contributetodangerousEDcrowding,weconductedapatient ﬂowinvestigationtodiscoverandsolve outﬂowdelays.Aftersolutionimplementation,wemeasuredwhetherthetimeadmittedEDpatients waitedtoleavetheEDwasreduced.

Methods: InJune2022,ateamusingLeanHealthcaremethodologiesidentified flowdelaysand underlyingbarriersinaMidwest,mid-sizedhospital.Wecalculatedbarriers’ magnitudesofburdenbythe frequencyofinvolvementindelays.DuringOctober–December2022,solutionstargetingbarrierswere implemented.InOctober2023,wetestedwhetherwaitingtime,definedasdailymediantimeinminutes fromadmissiondispositiontodeparture(ADtoD),declinedbyconductingindependentsample,singletailed t-testcomparingpre-topost-interventiontimeperiods,January1–September30,2022(273days) toJanuary1–September30,2023(273days).Additionally,weregressedADtoDontopre-/postperiod whilecontrollingforEDvolume(totaldailyadmissionsandEDdailyencounters)andhospitaloccupancy. ArunchartanalysisofmonthlymedianADtoDassessedimprovementsustainability.

Results: Processmappingrevealedthatthreedepartments(ED,environmentalservices[EVS],and transportservices)co-producedtheoutflowofadmittedEDpatientswherein18delayswereidentified. TheEVS-clinicalcarecollaborationfailuresexplained61%(11/18)ofdelays.Technologycontributedto 78%(14/18)ofdelaysprimarilybecausestaff’stechnologydidnotdisplayneededinformation,a conditionwecoined “digitalblindness.” Comparingpre-andpost-interventiondays(3,144patients admittedpre-interventionand3,256patientspost),themedianminutesapatientwaited(ADtoD) significantlydecreased(96.4to87.1minutes, P = 0.04),evenwhiledailyEDencountervolume significantlyincreased(110.7to117.3encountersperday, P < 0.001).Aftercontrollinginregressionfor otherfactorsassociatedwithwaiting,theinterventionreducedADtoDby12.7minutesperpatient (standarderror5.10, P = 0.01;95%confidenceinterval 22.7, 2.7).Weestimatethattheintervention translatedtoEDstaffavoiding689hoursofadmittedpatientboardingoverninemonths(ADtoD coefficient[ 12.7minutes]multipliedbypost-interventionEDadmissions[3,256]anddividedby60). Runchartanalysissubstantiatedtheintervention’ssustainabilityoverninemonths.

Conclusion: Aftersystemwidepatient ﬂowinvestigation,solutionsresolvingdigitalblindnessand environmentalservices-clinicalcarecollaborationfailuressigniﬁcantlyreducedEDadmittedpatient boarding.[WestJEmergMed.2024;25(5)748–757.]

INTRODUCTION

EmergencyphysiciansintheUnitedStateshaveraisedthe alarmaboutdangerousandworseningemergencydepartment (ED)crowding.1,2–4 Crowdingisassociatedwithpatient harm,2,5 increasedstaffstress,4,6 medicalerrors,7 andpatient mortality.5,8,9 Althoughthereisnotasinglecauseforcrowding, inlargepartitoccurswhenadmittedpatientsareboardedinthe EDbecauseaccesstoanappropriatebedisblocked.1,2–4,10,11 Accessblockstemsfromover-capacityunitsaswellasalarger, long-standingissue:inefficientpatient flowinUS hospitals.3,10,12–14 Inefficientpatient flownotonlybottlenecks patientsintheEDbutisalsoknowntodrivepatientoutcomes downandcostsup,12 twoproblemstheUSisurgentlyworking toresolve.15 Comparedtopeerhigh-incomecountries,theUS rankslastinhealthoutcomes16 and firstincosts.17

ConsideringthatreducingEDboardingtimeisassociated withreducedharmtopatientsandstaffandreducedcosts,11 policymakersresponsibleforcostandoutcometrendsand administratorsresponsibleforalleviatingcrowdingare acutelyinterestedinstrategiesthatimprovetheoutflowof admittedEDpatients.AmajorobstacletoimprovingED outflowisthatfewhospitalsareadeptatpatient flow investigationsandinterventions.Hospitalstendtoimprove patient flowonedepartmentatatime,assumingthatthese within-department flowefficienciesstackuptooverall gains.13 Expertswarnthatthisapproachcanbackfire.13,18 Well-intendeddepartmentimprovementprogramscan negativelyimpactpatient flowbecauseindividualsfocuson theirowndepartment’sefficiencyachievementsanddonot considertheeffectoftheiractionsonupstreamor downstreamdepartments.18 Moreover,becausehospital processesarecomplexanddeeplyinterlocked,19 itis unrealisticforstaffinonedepartmenttoaccuratelypredictor observeunintendedoutcomesinotherareas.

Administratorshavetriedtodecreaseboardingtimesby takingawithin-EDimprovementapproach;however,the interventionshavefailedandhaveevenworsened boarding.2,11 Forexample,Kelenetal’ s 2 literaturereview foundthat1)neitherincreasingthenumberofEDstaffnor improvingancillaryservices’ turnaroundtimehadany impactonboarding,and2)increasingthesizeoftheED madeturnaroundtimeworse.Whathasworkedtoimprove EDoutﬂowisdirectlyreducingaccessblocks.Onehospital reducedboardingbyblockingtheirsurgerydepartmentfrom usingacertainnumberofbedsbasedonapredictednumber ofEDadmissions.2 Anotherhospitaltookaprocessimprovementapproachandreducedaccessblocksbysimply dischargingpatientsearlierintheday,incrementally improvingaccessbyimprovingprocesses.14

Thepresentstudyistwo-pronged.InPhase1,wemoved awayfromsingle-departmentpatient ﬂowinvestigationsand insteadconductedamulti-department,systemwide,patient ﬂowstudytoidentifypotentialprocessimprovementsto reduceaccessdelays.InPhase2,weevaluatedtheeffectof

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

BoardingadmittedpatientsintheED threatenspatientandstaffhealth.Itisata crisislevelintheUS,butreducingithas provendif ﬁ cult.

Whatwastheresearchquestion?

Canasystemwidepatient ﬂ owinvestigation leadtosigni ﬁ cantreductioninadmitted patientboardingtime?

Whatwasthemajor ﬁndingofthestudy?

Admittedpatientboardingwasreduced by12.7minutes/patient(P = 0.01;95% CI 22.7, 2.7).Technologywasthe primaryissue.

Howdoesthisimprovepopulationhealth?

These ﬁ ndingswillhelpotherinstitutionsto reduceEDboardingandpreservecommunity accesstoemergentcarewithoutincreasingthe costofcare.

ourprocessimprovementsonadmittedEDpatientbed-wait timesmeasuredbydailymedianofadmissiondispositionto departure(ADtoD)minutescomparingpre-andpostprocessimprovementintervention.Wehypothesizedthata patient ﬂowinvestigationwouldrevealdelaysandthatthe subsequentprocessimprovementwouldsigniﬁcantlyreduce thetimeadmittedEDpatientswaitedforabed.

METHODS

In2022,amid-sized,urban-basedhospitalintheMidwest partneredwithauniversityhealthinnovationcenterthat specializesinworkflowdesigntohelpresolveadmittedED patientoutflowdelays,identifysolutions,andmeasurethe effectivenessofimplementedsolutions.Theinnovationteam chosetouseLeanHealthcaremethodologies.Lean Healthcarehasbeenappliedtoimprovepatientcare processesandmaterial flowsand,toalesserextent,patient flow.20,21 Leanisaproductionimprovementprocess developedbytheToyotaProductionSystem(ToyotaMotor Corp,Toyota,Aichi,Japan),whichhasbeenusedin healthcaretoincreaseefficiency,reducecosts,andimprove patientoutcomes.22 Leanprovidesapracticalapproachto understandingcomplexsystems.23

Theinnovationcentertrains ﬁrst-andsecond-year medicalstudentsinLeanHealthcare,aprogramdesignedto teachsystemsthinkingearlierinmedicaleducation.24 In

2022,aLeanHealthcareexpertassembledateamofnine second-yearmedicalstudents,trainedtheminLean,and assignedthecurrentproblemtothemtoinvestigateandsolve collectively.Theinvestigationwasdeemednon-human subjectresearchbytheuniversityinstitutionalreviewboard.

ObservationalFieldInvestigation,ProcessMapping,and DelayIdentiﬁcation

Theteam’ s ﬁeldinvestigationwasconductedinJune2022. Hospitalexecutivesintroducedtheteamtoemployeesto ensurefrontlineworkercooperation.Theteamcollected proceduremanualsfromdepartmentsandcreatedan observationscheduletoinvestigatesegmentsofpatient ﬂows fromEDadmissionthroughdischarge.Patientdelaysinthe EDwerethelongestbetween3 PM–8 PM;therefore,that periodwasprioritizedforobservation.

Thehospital’stechnologyincludedtheEpicelectronic healthrecordsystem(EHR)andtheEpicenvironmental servicessystem(EpicSystemsCorp,Verona,WI)withan Ascomphoneintegration(AscomHoldingAG,Baar, Switzerland).Over21days,theteamobservedandmapped patient flow,observedworkers,andfollowedpatients,noting workarounds,bottlenecks,andcoordinationpointswith otherdepartments.Teammembersdiscussedprocessesand patient flowwithover100staff,includingmanagers,ED staff,physicians,transfercoordinators,environmental services(EVS)staff,transporters,maintenancestaff,and receiving floornurses.Theteamidentifieddiscrepancies betweenprotocolsandactualwork,gatheredtime-stamped data,anddirectlytimedsomeprocesssteps.

Theteamintegratedtheprocessesandmappedthepatient journeyfromEDadmissionthroughdischargeandtheEVS processesusedtoturnabedbetweenpatientoccupancies.The teamused “swimlanes,” atechniquetomapprocessesoccurring simultaneouslyindifferentdepartments.Theteamcreatedalist ofdelays;delaysweredefinedaswhenpatient flowstalledfor anyreason.Theswimlanesidentifiedkeystaffrolesacross multipledepartmentsthatco-producedEDpatientoutflow.

UnderlyingBarrierCategorizationandMagnitudeof BurdenAnalysis

Post-investigation,wegroupedcommonissues,named them,andbuiltaconceptualframeworkrepresentingsystemleveloutﬂowbarriers.Weassessedwhichbarrierscontributed toeachdelayandtalliedthefrequencywithwhicheachbarrier contributedtodelays.Wecomparedeachbarrier’smagnitude ofburdenbyfrequencyandpercentage(numberofdelays affectedbyabarrier/totalnumberofdelays);morethanone barriertypecouldbeassociatedwitheachdelay.

RecommendedSolutionPrioritization

Wedesignedspeciﬁcsolutionsforadministrativeaction, organizedthembybarriertargeted,andsortedthemintoa 3 × 2matrixbythedegreetowhichthesolutionwasdeemed

controllable(controllable,probablycontrollable, uncontrollable)andtheestimatedassociatedcost(nocost, cost).Wereliedonthemagnitudeoftheburdentoprioritize solutionswithinthehighcontrollabilityandlow-cost categorytoprioritizeselectedsolutions.Inthefourthquarter of2022,solutionswereimplemented.

InterventionEffectiveness

InOctober2023,weusedaquasi-experimentaldesignto evaluatewhetherinterventionsreducedthetimeadmitted patientswaitedtoleavetheED.Quasi-experimentaldesignsare appropriatetoassessinterventionswithoutrandom assignment.25 Wedeﬁnedindividual-levelpatientwaitingtime asthetimefromwhenapatient’sdispositionbecame “admitted” intheEHRtowhenthatpatientdepartedtheED, ensuringthatweevaluatedonlyadmittedpatients.Fromthis data,theEHRprovidedadailymediantimeofpatients’ admissiondispositiontodepartureinminutes(ADtoD),andwe usedthedailymedianasaper-patientrepresentationtodetect waitingdifferencesbetweentwotimeperiods.Medianswere bothreadilyavailableintheEHRandpreferredinanalysisto avoidartiﬁciallyhighorlowdailyvaluescausedbyoutliers.

Thetwotimeperiodswecomparedwerepre-intervention days(January1–September30,2022)andpost-intervention days(January1–September30,2023).Weexcludedthe periodfromOctober–December2022becauseitwasthe periodwhensolutionswerebeingimplemented.Matching months(January–September)forbothtimeperiods minimizesseasonaleffects,whichisaconcernwithED outcomeinvestigationsbecauseEDvolumesfollowseasonal trends.26 Thestrengthofusingday-levelmeasuresacrossthe twonine-monthtimeperiodsisthattheyprovideagood samplesize(totalnumberofdays546,273daysineach period)forstatisticalcomparisonvsmonthlyleveldata (18monthswith9ineachperiod).

Dayswerecategorizedasbelongingtoeitherthepre-or post-interventionperiodsamples.Becauseourhypothesiswas thattheADtoDwoulddecreaseinthesecondperiod,weused asingle-tailed t -testtocompareADtoDbetweenperiods.To describehowthetimeperiodsdifferedinEDvolumeand hospitalcapacity(factorsthatcouldtheoreticallyaffect ADtoD),wepulleddatabydayfor1)totalnumberof occupiedhospitalbeds,includingobservationbeds;2)total numberofpatientsadmittedfromtheED;and3)totalnumber ofEDencounters.Inadditiontodescriptiveanalytics,we conductedindependentsampletwo-tailed t -testsonthesethree variablestodetectperioddifferences.Finally,weused standardleastsquaresregressiontotestfortheeffectsofthe intervention(pre,post)onADtoD,whilecontrollingforED volumeandhospitaloccupancyvariables.

Weusedarunchartforavisual,temporalanalyticviewof improvementtoevaluatewhetherimprovementoccurred afterinterventionandtodeterminewhetherimprovements weresustainable.27

RESULTS

ObservationalFieldInvestigation,ProcessMapping,and BarrierIdentiﬁcation

Thetotalpersonnelcostfortheinvestigationwas$16,000. Becausethehospitalpartneredwiththeuniversityinajoint efforttotrainmedicalstudentsinsystems-basedpractice,the investigationcameatnocosttothehospital.Theuniversity paideachoftheninemedicalstudents$12.50/hourfor0.5 full-timeequivalent(FTE)foraone-month(80hours) internship,whichtotaled$9,000.TheLeanconsultantwasa full-timeinnovationcenteremployeewhoweestimated dedicated0.75FTEforthemonth(90hours)atacostof $7,000,includingsalaryandbeneﬁts.

TheteamidentifiedthatboardedEDpatientsprimarily waitedfortwosuppliesfromotherdepartments:cleanbeds providedbyEVS;andtransportservices.Thedepartments’ processeswereinterlocked;interlockingprocessesaredefined aswhenoneprocess flowisrelianton/triggeredbyanoutputof anotherprocess,suchasadigitalsignaloranaction.Mapping thesupplyprocessforeachandtheirintersectionwiththeED processgenerated Figure1.Wecalledthisthree-department processmap globalbedmanagement .Wecategorized flow throughbedmanagementintofourmulti-department collaborativesteps:1)processesusedtoprovideclean,ready beds;2)processesusedtoassignpatientstoopenbeds;3) processesusedtotransportapatientforbedoccupancy;and4) processesusedtoresupplybedsfreedfromdischarge.Across thesesteps,welogged18delays.Thelocationofthedelaysis depictedin Figure1.Asupplemental fileprovidesahigher qualityimage;anddetaileddescriptionsofdelaysarelistedin AppendixExhibitA

Acrosstheinterlockingdepartments,sixstaffrolescoproducedglobalbedmanagementwhomwenamed ﬂow facilitators;fourwerepatientcare-based(transfer coordinator,transporters,EDnurses,and ﬂoornurses),and twowereEVS-based(supervisorandstaff).TheEVSand clinicalcarestaffdependedprimarilyontheEHRplatforms tosenddigitalsignalstoeachotherforcoordination,in

contrasttotransportservices,whichwerecoordinatedby phone.AnexampleofclinicalcaresendingEVSasignalwas when ﬂoornursesenteredapatient’sdischargeintotheEHR; thatentrytriggeredthepostingofthatpatient’sbedontothe EVScleaningqueue.Intotal,11ofthe18(61%)delayswere causedbyEVS-clinicalcarecollaborationfailurescausedby themnotperceivingthemselvesasacollaborativeteam. Becausetheylackedasharedgoaltoconnectpatientsas efﬁcientlyaspossibletobeds,theylackedcommunication processestofacilitatethatprocess. AppendixExhibitA detailsEVSandclinicalcarestandardworkprocessesthat disregardedtheeffecttheyhadoneachother.TheEVSstaff hadnovisibilityintoclinicalinformationduetopatientdata protection.Therewasnoreasonthatclinicalcarestaff’ s visibilityintoEVSsystemswaslimited.

BarrierTypes

Weidentiﬁedfourcommon,system-levelcauses(barriers) forthe18delays.Twostemmedfromtechnologydesign (rigidsystemsettingsand “digitalblindness”)andtwo stemmedfrommanagementissues(workforceshortageand policyandprocedures).

Technology-basedbarriers

Wefoundrigid systemsettings embeddedintechnology applicationspreventedstafffromchanginginaccurate informationsuchaswhenacleanbedwaslistedasdirty becauseEVSlackedaccesstochangebedstatusesnotassigned tothem. Digitalblindness, atermwecoinedtodescribethe commonconditionwhenstaffwereunabletoseepertinent informationduetopoortechnologydesign,suchasEVSnot seeingwhichbedshadwaitingpatients.Insum,usersreliedon inaccurateinformationormadedecisionswithoutcomplete information.Becausedigitalblindnesswaswidespreadacross clinicalcareandEVS,welabelledthreedistincttypes: true statusblindness (eg,beingshowntheinaccuratestatusofa bed), collaborationblindness (eg,assigningpatientstobeds withoutknowingorderofreadiness,causingpatientstoexit

theEDoutofadmissionorder),and sporadicoutput blindness (eg,nursedischargedataentrycreatingEVSdirtybednotiﬁcationin0–20minutes).

Delaysassociatedwithrigidsystemsettingsaredesignated as “S” in Figure1 and AppendixExhibitA.Alltypesof digitalblindnessaredesignatedas “D” in Figure1 and AppendixExhibitA

Management-basedbarriers

Transporters,clinicalcare,andEVSstaffsufferedfrom understaffingdueto workforceshortages, amanagement issueconstrainedbylocalresources.28–30 Policyand procedures contributedtodelaysintwoways.First,inall casesexceptonethedelaysassociatedwithworkforce shortagewerealsoassociatedwithpolicyandprocedure issues(AppendixExhibitA).Weconcludedthatpolicyand procedurescanreflectanassumptionofanoptimal workforcesupply,andadherencetothemduringshortages canbackfireandexacerbatedelays.ConsideroneEDpolicy thatrequiredEDnursestowait30minutesaftercalling transportservicesbeforeusingtheirowntechsfortransport. Adherencecreated30-minutedelayswhentransporterswere short-staffedandEDtechswereavailabletotransport.

Second,wediscoveredwithin-departmentproceduresthat causeddelaysinotherareas.Forexample,priorto intervention,EVSproceduresincludedallstaffchangingshift atthesametimeandconductingabriefmeetingatshift change.Toaccommodatebothshiftchangeandthemeeting, staffstoppedcleaningthequeuedbedsforonehoureveryday towinddowntheircleaningworkpre-shiftchange,toattend themeeting,andtorampituppost-shiftchange. Compoundingthisproblematicprocedure,itoccurredat3 PM, helpingtoexplainwhyEDpatientwaitingincreasedat3 PM eachday.TheEVSproceduresweren’ttheonlyproblematic ones;othersincludedallowingnursestodelaydischargeentry, thuseliminatingtimelysignalstoEVSofdirtybedsandno transportercancellationpolicycausingtransporterstowaste timelookingforalreadytransportedpatients.

Delaysassociatedwithworkforceshortagearedesignated witha “W” in Figure1 and AppendixExhibitA.Delays

causedbypolicyandproceduresaredesignatedwitha

Figure1 and AppendixExhibitA

Figure2 summarizesthesystem-levelbarriersand underlyingcauses.Ofthese,onlyworkforceshortagewasa recognizedcausefordelaysbeforeourinvestigation.

Magnitudesofburdenfrombarriertypes

Usingthedelaydatacompiledandavailablein Appendix ExhibitA,wefoundthattechnology-basedbarriers(barriers associatedwithdigitalblindnessorsystemsettings)were twiceasprevalent(14/18;78%)comparedtomanagementbasedbarriers(barriersassociatedwithworkforceshortage orpolicyandprocedures)(7/18,39%).Digitalblindnesswas associatedwiththemostdelaysat61%(11/18),followedby systemsettings39%(7/18),policyandprocedures39%(7/18), andworkforceshortage33%(6/18)(see Figure3).

SolutionGenerationandSelection

TheLeanteamgeneratedandevaluated25solutions (AppendixExhibitB).Overhalfoftheidentiﬁedsolutions (59%;13/22)wereconsideredcontrollableandestimatedto havenocostbasedoninformationtechnology(IT) capabilities.Solutionswithcostsreﬂectedtheneedtohire staff,whichmayormaynothavebeenviabledueto localshortages.28–30

Forsolutionselection,weturnedtothemagnitudeof burdencalculationpointingtodigitalblindness,system settings,andpolicyandprocedureissues,eachofwhichhada no-costsolution.Thefollowingsolutionswereimplementedin thefourthquarterof2022:1)theITdepartmentcorrectedthe systemsettingthatpreventedEVSstafffromupdatingdirty roomstobecleanedbyallowingEHRaccesstotheelectronic processesthatassignedEVSstafftorooms accessthat resolvedtransfercoordinatorblindnesstotruebedstatus;2) ITfurtherdecreasedtransfercoordinators’ digitalblindnessby creatingvisibilityintheEVScleaningqueue,therebyrevealing thelikelyorderofavailablebeds;and3)EVSmanagement changeddepartmentalpolicyandproceduresbystaggering EVSstaffshifts,toensurecontinuousprogressinreadybed supply,andeliminatingall-staffdailymeetings.Theeffectsof

individualsolutionswerenotmeasured.Collectively,these solutionsweretheintervention.

InterventionEffectiveness

WecompletedallstatisticalanalyseswithJMPPro16 software(SASInstitute,Cary,NC).Sample1(year2022preintervention)andSample2(2023post-intervention)eachhad thesamesamplesize(273).Descriptivestatisticsand independentsample t -testresultsarepresentedin Table1. ADtoD(themediannumberofminutesapatientwaited eachday)wassigniﬁcantlylowerinthepost-intervention period(P = 0.04),whiletheEDstaffmanagedsubstantially higheraveragedailyEDencounters(P < 0.001).Thenumber ofdailyadmitsdidnotsigniﬁcantlydiffer(P = 0.24),nordid thedailycensus(P = 0.51).Notably,aftertheintervention,a busierEDachievedlowerADtoDtimes.Regressionof ADtoDmediantimeontopre/postcategorizationwhile controllingforthreeotherindependentvariablesrevealsthat

Sample1: pre-intervention days

Jan–Sep2022 (n = 273)

theinterventionsigniﬁcantlyreducedADtoDtimesby12.7 minutes(P = 0.01). Table2 showstheintervention’seffectof admissiondispositiontodeparturemediantimes(ADtoD) whilecontrollingforbedoccupancybyday,totaladmitted EDpatientsbyday,andtotalEDencounterbyday.

Toestimatetheintervention’seffectonEDstaff’ s exposuretoadmittedpatientboarding,wemultipliedthe ADtoDcoefﬁcient( 12.7minutes)representingeach patient’sreducedwaitingtimebythenumberofpostinterventionEDadmissions(3,256)anddividedby60to converttohours,resultinginanestimationthatEDstaff avoided689hoursofEDboardingoverthenine-month post-interventionperiod.

Inadditiontostatisticalsigniﬁcanceanalysessupporting theeffectivenessoftheintervention, Figure4 depictsa runchartsupportingthatimprovementoccurredafterthe interventionandtheinterventionachievedashift,arun ofatleastsixsub-baselinevalues.27 Baselineisthe

Sample2: post-intervention days

Jan–Sep2023 (n = 273)

Figure3. Comparisonofbarriertypes’ magnitudeoftheburdenonemergencydepartmentpatientout ﬂowbyfrequencyofbarriercontribution tooutﬂowdelays.

Table1. T-testresultsofpre-andpost-intervention.

ADtoD,admissiondispositiontodeparture; SE,standarderror; CI,conﬁdenceinterval.

pre-interventionperiodmedianADtoD.Becauserundata mustbeinterpretedincontext,27 weinterpretedJanuary ADtoDincreasesasreﬂectingpeakhospitaloccupancy,the effectofwhichwasreducedinJanuary2023bythe interventionbutnoteliminated.ByFebruary2023the medianADtoDapproachedbaseline;afterward, improvementwassustained.

DISCUSSION

The findingsfromthisinvestigationindicatethat emergencyphysiciansandtheirpatientswereenduring unnecessaryoutflowdelaysdiscoverablethrougha systemwidepatient-flowinvestigation.Althoughovercapacityinpatientunitstendtodominatediscussionsabout EDboarding,2–4,11 wediscovereddelaysburiedin technologyandwithin-departmentprocedures.InPhase1, theuseofLeanmethodologiesrevealedtheoutflowprocess anditsdependenceonglobalbedmanagement(Figure1),

ﬂowfacilitatorsandtheirrelianceontechnologyto collaborate,andthesystem-levelrootcausesdrivingdelays (Figure2).Theinvestigationledtodesigninglow-cost solutionsthatinPhase2achievedadministration’sgoalof reducingadmittedpatientboardingintheED.

Theinterventionconsistedofthreesolutionsgearedto improveEVS-clinicalcarecollaboration. T -testanalysisof pre-vspost-interventionperiodsshowedthatADtoDwas significantlydecreasedwhiletheEDwassignificantlybusier (Table1).Regressionanalysiscontrollingforeffectsfrom hospitalcapacityandEDvolumedemonstratedthatthe interventiondecreasedthemedianADtoDbynearly13 minutes(Table2).BecauseweestimatethattheEDstaff avoided689hoursofEDboardinginthepost-period,we contendthattheinterventionsubstantiallybenefitedstaff. Finally,chartingthemonthlymedianADtoDtrend substantiatedthatimprovementoccurredafterthe interventionperiodandwassustainable(Figure4).

Notsurprisingly,giventhewidespreadhealthcarestaffing shortagesof2022,28–30 workforceshortages affected outflow.Patientswaitedforunderstaffedtransportersto movethem,understaffednursestocompletedischarges,and understaffedEVStocleanrooms.However,ouranalysis showedthatthoseshortageshadthelowestmagnitudeof burdenonoutflowcomparedtoreadilysolvableissues: digitalblindness;systemsettings;andpolicyandprocedures (Figure3).Beforethepresentinvestigation,nooneatthe hospitalhadeverseentheinter-related,multi-department workflowsnecessarytomoveanadmittedpatientfromthe

ArunchartdepictingtheadmittedpatientEDoutﬂowprocessimprovementwithsustainedmediantimeunder pre-interventionbaseline.

Table2. Standardleastsquaresregressionmodelresults(N = 576).

Figure4.

EDtoacleanbed.The ﬂowmapandanalysisshifted administrationstrategiesforalleviatingboardingfrom saddlingfrontlineworkerstosolvetomakingtheseworkﬂow adjustmentsmanagementdecisions.

Thedegreetowhichtechnology hindered patient ﬂowwas unexpected.Althoughresearchshowsthatnurseshavecalled fornew,effectivetechnologytoolstomanagethepatient ﬂow foryears31 andsomeinitiativeshavebeencreated,18,32,33 our researchuncoveredshortcomingsofexistingtooldesign,an issuethathadgoneunnoticed.Theupsidetodiscovering problemswithexistingtechnologywastheavailabilityof low-andno-costsolutions.

AlthoughEHRsarethecomplexbackboneofhospital processes,theirembeddedprocesseswereunquestionedby staffanduntestedforoptimizationbyadministration. Althoughmultiplesystematicreviewshavereportedoncauses ofEDcrowding,2,3,11 nonesuggestedthattheefﬁciencyof technologyprocessesbetested.Therealityofhowmuchstaff reliedontechnologytocollaboratewithothersmade digital blindness thelargestbarrier.Digitalblindnessisanissuethat hasgoneunnamed;thus,themagnitudeofitseffectsonother processes,staff,andpatientshasgoneunmeasured.Deﬁning digitalblindness openstheissueforpracticalexploration, futureresearch,andinnovationdesign.

Thepresentstudyresultsalsospotlighttheimportanceof EVS,whichhasbeenoverlookedincurrentresearch.Although EVSismentionedinafewpatient-ﬂowimprovement studies,18,32 innocasewasEVS-clinicalcarecoordination centraloremphasized.Policymakersshouldtakenoticeof how,inthisstudy,within-hospitalintegrationlapseswere erodingcareandproductivity.Althoughtheintegrationof healthinformationsystemsbetweenhospitalsandclinicians monopolizesinitiativesacrossfederalagencies(ie,Agencyfor HealthcareResearchandQuality,34 CentersforDisease ControlandPrevention,35 CentersforMedicare&Medicaid Services36),wecallattentiontohowwithin-hospitalintegration issuesarethreateningpatientoutcomesandstressingstaff.

InsightsintoEDoutflowbarriersaretimelyforpractical application.TherearediscussionsthattheEDboardingtime standardwillbeloweredfromfourtotwohours,a50% reduction.2 Whenadministratorsseekstrategiestomeetthis aggressivereductioninboarding,werecommendanalyzing thebedmanagementcycleandprocesseswithLean methodologies.Ourprocessuncovereddelaysunnoticedby anysingledepartment,avoidedindividualpatient variabilitiesthatcanderail flowinvestigations,8 found problematicwithin-departmentefficiencysolutions,andwas appreciatedbyfrontlinestaff.Administrationreportedtothe innovationteamthattheybelievedtheinvestigation improvedmoraleandcreatedenthusiasmforthesubsequent solutionimplementationsbecausetheresultsexplained confusingworkplaceexperiences:whystaffdidnotknow whatwastakingsolongforEDpatientsto flowto floorbeds; whyEVSstaffwerenotcleaningadirtyroom;whyaclean

roomwouldgovacant;andwhysimilarEDpatientsexited outoforderofadmission.

LIMITATIONS

Themainstrengthsofthisstudyareitscompletereviewof processesanddepartmentsaffectingEDpatientoutflowand thedurabilityoftheintervention’sgains.However,the generalizabilityofour findingsislimitedbecauseitisasinglesitestudyofamid-sizedhospitaloperatingoneEHRsystem duringaone-monthtimeframe.Datawasnottestedwith timeseriesmodeling,whichcouldprovideadditional temporalinsightsnotprovidedbypre/postdesign.A limitationtoreplicabilityisahospital’saccesstoLean Healthcaretraining,whichcoulddriveupthepriceofthe interventionbutmaybejustifiedgivenhowquicklytheteam couldpracticallyapplynewLeanskills.Moreover,the solutionsidentifieddonotaddressotherissuesdriving crowding,suchashighcommunitydemandforEDservices.

CONCLUSION

Asystemwidepatient-flowinvestigationatasinglehospital usedLeanmethods,whichprovedeffectiveinidentifyingthe barriersthatincreasedthetimeadmittedEDpatientswaited foraccesstobeds.Thebarriersweresystem-levelissues (technology,workforceshortage,andpolicyandprocedures); thegreatestwastechnology.Givenhealthcaresystems’ dependenceontechnologyandthecrisislevelofEDboarding, thisstudycallsformulticenterregionalandnationalresearch tounderstandtowhatextentwithin-hospitaltechnology integrationlapsesareblindingstaffanderodingcare. Meanwhile,administratorsshouldtesthowtheirtechnology supports(orhinders)environmentalservices-clinicalcare coordinationandbewaryoftheeffectof within-department efficiencygainsonpatient flow.Becausethecostofthe investigationwaslowandwewereabletogeneratesolutions for flowbarrierswithlittletonoassociatedcosts,weconclude thatthesetypesofinvestigationscanreduceEDcrowdingby movingadmittedpatientsoutoftheEDmorequicklywithout escalatingthecostofcare.

AUTHORSCONTINUED

AddressforCorrespondence:MarjorieA.Erdmann,MS,PhD, OklahomaStateUniversity,CenterforHealthSystemsInnovation, 1111W.17th St.,Tulsa,OK74107.Email: marjorie.erdmann@ okstate.edu

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

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ORIGINAL RESEARCH

InterfacilityPatientTransfersDuringCOVID-19Pandemic: Mixed-MethodsStudy

MichaelB.Henry,MD,MS*

EmilyFunsten,MS†a

MarisaA.Michealson,BA†a

DanielleAlbright,PhD‡

CameronS.Crandall,MD‡

DavidP.Sklar,MD‡§

NaomiGeorge,MD,MPH‡

MargaretGreenwood-Ericksen,MD,MSc‡

SectionEditor:ShiraSchlesinger,MD,MPH

*CreightonUniversityArizonaHealthEducationAlliance,Maricopa EmergencyMedicineResidency,Phoenix,Arizona

† UniversityofNewMexico,SchoolofMedicine,Albuquerque,NewMexico ‡ UniversityofNewMexico,SchoolofMedicine,DepartmentofEmergency Medicine,Albuquerque,NewMexico § ArizonaStateUniversity,CollegeofHealthSolutions,Phoenix,Arizona a Equalcontribution

Submissionhistory:SubmittedApril24,2024;RevisionreceivedAugust21,2024;AcceptedAugust23,2024

ElectronicallypublishedSeptember10,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20929

Introduction: TheUnitedStateslacksanationalinterfacilitypatienttransfercoordinationsystem.During thecoronavirus2019(COVID-19)pandemic,manyhospitalswereoverwhelmedandfaceddifﬁculties transferringsickpatients,leadingsomestatesandcitiestoformtransfercentersintendedtoassist sendingfacilities.Inthisstudyweaimedtoexploreclinicianexperienceswithnewlyimplemented transfercoordinationcenters.

Methods: Thismixed-methodsstudyusedabriefnationalsurveyalongwithin-depthinterviews.The AmericanCollegeofEmergencyPhysiciansEmergencyMedicinePracticeResearchNetwork(EMPRN) administeredthenationalsurveyinMarch2021.FromSeptember–December2021,semi-structured qualitativeinterviewswereconductedwithadministratorsandruralemergencycliniciansinArizonaand NewMexico,twostatesthatstartedtransfercentersduringCOVID-19.

Results: Among141respondents(of765,18.4%responserate)tothenationalEMPRNsurvey, only30%reportedimplementationorexpansionofatransfercoordinationcenterduringCOVID-19. ThosewithnewtransfercentersreportednochangeindifficultyofpatienttransfersduringCOVID-19 whilethosewithouthadincreaseddifficulty.The17qualitativeinterviewsexpandeduponthis,revealing fourmajorthemes:1)limitedresourcesforfacilitatingtransfersevenbeforeCOVID-19;2)increased numberofanddistancetotransferpartnersduringtheCOVID-19pandemic;3)generallypositive impactsoftransfercentersonworkflow,and4)thepotentialforcontinueduseofcentersto facilitatetransfers.

Conclusion: Transfercentersmayhaveoffsetpandemic-relatedtransferchallengesbroughtonbythe COVID-19pandemic.Clinicianswhofrequentlyneedtotransferpatientsmayparticularlybeneﬁtfrom ongoingaccesstosuchtransfercoordinationservices.[WestJEmergMed.2024;25(5)758–766.]

INTRODUCTION

Inearly2020,criticallyillpatientswithcoronavirus disease2019(COVID-19)overwhelmedmanyhospitalsand emergencydepartments(ED)acrosstheUnitedStates. Surgeswereunpredictable.Patientsoverransomehospitals, whileotherfacilitiesmadesigniﬁcantpreparationsfor COVID-19patientswhoneverarrived.1 Smallerhospitals neededtotransferpatientstofacilitieswithmorebeds, stafﬁng,andspecialistservices.Theunpredictable distributionofpatientsandbedavailabilityplacedstrainon

somelargerregionalreceivinghospitals,leadingsomestates andhealthsystemstoidentifymechanismsto “load-level” patienttransfersamongreceivingfacilities.2

Historically,interfacilitypatienttransfersbetweensmall orruralhospitalsandlargerregionalhospitalshasoffered accesstocarethatmaynototherwisehavebeenavailable. HospitalsintheUStransferoveronemillionpatientsfor admissionannually,3 andnearlyeveryUShospital participatesinthetransferprocesseitherasareceiver,a sender,orboth.4 Thesetransfers,drivenbylimitedbed capacity,theneedforspecialtyservices,oralackof certaindiagnosticmodalities,arechallengingforreferring hospitalclinicians.5

Nationaleffortstotrackavailablehospitalcapacityand coordinatetransfersduringtheearlyCOVID-19pandemic wereseenaslargelydisorganizedandunreliable,leading manystates,cities,andhospitalstodeveloptheirown systems.6 TheArizonaDepartmentofHealthServices createdtheArizonaSurgeLine,acentralizedsystemstaffed bytransfercoordinatorswithaccesstoupdatedbedand ventilatorcapacitydataaroundthestate.2 NewMexico createdaCentralCommandCentertocoordinateplacement ofcriticalcarepatientsthrougha “hub-and-spoke” model.7 HospitalsinBoston,NewYorkCity,Chicago,Washington, andMinnesotamadesimilarefforts.1,8–12

Whileviewpointsandlaypressarticleshaveexplored transfercenterefﬁcacy,researchdescribingthereachof transfercentersandtheirimpact,asperceivedbyclinicians, policymakers,andhospitalleadershiparelacking.Weuseda mixed-methodsapproach,includinganationalsurveyto describeaccesstotransfercentersbeforeandduringCOVID19,andsemi-structuredinterviewswithstakeholdersintwo statestogenerateanin-depthpictureofthefunctionandthe impactoftransfercenters.Wehypothesizedthat implementationofanewtransfercenterwouldleadtoeasier transferprocesses.

METHODS

Weconductedanexplanatory,mixed-methodsstudywith anational,web-basedsurveytocapturethetransfer-center experiencesinavarietyofemergencycarepracticesettings followedbysemi-structuredqualitativeinterviewswith sendingfacilitycliniciansandadministratorsintwostates (ArizonaandNewMexico)toprovidedeeperinsightintothe experiencesofsendingfacilities.Bothstatesestablishednew interfacilitytransfercoordinationsystemsduringpeak COVID-19.The ﬁrstauthor’sinstitutionalreviewboard approvedthestudydesign.

Web-basedNationalSurvey

AmultidisciplinaryteamofArizona-andNewMexicobasedresearchersfromamixofurbanandruralhospitals developedandrevisedthesurvey.Attendingphysicianswith clinical,administrative,andresearchexperiencewho

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Interfacilitypatienttransfersarechallenging forclinicianstoarrangeinruralandlimited resourcesettings.Thiswasexacerbatedbythe COVID-19pandemic.

Whatwastheresearchquestion?

Didtransfercoordinationcentersimprovethe clinicianexperienceofarrangingpatient transfersduringthepandemic?

Whatwasthemajor ﬁndingofthestudy?

Surveyresultsandinterviewssuggest transfercentersmayhaveoffsetpandemic transferchallenges.

Howdoesthisimprovepopulationhealth?

Clinicianswhofrequentlytransferpatients maybene ﬁ tfromongoingaccesstotransfer coordinationservices.

practiceinreferringandreceivinghospitalsettings pilot-testedthesurveytoensurequestion-and-response relevanceandclarity.Publishedguidelinesinformed surveydevelopment.13,14

WeadministeredoursurveyusingtheAmericanCollege ofEmergencyPhysiciansEmergencyMedicinePractice ResearchNetwork(EMPRN),anationwidecohortof765 emergencyphysicianswhohavevolunteeredtoanswershort researchsurveysseveraltimesayear.Thesurveyincluded questionsonpracticesetting,transfercenterpresenceduring COVID-19,andtransferredpatients’ characteristics (AppendixA).Noincentiveswereofferedforparticipation. TheEMPRNsentsurveyinvitationsonMarch3,2021,with threeadditionalreminderemailsoverasix-weekwindow.

Variablesanddataanalysis

Wecalculatedsurveyresponseratebasedonthenumber ofEMPRNparticipantswhowereemailedthesurvey(765) andthenumberofsubmittedsurveyresponses.Nosurveys wereexcludedduetoitemnonresponse,sinceallbutoneof thequestionswererequiredforsurveysubmission.We collectedordinalresponsesforyearlyEDvolume,inpatient bedcapacity,andviewsonthefutureutilityoftransfer coordinationsystemsandLikert-scaledresponsesfor perceptionofCOVID-19impactandtransfermetrics.We deﬁned sending facilitiesasthosethat always or mostly tendedtotransferpatientsoutcomparedtoreceiving patients.Wedeﬁned receiving facilitiesasthosethat always

or mostly tendedtoreceivetransfers.Wedeﬁnedatransfer centerasa “new/expandedcentralizedentity(suchasacall center)createdtocoordinateinterfacilitytransfers.” In additiontodescriptivecharacteristics,ourprimaryoutcome measureofinterestwasthetransfercentereffectonpatient transfersduringCOVID-19.Wecomparedsendingand receivingrespondents,facilitycharacteristics,effectsofthe COVID-19pandemic,andperceptionsoftransfercenters usingchi-square,Student t -test,Spearman’srho,Wilcoxon signed-ranktests,andMann-Whitneytests,asappropriate. Weusedatwo-tailedtypeIerrorrateof5%todetermine statisticalsigniﬁcance.WeusedJASP0.14.1.0(Universityof Amsterdam,Netherlands)forstatisticalanalyses.

QualitativeInterviews

Weconductedsemi-structuredinterviewstofurther exploreclinicianandpolicymakerperceptionsofinterfacility transfersbeforeandduringthepandemic,alongwiththe beneﬁtsandchallengesofthenewtransfersystems. Researchersiterativelydevelopedtheinterviewguideswith inputfromphysiciansfrequentlyinvolvedinthetransfer process.Clinicianswhogaveinputonthedevelopmentofthe interviewtoolwerenotincludedamongthe ﬁnalinterviews. Theinterviewquestionsfocusedontheorganizationofand overallchallengesassociatedwithinterfacilitytransfersand ontheperceivedimpactsoftransfercentersonthetransfer processes(AppendixB).

Threeauthorsconductedtheinterviewsbetween September–December2021.Clinicianswhogaveinputonthe surveytoolhelpedidentifythe firstinterviewees.Wethenused snowballsamplingtorecruitcliniciansfromrural(sending) hospitalsthatfrequentlyneededtotransferpatientstoother facilitiesandadministratorstaskedwithimplementingand runningthetransfercentersduringCOVID-19.We interviewed fivecliniciansandthreeadministratorsfromNew Mexicoandsixcliniciansandthreeadministratorsfrom Arizonabeforethematicsaturationwasreachedandno furtherparticipantswererecruited.Interviewsgenerally rangedfrom30–60minutesinlength.Withpermission,we recordedtheinterviews,savedthemsecurely,andtranscribed themusingRevtranscriptionservices(Rev.ComInc,San Francisco,CA).Weassignedalphanumericidentifiersto transcriptsforconfidentiality.Eachofthethreeinterviewteammembersindependentlycodedthesameadministrator andclinicianinterviewtoensureconcordanceandtodevelopa codingstructurebeforeinductivelycodingandanalyzing themesontheremaininginterviews.Weusedaniterative processthroughouttheanalysistoensurereliabilityin thematiccategorydevelopment.

RESULTS Survey

Atotalof141physicians(of765whoweresentthesurvey, 18.4%responserate)from39statesrespondedtothe

EMPRNsurvey.Respondentaverageagewas53,andmost wereWhiteandmale.Facilitiesthatprimarilytransferred patientstolargercenters(ie,sendingfacilities)tendedtohave loweryearlyEDvolumes(P < 0.001)andlessinpatientbed capacity(P < 0.001)comparedtofacilitiesthatprimarily receivedpatientsintransfer(ie,receivingfacilities)(Table1). Lackofspecialtyserviceswasthemostcommonreasonfor transferreportedamongbothsendersandreceivers;other reasonsincludedinadequatelocalinpatient-andintensive careunit(ICU)capacity(Figure1).

Mostrespondentsreportedmoderate-to-highperceived severityofCOVID-19impactintheirareas(mean3.9with1 beingthelowestseverityand5thehighestseverity). Physiciansatreceivingfacilitiesperceivedtheseverityofthe COVID-19pandemictobegreaterthansendingphysicians (P = 0.05),see Table1.Mostrespondentsalsoreported transfersovergreaterdistances(mean3.58)andincreased numberoftransferpartners(mean3.54)requiredto accomplishpatienttransfersduringtheCOVID-19 pandemiccomparedtoprior(mean3.00,indicatingno change).ReportedCOVID-19intensityappearedtobe correlatedtodistanceoftransfers(Spearman’srho0.141, P = 0.10)andnumberoftransferpartners(Spearman’srho 0.140, P = 0.10)althoughnotstatisticallysigniﬁcant.

Mostrespondentsreportednoaccesstoatransfercenter priortotheCOVID-19pandemic,orimplementationofa neworexpandedtransfercenterinresponsetoCOVID-19 (Table1).Atotalof37respondents(30%)reported implementationorexpansionofatransfercoordination centerinresponsetotheCOVID-19pandemic.Thosewho hadaneworexpandedcenterreportedsimilaramountsof overalleffort(mean2.91,whereamean = 3indicatesno change,Wilcoxonrank-sumtest, P = 0.55)andtimeto achievetransfers(mean3.17,Wilcoxon P = 0.32).In comparison,thosewhodidnothaveaneworexpanded centergenerallyreportedahigherdifﬁculty(mean3.89, Wilcoxonrank-sumtest P < 0.001)oftransferringpatients becauseoftheCOVID-19pandemic.

Ofthosewithaccesstoneworexpandedtransfercenters duringCOVID-19,mostsawutilityinhavingthesetransfer servicesavailableinthefuture.Among36respondentswith neworexpandedtransfercenters,15(42%)thoughtthey wouldbeusefulinthefuturebutonlyinemergency circumstancesand16(44%)thoughttheywouldbeusefulin allsituations.Incomparison,of83respondentswithout transfercenters,only17(20%)thoughttransfercenterscould helpinfutureemergencies,35(42%)thoughttheywouldbe usefulinallsituations,and31(37%)thoughtthesewouldnot behelpfulinthefuture.

Interviews

Interviewswithadministratorsandsendingfacility cliniciansprovidedadditionalinsightontheutilityoftransfer centers.The17intervieweesincluded ﬁvecliniciansandthree

*EMPRN,EmergencyMedicinePracticeResearchNetwork. Figure1. PerceivedreasonsnecessitatingpatienttransfersduringtheCOVID-19pandemic,receivingvssendingfacilities (%ofrespondents). COVID,coronavirus2019; ICU,intensivecareunit.

administratorsfromNewMexicoandsixcliniciansand threeadministratorsfromArizona.Theintervieweeswere mixedingenderandage.The11cliniciansincludedsix workingontribalhealthsitesofvaryingsizes(alargenumber ofruralfacilitiesintheregionserveNativeAmericantribes), oneatanon-tribalnonproﬁtcriticalaccesshospital,two atmid-sizedcommunitynonproﬁthospitals,oneat severalfreestandingEDs,andoneataruralcommunity teachinghospital.

Weidentiﬁedfourprimarythemesrelatedtothe functioningandutilityoftransfercenters,includingthe following:1)limitedresourcesforfacilitatingtransferseven beforeCOVID-19;2)increasednumberofanddistanceto transferpartnersduringtheCOVID-19pandemic;3) generallypositiveimpactsoftransfercentersonworkﬂow; and4)thepotentialforcontinueduseofcentersto facilitatetransfers.

Theme1:Limitedresourcestocoordinatetransfers

Intervieweesreportedthat,priortoandduringthe COVID-19pandemic,transfercoordinationplacedalarge burdenoncliniciansandstaffatsendingfacilities.One respondentnotedthattheyspent “ halfmyshiftonthe phone, ” andanothercalled “ asmanyas10to12facilities ” beforecompletingatransfer.Withoutcentralizedaccessto learnaboutwhichreceivingfacilitieshadneededbedsand specialtyservices, “ youhadnowayofknowingthatuntilyou actuallytalktosomebody. ”

Respondentsatsendingfacilitiesreportedavarietyof reasonsforpatienttransfer.Arespondentsummarizedthe relationshipbetweenresourcesanddecisionstotransfer:

Therearethree[reasons],oneislackofcapacity The otherreasoniscalled ‘serviceisnotavailable’ And thethirdreasonishigherlevelofcare thatthe patientistoosickforusandoursystem.

Beforetransfercenterimplementation,decisionswereoften basedonsendingclinicians’ personalrelationshipsand knowledgeofreceivingfacilities,totheextentthatone intervieweenotedtheir “ ﬁ rst-namerelationships ” withthose atreceivingfacilities.

Theme2:IncreasedtransfercomplexityduringCOVID-19

Surveyrespondentsreportedincreasednumbersof transferpartnersandincreaseddistancesoftransfers, suggestingincreasingcomplexityofpatienttransferasan earlyresultofthepandemic.Interviewrespondents elaboratedonthecomplexitiesofthisexpandedtransfer area,withonenotingthat “ transferringpatientsmuch fartherdistances ” placesstrainon “ thepatientandontothe familyandtheirsupportnetwork. ” Anotherintervieweehad asimilarnumberoftransfersaspre-pandemicbut “ the complexityincreased,thenumberofphonecallsincreased. ”

Manyneededtoidentifynewreceivingfacilitiesbeyondtheir normaltransferpartnerstoaccesstheneededlevelofcare, speciﬁcallyICUbeds.Arespondentreported,

Beforethis[COVID-19pandemic],I’veneverhadto transferforbedavailability,butwedidstarthavingto dothatforICUbeds.[Forthesereasons] “lengthofstay intheemergencydepartmenthasgoneupdramatically.

Theme3:Thepositiveimpactoftransfercenters

Almostallrespondentsnotedthatthetransfercenters decreasedtheburdenofpatienttransfer,providingan importantresourceinmaintainingworkﬂow.Aprimary impactwasreductionintimespentonthephone,withone respondentlikingthatthey “ onlyhadtodialonenumber,give somebasicinfo youonlyhadtohaveoneconversation withonedoctor itdramaticallydecreasedadministrative work. ” Anotherintervieweenoted, “ better ﬂ owthroughout ouremergencydepartmentsothatotherpatientscouldbe seenandcaredforaswell. ” Eventhosewhodidnotseeabig impactontheirtransferprocessacknowledgedthepossibility thatthecentershelpedsubtly:

Asthetransferringphysician,Ididnotseemuchchange Now,whatIcan’ttellyouiswhatitwouldbelike,giventhe ongoingsurges,iftherehadbeenanabsenceofthatcall center,thingscouldhavebeenmuchworse Maybeno changewasagoodthing,becausethealternativewas thatthingswould’vedeclinedinaverybadway.

Theme4:Transfercentersasapotentialpolicysolution

Thetransfercenterexperienceledintervieweestoconsider howthisarrangementmaycontributetoimprovedcare deliverybeyondthepandemic.Despitelowernumbersof COVID-19patientsatthetimeofinterview,oneclinician notedtransfersstill “ takingquiteabitoftime ::: transfer centerassistancecouldstillbeveryhelpful eventhough technicallytheCOVIDcrisishassubsided. ”

Onerespondentsuggestedastandingstatewidetransfer centercouldassistsendingfacilitiesandincreasepatient agency: “ Onephonenumberthatyoucallforanytransfers withinyourstate youcanputthatpatients ’ preferenceis transferredtoXhospitalortostaynearhome. ” Others statedtheywouldliketo “ expandthisouttootherdisease statesotherthanjustCOVID. ” Anotherwantedtosee “ a [phone]lineataminimumthatdealtwithallICUbeds withinaregion ::: abletoknowwhathospitalshadwhat servicesandputyouintouchwiththemratherthan [taking]awayfrompatientcare. ”

Meetingtheneedsofbothfacilitiesandcommunities requiressigniﬁcantplanningandcoordination.One respondentnoted,

Table2. Additionalqualitative ﬁndingsandextended-lengthquotes.

ThemeQuote

Limitedresourcesto coordinatetransfers

Youmakeallyourownphonecalls.SoI’vespentuptohalfmyshiftonthephone,randomly dialingphonenumbersfornon-COVIDpatientsbefore.

Therearetimeswhentheycallasmanyas10to12facilitiesbeforeyoucan ﬁndanacceptable bed sothemoretimespenttryingto ﬁndanappropriatefacilityforpatient,thefewerother patientsthatthatprovidercansee.

I’vespentmoretimeonthephone tryingtogetpeopletransferredduetoCOVIDthanIever thoughtwaspossible.

EvenifaplacesaidthattheyhavespecialtyservicescoveringspecialtyX,theymaynothaveit thatdayorthatweekandyouhadnowayofknowingthatuntilyouactuallytalktosomebody.You wouldn’tknowwhohadthetypeofbedavailablethatyouwerelookingfor.Soyou’d[make] multiplephonecallssayrequestinganICUbeduntilyoufoundsomebodywhohadanopenICU bed.Andsojustalotofredundancyofworkthattookawayfrompatientcaretime.

Therearethree[reasons],oneislackofcapacity,becausewecan’tadmitthatmanypatients becausewedon’thaveenoughnurses.Theotherreasoniscalled “serviceisnotavailable”,which meanswejustdon’thavetheservice,wedon’thavethespecialist,wedon’thavetheMRI,we don’thavetheCT,ourCTswentdown.There’salotofthingswedon’thave.Wedon’thave platelets,wedon’thavedialysis,don’thaveanyonetodoacardiaccheck.Eitherwedon’thavethe specialist,wedon’thavetheequipment,butwedon’thavetheservicethatserviceisnotavailable. Andthethirdreasonishigherlevelofcare.Andthat’sthatthepatientistoosickforusandour system,whichisdifferentthanserviceisnotavailable.Serviceisnotavailablewouldbeifwehad aneurologistandMRI,wecouldprobablykeepthepatient.Sothoseareonlythreereasonswe sendpeopleout.

Wehave ﬁrstnamerelationshipswithsomeoftheattendingphysicians,andthey’remorefamiliar withoursettingandourlimitations

Increasedtransfercomplexity duringCOVID

Wearenowtransferringpatientsmuchfartherdistances,whichisverysigniﬁcantontothepatient andontothefamilyandtheirsupportnetwork.Manypatientsarebeingtransferrednowtolocations wheretheydon’thavearidehome

Ithinktheproportionoftransferswasprobablysimilar.But,thecomplexityincreased,thenumber ofphonecallsincreased

Wedon’thavealotofspecialistsandsoitisnotinfrequentthatwehavetotransferforcertain specialistsbutbeforethis[COVIDpandemic],I’veneverhadtotransferforbedavailability,butwe didstarthavingtodothatforICUbeds

Ourlengthofstayintheemergencydepartmenthasgoneupdramatically,comparedfromevenin thelastmonth,wewereup109minutesonaverageforpatientsthatwerebeingadmitted

Thepositiveimpactof transfercenters

Transfercentersasapotential policysolution

Ithinkwhereitwasmostnotablewasjustthefactthatyouorasecretaryonlyhadtodialone number,givesomebasicinfo.Andthenoncetherewasanacceptinghospital,thenasaphysician, youonlyhadtohaveoneconversationwithonedoctor.Sometimesnoteventhat.Andsofromsort ofthatendoftheadministrativework,itdramaticallydecreasedadministrativework.

Sopatientshavingtowaitlesstimetogettoanappropriateinpatientfacilitywouldbebeneﬁcial andthenwouldalsoallowustohavebetter ﬂowthroughoutouremergencydepartmentsothat otherpatientscouldbeseenandcaredforaswell

Frommyend,asthetransferringphysician,Ididnotseemuchchange Now,whatIcan’ttell youiswhatitwouldbelike,giventheongoingsurges,iftherehadbeenanabsenceofthatcall center,thingscouldhavebeenmuchworse.Sointhebackofmymind,Ithinkaboutthat.Maybe nochangewasagoodthing,becausethealternativewasthatthingswould’vedeclinedinavery badway

We’restill ﬁndingthattheprocessto ﬁndanappropriatefacilityistakingquiteabitoftime.Andso thattransfercenterassistancecouldstillbeveryhelpfulevennowbecauseofthefactthatthe stateisjustseeinglimitedbedavailability,eventhoughtechnicallytheCOVIDcrisishassubsided. Onephonenumberthatyoucallforanytransferswithinyourstate.Andthatyoucanput thatpatients’ preferenceistransferredtoXhospitalortostaynearhomeorwhatever [theirpreference]is.

(Continuedonnextpage)

Table2. Continued.

ThemeQuote

Transfercentersasapotential policysolution

IthinkthatIwouldlovetoexpandthisouttootherdiseasestatesotherthanjustCOVID.Ithink havingthatcentralizedcommunicationsystemseemedtobeaveryeffectivemanner. HavingalineataminimumthatdealtwithsayallICUbedswithinaregion.Butideallyonelinethat wasabletoknowwhathospitalshadwhatservicesandputyouintouchwiththemratherthan havinghospitalstaffspendingmostoftheirtimedialingnumbersandawayfrompatientcare Iwouldbefullyinfavorofarobust,well-supportedtransfermechanism.Myimpressionisthat outsideofpandemictimesthereisnotawell-coordinatedtransferarchitectureforgettingpatients fromdeeplyruraltourbancentersandtertiarycarecenters veryhopefulthatwecanpull togetherawell-coordinatedtransferframework,whichrevolvesaroundtransfercenters Eveniftheycannotcovereverysingletransfer,especially,whenwe’reseeinghighervolumesand pressedfortimeandresourcesintheER,anythingthatcouldbedonetofacilitatepatients ultimatelygettingthecaretheyneedisahugebeneﬁt.Ithinkthere’salsosortofasensethatifwe canoptimizetheresourceswithinthestatetoallowforcoordinationacrossthehospitalsystems, justhereforthesepatients,thatwouldbeidealaswell

Idon’tfeellikeIneeditduringnon-crisistimes,personally.Iusuallyhavebeenabletotransfer patientsprettyquick

We’resorural.There’snowhere Whenittakesussolongtogetabed,wealsostillhaveto arrangefor ﬂightandfortheactualtransportation.So,ifittakes22hourstogetabed,andthenI don’thavea ﬂightteamavailableforsixhours,that’s28hoursbeforethepatientleavesmy emergencydepartment,youknow?

CT,computedtomography; COVID,coronavirus2019; ICU,intensivecareunit; MRI,magneticresonanceimaging.

Outsideofpandemictimesthereisnotawell-coordinated transferarchitectureforgettingpatientsfromdeeplyrural tourbancentersandtertiarycarecenters ::: [Iam] hopefulthatwecanpulltogetherawell-coordinated transferframework.

Anothercommented,

Whenwe’reseeinghighervolumesandpressedfortime andresourcesintheER,anythingthatcouldbedoneto facilitatepatientsultimatelygettingthecaretheyneedis ahugebeneﬁt ifwecanoptimizetheresourceswithin thestatetoallowforcoordinationacrossthehospital systems ::: thatwouldbeideal.

Asubsetofrespondentswaslessenthusiasticabout transfercentersoutsidethepandemiccontext.Onestated, “ Idon ’ tfeellikeIneeditduringnon-crisistimes,personally. Iusuallyhavebeenabletotransferpatientsprettyquick. ” Othersnotedinterrelatedchallengesthatwouldneedtobe overcomebeforefullyrealizingthebeneﬁtsofatransfer center: “ We ’ resorural ::: wealsostillhavetoarrangefor ﬂ ightandfortheactualtransportation. ” Additionaland expandedrespondentquotesareprovidedin Table2

DISCUSSION

Inthismixed-methodsstudy,wehypothesizedthat physiciansparticipatinginpatienttransfersduringCOVID19would ﬁndutilityinhavingaccesstotransfercoordination

centers.Inournationalsurvey,thosewithoutaccessto transfercentersreportedasignificantincreaseinthedifficulty ofexecutingtransfersduringCOVID-19surges,contrasting torespondentswithaccesstonewtransfercoordination servicesreportingnosignificantchangeineffortortimeto organizeapatienttransfer.Thissuggeststhattransfercenter implementationmayhaveoffsetpandemic-relatedtransfer challenges.Respondentswhohadexperiencewithtransfer centersalsoweremoresupportiveoftheirongoinguse, particularlyinfuturehealthcrises.

OurqualitativeinterviewsinArizonaandNewMexico, twostateswheretransfercenterswereimplemented,shed additionallightontheirbenefitswhileidentifyingareasfor futureimprovement.Withfewexceptions,theseclinicians foundthetransfercenterservicestobehelpful,specificallyin reducingtransferworkflowcomplexity.Sincethecompletion ofthisstudy,feedbackinArizonawassopositivethatthe stateevolveditstemporarytransfercenterintothefederal grant-funded “AZREACH” system,administeredbythe ArizonaPoisonandDrugInformationSystem.15

MostUShealthcarepractitionersdonotworkinareas servedbytransfercoordinationcenters,consistentwithour surveyresults.1,2,6–12 InthewakeoftheSeptember11,2001, terroristattacks,attemptsweremadetocreateanational centralizedsystembutwereneverwidelyimplemented.6 While someregionshavetransferpatternsforspeciﬁcconditions suchastraumaandacutemyocardialinfarction,16,17 transfers generallyoccurthroughinformal,looselycoordinated regionalnetworksthatsufferfromfragmentationandpoor

communication.4,5 Ourstudyconcurswithpriorresearch ﬁndingthatthelaborioustransferprocessrequiresthesending cliniciantoidentifyanacceptingfacilityusingtheirknowledge ofhistoricaltransferpatternsandinformalrelationships,and thecomplexcoordinationandmultiplephonecallscan distractfrompatientcare.5 Itispossiblethatexistingtransfer serviceswereavailabletosomeofourrespondentspriorto COVID-19butcliniciansonlybecameawareofthemdueto thestrainsofthepandemic.

Oursurveyfoundreceivingcentersreportedagreater perceivedimpactofCOVID-19.Receivinghospitalsare generallylocatedinurbanareas,whichexperiencedthe first wavesofCOVID-19duringatimeofintenseuncertaintyand fear.This,alongwithsubsequentsurgesofruraltransfersto urbanfacilities,mayhaveinfluencedtheperspectivesof receivinghospitalrespondents.18 Itisalsopossiblethat sendingfacilitiesandruralrespondentsfromthesurveymay havelivedinregionslessimpactedbyCOVID-19,orthat closerrelationshipsbetweenruralfacilitiesandtheirlocal communitiesmayyieldincreasedresilienceinrespondingto crises.19 However,thequalitativeinterviewsrevealedthat significantstressesfromCOVID-19,includingwithtransfers, alsoaffectcliniciansatsmallerfacilities.Thisislikely exacerbatedbythestrugglesofruralfacilitiestohire physicianswhooftenchoosetoworkinurbancenters,2 while inabilitytoretainstaffandrisingruralhospitalclosures21 placeanincreasedburdenamongthosewhoremain.Lackof specialistservicesandinpatient/ICUcapacitywerethetop reasonspromptingtransferspersendingandreceiving physicians,similartowhatwasreportedinpriorstudies.5

Smallandruralhospitalshavehadlongstanding challengestransferringpatientswithtime-sensitive conditions,whichwereampliﬁedduringCOVID-19. Transfercentersseemtoholdgreatpromiseinmaking patienttransferlessonerous.AstheUShealthcaresystem continuestostrugglewithworseningstafﬁngissuesand patientcrowding,transfercentersmaybeonepartofthe largersolutiontogetpatientsneededcare.

LIMITATIONS

Thelowresponserateinthenationalsurveypotentially limitsinterpretationandintroducesbias.Thestrict requirementtocompletenearlyallquestionsonthesurvey mayalsohaveledtounitnon-responseamongsome physicians.Whilewetriedtoimproveresponserateswith multipleemailremindersandashortersurvey,otherproven strategiescouldhavebeenconsidered,suchasreachingout viapostalmailorincludingincentives.22,23 Itdoesappear thatsurveyresponseratesmaybedecreasingovertimeand mayalsovarybymedicalspecialty,withsomehavinglow responseratesbelow30%.24,25

SinceEMPRNrequestssurveysbeasshortandsimpleas possibletoencourageparticipation,wefurtherexplored clinicians’ experiencesviakeyinformantinterviews.The

smallpoolofinterviewrespondentslimitedourqualitative data,whiletheuseofsnowballsamplingfromtwo neighboring,largelyruralstates(andmanytribalsites)may havelimitedthediversityofviewpointsandexternal generalizability.Futurestudiescouldincorporateexpanded interviewstogatherperspectivesfromcliniciansindifferent statesandpracticesettings.

CONCLUSION

ThewidespreadstrainontheUShealthcaresystemduring theCOVID-19pandemicmanifestedsigniﬁcantchallengesin interfacilitypatienttransfers.Cliniciansatsmall,rural facilitiesinArizonaandNewMexicofoundcentralized transfercoordinationcenterstobehelpful.Inthefuture, otherstatescouldconsidertrialingimplementationofsimilar services,bothincrisisandnon-crisistimes.

AddressforCorrespondence:MichaelB.Henry,MD,MS,Parker IndianHealthCenter,12033WAgencyAve.,ParkerAZ85344. Email: Mhenry12@gmail.com

REFERENCES

1.DwyerJ.Onehospitalwasbesiegedbythevirus.Nearbywas ‘plentyof space.’ 2020.Availableat: https://www.nytimes.com/2020/05/14/ nyregion/coronavirus-ny-hospitals.html AccessedSeptember29,2020.

2.WhiteDB,VillarroelL,HickJL.Inequitableaccesstohospitalcare: protectingdisadvantagedpopulationsduringpublichealth emergencies. NewEngJMed. 2021;385(24):2211–4.

3.Hernandez-BoussardT,DaviesS,McDonaldK,etal.Interhospital facilitytransfersintheUnitedStates:anationwideoutcomesstudy. JPatientSaf. 2017;13(4):187–91.

4.IwashynaTJ,ChristieJD,MoodyJ,etal.Thestructureofcriticalcare transfernetworks. MedCare. 2009;47(7):787–93.

5.McNaughtonCD,BonnetK,SchlundtD,etal.Ruralinterfacility emergencydepartmenttransfers:frameworkandqualitativeanalysis. WestJEmergMed. 2020;21(4):857–64.

6.EvansMandBerzonA.Whyhospitalscan’thandleCOVIDsurges: They’re ﬂyingblind.2020.Availableat: https://www.wsj.com/articles/ hospitals-covid-surge-data-11601478409?mod=hp_lead_pos10 AccessedOctober15,2020.

7.MedicalAdvisoryTeam.NewMexicoStatewideAcuteCareMedical SurgepPanforCOVID-19PandemicResponse.2020.Availableat: https://cv.nmhealth.org/wp-content/uploads/2020/04/NM-CSC-Plan-V. 4.17.20.pdf.AccessedNovember5,2023.

8.LeeAH,DunnPF,CooperS,etal.COVID-19level-loading: transferringemergencydepartmentpatientstoapartneracademic medicalcenterwithinahealthcaresystem. AmJMedQual. 2021;36(5):368–370.

9.IPAL(IllinoisProviderAccessLine)TransferCenter.Universityof IllinoisHospital&HealthSciencesSystem.2022.Availableat: https://hospital.uillinois.edu/referring-physicians/patient-transfer AccessedNovember5,2023.

10.SchorschK.TransferringpatientswithCOVID-19difﬁcultinChicago. 2020. https://www.wbez.org/stories/one-chicago-hospital-called-for-8hours-to-transfer-covid-19-patients-thats-problematic-for-futureoutbreaks/1ecd60f3-f185-4deb-ae65-3e3ca25f0063 AccessedSeptember29,2020.

11.CityofChicago.ChicagoHospitalCapacityDashboard.2022.Available at: https://www.chicago.gov/city/en/sites/covid-19/home/ hospital-capacity-dashboard.html. AccessedNovember5,2023.

12.MitchellSH,RiglerJ,BaumK.Regionaltransfercoordinationand hospitalloadbalancingduringCOVID-19surges. JAMAHealthForum. 2022;3(2):e215048.

13.ArtinoAR,DurningSJ,SklarDP.Guidelinesforreportingsurveybasedresearchsubmittedtoacademicmedicine. AcadMed. 2018;93(3):337–40.

14.ArtinoAR,LaRochelleJS,DezeeKJ,etal.Developingquestionnaires foreducationalresearch:AMEEguideno.87. MedTeach. 2014;36(6):463–74.

15.UniversityofArizona.AZREACHFAQs.2023.Availableat: https:// az-reach.com/reach-faqs.AccessedNovember5,2023.

16.CommitteeonTraumaoftheAmericanCollegeofSurgeons.Regional traumasystems:optimalelements,integration,andassessment.

Systemsconsultationguide.2008.Availableat: https://www.facs. org/media/sgue1q5x/regionaltraumasystems.pdf. AccessedNovember5,2023.

17.JollisJG,GrangerCB,HenryTD,etal.SystemsofcareforST-segmentelevationmyocardialinfarction:areportfromtheAmericanHeart Association’smission:Lifeline. CircCardiovascQualOutcomes. 2012;5(4):423–8.

18.CDCNationalCenterforHealthStatistics.COVID-19hospital encountersbyurban-rurallocationofthehospitalbyweekfromselected hospitals.2022.Availableat: https://www.cdc.gov/nchs/covid19/nhcs/ hospital-encounters-by-urban-rural.htm.AccessedDecember7,2022.

19.AtkinsonMK,HickJL,SingerSJ,etal.Doruralhospitalshavean advantageduringapandemic?2022. https://www.healthaffairs.org/do/ 10.1377/forefront.20220321.42134/.AccessedDecember6,2022.

20.MohammadiaghdamN,DoshmangirL,BabaieJ,etal.Determining factorsintheretentionofphysiciansinruralandunderdevelopedareas: asystematicreview. BMCFamPract. 2020;21(1):216.

21.UnitedStatesGovernmentAccountabilityOfﬁce.Ruralhospital closures:Affectedresidentshadreducedaccesstohealthcare services.2020. https://www.gao.gov/assets/gao-21-93.pdf AccessedSeptember21,2023.

22.PhillipsAW,ReddyS,DurningSJ.Improvingresponseratesand evaluatingnonresponsebiasinsurveys:AMEEguideno.102. MedTeach. 2016;38(3):217–28.

23.PhillipsAW,FriedmanBT,UtrankarA,etal.Surveysofhealth professionstrainees:prevalence,responserates,andpredictivefactors toguideresearchers. AcadMed. 2017;92(2):222–8.

24.CunninghamCT,QuanH,HemmelgarnB,etal.Exploringphysician specialistresponseratestoweb-basedsurveys. BMCMedRes Methodol. 2015;15:32.

25.CookJV,DickinsonHO,EcclesMP.Responseratesinpostalsurveysof healthcareprofessionalsbetween1996and2005:anobservational study. BMCHealthServRes. 2009;9:160.

SYSTEMATIC REVIEW

ImpactofMedicalTraineesonEfﬁciencyandProductivity intheEmergencyDepartment:SystematicReview

andNarrativeSynthesis

JakeValentine,MD*

JonathanPoulson,DO†

JesusTamayo,BA‡

AmandaValentine,MEng,MSHI§

JacquelineLevesque,EdD*

ShaneJenks,MD,MEd†

SectionEditor:CaseyM.Clements,MD,PhD

*UniversityofHouston,TilmanJ.FertittaFamilyCollegeofMedicine, Houston,Texas † HCAHoustonHealthcare,Kingwood,Kingwood,Texas ‡ TheUniversityofNorthTexasHealthScienceCenter,FortWorth,Texas § UniversityofTexasHealthScienceCenteratHouston,Houston,Texas

Submissionhistory:SubmittedNovember13,2023;RevisionreceivedMarch8,2024;AcceptedMarch22,2024

ElectronicallypublishedJuly18,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18574

Introduction: Effectivemedicaleducationmustbalanceclinicalservicedemandsforinstitutionsand learningneedsoftrainees.Thequestionofwhetherthesearecompetingdemandsorcanserve complementaryroleshasprofoundimpactsongraduatemedicaleducation,rangingfromfunding decisionstothewillingnessofcommunity-basedhospitalsandphysicianstoincludelearnersattheir clinicalsites.Ourobjectiveinthisarticlewastosystematicallyreviewtheevidenceontheimpactof medicaltraineesonproductivityandefﬁciencyintheemergencydepartment(ED).

Methods: WequeriedPubMed,Embase,Scopus,andWebofSciencefromearliestavailabledatesto March2023.Weidentifiedallstudiesevaluatingtheimpactofmedicalstudentsand/orresidentsinthe EDoncommonlyusedproductivityandefficiencymetrics.OnlystudiesinEDsintheUnitedStateswere included.Noadditional filterswereused.WeassessedtheriskofbiasofincludedstudiesusingtheRisk ofBiasinNon-randomizedStudies – ofInterventions(ROBINS-I)tool.Certaintyofevidencewasrated usingtheGRADE(GradingofRecommendationsAssessment,DevelopmentandEvaluation)approach. Study findingswerecombinedinanarrativesynthesisandreportedaccordingtoPRISMAguidelines.

Results: Theliteraturesearchyielded3,390uniquearticlesforabstractscreening.Eighty-oneabstracts wereidentiﬁedasrelevanttoourPICOquestion(population,intervention,control,andoutcomes),76of whichhadretrievablefull-textarticlesandthethemesofwhichwerediscussedinanarrativesynthesis. Weselected13ofthefull-textarticlesfor ﬁnalinclusioninasystematicreview.Studieswereroughlysplit betweenobservational(6)andquasi-experimental(7)designs.Themajorityofstudies(11)weresinglesitestudies.OnlytwostudiescouldbegradedaslowriskofbiaspertheROBINS-Itool.

Conclusion: Low-GRADEevidencesuggeststhatstudentsandresidentsdecreaseEDefficiencybya statisticallysmalleffectsizeofdebatableclinicalimportance.ResidentsprovideamoderateboosttoED productivity.StudentsdonotproduceastatisticallyorclinicallysignificantimpactonEDproductivity. Residentsincreaseemergencydepartmentrelativevalueunitsrevenueby$26.30anhour,whilestudents havenoimpact.Bothtypesoflearnersdecreaseefficiency.[WestJEmergMed.2024;25(5)767–776.]

INTRODUCTION

Therearecon ﬂ ictingopinionsontheperceivedvalueof medicaltrainees,stemmingfromtheirdualrolesoflearning

andservice.Traineesde ﬁ nevalueasmaximizinglearning opportunitiesandinteractionswithfaculty.Attending physiciansidentifyvalueastraineescompletingclerical

tasksandfreeinguptimeforpatientcare.Administrators seevaluethroughthelensofaddressingeconomic challengesofthehospital,withtraineesproviding potentialvalueviadocumentationandimprovementof organization-widemetrics bothofwhichareseenaslowvalueactivitiesbytrainees. 1 Itisnotpossibletosidestepthe con ﬂ ictbetweentheseroles,astimespentonteaching activitiesduringanEMshiftisindependentlyassociated withresidentperceptionsontheeducationvalueof theshift.2

Thereareseveraladditionalstakeholderconsiderations pertinenttoourresearchquestion.Communitypreceptors areincreasinglyseekingcompensationforteachingtime.3 Currentpracticesregardingcompensationforteachingtime ofcommunitypreceptorsareinconsistent.3 Alogicmodel mightpositthattraineesdecreasecompensationtothe supervisingphysicianbydecreasingrelativevalueunits (RVU)orincreasingtheamountoftimespentpost-shiftvia teaching,feedback,ordeferringon-shiftactivitiesforthese purposes.Ifthisisthecase,thenthiswouldstrengthen argumentsforcompensatingphysiciansforaccommodating learnersonshift.Ofcourse,traineesalsoprovideservicesthat mightbevaluedbyattendingsphysicians,suchasdecreasing theirdocumentationburden,arrangingconsults,and gatheringpatienthistories.

Stakeholdersintheadministratorandhospitalleadership categorymightbemoreorlessinclinedtoenteranaffiliation agreementwithamedicalschoolorgraduatemedical education(GME)programdependingontheprojected impactonimportantefficiencymetrics.Lastly,andperhaps mostcontroversially,therearehigh-stakesdecisions regardingthecontinuationofindirectgraduatemedical education(IME)funding,whichrelyontheimplicit assumptionsthattraineesincreasethecostofcareatleast partlyduetoimpactsonattendingphysicianproductivity andefficiency.Thisisbasedondatafromtrainingsitesthat historicallyhaverepresentedlarge,urban,universityaffiliatedhospitals,withlimitedgeneralizabilitytothe majorityofEDsacrossthecountry.Medicarehas reimbursedhospitalsforIMEcostssince1983basedon theratioofresidentsperhospitalbedandthepremise thatthehighercostsofpatientcareatteachinghospitalsis duetothepresenceoftrainees.4 In2019,over$10billionin IMEpaymentsweredistributedtoteachinghospitals, supportingroughly90,000residentsatacostof$110,000 perresident.5

Despitethisclearlydemonstratedneedfordataonthe impactoftraineesonefﬁciencyandproductivityintheED, therearenorandomizedcontrolledtrials,systematicreviews, ormeta-analysesonthesubject.Inthisarticleweaimedto ﬁll thatvoidbyexaminingexistingevidenceonthetopic, clarifyingcurrentgapsintheliterature,andmaking suggestionsforfutureresearch.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Learnerscanbebothanassetandaliabilityin termsofemergencydepartmentoperations.

Whatwastheresearchquestion?

Whatisthenetimpactoflearnerson ef ﬁ ciencyandproductivityinthe emergencydepartment.

Whatwasthemajor ﬁndingofthestudy?

Residentsincreaseemergencydepartment relativevalueunitsrevenueby$26.30anhour, whilestudentshavenoimpact.Bothtypesof learnersdecreaseef ﬁ ciency.

Howdoesthisimprovepopulationhealth?

This ﬁ ndingmayguidestakeholders regardingdecisionsaboutreimbursementfor educationservicesorhavinglearnersin theirdepartment.

METHODS

WequeriedPubMed,Embase,Scopus,andWebof SciencefromearliestavailabledatetoMarch9,2023.Search termsandsearchstrategyweredevelopedcollaborativelyby twocontentexpertsinmedicaleducation,onecontentexpert inhealthcareadministrationandpublicpolicy,andtwo researchlibrarians.OurPICOquestion(population, intervention,control,andoutcomes)was “Whatisthe impactoflearnersinthe(ED)onefﬁciencyandproductivity metrics?” Thepopulationforourquestionwaslearners.We includedbroadertermssuchas “trainee” and “learner” in oursearchstrategyincasetherewasliteratureonnontraditionalrotatorssuchasstudentsinundergraduate, scribe,oradvancedpracticepractitionerprograms.Wealso includedsynonymsusedtodescribemedicalstudentsand residentsuchas “clerk” and “intern” (AppendixA).

Theinterventionofinterestwaspresenceofalearner, comparedtoabsenceofalearner.Thelearnerhadtobe presentintheEDandunderthedirectsupervisionofan emergencymedicineattending.Ouroutcomewasefﬁciency andproductivity.Efﬁciencydescribedhowquicklypatients movedthroughthedepartmentandincludedsynonymssuch as “throughput.” Productivityreferredtohowmuchworkan attendingphysicianwasabletocomplete,mostcommonly measuredbypatientsseenorRVUsgeneratedperunitof time(AppendixA).ThesePICOcharacteristicswere capturedbythesearchtermsoutlinedin AppendixB.

The firstauthorreviewedtheinitial6,175resultstoensure thattheautomaticallydetectedduplicateswereappropriate andmanuallyexcludedundetectedduplicates.The remaining3,390abstractswerescreenedbytworeviewersto judgewhetherthearticlewouldsatisfyourPICOquestion, withdifferencesadjudicatedbyathirdreviewer.Reviewers workedindependentlyandwereblindedtotheresultofthe firstvoteforcasesinwhichtheyservedassecondreviewer. Adjudicationalsooccurredblindly,withoutaccesstothe individualreviewer’svotes.Ofthese81abstracts,76were availableforfull-textreview.Full-textreviewswere performedbythe firstauthorwithnotationsdescribing justificationforproposedinclusionorexclusion.Annotated fulltextswerethenputtoaconsensusvoteamongthefour reviewers.Weappliedanadditionalinclusioncriterionof studiesconductedintheUnitedStatesduringthisstep,owing todifferencesintrainingandsupervisionrequirementsfor medicaltraineesinothercountries.Recordswerecompiled usingCovidencesystematicreviewsoftware(VeritasHealth Innovation,Melbourne,Australia).

Thereferencessectionsofincludedstudieswerehandcheckedforadditionalcandidatesforinclusion,butthissearch didnotrevealanynewstudiestoaddtothe finalinclusionlist. Datawasextractedbythe firstauthorandorganizedby populationandoutcome.Theimpactofresidentsandstudents ontheoutcomecategoriesweredisplayedseparatelywhen possible.Weconstructedtablesand figuresaccordingtothe CochraneHandbookforSystematicReviewsof Interventions 6 Astandardizedeffectsize(Cohen d )with95% confidenceintervalswascalculatedforstudiesthatprovided thenecessarydata.Weratedcertaintyofevidenceusingthe GradingofRecommendation,Assessment,Developmentand Evaluation(GRADE)approach,adaptedforreviewsnot includingasingleestimateofeffect.7

WeassessedriskofbiaswasassessedusingtheRiskofBias inNon-randomizedStudies – ofInterventions(ROBINS-I) tool,8 withnotationsmadethroughCovidenceandconsensus assessmentvoteduponbythefourreviewers.Effectmeasures werepresentedasreportedbyeachincludedarticle.We presentedresultsofthesystematicreviewandnarrative synthesisaccordingtoPRISMAguidelines.9

RESULTS

AsearchofPubMed,Embase,Scopus,andWebof Scienceidentified6,175articleswith2,785duplicates,leaving 3,390articleabstractstobescreened.Weexcluded3,309 abstractsthatdidnotaddressourPICOquestions,yielding 81full-textarticlessoughtforretrieval, fiveofwhichwere unavailableastheywereabstract-onlypublications.Themes fromthese76articlesarediscussedinthenarrativesynthesis, witha final13selectedforinclusionforthesystematicreview (Figure1).Characteristicsofincludedstudiesare summarizedin AppendixC

ThemesofExcludedStudies

Commonreasonsforexclusionafterfull-textreviewwere wrongsettingorwrongoutcome.Somestudiesevaluated fellows10 ormoonlightingresidents11,12 whowerepracticing independentlyandnotbeingdirectlysupervisedbyanEM attending.AnEmory-basedstudyshowedEM-trained criticalcarefellowscaringforboardingintensivecareunit patientsgeneratedanadditional3.07RVUs/hourforthe department.10 NorthwesternUniversityevaluatedthe economicsofpayingresidentstoserveastriagephysiciansin amoonlightingroleintheirEDandfoundthatthereturnon investmentfrom “leftwithoutbeingseen” chargecapture was +54%.11 Svirskyetal(2013)showedasimilar moonlightingprogramreducedlengthofstay(LOS)by25 minutes.Thesestudieswerenotincludedinourreviewasthe residentsandfellowswereneitheractinginalearnerrolenor beingsupervisedbytheon-shiftEMattendingphysician.

SeveralexcludedstudiesinvolvedlearnersintheEDon non-EMserviceswhowerenotsupervisedbytheon-shiftEM attending.ReplacingasurgicalresidentwithanMLP (midlevelpractitioner)duringprotectededucationtime added67minutestoEDLOS.13 Residentpresenceona traumarotationdecreasedEDLOSforadmittedtrauma patients.14 Residentsonatraumaconsultservicedidnottake anylongerthanattendingsurgeonstocomplete consultations.15 Presenceofanin-housecardiologyfellow decreaseddoor-to-balloontimesforST-segmentelevation myocardialinfarction(STEMI).16

Somestudiesevaluatedtheimpactoflearnersonefficiency orthroughputmeasuresbutcomparedthemtoMLPsor simultaneouslyadjustedattendingphysicianstaffing. 16–18 McGarryetal(2010)usedapre-postdesignevaluatingLOS afteranewEMresidencyprogramwascreatedattheir hospital.Theyredistributed33%oftheattendingphysician coveragetowardthelow-acuity “urgent-care” areaoftheir department.TherewasaslightincreaseinLOSpostimplementationoftheresidencyprogram,butgreater differencesmayhavebeenmaskedbythefactthatthelowacuityarea theareamostlikelytobebottleneckedby clinicianefficiency hadmorecoverage.Frenchetal(2002) foundthatpatientswaitedanadditional20minutesfor dispositiondecisionswhenresidentswereabsenton conferencedays.However,conclusionsregardinglearner presencewouldbedifficulttomake,astheyreplacedthe roughly60hoursofresidentcoveragewith40hours ofMLPandfacultycoverage.Clearly,residentswereviewed asassetsrequiringincreasedstaffingtooffsettheirabsence, butthesestudiescomparetraineeperformancetoMLPor attendingphysicianperformanceratherthanstrictly presencevsabsenceoflearnersandwerethusomitted fromourreview.

Otherstudiestookplaceinapediatric-onlyED.These studiesgenerallydemonstratedanincreaseinLOSwith residentand/ormedicalstudentteams,likelymediated

,PreferredReportingItemsforSystematicreviewsandMeta-Analyses.

throughincreasedlaboratoryandimagingutilization.19,20,21 Jadhavetal(2019)showedaclearassociationbetween residentinvolvementinacase,thenumberofstudiesordered, andtheLOSincreaseforthosecases.Coreyetal(2022) redemonstratedthese ﬁndingsandalsoshowedthatresident involvementwaslinkedwithanincreaseinRVUs/patient, againlikelymediatedbyincreasedtestutilization.Whilethis resultispotentiallypositivefromahospitaladministration perspectiveinthatitincreasesrevenue,italsolikely

representslow-valuecarethatinﬂatesthepatient’sbilland thecostofhealthcareasawhole.Wedidnotincludestudies frompediatricEDsastheyhaveverydifferentoperational characteristicsthanadultorcombinedEDs.

Thereweremultiplestudiesinothercountriesusinga naturalexperimentalconditionofferedbyjuniorphysicians goingonstrike,buttheapplicabilityofthesejuniordoctors toresidentphysiciansintheUSislimitedduetodifferencesin trainingandsupervisionrequirements.22,23,24,25 Studiesfrom

Figure1. PRISMA* ﬂowdiagram. PRISMA

Korea,22 NewZealand,23 Spain,24 andAustralia25 all provideinterestingcasestudies,butthe “juniordoctor” terminologyisvariablydeﬁned,sometimesreferringto independentlypracticingphysiciansandatothertimes referringtophysiciansintraining.

Studiesexcludedonthebasisofwrongoutcometendedto measurepatientsatisfactionorqualityofcaremetrics. Perhapsmostinterestingly,Michaeletal(2022)showedthat EMresidentsimprovedtime-limitedqualitymetricsfor stroke,sepsis,andSTEMI,whileoff-serviceresidentsinthe EDhadanegativeimpact.26

NarrativeSynthesisofIncludedStudies

The13includedstudiesaddressedourPICOquestionby isolatingpresencevsabsenceoflearnerastheintervention andcomparisongroups,restrictingthepopulationto learnersintheEDunderthesupervisionoftheon-shift emergencymedicineattendingphysician,andincludeda measureofefﬁciencyorproductivity.

EfficiencymetricswereasdefinedbytheEmergency DepartmentBenchmarkingAllianceConsensusSummit (Figure2).27 Non-standardizeddefinitionsareexplainedin relationtothe figure.Otherabbreviationsencountered includeddLOS,whichstandsforlengthofstayfor dischargedpatients,andTT,whichistheintervalfrom treatmentspacetime “towhen[thepatient]iseither dischargedoradmittedtothehospital.”28 Itwasunclear whethertheendpointofthisintervalwasdispositionor departuretime,andtheauthorsdidnotrespondtoemail inquiriesrequestingclarification.

Sevenstudiesassessedtheimpactofresidentsonefficiency intheED(Table1).Most(6/7)ofthestudiesshowedasmall decreaseinefficiency.Themeasuredimpactsonefficiency wereallstatisticallysmall(Cohen d rangedfrom 0.15to 0.15),buttheclinicalsignificanceoftheimpactismore difficulttodetermine.Thenetdifferenceinefficiencyranged

EmergencyDepartmentBenchmarkingAlliancetime stampsandintervals.

LOS,lengthofstay; DTDD,doortodispositiondecision; RTDD,room todispositiondecision; PDI,practitionerdispositioninterval.

from( 58)to73moreminutesspentintheED,withstudies clusteringreasonablywellaroundthemedianvalueof26 minutes.Atacademicdepartmentswithverylongaverage LOS,26minutesmaynotbeameaningfulincrease.These sevenstudies,withtheexceptionofthePittsetalstudy (2014),wereconductedatasingleacademicsite.32 Each study,withtheexceptionofLammersetal(2003),31 included anaveragetimemetricabovethreehours,helpingtoexplain thesmallstatisticaleffectsize.Weidentiﬁedthreeissueswith interpretationofclinicalmeaningfulnessoftheimpactof residentpresenceonEDefﬁciency.

Firstly,thevaryingmeasuresofefficiencymakesynthesis ofeffectsizeproblematic.Metricsthatincludetheinterval betweendispositionanddeparturetimeareinfluencedby boarding,whichisathroughputbottleneckthatislargely unaffectedbyresidentpresenceintheEDandservesto attenuateanydifferencesinefficiencybetweengroups.28,29,32 Theefficiencyoftheemergencyteamcaringforapatientwho spendsseveralhoursawaitinganinpatientbedispoorly reflectedinthesemetrics.

Secondly,someofthestudiesexcluded “fast-track” patients.28,33 Emergencydepartmentshaveseveralnamesfor thesesplit-flowmodels,whichallemphasizeidentifying patientswithlowerdepartmentalresourceneedswiththeaim ofexpeditingtheirworkupanddisposition.Thesearethe patientencountersinwhichefficiencyispotentiallymost subjecttothepresenceofatrainee,astheremaybeno competingthroughputbottleneckslikeimagingor laboratoryturnaroundtime.Exclusionoffast-trackpatients attenuatesmeasuredefficiencydifferences.

Thirdly,selectionandgroupallocationbiaseswere presentinvaryingdegreesoftheincludedstudies.Whenthe unitofanalysisistheindividualpatientencounter,30,32 there isahighriskofselectionbiasastheresidentsmaybe preferentiallyoptingforcomplexcases,whicharemorelikely tomeaningfullyaugmenttheirlearning.Thepresenceofa residentisthusbestviewedasaconfounder,tightly associatedwithcasecomplexity,whichisaknowndriverof LOS.41 Thislimitationisperhapsmoststronglypresentinthe Pittsetal(2014)study.32 Thisnationallyrepresentative sampleassessedLOSforpatientencountersthatincludeda residentcomparedtoencounterswithonlyanattending physician.Whiletheauthorsattemptedtolimitconfounding byadjustingforpatientfactorssuchasageandtriageacuity, thenuancesofpatientcomplexityarelikelytoescapethe simpliﬁcationofacontrolvariable.Theauthors’ suggestion that “residentsseevirtuallyallpatientsinmajorteaching EDs” appearsempiricallyuntruegiventhemultiplestudiesin ourreviewthatnotetheabsenceoflearnerinvolvementfor loweracuitypatientsinsplit-ﬂowEDmodels.

Groupallocationbiasariseswhenthepropensityfor attendingphysicianstoworkwithresidentsislinkedto differencesinefﬁciencymetrics.Forexample,physiciansin educationleadership(corefaculty,assistantprogram

Figure2.

Table1. Studycharacteristicsgroupedbyparticipantandoutcomecategories.

Study(measure)

Efﬁciency – Residents

Andersonetal,201328 (TT)246visits7,689visits 58minutest 0.15[ 0.27, 0.02]K–S0.02

DeLaneyetal,201329 (LOS)

DeLaneyetal,201329 (DTDD)

153,703visits40,331visits26minutes*N/AN/AK–W <0.001

153,703visits40,331visits30minutes*N/AN/AK

Krautetal,202030 (RTDD)4,537visits3,421visits10minutes0.10[0.06,0.15]N/A0.01

Lammersetal,200331 (DTDD) N/AN/A40minutesN/AN/A t <0.001

Pittsetal,201432 (LOS)3,374visits25,808visits73minutes*N/AN/AN/A <0.05

Robinsonetal,202033 (PDI)103,871visits7,283visits18minutes0.15[0.13,0.17] t <0.001

Efﬁciency – Students

ChanandKass,199934 (dLOS)

DeLaneyetal,201329 (LOS)

DeLaneyetal,201329 (DTDD)

13,949visits40,331visits24minutes*N/AN/AK–W <0.001

13,949visits40,331visits15minutes*N/AN/AK–W <0.001

Ioannidesetal,201535 (LOS) 1,029,165

Smalleyetal,201436 (dLOS) 6,880visits2,188visits14minutes*N/AN/AWN/A

Efﬁciency – MixedTrainees

Dehonetal,201537 (LOS)377days18days2.4minutes0.07[ 0.41,0.54] t 0.28

Productivity – Residents

Bhatetal,201438 (PPH)1,935shifts2,199shifts0.12PPH0.34[0.28,0.41]

Clinkscalesetal,201639 (RVUs/patient)

Robinsonetal,202033 (PPH)

Productivity – Students

12,494visits11,560visits0.2RVUs/patient0.53[0.50,0.55]

103,871visits7,283visits0.4PPH0.21[0.19,0.24]

<0.001

Bhatetal,201438 (PPH)514shifts2,199shifts0.0PPH0.00[-0.10,0.10] t 0.99 Hilleretal,201440 (RVUs/shift) 101shifts101shifts0.13RVUs/shift0.01[ 0.27,0.28]

tDenotesdifferencesofmedians.Meanvaluesnotexplicitbutweredisplayedgraphicallyandacceptablyclosetostatedmedianvalues. *Denotesdifferencesofmedians.

TT,treatmenttime; LOS,lengthofstay; DTDD,doortodispositiontime; RTDD,roomtodispositiontime; dLOS,dischargelengthofstay; PDI,practitionerdispositioninterval; PPH,patientsperhour; RVU,relativevalueunit; t,two-tailedStudent t-test; K–S,Kolmogorov–Smirnovtest; K–W,Kruskal-Wallistest; W,Wilcoxonrank-sumtest.

directors,andprogramdirectors)wouldlikelybepulledto attendconference.Thesephysiciansasagroupmayexhibit differentpracticepatternsandefﬁciencytrendsthantheir colleagues.42 Thedirectionandmagnitudeofthisbiasis difﬁculttoguessowingtothepaucityofliteratureonthe topic.Robinsonetal(2020)didacommendablejobat controllingthisbiasbyonlyincludingdatafromattendings

with “balancedschedules” meaningthosewhoroutinely workshiftsbothwithandwithoutresidents.33 Therestofthe studiesthatusedshiftsastheunitofanalysisdonotmention orcontrolforthispossibleinteractionbetweenlearnerand attendingschedules.28,29,31

Fourstudiesassessedtheimpactofmedicalstudentson efﬁciencymetricsintheED.Most(4/5)showedthatstudent

Table2. Certaintyofevidenceofincludedstudies.

OutcomeEffect

Residentimpacton efﬁciency

Studentimpacton efﬁciency

Residentimpacton productivity

Studentimpacton productivity

Most(6/7)studiesshowedasmall tomoderatedecreaseinefﬁciency.

Most(4/5)studiesshowedasmall decreaseinefﬁciency.

All3studiesshowedanincreasein productivity,centeringaroundamedium effectsize.

Bothstudiesshowednoassociationwith productivity.

Numberof studiesCertaintyoftheevidence(GRADE)

7LOW 00 (duetoseriousriskofbiasandindirectness)

5LOW 00 (duetoseriousriskofbiasandindirectness)

3LOW 00 (duetoseriousriskofbiasandmoderate indirectness)

2LOW 00 (duetomoderateriskofbiasand severeindirectness)

GRADE,GradingofRecommendationsAssessment,DevelopmentandEvaluation.

presencehadastatisticallysmalldecreaseonEDefficiency, withimpactsrangingfrom( 5)to24minutesandamedian effectof14minutes.Similardifficultiesasmentionedabove precludedconclusionsontheclinicalsignificanceofthis impact.Theefficiencymeasuresgenerallyincludedboarding time,29,34–36 althoughexclusionoffast-trackpatientswasless ofathreatforthisgroup,asChanandKass(1999)and Smalleyetal(2014)focusedonlyondischargedpatients.34,36 SelectionbiaswaslikelypresentintheSmalleystudy,since themedicalstudentswerepartofaspeciallydesignated teachingservicethatonlysawpatientsinparticular treatmentrooms,presumablyinthehigher-acuityareasof theED.36

Groupallocationbiaswasrelativelywell-protected againstintheIoannidesetal(2015)studybyusinganatural experimentalblockdesignwithstudentsbeingpulled fromthedepartmenttoattendanesthesiatrainingforthelast weekofeachmonth-longrotation.35 Smalleyetaluseda similarconditionofstudentabsenceduringthelastFridayof eachrotation,duringwhichstudentstooktheirend-ofrotationexam.36 Therewouldbealessobviousconnection betweenattendingcharacteristics(ie,involvementin educationleadership)andlearnerpresenceunderthese conditionsthanwithonebasedonresidentconference timeascommonlyseeninthestudiesonresidentimpact ofEDefﬁciency.

Allthreestudiesthatmeasuredresidentimpacton productivityshowedamoderatetolargestatisticalincrease, withCohen d rangingfrom0.21–0.53.33,38,39 Theclinical signiﬁcancecanperhapsbebestillustratedinthefollowing example,whichassumestheaverageoflevel4charting, reimbursedatthe2022rateof2.74RVUsperlevel4patient. ThePPHdifference(0.26)andRVUs/patientdifference(0.2) add0.76RVUs/hourtoanattendingphysician’ s

productivity.43 TheCentersforMedicareandMedicaid Servicesreimbursed$34.61/RVUin2022.43 Thus,a residentwouldbringanadditional$26.30/hourofrevenue fromworkRVUstotheED.Thetwostudiesonmedical studentimpactonproductivityshowednostatistically signiﬁcantdifference.38,40

Lastly,Dehonetal(2015)offeredauniqueanalysis incorporatingthetotalnumberoflearnersintheED, inclusiveofbothstudentsandresidents.37 Thecorrelation approachtototalnumberoflearnersandefficiencyand productivitymetricsisinterestingbutpotentially flawedin thatthereisreasontothinkresidentandstudentpresencehas aninteractiveratherthancumulativeeffect.Thesuspicion thatresidentsmaymitigatestudentimpactsonefficiencyand productivityisreflectedinHilleretal’s(2014)observation that “residentsperformedthebulkofteachingandclinical supervision” ofmedicalstudents.40

Asummaryofthecertaintyofevidenceofincludedstudies isprovidedin Table2

DISCUSSION

Oursystematicreviewevaluated13studiesexaminingthe effectoflearnerpresenceonefﬁciencyandproductivityin EDs.Themajorityofthesestudies(10outof13)showed moderatetosevereriskofbias,leadingtolow-GRADE (GradingofRecommendationsAssessment,Development andEvaluation)evidenceforthefourinvestigatedoutcomes. Thisbiaswasprimarilyduetopotentialconfoundersand indirectnessofoutcomemeasures,factorswhichledusto downgradethereview’sevidencelevel.

Thelow-GRADEevidencesuggeststhatstudentsand residentscausestatisticallysmall-to-moderatedecreasesin EDefﬁciency,withdebatableclinicalmeaningfulness. ResidentsincreaseEDproductivitybyastatistically

andclinicallymoderateeffectsize.Studentsdonot produceastatisticallyorclinicallysigniﬁcantimpact onEDproductivity.

Wecanreviewtheimplicationsofthisreviewonthe multiplepartiesinvolvedinthedecisiontohostmedical studentsandresidentsatanemergencydepartment.

Hospitalanddepartmentaladministratorsmaycontinue tohaveconcernsaboutlearnerimpactonEDefﬁciency. Thisappearstobeatmostamodesteffectandcanbe reframedasanecessarycostforensuringaviable physicianpipeline.

Fromapublicpolicystandpoint,theroleoftraineesinthe inefficienciesofteachinghospitalsandincreasedcostofcare shouldcontinuetobeinvestigated.InEM,thereis24/7 bedsidesupervision,andmostresourceutilizationandall dispositiondecisionsarerunbyanattendingphysician.This mayexplainthenon-intuitivesuggestionthatEM postgraduateyear-(PGY)3residentsslowdowna departmentasmuchasinternsdo,31 possiblyduetogreater deferencetothePGY-3residentonmedicaldecisionmaking,whichincreaseslaboratoryandimaging utilization.19–21 Importantdifferenceslikelyexistbetween servicelinesintherelativecontributionoftraineesto inefficiencyanddecreasedproductivity.Whilecost-of-care differenceswerenotdirectlyaddressedbythisreview,it wouldnotappearthattraineesintheEDarealargesourceof varianceforefficiencyorproductivity.Forattending physicians,thisreviewshouldprovidereassurancethat havinglearnersonshiftwillnotnegativelyimpacttheir RVU-basedcompensation.

Medicalschoolswithoutsalariedclinicalfacultythathave built-inteachingexpectationswillneedtocontinuerecruiting communitypreceptors.Thedecisiontocompensatethese preceptorsremainscomplicated.3 Thereviewsuggeststhat attendingphysiciansbalanceteachingobligationswithout sacriﬁcingproductivity.However,thisbalancemaybe achievedbydeferringlessurgentclinicalobligations,suchas charting,untilaftershiftend.Thiscouldcreateasigniﬁcant, unmeasuredtimecost.Futurestudiesmightinvestigatethe timespentaftershiftswhenaccommodatingtrainees,using timestampspulledfromelectronichealthrecords.

LIMITATIONS

Thisreviewissubjecttocertainlimitations. Inconsistenciesinoutcomereportingprecludedmetaanalysis.Asanexample,therelativecontributionofastudy with1,935shiftsvsonewith103,871patientencountersis difﬁculttoreconcile,evenifstandardizedeffectsizesare available.Also,itwouldbechallengingtocombinean indirectefﬁciencymeasurelikeLOSwithamoredirect measurelikedoor-to-dispositiondecision.Thelearner populations’ varyingservicelinesandtraininglevelsadded anotherlayerofnuanceprecludingdirectcomparison betweenstudies.

Weidentifiedfourrepeatedthemesleadingtoanincreased riskofbias.First,themethodsofgroupallocationwereoften unclearinthestudies.Aphysician’stendencytoworkshifts withouttraineescouldrelatetotheirefficiencyor productivity.Onlytwostudiescontrolledforthis influence.33,41 Giventheethicalissuesthatwouldarisefroma randomizedexperimentaldesign,havinganatural experimentalsettingislikelythebestevidence-generating opportunitythatwillbeofferedonthetopicoftrainees’ impactonEDefficiencyandproductivity.Futureresearch shouldexplicitlyaddressorcontrolthispotentialbiasfrom groupallocation.

Second,cross-sectionaldesignsshouldcontinuetobe used.DatafromtheEmergencyDepartmentBenchmarking Alliancehaveshownaconsistent,gradualincreaseinED LOSfrom2010–2022,44 indicatingariskofmaturationbias inpre-/post-residencydesigns.31,39 Third,LOSisnota reliablemarkerofEDefficiencyasitisgreatlyinfluencedby externalfactorssuchasboardingtimes,whicharebeyondthe ED’scontrol.Futurestudiesshouldfocusonmetrics primarilyinfluencedbyEDoperations.

Fourth,theunitofanalysisshouldbeshifts,notindividual patientencounters.Thisapproachcanreducetheriskof reversecausation,whereresidentsarepreferentiallyassigned tomorecomplexpatients.Thepresenceofthisbiaswas highlightedinseveralstudies.29,30,32 Thiswouldalsocontrol forvaryingpracticesamongattendingphysiciansinwhich somemayindependentlyseelow-complexitycasesthatare felttobeunlikelytomeaningfullycontributetolearning.

The findingthatresidentsmaydecreaseEDefficiencyand onlymodestlyincreaseproductivitymaycontrastwiththe experienceofphysiciansat “resident-run” or “county” programs.Anecdotally,theseareunder-resourced departmentsthatrelyonresidentstoperformnecessary servicesthatwouldbeoffloadedtonon-physicianstaffat otherdepartments.Thesenon-RVU-generatingactivities suchasgatheringequipmentforprocedures,starting intravenouslines,andtransportingpatientswouldnotbe capturedinourstudy’sproductivitymetricsbutarecertainly necessaryandvalue-addedactivities.

ThelegalmandateofEHRimplementationaspartofthe 2009AmericanRecoveryandReinvestmentActmay challengeapplicabilityofearlierstudiessincepartofresident andstudentefficiencybenefitslikelyincludeoffloadingthe documentationburdenfromtheattendingphysician. However,thetimeincreasespentchartinganddocumenting post-EHRimplementationseemstobesmall,notwarranting theexclusionofpre-EHRstudies.45

Historically,thevastmajorityofmedicaltrainees havebeenlocatedatuniversity-associatedhospitalsthat representlarge,urban,tertiary-care,traumacenters. Thus,weexpectanysystematicreviewtobeskewedtoward thesecharacteristics.Ourreviewincluded11studies fromacademicsitesandonlyonefromacommunitysite,

whichlimitsgeneralizabilitytoEDsnotmatching thosecharacteristics.

Werecommendfutureresearchonthistopictofocuson communitytrainingsites,giventheirincreasingroleinGME training.46,47 Applying findingsfromacademicEDsto communityEDscanbemisleadingduetodifferencesin operationalcharacteristics.48 Theimpactoftraineeson efficiencyandproductivitycouldbemorepronouncedin smallercommunityEDsthatservealowerpercentageof complexpatientsanddonotemploythesplit-flowmodels commonlyusedinthestudiesincludedinourreview.

CONCLUSION

Oursystematicreviewprovideslow-GRADEevidence thatthepresenceoflearnersintheEDmaymodestly decreaseefﬁciency.However,thiseffectmaybeoffsetbya similarlymodestincreaseinattendingphysicianproductivity whensupervisingresidents.Medicalstudentsdonotimpact attendingphysicianproductivity.Thediscussionhighlights howtheseeffectsimpactthemultiplestakeholdersinmedical educationandoffersseveralconsiderationsforfuture researchonthistopic.

wp-content/uploads/imported-ﬁles/Recruiting-and-Maintaining-U.S. -Clinical-Training-Sites.pdf.AccessedJanuary26,2023.

4.NguyenNXandSheingoldSH.Indirectmedicaleducationand disproportionateshareadjustmentstoMedicareinpatientpayment rates. MedicareMedicaidResRev. 2011;1(4):001.04.a01.

5.MedPAC.ReporttoCongress:MedicareandtheHealthCareDelivery System.Chapter6:RevisingMedicare’sindirectmedicaleducation paymentstobetterreﬂectteachinghospitals’ costs.2021.Availableat: https://www.medpac.gov/wp-content/uploads/import_data/scrape_ ﬁles/docs/default-source/default-document-library/jun21_ch6_ medpac_report_to_congress_sec.pdf.AccessedApril10,2023.

6.SchünemannHJ,HigginsJP,VistGE,etal.Completing ‘summaryof ﬁndings’ tablesandgradingthecertaintyoftheevidence. In:Cochrane HandbookforSystematicReviewsofInterventions(375–402) Hoboken,NJ:JohnWiley&Sons,2019.

7.MuradMH,MustafaRA,SchünemannHJ,etal.Ratingthecertaintyin evidenceintheabsenceofasingleestimateofeffect. EvidBasedMed. 2017;22(3):85–7.

8.SterneJA,HernánMA,ReevesBC,etal.ROBINS-I:atoolforassessing riskofbiasinnon-randomisedstudiesofinterventions. BMJ. 2016;355:i4919.

9.PageMJ,McKenzieJE,BossuytPM,etal.ThePRISMA2020 statement:anupdatedguidelineforreportingsystematicreviews. BMJ. 2021;372:n71.

AddressforCorrespondence:JakeValentine,MD,Graduate MedicalEducation,22999USHwy59N,Kingwood,TX77339. Email: jvalent3@central.uh.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisresearchwassupported(inwhole orinpart)byHCAHealthcareand/oranHCAHealthcare-affiliated entity.Theviewsexpressedinthispublicationrepresentthoseofthe author(s)anddonotnecessarilyrepresenttheofficialviewsofHCA Healthcareoranyofitsaffiliatedentities.Therearenootherconflicts ofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

TelemedicalDirectiontoOptimizeResourceUtilizationinaRural EmergencyMedicalServicesSystem

RameshKarra,MD*

AmberD.Rice,MD*†

AileenHardcastle,BS*

JustinV.Lara,BS*

AdrienneHollen,MS*

MelodyGlenn,MD*†

RachelMunn,DO*

PhilippHannan,MD*

BrittanyArcaris,MD*

DanielDerksen,MD*†

DanielW.Spaite,MD*†

JoshuaB.Gaither,MD*†

SectionEditor:ScottGoldstein,DO

*TheUniversityofArizona,CollegeofMedicine,DepartmentofEmergencyMedicine, Tucson,Arizona

† TheUniversityofArizona,CollegeofMedicine,DepartmentofEmergencyMedicine, Phoenix,Arizona

Submissionhistory:SubmittedAugust11,2023;RevisionreceivedApril23,2024;AcceptedJune17,2024

ElectronicallypublishedAugust27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18427

Background: Telemedicineremainsanunderusedtoolinruralemergencymedicalservces(EMS) systems.Ruralemergencymedicaltechnicians(EMT)andparamedicsciteconcernsthattelemedicine couldincreaseAdvancedLifeSupport(ALS)transports,extendon-scenetimes,andfacechallenges relatedtoconnectivityasbarrierstoimplementation.Ouraiminthisprojectwastoimplementa telemedicinesysteminaruralEMSsettingandassesstheimpactoftelemedicineonEMSmanagement ofpatientswithchestpainwhileevaluatingsomeoftheperceivedbarriers.

Methods: Thisstudywasamixed-methods,retrospectivereviewofqualityassurancedatacollected priortoandafterimplementationofatelemedicineprogramtargetingpatientswithchestpain.We comparedquantitativedatafromthe12-monthpre-implementationphasetodatafrom15monthspostimplementation.Patientswereincludediftheyhadachiefcomplaintofchestpainora12-lead electrocardiogramhadbeenobtained.TheprimaryoutcomewastherateofALStransportbeforeand afterprogramimplementation.SecondaryoutcomesincludedEMScallresponsetimesandEMSagency performanceonqualityimprovementbenchmarks.Qualitativedatawerealsocollectedaftereach telemedicineencountertoevaluateparamedic/EMTandEMSphysicianperceptionofcallquality.

Results: ThetelemedicinepilotprojectwasimplementedinSeptember2020.Overall,therewere58 successfulencounters.Forthisanalysis,weincluded38patientsinboththepre-implementationperiod (September9,2019–September10,2020)andthepost-implementationperiod(September11, 2020–December5,2021).Amongthispopulation,theALStransportratewas42%beforeand45%after implementation(oddsratio1.11;95%conﬁdenceinterval0.45–2.76).TheEMSmedianout-of-service timeswere47minutesbefore,and33minutesafter(P = 0.07).Overall,64%ofparamedics/EMTsand 89%ofEMSphysiciansratedthetelemedicinecallqualityas “good.”

Conclusion: InthisruralEMSsystem,atelehealthplatformwassuccessfullyusedtoconnect paramedics/EMTstoboard-certiﬁedEMSphysiciansovera15-monthperiod.Telemedicineusedidnot alterratesofALStransportsanddidnotincreaseon-scenetime.Themajorityofparamedics/EMTs andEMSphysiciansratedthequalityofthetelemedicineconnectionas “good.” [WestJEmergMed. 2024;25(5)777–783.]

INTRODUCTION

Telemedicinehasimprovedhealthcaredeliveryand outcomesforruralpopulations.1–5 Asruralcommunities acrosstheUnitedStates(US)struggletorecruit,train,and retainparamedicsandemergencymedicaltechnicians (EMT),thesecommuitiesareleftwithashortageofqualiﬁed individualstoprovidehealthcareandanincreasedcostto deliverthatcare.6–9 Telemedicineforemergencymedical services(EMS)maybeparticularlyusefulinrural communitiesthatfaceparamedicshortages.2–4

Withparamedicshortages,manyruralEMSagenciesoften dependonaloneparamedictoservetheircommunity.Inthis setting,whentwo911callsoverlap,theruralcommunityisleft withoutAdvancedLifeSupport(ALS)coverage.Thisgapin ALSserviceisparticularlyimportantinthecareofpatients withchestpain.Forexample,assumeanALStransportis neededinaruralcommunityandthesoleparamedicistaken outoftheserviceareaforhours.Thenassumethatduringthat sameperiod,asecond911callforchestpainoccurs.Forthat secondcall,thecommunityisleftwithonlyaBasicLife Support(BLS)responderwhocannotinterpret electrocardiograms(ECG).Inthisscenarioeitherahelicopter iscalled,increasingcostofservicedelivery,orthepatientis transportedemergentlybyBLSresponders,increasingriskto boththeEMTsandthepatient.Clearly,inthisscenariothere isthepotentialforatelemedicinephysiciantoreducesomeof theburdenplacedonresource-limitedcommunities.

However,wefoundthatsomeEMSsystemsarereluctant toimplementtheseprogramsforavarietyofreasons.

Paramedicssharedconcernsthataphysician’spolicyof mandatingALStransportforallpatientsmightlowerthe physician’sliabilityattheexpenseofincreasingthenumber ofALS-requiredtransports.Otherswereconcernedthat performingatelemedicinevisitwouldtakeasigniﬁcant amountoftime,thusfurtherreducingavailabilityofALS resources.Finally,therewerealsosomeconcernsaboutthe lackofaccesstocellulardataandwhetherthetelemedical solutionwouldbeavailablewhenneeded.

Thesepotentialbarriersareimportanttoevaluatepriorto widespreadimplementationofEMStelemedicinesolutions. Toevaluatethebeneﬁtsandpotentialrisks,aruralEMS telemedicinepilotprojectwasimplementedtargetingpatients withchestpain.Throughoutthatpilotproject,program partnerscollectedqualityimprovement(QI)datatoensure thatthetelemedicineprogramwasfunctioningasdesigned anddidnotadverselyaffectsystemperformance.Ouraimin thisanalysiswastoevaluatequalitydatapointsandassessthe impactoftelemedicineonEMSmanagementofpatientswith chestpain;wealsoevaluatedperceivedbarriersbyEMSstaff.

METHODS

StudyDesign

Thisstudywasaretrospectivereviewofdatacollectedbya singleEMSagencythroughouttheproject.Wecollecteddata

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Telemedicineremainsunderusedinrural EMSsystems,withconcernsaboutincreasing ALStransports,extendingon-scenetimes, andconnectivityissues.

Whatwastheresearchquestion?

Howdoesimplementingtelemedicineinrural EMSaffectpatientmanagementandsystem performanceforchestpaincases?

Whatwasthemajor ﬁndingofthestudy?

TelemedicinedidnotchangeALStransport rates(42vs.45%,OR1.11,95%CI 0.45 – 2.76)orincreaseon-scenetimes(47vs. 33minutes,p = 0.07),and64%ofEMSstaff ratedcallqualitygood.

Howdoesthisimprovepopulationhealth?

TelemedicineallowsruralEMStomaintain ALSavailability,reducingstrainonlimited resourcesandpotentiallyimprovingoutcomes forchestpainpatients.

fortheprimarypurposeofQIandevaluationofthe telemedicineplatform.STROBEmethodologywasused.10 Weusedtwodatasetsforthisretrospectivereview.Firstly,we lookedatquantitativedatafromaprehospitalQIdatasetin whicha12-leadECGwasperformed.Secondly,weanalyzed theprimarychiefcomplaintofchestpain.CasesfromthatQI datasetwereincludedinthisanalysisiftheyoccurredduring the12-monthpre-implementationstudyperiodorthe 15-monthpost-implementationperiod.Wealsoevaluated qualitativedatafromasecondQIdatasetthatwascompleted byparamedics/EMTsandEMSphysiciansaftereach telemedicineplatformuse.Thatdatasetcontainedthe paramedic/EMTandEMSphysicians’ subjectiveevaluation ofthetelemedicinecallquality.

StudySetting

TheAzQualityprojectservedasapilotinitiativedesigned toestablishatelemedicineservice,enablingruralparamedics andEMTstoaccessurbanmedicalresourcesduring emergencycareforpatientsexperiencingchestpainwho dialed911.TheEMStelemedicinepilotwasimplementedat asingle,ruralEMSagency.Atthetimeofintroductionand duringnewemployeeorientation,bothEMTsand paramedicsweretaughthowtousethetelemedicinesystem viaabrieflectureandahands-onpracticesession.After

implementation,EMTsandparamedicswereinstructedto usetheTelemedicinetooltocontactboard-certiﬁedEMS physiciansforpatientsexperiencingchestpain24hoursa day,7daysaweek.Theycouldalsousethetoolforother encountersasneeded.Telemedicineserviceswereprovided byboard-certiﬁedEMSphysiciansfromasingle,largeEMS physiciangroup.

Thetelemedicinepilotprogramwasimplementedbythe Sonoita-ElginFireDistrict,aruralEMSagencyandsole911 respondingagencyforalarge,geographicallydiverseareain SoutheasternArizona.TheGD “e-Bridge” communication platform(GeneralDevicesLLC,Ridgeﬁeld,NJ)was selectedbytheprogramleadershipgroupasthetelemedicine platformforthispilotprogram.Thissoftwareallowed paramedics/EMTstoconductthetelemedicinevisitaswellas transmitphotosofECGsorotherclinicaldatatotheEMS physicians.Thee-Bridgesystemwasoperatedon commerciallyavailablesmartphones.

Priortoandduringthepilotproject,whenavailable, paramedicsrespondedtoall911calls.Whenunavailable, BLScrewswouldrespondalone.Bothparamedicsand EMTswereaskedtousethetelemedicinesystemanytime theyencounteredapatientwithchestpain.AfterEMTor paramedicpatientassessment,theEMSphysicianwas contactedviae-Bridgeandgivenabriefpatientpresentation. TheEMSphysicianhadaccesstothepatient’svitalsignsand 12-leadECGthroughthee-Bridgesoftware.Afterabrief interactionwiththepatient,thephysicianrisk-stratiﬁed patientsaslow,moderate,orhighriskforadverseevents duringtransporttodeﬁnitivecare.Theparamedics/EMTs werethengivenonlinemedicaldirectionforground transportbyBLSforlow-riskpatients,ALSground transportformoderate-riskpatientsandhelicopterEMS transport(HEMS)ofpatientswhowerefelttobeathighrisk foradverseeventsduringtransport.

OutcomeMeasures

Theprimaryoutcomeofthisretrospectivereviewwasthe rateofBLS,ALS,andHEMStransport.Secondary outcomes(Table1)includedEMSsystemservicedelivery timesandsubjectiveevaluationofhowwelltheinteraction

went(good,fair,poor).TheEMSservicedeliverytimeswere collectedfromEMSagencycomputer-aideddispatch systems.Subjectivedataontheoverallsystemperformance andtelemedicineplatformcallqualitywerecollectedand managedusingResearchElectronicDataCapture (REDCap)toolshostedattheUniversityofArizona. REDCapisasecure,web-basedsoftwareplatform.11,12 Asurveywasalsolaunchedimmediatelyaftereach telemedicineencounter.Basiccalldata(dataandtime)was thenusedtolinkthesubjectivetelemedicineplatform evaluationtoEMScalldata.

DataAnalysis,RegulatoryApprovalandRoleofFunding

TheEMSagencyanditsmedicaldirectorprovided deidentiﬁedQIdataforthepurposeofreviewforthis analysis.Simpledescriptivestatisticssummarizedtheresults. TheUniversityofArizonaInstitutionalReviewBoard approvedthereviewofthisproject’sQIdataanalysisand publication.TheRuralHealthEMSFlexSupplementgrant fromthefederalHealthResourcesandServices Administration(HRSA-19-095)fundedthisproject. Fundingwasusedforprojecttraining,implementationand QI,butnotforreportingontheproject.Thefundingagency wasnotinvolvedin1)designingorconductingthestudy; 2)collecting,managing,analyzing,orinterpretatingthe data;3)preparing,reviewing,orapprovingthemanuscript; or4)decidingtosubmitthemanuscriptforpublication.

RESULTS

ProgramInformationandDemographics

Thetelemedicinepilotprogramwasinitiatedon September10,2020.Therewere58casesforwhichthe telemedicineplatformwasused.Qualityimprovementdata forpatientswithchestpainorforwhoma12-leadECGhad beenobtainedwereanalyzed12monthspriortotelemedicine implementation(September9,2019–September10,2020), and15monthsafterimplementation(September11,2020–December5,2021).Duringthepre-implementationperiod, theEMSagencyhadatotalof326medicalcalls.Duringthe post-implementationperiod,therewere411calls.Therewere

Table1. Secondaryoutcomesinstudyoftelemedicineuseby ﬁrstrespondersinruralArizona.

SecondaryoutcomeDeﬁnition

Totalunitout-of-servicetimeTimefromdispatchtowhenthetransportingunitbecomesavailable. ResponsetimeTheintervalfromdispatchtoarrivalonscene.

On-scenetimeDurationfromarrivalonscenetoeithertheinitiationoftransportorthepointatwhichthepatient refusestransportortheunitbecomesavailablewithouttransport.

TransporttimeTimefromtheinitiationoftransporttowhentheunitisagainavailable. Responder/clinicianexperienceSubjectiveexperienceofparamedics/EMTsandEMSphysiciansusingthetelemedicinesystem ratesaspoor,fair,orgood.

EMT,emergencymedicaltechnician; EMS,emergencymedicalservices.

Table2. Demographicsandchestpaincallqualityimprovementbenchmarkperformance. Pre-implementationPost-implementation

Numberof911calls3838

P-value(p)oroddsratio(OR)with 95%conﬁdenceinterval(95%CI)

Meanage7275 P = 0.34

Gender,female39%(n = 15)53%(n = 20)1.70(0.69–4.24)

Ethnicity

%White82%(n = 31)74%(n = 28)0.63(0.21–1.89)

%Non-White11%(n = 4)24%(n = 9)4.02(1.09–14.84)

%Unknown8%(n = 3)3%(n = 1)0.31(0.03–3.09)

Benchmarkperformance

3-leadacquired100%(n = 38)97%(n = 37)0.33(0.01–8.23)

12-leadacquired97%(n = 37)97%(n = 37)1.00(0.06–16.59)

Aspirinadministered45%(n = 17)42%(n = 16)1.11(0.45–2.76)

Nitroglycerinadministered21%(n = 11)18%(n = 7)1.80(0.61–5.30)

O2 administered37%(n = 14)37%(n = 14)1.00(0.40–2.48)

Primaryimpression

Chestpain76%(n = 29)79%(n = 30)0.91(0.29–2.82)

Palpitations11%(n= 4)13%(n = 5)1.29(0.32–5.22)

Difﬁcultybreathing5%(n = 2)3%(n = 1)2.06(0.18–23.68)

Hypertension5%(n = 2)3%(n = 1)2.06(0.18–23.68)

Abdominalpain3%(n = 1)3%(n = 1)1.00(0.06–16.59)

O2,oxygen.

38chestpaincasesinthepre-implementationQIdatasetand 38casesduringthepost-implementationperiod.

Afterimplementationofthetelemedicineprogram,24 (63%)patientseligiblefortelemedicineconsultationreceived telemedicineservicesinrealtime,comparedtotwo(5%) patientsinthepre-implementationperiod.Preimplementationpatientsreceivedreal-timeonlinemedical directionbyeitherphoneorradio.Duringtheentire 15-monthproject,paramedics/EMTsusedthetelemedicine system58times.Outsidetheprimaryuseforpatientswith chestpain,otherusesincludedvariouscomplicatedmedical andmedicolegalsituationsinwhichtheparamedic/EMT wouldhavenormallycalledbyphoneorradioforonline medicaldirection.

Thedemographicandqualitybenchmarkdatacollected aspartofthepilotprogramisillustratedin Table2.The

pre-implementationchestpainpatientmeanagewasslightly lowerat72yearsold(interquartilerange[IQR]55–80)than thepost-implementationpatientsmeanof75(IQR55–80). Thepercentofnon-Whiteethnicity(identiﬁedbyparamedic) increasedfrom11%inthepre-implementaioncohortto24% inthepost-implementationcohort.TheEMSagency medicationadministrationratesandECGacquisitionrates wereessentiallythesame.

PrimaryOutcome

Overall,therewasaslightreductioninBLStransportsand slightincreaseinALStransports,althoughthesedidnot achievestatisticalsignificance(see Table3).Therewasalsoa non-significantincreaseinHEMStransportratesinthe implementationgroup.Lastly,therewasanon-significant reductioninpatientrefusal.

Table3. Dispositionofpatientsincludedinthechestpainqualityimprovementdataset.

,BasicLifeSupport; ALS,AdvancedLifeSupport; HEMS,helicopteremergencymedicalservice; CI,conﬁdenceinterval.

SecondaryOutcome – EMSSystemPerformance

TheEMSagencyresponseandtransporttimesdidnot changesigniﬁcantlyfollowingimplementation(see Table4). Medianout-of-servicetimewas127minutes(IQR49–172) beforeand95minutes(IQR52–159)afterimplementation. Thistotalout-of-serviceintervalincludedamedianresponse timeof11minutes(IRQ1–19)inthepre-implementation cohortand13minutes(IQR7–16)post-implementation. Medianon-scenetimewas27minutes(IQR21–61)inthe pre-implementationgroupand28minutes(IQR20–29) post-implementation.Amongthosepatientswhowere transported,mediantransporttimewas124minutes (IQR49–172)beforeand90minutes(IQR14–141) afterimplementation.

SecondaryOutcome – Performanceof TelemedicinePlatform

Followingimplementation,QIdatawerecollectedfrom thecaller/callrecipientsfor35of58(60%)calls.Inpost-call surveyscompletedbyparamedics/EMTs,thecallqualitywas notedtobe “good” or “fair” in86%ofthecalls.TheEMS physiciansjudged98%ofthecallstobe “good” or “fair.” Connectivityissueswereidentiﬁedasconcernsmoreoftenby paramedics/EMTsthanbyEMSphysicians(see Table5).

DISCUSSION

WhilelargerEMSagencieshaveadoptedtelemedicine servicestoimprovethebreadthofservicesprovidedtotheir communities(eg,MDAlly,ETHANproject),13–15 rural EMSagencieshavebeenslowertoadopttheseservicesdueto

Table5. Emergencymedicalservicesresponderandphysician subjectiveevaluationoftelemedicinecallquality.

Paramedics/EMTs, percent(number)

EMSphysicians, percent(number)

Completedsurveys62%(36)60%(35) Callquality

Good64%(23)89%(31)

Fair22%(8)9%(3)

Poor14%(5)3%(1)

Connectivityissue

Anyissue64%(23)14%(5)

Poorcellsignal6%(2)3%(1)

Laggingvideo6%(2)6%(2)

Poorsound3%(1)0%(0)

Missedcall6%(2)6%(2)

Other19%(7)0%(0)

EMS,emergencymedicalservice; EMT,emergency medicaltechnician.

limitedaccesstohigh-qualitytelecommunicationsystems andlowutilizationrates.16,17 Increasingly,platformssuchas AT&T’ s “FirstNet” andVerizon’ s “Frontline” havebecome moreaccessibletoruralEMSsystems.18,19 Thesesystems providehigh-speeddataservicesandprioritize ﬁrstrespondercommunicationsintimesofhighsystem usage.17,20,21 WiththesetoolsnowavailabletoruralEMS agencies,itisimportanttoevaluatetheimpactthat telemedicineprogramshaveonthesesystems.

Inthisretrospectivereview,aruralEMStelemedicine systemwasused58timesduringthe15-monthpilotproject forpatientswithavarietyofout-of-hospitalmedical emergencies.Overall,thetelemedicinesystemfunctioned wellwith89%ofEMSphysiciansand65%ofparamedics/ EMTsratingthetechnicalqualityofthetelemedicine encounteras “good.” Ofnote,theuseofanyformofonline medicaldirectionincreaseddramaticallyto63%inthepostimplementationphaseincomparisonto5%inthepreimplementationphase.

Ourprimarygoalinthisstudywastoevaluatetheimpact oftelemedicineserviceonthecareofpatientswithchestpain anddeterminewhethertelemedicinemightchangemodeof transport(BLSvsALSvsHEMS)totheclosesthospitalwith percutaneousinterventioncapabilities.Theultimategoal wastoallowALSresponderstostayinthecommunityand increasetheamountoftimeALSservicewasavailable.In thisretrospectiveanalysis,wefoundnostatistically signiﬁcantdifferencedemonstratedintheBLS/ALS transportratesafterthetelemedicineprogramwas implementeddespiteagoalofincreasingBLStransports. Thereareseveralpossiblereasonsthatnochangeintransport rateswasobserved.Primarily,thesmallpatient-samplesize

Table4. Emergencymedicalservicessystemutilizationtimes.

bothbeforeandaftertheinterventionlimitstheabilityto detectachange.Moreover,theperiodfollowingthe interventioncoincidedwiththeonsetoftheCOVID-19 pandemic,aneventthatlikelyincreasedpatientacuitylevels aswellastheutilizationofHEMStransport,giventhe heightenedconcernovervirustransmission.Inthiscontext, groundambulancetransportforlongdistancesmayhave beenconsideredlesssafecomparedtoHEMS,duetothe perceivedincreasedriskofCOVID-19exposure,asground transporttimesaremuchlongerthanHEMStransporttimes.

Duringimplementation,paramedics/EMTsvoiced severalconcernsaboutusingtelemedicineintheruralEMS setting.Theseincludedtheconcernthatcontactinga physicianviathetelemedicineplatformwouldincreasetheir on-scenetimeandoverallout-of-servicetimes.Inthissmall cohort,theEMSsystemon-scenetimesandout-of-service timeswerenotincreasedbutrathertrendedtowardbeing shorter.Twofactorslikelycontributedtothis ﬁnding.First, withmultiplerespondersonsceneformost911responses, oneteammemberwasabletodiscussthecasewitha physicianwhiletherestoftheteamcontinuedtoprovide patientcare.Second,althoughnotmeasuredaspartofthis project,telemedicinecalldurationseemedtobeverybrief (1–2minutes)andlikelythisshortencounterdidnot signiﬁcantlychangearelativelylongerEMSon-scenetime.

Thequalityoftelemedicinecommunicationwasaconcern forruralparamedics/EMTs.Inthisretrospectivereviewwe foundthatself-reportedtelemedicinesystemperformance wasmostlyreportedasgood.Paramedics/EMTsweremore likelytohaveconcernsaboutthetelemedicinesystemthan weretheEMSphysicians.Systemperformancecouldhave beenworseintheruralsettingduetolimiteddatatransfer;in otherwords,cellularservicewasmorelikelytobepoorinthe ruralthanurbansetting.However,ifthathadbeenthecase, onewouldexpectbothpartiestohavethesameissue.Itis alsopossiblethatwithalargeEMSusergroupandasmall EMSphysicianusergroup,theEMSphysiciansweresimply morecomfortableusingtheplatformandexperiencedfewer technicalissues.

Themajorityoftelemedicineconcernsexpressedby paramedics/EMTs,andEMSphysicianswerelaggingvideo andpoorcellsignal.Therewereseveninstancesinwhich paramedics/EMTslisted “other” issueswiththeplatform, butfurtherinformationwasnotavailable.Itwouldbe expectedthattherewouldbemoretelemedicinetechnical issuesontheparamedic/EMTsideinruralareasthanonthe EMSphysiciansidewherephysiciantookcallsinanurban, academiccenter.

LIMITATIONS

Limitationsincludedthedatacollectionand implementationofthetelemedicinepilotprojectatasingle EMSagency.Additionally,thisanalysisreliedonretrospective reviewofdatacollectedforthepurposeofQI.Thesetwo

factorsintroduceboththestrongpossibilityofobserver biasandreportingbias.Also,thesmallnumberofencounters limitstatisticalanalysisandsigniﬁcance.Itispossible thatnotallchestpainpatientswereincludedintheQI datasetandmissingorincludedpatientscreatedan inclusionbias.

Thepost-interventionstudyperiodcoincidedwiththe COVID-19pandemic.Themassivepsycho-socialchangesthat occurredduringthisperiodalmostcertainlyimpactedthe communityinwhichthispilotprogramwasconducted. Unfortunately,theimpactofthepandemiconthisdatasetis unknown;however,theunfortunatetiminglikelyintroduceda confounderintoourresults.Finally,theEMSagency participatinginthisprojectwashighlyengagedandmotivated, asdemonstratedbyhighperformanceonEMSbenchmarks.It ispossiblethatitwasdifﬁculttodetectachangeinsystem performanceduetoboththelowcallvolumeandthehighqualitypatientcarealreadyprovidedbytheEMSagency.

CONCLUSION

InthisruralEMSsystem,atelehealthplatformwas successfullyusedtoconnectparamedics/EMTstoboardcertiﬁedEMSphysiciansovera15-monthperiodfor58 patients.Amongthosepatientswithchestpain,theuseof telemedicinedidnotresultinanychangeintherateofALS transportsorincreaseon-scenetimes.Overall,paramedics/ EMTsandEMSphysiciansratedthequalityofthe telemedicineconnectionasgood.Futurestudiescould expanduponthisworkbyexploringlargerpatient populationsanddiverseclinicalconditionstofurther establishtheefﬁcacyoftelemedicineinruralEMSsettings. Additionally,examininglong-termpatientoutcomesand costeffectivenesscouldprovidemoreinsightintothe sustainedimpactoftelehealthinterventionsonrural emergencycare.

AddressforCorrespondence:RameshKarra,MD,TheUniversityof Arizona,1501NCampbellAve.Tucson,AZ,85724.Email: rkarra@ aemrc.arizona.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Portionsofthisworkweresupportedby theHealthResourcesandServiceAdministration(HRSA)Medicare RuralHospitalFlexibilityProgram – EmergencyMedicalServices Supplement;ArizonaRuralEMSAdvancedTelemedicine DemonstrationInitiative(AzREADI);HRSA-19-095.Thereareno otherconflictsofinterestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

ImpactofPrehospitalUltrasoundTrainingonSimulated ParamedicClinicalDecision-Making

AndreaRoche,BS‡

EvanWatkins,BS,NRP*

AndrewPettit,BS*

JacobSlagle,BSME*

IsainZapata,PhD§

AndrewSeefeld,MD†

NenaLundgreenMason,PhD*

SectionEditor:ScottGoldstein,DO

*DartmouthCollege,GeiselSchoolofMedicine,DepartmentofMedicalEducation, Hanover,NewHampshire

† SpeareMemorialHospital,DepartmentofEmergencyMedicine,Plymouth, NewHampshire

‡ NewEnglandCollegeofOsteopathicMedicine,Biddeford,Maine § RockyVistaUniversity,CollegeofOsteopathicMedicine,Englewood,Colorado

Submissionhistory:SubmittedAugust21,2023;RevisionreceivedMarch8,2024;AcceptedMarch22,2024

ElectronicallypublishedJune28,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18439

Introduction: Whenusedappropriately,focusedlimited-scopeultrasoundexamscouldpotentially provideparamedicswithaccurateandactionablediagnosticinformationtoguideprehospitaldecisionmaking.Inthisstudyweaimedtoinvestigatetheimpactofa13-hourprehospitalultrasoundtraining courseonthesimulatedclinicaldecision-makingofparamedicsaswellastheirultrasoundskills, knowledge,andself-conﬁdence.

Methods: Weevaluatedtheultrasoundcompetenceof31participantsusingpost-coursewrittenand practicalassessments.Writtenclinicaldecisionscenarioswereadministeredpre-andpost-training. Post-trainingscenariosincludedanuninterpretedultrasoundcliptoaiddecision-making.Scenarios includedextendedfocusedassessmentwithsonographyintrauma,pulmonaryexam,andfocused echocardiographycombinedwithcarotidpulsecheckexams.Correctanswerstoscenariosweredeﬁned asthoseselectedbyaveteranemergencyphysician.Participantsalsoindicatedtheirconﬁdenceineach oftheirdecisionsusingaLikertscale.

Results: Trainingyieldedastatisticallysignificantincreaseinbothmeanscenarioscore(35.5% absoluteincrease)andmeanparticipantself-confidence(15.8%relativeincrease),acrossallexam/ decisiontypesassessed(P ≤ 0.001).Thefocusedpulmonaryexamyieldedthelargestincreaseinboth meanscoreimprovement(59.7%absoluteincrease)andparamedicconfidenceintheirdecisions (28.6%increase).

Conclusion: Trainedparamedicscanperformfocusedultrasoundexamsandaccuratelyinterpretand applyactionableexam ﬁndingsinthecontextofwrittenscenarios.Analysisthroughourmodel characterizedthetheoreticalclinicalyieldofeachprehospitalultrasoundexamanddemonstrated howeachexammayprovideimproveddecisionaccuracyinseveralspeciﬁcsimulatedclinical contexts.Theseresultsprovidesupportforgrowingevidencethatfocusedlimited-scopeultrasoundmay beaneffectiveprehospitaldiagnostictoolinthehandsoftrainedparamedics.[WestJEmergMed. 2024;25(5)784–792.]

INTRODUCTION

Paramedicsmakecriticalprehospitaltreatmentand transportdecisionsthatoftengreatlyimpactpatient

outcomes.Appropriateprehospitaltreatmentandreceiving facilitychoices,aswellaseffectivepre-arrivalalerts,improve patientoutcomes,decreasetreatmentcost,andreduce

emergencydepartment(ED)crowding.1–3 Theprehospital environmentisinherentlycomplexanddynamicandcanbe resourcelimited,creatingsignificantbarrierstoobtaining accuratediagnosticinformationneededtomakeappropriate decisions.4–6 Whilestudiesindicatethatprehospitallung auscultationis54%accurate7 andpalpatedcarotidartery pulsecheckis55%accurate,8 prehospitalpredictionsof hospitalcareandclinicalcoursearegenerallyinaccurate.9,10 Diagnosticlimitationsrenderdecision-makinginthe field difficultandcannegativelyimpactpatientoutcomes.(For example,22%ofpatientstreatedwithprehospitalneedle decompressionfortensionpneumothoraxwerefound tonothaveapneumothoraxafterassessmentin theED.11)

Integrationofadvanceddiagnostictoolsintheprehospital settinghashistoricallybeensuccessfulinreducingdecision barriersandimprovingoutcomes.Useofelectrocardiograms improvedprehospitaldiagnosticpositivepredictivevaluefor acutemyocardialinfarctionfrom33%to93%.12 Point-ofcareultrasound(POCUS)isanadvanceddiagnostictoolthat hasimmensepotentialtoimprovetheaccuracyof prehospitaldecision-making.Limited-scopePOCUSisbeing implementedinemergencymedicalservices(EMS)agencies acrosstheUnitedStatesandinternationally.In2014,4.1%of respondingEMSmedicaldirectorsreporteduseofPOCUS bytheiragencies,and21.7%wereconsideringfuture implementation.13 Commonprehospitalultrasound(PHUS) examsincludetheextendedfocusedassessmentwith sonographyintrauma(eFAST),pulmonaryexam,and focusedechocardiographyduringcardiacarrest.Whenused appropriately,theseexamscanprovideparamedicswith accurateandactionablediagnosticinformationtoguide prehospitaldecisions.14

Forlimited-scopePHUStobesafelyimplemented,we needacomprehensiveunderstandingofthreecritical elements:paramedicperformance;paramedicinterpretation ofPOCUSexams;andtheappropriateapplicationofthose exam findingstosupportprehospitaldecisions.Previous studieshavedemonstratedsuccessfulexamacquisitionand interpretationbyparamedics,suchaseFAST,with100% interpretationaccuracyinamean2.6-minuteexamtime,15 lungultrasoundwithasensitivityof80%andspecificityof 72%fordetectingpulmonaryedema,16 and88%accurate imageinterpretationofechocardiographyduringcardiac arrest.17 Toourknowledge,nostudyhasexaminedhow POCUStrainingandeducationimpactaparamedic’sability toappropriatelyintegratePHUSexam findingsinto prehospitalcareinasimulatedenvironment.Training paramedicstoappropriatelyapply findingsisessentialtosafe implementationoftheseskillsinthe field.14 Athorough understandingofhowPHUS findingsimpactdecisionsabout prehospitaltreatment,receivingfacilitychoice,andprearrivalalertisneededpriortosafeandeffective implementationofPOCUSintheprehospitalsetting.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Appropriateprehospitaltreatmentimproves patientoutcomesandreducesEDcrowding.

Whatwastheresearchquestion?

Howdoesfocusedprehospitalultrasound trainingandknowledgeaffectparamedic clinicaldecisionsinasimulatedenvironment?

Whatwasthemajor ﬁndingofthestudy?

Therewasasigni ﬁ cantincrease(p ≤ 0.001) inbothmeanscenarioscore(absolute35.5%, from55.1%to90.6%correct)andmean self-con ﬁ dence(6.0%absolutefrom38to 44%,15.8%relative)acrossallexam/ decisiontypesassessed.

Howdoesthisimprovepopulationhealth?

Focused,limited-scopeultrasoundexams couldprovideparamedicswithaccurateand actionablediagnosticinformationtoguide prehospitaldecision-making.

Weexaminedhowahands-onPHUStrainingprogram impactedaccuracyofsimulatedparamedicdecision-making regardingprehospitaltreatment,receivingfacilitychoice, andpre-arrivalalertsusingwritten,clinicaldecision scenariosadministeredpre-andpost-training.Thescenarios includedeFAST,pulmonaryexam,andfocused echocardiographycombinedwithcarotidpulsecheckexams. InthisstudywealsoexaminedtheimpactofPHUStraining andimagingonparamedicself-conﬁdenceintheirsimulated clinicaldecisions.Toaddcontextregardingtheeffectiveness oftheeducationprovidedbythePHUStraining administered,wealsoreporttheperformanceofthe participantsoncourseassessmentsincludingawritten knowledgeexamandscenario-basedpracticalexams.

METHODS

StudyDesignandEquipment

Thiswasaprospectiveobservationalcohortstudy designedtoevaluatetheeffectivenessofasmall-scale,mixedmodality(containingasynchronousdigitalindependent prework,hands-onscanningpractice,andclinical applicationscenarios)trainingprogram.The13-hourcourse coveredlimited-scopePOCUSexamsthatwerefocused speciﬁcallyonaspectsandapplicationsoftheexamswith relevancetoprehospitalcare.Examsincludedwerethe eFAST,focusedpulmonaryexam,andfocused

echocardiographycombinedwithfocusedvascularexamfor Dopplerandvisualcarotidarterypulsatilityincardiacarrest. Thisstudywasapprovedandgivenanexemptdetermination bytheInstitutionalReviewBoardCommitteeforthe ProtectionofHumanSubjectsatDartmouthCollege (#00032581).Ultrasoundmachinesusedinthecourse sessionsincludedClariusHDportableultrasoundunits (ClariusMobileHealthCorp,Vancouver,BC,Canada),and ButterﬂyiQ+ (ButterﬂyNetworkInc,Burlington,MA).

SettingandParticipants

NewHampshirehasapopulationof1.39millionwith >1,100licensedparamedicsworkinginthestate.18,19 New HampshireposesauniquechallengetoEMSsystems,given itsruralgeographywithoftenextendedtraveltimesto tertiarycarecenters.Participantsinthisstudywereprimarily full-timeparamedicslicensedinNewHampshire. Participantswererecruitedfortwoin-personPHUScourses deliveredontwodifferentdaysthroughadvertisementviathe NewHampshiteDivisionofFireStandardsandTraining andEmergencyMedicalServicesmailinglistandwebsite. Participantsweregivenanoverviewofthestudy,providedan optiontoopt-out,andsignedwrittenconsentforms.Thirtyoneparticipantswereenrolled.Wecollectedparticipant experience-level,demographic,andemploymentdataina post-trainingsurvey.

CourseProcedure

TheNewHampshireFireAcademy&EMShostedthe courseattheirtrainingfacilityin.Thewasnotinvolvedin planningorconductingthisstudyanddidnot financially supportanymembersofthestudyteamtoconductthisresearch project.Thecourseanditsmaterials(Appendix2)were assembled,created,overseen,anddeliveredbyaboard-certified emergencyphysicianandultrasoundexpertwhoalsoservesas anEMSmedicaldirectorinconjunctionwithparamedics.This physicianalsoselectedandtrainedasmallteamofinstructors withexpertiseinultrasoundimaging,paramedicine,and ultrasoundeducationtoassisthimindeliveringthecourse. Courseobjectivesincludedlearningappropriateindicationsfor PHUS,ultrasoundtransducermanipulation,comfortwiththe userinterface,abilitytointerpretresultsfromselectedPOCUS exams,andabilitytoapply findingstoclinicaldecision scenariosrelevanttoprehospitalcare.Specificdetailsregarding coursestructure,content,andstudent/instructorratioscanbe viewedin Appendix2

Priortothein-personcomponent,participantswere providedwiththreehoursofasynchronouseducation consistingofanintroductiontorelevantphysics,useof ultrasoundunits,integrationofultrasoundintoworkﬂow, selectedPOCUSexams,andcases.Thein-personcomponent ofthecourseconsistedofshortdidacticlectures,ampletime forhands-onpracticeusinglivemodels,groupdiscussionof

cases,andstandardizedscenarios.Lecturesreviewedselected POCUSexamsandexamplesofpathologyrelevantto prehospitalcare.Aninstructorprovidedguidanceandrealtimefeedbacktoparticipantsinsmallgroups.Contentwas reinforcedanddiscussedinalarge-groupsettingusing integrationquestionsandpollingsoftware.

Measurements

CourseAssessments

Participantsendedthein-personcoursebytakinga writtenknowledgetestandcompletingsixscenario-based examscoveringcardiacarrest,respiratorydistress,and traumainEMScasesaspartofapracticalexam(Appendix 2).Forthepractical,participantsperformedselected POCUSexamsonlivemodelsinsmallgroupsandreceived predeterminedresultsviauninterpretedultrasoundvideo clipsaftersuccessfullycompletingtheexam.Scenario stationswereoperatedbycourseinstructors,and participantsreceived “ pass ” or “fail” gradesbasedonpreestablishedcriteriaforperformance,imageinterpretation, andtreatment/transportdecisions.Case-basedscenarios werecompletedasateamtosimulatetheprehospital environment,althougheachparticipanthadtoindividually acquireacardiac,lung,andeFASTexamonamodelwith normal ﬁndingsandsubsequentlyinterpretaunique ultrasoundimagewithpathologydisplayedonacomputer screenandthenapply ﬁndingstotheirtreatmentand transportplanwithoutinputfromotherteammembers.The post-coursewrittenexamconsistedof24multiple-choice questionsmappedtocourseobjectives(topicscoveredin writtenexamquestionscanbeviewedin Appendix2). Ascoreof ≥80%wassetasthepassingthresholdforthe writtenportionofthepost-courseexam.

ClinicalDecisionScenarios

Priortoreceivingeducationalcontent,participantswere givenwrittenclinicaldecisionscenarios(Table1 and Appendix1).Thisinstrumentwasdesignedtomeasurethe impactofPHUStrainingandavailabilityofuninterrupted ultrasoundimagesonparamedicclinicaldecisions.The instrumentconsistedof10vignettesthatwereintentionally ambiguous,reﬂectingtherealityofprehospitalemergency care.Scenariosprovidedanextensivedescriptionofthe scene,patientassessmentandhistoryofpresentillness/ injury,andwereeditedbymultipleinvestigators.

Editinginvestigatorsincludedanemergencyphysician andultrasoundexpertwhoalsoservesasanEMSmedical director;aparamedicwithover20yearsofexperiencein prehospitalEMSeducation;andseveralparamedics, advancedemergencymedicaltechnicians(EMT),andEMTBswith ﬁeldexperience.Eachscenarioincludedoneormore questionsaboutprehospitaltreatment,receivingfacility choiceandtransportmodality,and/orpre-arrivalalert. Scenario-baseddecisionsweredesignedtospeciﬁcally

Table1. Clinicaldecisiontopicsandthetypeofprehospitalultrasoundexamincludedwithineachwritten,clinicaldecisionscenariolistedby scenarionumber.Eachscenarionumbercorrelateswiththenumberlistedin Appendix1,whichshowsthecompletetextofeachscenario.

ScenarionumberPHUSexamassessedScenariotypeClinicaldecisionquestions

Prehospitaltreatmentscenarios

2eFASTTraumaNeedledecompressionvsnoneedledecompressionin possiblepneumothorax

4eFASTTraumaTXAinfusionvsnoTXAwithanunclearbleedingsource

3FocusedpulmonaryRespiratoryTreatmentofCHFvsCOPD

5FocusedpulmonaryRespiratoryTreatmentofCHFvsCOPD

7Echo + carotidpulseCardiacarrestContinuationvsterminationofresuscitation

8Echo + carotidpulseCardiacarrestContinuationvsterminationofresuscitation Transportandpre-arrivalalertscenarios

1eFASTTraumaTraumacentervsclosestED,groundvsairtransport, pre-arrivaltraumaalertvsnoalert

6eFASTTraumaTraumacentervsclosestED,groundvsairtransport, pre-arrivaltraumaalertvsnoalert

9eFASTTraumaTraumacentervsclosestED,groundvsairtransport, pre-arrivaltraumaalertvsnoalert

10eFASTTraumaTraumacentervsclosestED,groundvsairtransport, pre-arrivaltraumaalertvsnoalert

PHUS, prehospitalultrasound; eFAST,extendedfocusedassessmentwithsonographyintrauma; TXA,tranexamicacid; CND,chestneedle decompression; CHF,congestiveheartfailure; COPD,chronicobstructivepulmonarydisease; ED,emergencydepartment; POCUS,pointof careultrasound.

maptoanassociatedelementoftheNewHampshire EMSprotocols.

Participantsalsoindicatedtheirconfidenceintheir decisionsusinga1–5Likertscale.Post-training,participants weregiventhesameinstrument,withtheadditionofan uninterpretedultrasoundclipthatcouldbefeasiblyacquired inthe fieldasadecisionaidineachscenario.Correctanswers weredefinedasthoseselectedbyaveteranemergency physicianwithexpertiseinbothPOCUSandEMS,who reviewedeachclinicaldecisionscenariowithandwithoutthe associatedultrasoundcliptoestablishthecorrectdecisions foreachscenarioregardlessofavailabilityofultrasound images.Forscenarioswheretransporttoatraumacenterwas indicatedascorrect,groundandairambulancetransporttoa traumacenterwerebothconsideredascorrectanswersto reducescenario-basederroraroundairambulance availability,weatherconditions,andspecificlocation,etc. (Appendix1).

DataAnalysis

Wecalculateddescriptivestatisticsforcategorical variablesasfrequencieswiththeirrespectivepercentages. Pre-vspost-scoreimprovementwasexpressedin percentages;however,allassessmentsforassociation performedontheprevspostwereperformedusingpaired t -testsontheactualscores.Weevaluatednormality assumptionsinapreliminaryevaluationofthedistributionof

thescoreandconfidencevariablesusinggraphicalmethods (boxplotsandhistograms);nomajorconcernswithmeeting thenormalityassumptionswereobserved.WeusednonparametricWilcoxonrank-sumtestsforprevspost confidence-assessmentsscores.Thiswastoaccommodatefor Likertscalesused.Confidenceassessmentsareexpressedas sumsandaredisplayedwiththeirrespectiveinterquartile ranges.Associationstopreviousexperienceswithultrasound wereassessedthroughlinearmodelswhereprevious experiencewascodedasacategoricalvariable.Preliminary poweranalysiswasnotperformedbecauseparticipantswere recruitedviaconveniencesampling.Weperformedall analysesusingSAS/STATv.9.4(SASInstituteInc,Cary, NC).Significantdifferencesweredeclaredat P ≤ 0.05, althoughexact P -valuesarepresented.

RESULTS

ParticipantDemographics

Ofthe31participantsinthisstudy,30completedthe demographicssurvey(Table2).Amajorityofthe participantscamefrom ﬁredepartmentsorprivateEMS agenciesservingruralareasorsmalltowns.Amajorityof paramedicswerehighlyexperiencedwith >63%havingmore than16yearsinEMS.Nineofthe30paramedicsreported havingpriorultrasoundexperienceinsomecapacity,threeof whomdescribedtheirtrainingasspeciﬁctoPHUS.Prior ultrasoundexperienceconsistedofvascularaccesstraining

Table2. Participantdemographicsandemploymentcontextsurvey. Participant-reporteddataregardingtheirpriorexperienceworkingin emergencymedicalservicesandwithultrasoundimaging.

Category Frequency(%) N = 30*

EMSagencytype

Firedepartment17(56.7)

Privateorganization4(13.3)

Hospital8(26.7)

Airmedical1(3.3)

Primaryserviceprovided

911withorw/otransportcapability21(70.0)

Interfacilitytransport1(3.3)

Equalmixof911andinterfacilitytransport6(20.0)

Clinicalservices1(3.3)

Mobileintegratedhealthcareand communityparamedicine 1(3.3)

YearsofEMSexperience

>21years16(53.3)

16–20years3(10.0)

11–15years5(16.7)

8–10years3(10.0)

5–7years3(10.0)

Sizeofcommunityserved

Rural(<2,500)5(16.7)

Smalltown(2,500–24,999)19(63.3)

Medium-sizetown(25,000–74,999)6(20.0)

Priorultrasoundexperience

Receivedpriortraining–anycapacity6(20.0)

Receivedpriortraining-speciﬁcallyfor EMSuse 3(10.0)

Nopriortraining21(70.0)

Priorultrasounduseonthejob

Prioruse–anycapacity4(13.3)

Prioruse–speciﬁcallyinEMSjob2(6.7)

Noprioruse24(80.0)

*30ofthe31studyparticipantsarerepresented,(Oneparticipantdid notcompletetheemploymentcontextsurvey.) EMS,emergencymedicalservices.

forallbuttwoparticipantswhoreportedmorein-depthprior training.Duringanalysisnosigniﬁcantassociationswere foundbetweenparticipants’ priorultrasoundorEMS experienceandperformanceoncourseassessmentorwritten clinicaldecisionscenarios.

CourseAssessments

Ofthe31(87.1%)participants,27obtainedapassing gradeonthewrittenpost-courseexam.Thecohortaverage

scorewas92.2%,witharangeof62.5–100%.Thescenariobasedpracticalexamhada100%passrate.

ClinicalDecisionScenarios

Datadepictingthecomparisonofthepre-andpost-course written,clinicaldecisionscenariosareshowninthe Figure TheadditionofPHUSimagingyieldedastatistically significantincreaseinbothmeanscoreandmeanparticipant self-confidenceacrossallPHUSexamtypesanddecision typesassessedbythisinstrument(P ≤ 0.001).Thepulmonary examyieldedthelargestincreaseinbothmeanscore improvement(59.7%)andparamedicconfidenceintheir decisions(28.6%).Thesmallestincreasesinimprovement wereobservedintheecho/carotidpulseexamcategoriesat 29%and12.5%,respectively.Whencomparingchangesin prehospitaltreatment,transport,andreceivingfacility decisions,thelargestincreaseinmeanscoreandconfidence wasseeninprehospitaltreatmentchoices.

Ofthe14scenarioquestionsansweredbyall31participants (434uniqueanswers),168answers(38.7%)were changedfromincorrecttocorrectwiththeaidof ultrasoundimages.

PreviousParticipantUltrasoundExperience

Participantpreviousexperienceswithultrasoundare presentedin Table2.Only9of30participantsreported havinganytypeofpreviousexperienceusingorbeingtrained withultrasoundimagingandonlytwoindividualsreported havingusedultrasoundonthejobbeforeparticipationinthis study.Weusedlinearmodelstolookforassociations betweenanytypeofpriorexperiencewithultrasoundthata participanthad,andtheirperformanceonstudyassessments; however,noassociationsweredetectedforanyofthe previousultrasoundexperience-typesreported.

DISCUSSION CourseAssessments

Thepost-coursewrittentestevaluatedparticipantmastery ofthecourseobjectives;87.1%ofparticipantspassedthetest withanaveragescoreof92.2%,demonstratingthatthe courseeducatedparamedicsinbasictheory,knowledge,and interpretationofthethree,goal-directed,limitedwindow PHUSexams.Thisresultsupportsagrowingbodyof evidencethat1–2daysofinstructionacrossavarietyof instructionalmodalitiesandexamtypesislargelyadequate forparamedicstoachievecompetencywithlimitedscope PHUSexams.17,20–23

Thepracticaltestevaluatedparticipantpsychomotor skills,aswellastheabilitytointegratePHUSintoEMS workﬂow,accuratelyinterpretexams,andappropriately apply ﬁndingsinrealtime.Onehundredpercentof participantspassedthepractical,demonstratingthatthe coursesuccessfullytrainedparamedicstoacquire,interpret, andintegratePHUSintopracticalEMSscenarios.This

Figure. Changesinparamedics’ simulatedclinicaldecision-makingandself-con fidencefollowingtraining. PanelAdepictsthemeanimprovementinbothmeanscoreandparticipantself-confidenceassociatedwitheachwrittenclinicaldecision scenario(Table1 and Appendix1).Scoresaresortedbyspecificprehospitalultrasound(PHUS)examtypeandclinicaldecisiontype.Panel Breportshowaggregateparticipantresponsestoall10scenarioschangedwithregardtocorrectnesswhentheyhadaccesstouninterpreted PHUSimagesasadecisionaid.Allchangesarehighlysignificantat P ≤ 0.001. IQR,interquartilerange; eFast,extendedfocusedassessmentwithsonographyintrauma.

supportspreviousevidencethatparamedicscanacquireand interpretPHUSimagesinthe ﬁeld.15–17,24

ClinicalDecisionScenarios

Thewrittenclinicaldecisionscenariosusedinthisstudy presentanovelwaytoevaluatetheimpactofPHUSon paramedicdecision-makinginarisk-freemanner.Theprecoursescenariosdidnotincludeultrasoundimagesand requiredtheparamedictomakedifficultandpotentially ambiguousdecisionsbasedonhistory,physicalexam,and conventionaldiagnosticsalone,accuratelymimickingthe difficultyofrealdecisionsmadeonshift.Manystudieshave showntheinaccuracyofconventionalprehospital diagnosticsandhighlightthedifficultyinpredictingpatient conditionanddispositionbasedonprehospitalhistoryand physicalexamalone.1,5–10 Accesstouninterpreted,raw ultrasoundclipsthattheparticipantsweretrainedtoacquire andcouldfeasiblyobtaininthe fieldyieldedastatistically significantincreaseincorrectdecisionmakinginevery categoryevaluated,includingtreatment,transport,andprearrivalalert.Meanscoresalsoincreasedsignificantlyinall typesofPHUSexamsevaluated(Figure).Despitepotential sourcesoferrordescribedabove,theseresultsprovidea compellingtheoreticalframeworktoanalyzehowPHUS mayimpactparamedicdecisions.

FocusedPulmonaryExam

Accesstofocusedpulmonaryultrasoundacross respiratorydistressscenarios(3and5)improveddecision accuracyinprehospitaltreatmentby59.7%andconﬁdence by28.6%(Figure).Scenarios3and5requiredparticipantsto

determinewhethertofollowthecongestiveheartfailure (CHF)orchronicobstructivepulmonarydisease(COPD) treatmentprotocolsinapatientinrespiratorydistressof unclearetiologysuspectedtohaveCHFvsCOPD.Accessto uninterpretedPHUSsignificantlyimprovedthesedecisions. Thisresultsupportsexistingdatathatparamedicscan accuratelyinterpretlungultrasoundinthesettingof pulmonaryedema.16 Italsoindicatesthatintheunclear circumstanceofarespiratorydistresspatientwhereCHFvs COPDissuspected,focusedpulmonaryultrasoundmay provideimprovedaccuracyofparamedicworkingdiagnosis, increasedconfidence,andaccuracyofprehospitaltreatment inthisspecificclinicalsetting.Theabilityofparamedicsto appropriatelyapply findingstosupportsimulateddecisions indicatesthattheimproveddiagnosticaccuracyof pulmonaryultrasoundinundifferentiateddyspnea demonstratedoutsidetheUSmayalsobeapplicableinthe prehospitalcontextwithintheUS.25

ExtendedFocusedAssessmentwithSonographyinTrauma AccesstoeFASTimagesintrauma(scenarios1,2,4,6,9, 10)improvedoveralldecisionaccuracyby32.3%and conﬁdenceby18.2%(Figure).Thisresulttheoretically supportspreviousstudiesthatparamedicscanaccurately interpretaneFASTexam.15,24 ItalsoindicatesthateFAST mayimproveparamedicaccuracyindeterminingthe appropriatetransportmethodandreceivingfacilitytypein complextraumapatients.Similarly,eFASTmayimprove theaccuracyofneedledecompressioninthisspeciﬁcclinical setting,whichmayhelptoreducethedemonstratedincidence ofunnecessaryprehospitalneedledecompression,aswellas

improvetheappropriateuseoftranexamicacidinfusionin unclearcircumstancessuchaswhenanintra-abdominal bleedingsourceisnotobviousonphysicalexam.11

FocusedEchocardiographyandPoint-of-careUltrasound (Carotid)PulseCheck

AccesstofocusedechocardiographyandPOCUS (carotid)pulsecheck(scenarios7and8)significantly improvedmeandecisionaccuracyby29%,andconfidenceby 12.5%.Scenariosrepresentedapulselesselectricalactivity (PEA)orasystolecardiacarrestcasewheretermination parametersweremetbyasmallmargin.Pseudo-PEAwasa feasiblepossibilityinscenario7.AccesstoPHUSimproved theaccuracyofappropriateterminationofresuscitationin theasystolescenario(8)aswellasappropriatecontinuation ofresuscitationinthePEAscenario,whichwasactually pseudo-PEAasidentifiedbyultrasoundexam.

Thisresultdemonstratesthatparamedicscanaccurately interprettheseexamsinthesettingofsimulatedcardiac arrest,supportingexistingdataonprehospital echocardiographyinterpretation.17,24 Additionally,focused echocardiographyandcarotidpulsecheckincardiacarrest mayimproveparamedicaccuracyindeterminingwhether andwhenterminationofresuscitationisappropriate.These resultsalsoprovideanoveltheoreticalrepresentationthat PHUSmaybeeffectiveinidentifyingandactingon prehospitalpseudo-PEAcardiacarrest.Lastly,theresult demonstratesthataccesstoPHUSincardiacarrestmay improveparamedicconﬁdenceinresuscitationdecisions, whichcanoftenbedifﬁcultandstressful.17

Althoughsignificant,thesechangesinmeanscoreand confidencearethesmallestinmagnitudethatweobserved. Thismayhavebeenduetoincreasedcomplexityand difficultyinimageacquisitionandinterpretationofcardiac imagesascomparedtootherPHUSexams.Althoughresults demonstratethatparamedicscanperformandtheninterpret andapplysimulated findingsfromafocusedvascularexam forpresenceorabsenceofcarotidpulseasanadjunctto cardiacarrestechocardiography,thisisinthecontextofa purelysimulatedtheoreticalenvironmentanddoesnot provideanyinsightintotheclinicalvalidity,utility,orideal methodofcarotidpulsecheck,whichremainsanareaof activestudy.26,27

IntegrationofPrehospitalUltrasound

AsPHUSisimplemented,itssafetyandefficacywill dependonathoroughunderstandingofhowparamedics applyexam findingstoprehospitaltreatmentdecisions.The currentbodyofevidencehasnotyetestablishedtheclinical yield,benefits,andrisksregardingeachPHUSexamtype. Understandingwhichexamsresultinsignificantlyimproved accuracyofdecisionsthatleadtoanactionablechangein prehospitalmanagementisacrucialnextstep.Judiciousand preciseintegrationofexamsthatareproventohavegood

prehospitalyieldmayhavethepotentialtoimprovepatient carethroughimproveddiagnosticaccuracy.Conversely, inaccurateapplicationofPHUStestcharacteristics, incongruencewiththeoverallclinicalpicture,orimaging resultinginunactionableinformationmayresultinpoorly appliedexam ﬁndingswithriskssuchasovertriage,extended assessmenttime,ordeviationfromexistingstandardsofcare. AnalysisofPHUS,likethetheoreticalmodelinthisstudy, mayhelptoinformparamediceducationandprotocols neededtoensurethatPHUS ﬁndingsareappliedinamanner thatimprovesdecisionsandminimizesthesepotentialharms.

LIMITATIONSANDFUTUREDIRECTIONS

Thisstudyusedarelativelysmallsamplesizeof31 participants.Itexaminedparticipantdataacrosstwo repeatedPHUScourseswithidenticalcurricula,thesame coursedirector,andsimilarinstructors.Thereispotential variabilitybetweenthetwocoursesessionsdueto uncontrollablefactorssuchascoursedynamicsor participantinteractionorvaryingpriorexperiencewith ultrasoundimagingandEMS.Thethreehoursofcourse assignedpreworkwerecompletedonthehonorsystem,and thestudyteamcouldnotverifycompletionofthatprework. Thiscoursewaspubliclyadvertisedtoparamedics;thus,selfselectionbiascouldhaveinﬂuencedthosewhoparticipated byattractingparamedicswithmoreexperienceandadvanced training.Theclinicaldecisionscenarioswereatheoretical frameworktosimulatereal-worldprehospitalcare.Aswith anysuchinstrument,therearepotentialsourcesoferrorsuch asvariablesimulation ﬁdelityandpotential misinterpretationofdepictedscenes.

Therepeateduseofthesamewrittenclinicaldecision scenariosbeforeandafterinterventionwithoutacontrol groupmayhaveintroducedpotentialconfounding.Because thepost-trainingscenarioscontainedadditionalinformation intheformofultrasoundimaging,itisdifficulttodetermine whetherchangesinparamedicaccuracywereinfluencedby repeatedassessment,theadditionalimaging,thetraining itself,oracombinationofthesefactors.Additionally,some oftheclinicaldecisionscenariosarewritteninamannerthat mayhave flaggedtheuninterpretedultrasoundimageas abnormal.However,theparticipantswerestillrequiredto identifythetypeofpositive findingsintheimageattachedto eachscenario,andcorrectlyapplythatinformationwithin theclinicalcontextofeachvignette.

Lastly,noneofthemodelspossessedpathology;therefore, studyparticipantswerenotabletoscanpathology themselvesduringthecourse.Rather,relevantpathological imageswerecoveredthoroughlyduringthedidacticsessions ofthecourse.Intermsofpreviousultrasoundexperience affectingparticipantscores,thecohortwaslimitedinits capacitytodetectsuchassociations.Thiscouldbebecauseof lowpowerduetoasmallportionoftheparticipanthaving

previousexperiencewithultrasoundingeneralorbecause thoseeffectsaresmallinthelargecontextofthis prehospitalapplication.

Furtherstudyinthe fieldisnecessarytoexpose paramedicstothetypicaldistractionsandsuboptimal imagingconditionstheywillexperienceinthe fieldto validatethesetheoretical,scenario-based findings,andto continueclassifyingtheclinicalyieldanddecisionsupportof PHUS,toguidethedevelopmentofPHUSprotocolsand bestpractices.Furtherstudyisalsoneededtocharacterize PHUSknowledgeandskillretentionovertime.

CONCLUSION

Thisstudyshowedthatwitha13-hourmixedmodality trainingprogram,paramedicscancompetentlyperform focusedeFAST,pulmonary,andcardiacarrestultrasound examsduringcourseassessments.Theycanalsoaccurately interpretexam findingsandapplytheseactionable findings withinascenariocontextresultinginatheoreticalsignificant increaseindecisionaccuracyandpotentialimprovementin prehospitalcare.Decisionanalysisthroughourclinical decisionscenariosmodelcharacterizedthetheoretical clinicalyieldofeachfocusedPHUSexamanddemonstrated howeachexammayprovideimproveddecisionaccuracyin severalspecificclinicalcontexts.Theseresultsprovide supportforgrowingevidencethatfocusedeFAST, pulmonary,andcardiacarrestultrasoundmaybesafeand effectiveprehospitaldiagnostictoolsinthehandsof trainedparamedics.

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AddressforCorrespondence:NenaLundgreenMason,PhD, DartmouthCollege,GeiselSchoolofMedicine,Departmentof MedicalEducation,1RopeFerryRd.,Hanover,NH03755. Email: nenalundgreen@gmail.com

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Theauthorsreceived financialsupport fromtheCarmenPettapieceStudentResearchFellowshipandthe UniversityofNewEnglandCollegeofOsteopathicMedicine.There arenootherconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.KoivulahtiO,TommilaM,HaavistoE.Theaccuracyofpreliminary diagnosesmadebyparamedics – Across-sectionalcomparativestudy. ScandJTraumaResuscEmergMed. 2020;28(1):70.

12.AufderheideT,HendleyG,ThakurR,etal.Thediagnosticimpactof prehospital12-leadelectrocardiography. AnnEmergMed. 1989;18(4):440.

13.TaylorJA,McLaughlinK,McRaeA,etal.Useofprehospitalultrasound inNorthAmerica:asurveyofemergencymedicalservicesmedical directors. BMCEmergMed. 2014;14:6.

14.BrookeM,WaltonJ,ScuttD.Paramedicapplicationofultrasoundinthe managementofpatientsintheprehospitalsetting:areviewofthe literature. EmergMedJ. 2010;27(9):702–7.

15.HeegaardWG,HildebrandtD,SpearDS,etal.Prehospital ultrasoundbyparamedics:resultsof ﬁeldtrial. AcadEmergMed. 2010;17(6):624–30.

16.SchoeneckJH,CoughlinR,BaloescuC,etal.Paramedic-performed prehospitalpoint-of-careultrasoundforpatientswithundifferentiated dyspnea:apilotstudy. WestJEmergMed. 2021;22(3):750–5.

17.KreiserMA,HillB,KarkiD,etal.Point-of-careultrasoundusebyEMS providersinout-of-hospitalcardiacarrest. PrehospDisasterMed. 2022;37(1):39–44.

18.UnitedStatesCensusBureau.QuickFacts.Availableat: https://www. census.gov/quickfacts/fact/table/US/PST045222.AccessedApril5,2023.

19.FireandEmergencyMedicalServicesAd-HocCommittee.Recruitment &retention:Reportandrecommendations.2022.Availableat: https://www.nh.gov/safety/divisions/fstems/documents/ 2022RecruitmentandRetentionReportFINAL.pdf AccessedMarch16,2023.

20.GuyA,BrysonA,WheelerS,etal.Ablendedprehospitalultrasound curriculumforcriticalcareparamedics. AirMedJ. 2019;38(6):426–30.

21.McCallumJ,VuE,SweetD,etal.Assessmentofparamedicultrasound curricula:asystematicreview. AirMedJ. 2015;34(6):360–8.

22.ChinEJ,ChanCH,MortazaviR,etal.Apilotstudyexaminingthe viabilityofaprehospitalassessmentwithultrasoundforemergencies (PAUSE)protocol. JEmergMed. 2013;44(1):142–9.

23.BrookeM,WaltonJ,ScuttD,etal.Acquisitionandinterpretationof focuseddiagnosticultrasoundimagesbyultrasound-naiveadvanced

paramedics:triallingaPHUSeducationprogramme. EmergMedJ. 2011;29(4):322–6.

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25.ZanattaM,BenatoP,DeBattistiS,etal.Pre-hospitallungultrasoundfor cardiacheartfailureandCOPD:Isitworthwhile? CritUltrasoundJ. 2018;10(1):22.

26.KangSY,JoIJ,LeeGT,etal.Point-of-careultrasoundcompressionof thecarotidarteryforpulsedeterminationincardiopulmonary resuscitation. Resuscitation. 2022;179:206–13.

27.BadraK,CoutinA,SimardR,etal.ThePOCUSpulsecheck:a randomizedcontrolledcrossoverstudycomparingpulsedetectionby palpationversusbypoint-of-careultrasound. Resuscitation. 2019;139:17–23.

ORIGINAL RESEARCH

UseofLongSpinalBoardPost-ApplicationofProtocolforSpinal MotionRestrictionforSpinalCordInjury

AmberD.Rice,MD,MS*§

PhilippL.Hannan,MD*§

Memu-iyeKamara,DO**

JoshuaB.Gaither,MD*†

RobynBlust,MPH*∥

VatsalChikani,MD∥

FrancoCastro-Marin,MD‡

GailBradley,MD*∥

BentleyJ.Bobrow,MD#**

RachelMunn,DO*§

MaryKnotts,MD*§

JustinLara,BS*†

SectionEditor:ScottGoldstein,DO

*CollegeofMedicine,DepartmentofEmergencyMedicine,TheUniversityofArizona, Tucson,Arizona

† CollegeofMedicine,DepartmentofEmergencyMedicine,TheUniversityofArizona, Phoenix,Arizona

‡ HonorHealthScottsdaleOsbornMedicalCenter,EmergencyDepartment, Scottsdale,Arizona

§ UniversityofArizona,ArizonaEmergencyMedicineResearchCenter, CollegeofMedicine,Tucson,Arizona

∥ ADHSBureauofEMSandTrauma,ArizonaDepartmentofHealthServices, Phoenix,Arizona

¶ McGovernMedicalSchool,TexasEmergencyMedicineResearchCenter, Houston,Texas

Afﬁliationscontinuedatendofpaper

Submissionhistory:SubmittedJune2,2023;RevisionreceivedApril9,2024;AcceptedMay16,2024

ElectronicallypublishedAugust27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18342

Introduction: Historically,prehospitalcareoftraumapatientshasincludednearlyuniversaluseofa cervicalcollar(C-collar)andlongspineboard(LSB).Duetorecentevidencedemonstratingharmin usingLSBs,implementationofnewspinalmotionrestriction(SMR)protocolsintheprehospitalsetting shouldreduceLSBuse,evenamongpatientswithspinalcordinjury.Ourgoalinthisstudywasto evaluatetheratesofandreasonsforLSBuseinhigh-riskpatients thosewithhospital-diagnosedspinal cordinjury(SCI) afterstatewideimplementationofSMRprotocols.

Methods: Applyingdatafromastateemergencymedicalservices(EMS)registrytoastatehospital dischargedatabase,weidentiﬁedcasesinwhichaparticipatingEMSagencyprovidedcareforapatient laterdiagnosedinthehospitalwithaSCI.Caseswerethenretrospectivelyreviewedtodeterminethe prevalenceofbothLSBandC-collarusebeforeandafteragencyadoptionofaSMRprotocol.We reviewedcaseswithLSBuseafterSMRprotocolimplementationtodeterminethemotivationsdriving continuedLSBuse.Weusedsimpledescriptivestatistics,oddsratios(OR)with95%conﬁdence intervals(CI)todescribetheresults.

Results: Weidentiﬁed52EMSagenciesinthestateofArizonawith417,979encounters.Therewere 225patientswithSCI,ofwhom74wereexcluded.TheLSBswereusedin52pre-SMR(81%)and49 post-SMR(56%)cases.TheoddsofLSBuseafterSMRprotocolimplementationwas70%lowerthanit hadbeenbeforeimplementation(OR0.297,95%CI0.139–0.643; P = 0.002).UseofaC-collarafter SMRimplementationwasnotsigniﬁcantlychanged(OR0.51,95%CI0.23–1.143; P = 0.10).Inthe49 casesofLSBuseafteragencySMRimplementation,themostcommonreasonsforLSBplacementwere easeoflifting(63%),placementbynon-transportingagency(18%),andextrication(16.3%).High suspicionofSCIwasdeterminedastheprimaryorsecondaryreasonfornotremovingLSBafter assessmentin63%ofthosewithLSBplacement,followedbymultipletransfersrequired(20%),and criticalillness(10%).

Conclusion: Implementationofselectivespinalmotionrestrictionprotocolswasassociatedwitha statisticallysigniﬁcantdecreaseintheutilizationoflongspineboardsamongprehospitalpatientswith acutetraumaticspinalcordinjury.[WestJEmergMed.2024;25(5)793–799.]

INTRODUCTION

PrehospitalcareoftraumapatientsintheUnitedStateshas historicallyincludedthenearuniversaluseofspinal immobilization(SI)byprehospitalprofessionals.1 Traditional SIincludescervicalcollar(C-collar)application,alongrigid spineboard(LSB),securingstraps,andheadblocksorother rotationalsupport.1 Thehistoricalrationaletomaintainthis practiceassumessafetyandefﬁcacyoftraditionalSIandaims tominimizemedicolegalconcerns,highmorbidity,andcost associatedwithspinalcordinjuries(SCI).2 Assumptionshave beenmadethroughouttheyearsthatSIperformedinthis mannerisprotectivebyreducingmovementofpotentialspinal fracturesandthattheriskofsecondarySCIandassociated morbidityismitigatedwithuseofLSB.2

Prehospitalevidencetosupporttheseassumptionsis sparse,leavingopentoquestionthesupposedbenefits.3–6 Hauswaldetalperformedalarge,retrospectivereview comparingimmobilizedandnon-immobilizedtrauma patientsanddemonstratedlowerratesofneurologicinjuryin patientswhowerenotimmobilizedonLSBs.7 Further complicatingtheuseofLSBsisthedifficultyinquantifying theactualrisksandbenefitsofSIduetothecomplexnature ofSCI.8–10 Numerousstudiesdescribetherealandpotential harmsofusingrigidLSBsandothertraditionalpracticesof SIequipmentduringthecareofacutelyinjuredpatients. WhileLSBusemayfacilitateextricationsinthetrauma setting,theiruseincreasesmorbiditybycausingpainand injury,includingpressurenecrosis,especiallyinpatients requiringlongtransporttimes.11 Furthermore,LSB usehasbeencorrelatedwithanincreasednumberof radiologystudiesorderedandsubsequentradiation exposuretopatients,increasedhospitalcost, inhibitionofrespiratoryfunction,andincreased intracranialpressure.11–18

In2018,apositionstatementonspinalmotionrestriction (SMR)waspublishedbytheAmericanCollegeof EmergencyPhysicians,theNationalAssociationofEMS Physicians,andtheAmericanCollegeofSurgeons CommitteeonTrauma.Thispositionstatementhighlighted theneedforSMRasthepreferredmethodofreducingspinal motionafteraninjuryandthatcompleteSIisnotpossible. Thispositionstatementhelpedprovideastandardofcarefor prehospitalpatientswithpossibleSCI,includinglanguage statingthatLSBs “shouldnotbeusedasatherapeutic interventionorprecautionarymeasure.”19 Toaddressthis recommendation,thestateofArizonaimplementeda statewideSMRprotocolwiththegoalofdecreasingLSBuse inhigh-risktraumapatients.Thisprotocol(IMAGE)deemphasizedLSBsbyrecommendingthatpatienttimeon LSBsbeminimized.

InthisstudyweaimedtoevaluateratesofLSBuseafter statewideimplementationofthisSMRprotocolinhigh-risk traumapatients,whomwedeﬁnedashavingadischarge diagnosisofSCI.Thisstudywillinformfutureresearchon

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Longspineboards(LSB)havebeenshownto causeharm.Spinalmotionrestriction(SMR) protocolsaimtoreduceLSBuseinpatients withsuspectedspinalinjurytominimize negativeeffects.

Whatwastheresearchquestion?

Wesoughttoevaluatetheratesofandreasons forLSBuseinhigh-riskpatientsafter statewideimplementationofaSMRprotocol.

Whatwasthemajor ﬁndingofthestudy?

StatewideSMRprotocolimplementationwas associatedwitha70%lowerrateinLSBuse (OR0.297,95%CI0.139 – 0.643;P = 0.002).

Howdoesthisimprovepopulationhealth?

ImplementationofSMRprotocolsdecreases LSBuseand,thus,thepotentialharms resultingusingthem.

theeffectivenessofSMRprotocolimplementationand hopefullyresultinthereductionofsecondaryinjuryin patientswithSCI.Additionally,weaimedtoclarify clinicalreasoningusedbycliniciansintheirdecisionto applyandnotlaterremoveaLSB,incontrasttoSMR protocolguidance.

METHODS

DataSourcesandStudyPopulation

Thiswasaretrospective,observational,multiagency, prehospitalstudyincludingcasesfromJanuary1,2013–December31,2015intheArizonaPrehospitalInformation andEmergencyMedicalServicesRegistrySystem (AZ-PIERS)andtheHospitalDischargeDatabase(HDD). BothdatasourcesaremaintainedbytheArizona DepartmentofHealthServices.TheAZ-PIERSdataset, whichismanagedbythedepartment’sBureauofEmergency MedicalServicesandTraumaSystem,isavoluntarypatient registrythatallowsEMSagenciestocollectandtransmit electronicpatientcaredatatotheState.Thedatabase includesbothrequiredandoptionalreportingelementsin NationalEMSInformationSystemformat.TheAZ-PIERS capturesagencyinformation,patientdemographics, responsetimes,incidentlocation,andtreatment.TheHDD collectsinpatientandemergencydepartmentvisitsfromall Arizonalicensedhospitalsexceptfederalhealthcarefacilities

suchastheVeteran’sAdministration,Departmentof Defense,ortribalhospitals.

TheEMStransportsinAZ-PIERSwerelinkedtothestate dischargedatabaseusingastepwisedeterministiclinkage algorithmwithdirectidentifiers(firstname,lastname,date ofbirth,SocialSecuritynumber,gender,dateofincident/ hospitaladmission,hospitalname).Pre-andpost-SMR protocolimplementationcohortswereidentifiedbasedon agencyprotocolimplementationdate,excludingathreemonthrun-inperiod.Foragenciesthatimplementedan SMRprotocolduringthestudyperiod,wereviewedthe protocoltoverifythatcriticalcomponentsofSMRwere present.Thesecomponentsincludedthefollowing:protocol applicationtopatientswithtraumaticinjury;identification ofasubgroupofpatientsveryunlikelytohaveaspinalinjury whoweresubsequentlyexcluded;andrestrictionofspinal motionwithoutrequiringLSBuse,meaningthataC-collar, scoopstretcher,vacuumsplint,orambulancestretcherwas used.Ofnote,SMRprotocolsdidrequiretheuseofa C-collarandmostallowedforthepatienttobepositioned withtheheadofthegurneyelevatedto30° ifthepatientdid nothavepainwithelevationfortheheadofthebed.

OfthecaseswithmatchedEMSandhospitaldata,this studyincludedonlypatientswithahospital-diagnosedSCI. Thesepatientswereincludedbecauseofthehigherrisk natureofinjuryandriskforsubsequentsecondarySCI. Thesepatientswereidentifiedasthosewithaprincipal diagnosisoftraumaticinjury(InternationalClassificationof Diseases,9th and10th Revisions,ClinicalModification [ICD-9]code800–959or[ICD-10]codeS00–T34orT79) mappingintotheUSCentersforDiseaseControland Prevention’sICD-9-CM(Barellmatrix)andtheproposed frameworkforICD-10-CMdiagnosiscodesforadiagnosisof SCI.20 Forthosecasesidentified,prehospitaldocumentation wasreviewedtodetermineC-collarandLSBuse.Caseswere excludedifagencySMRimplementationdatewasunknown; encounterswerenotedtobeinduplicate;patientshadno traumaintheprior24hours;reviewersdeemedinsufficient documentationtodeterminemethodofimmobilization;or managementinvolvedinterfacilitytransport.Theprevalence ofbothLSBandC-collarusewasdeterminedamongpatients withSCIandcomparedbetweenthepre-andpost-SMR cohortsusingsimpledescriptivestatisticsincludingoddsratios (OR)with95%confidenceintervals(CI).

ThecasesofSCIpost-SMRimplementationthathadLSB placedbyprehospitalcrewweresecondarilyreviewedbytwo independentphysicianreviewersusingaqualitative methodologytodeterminethelikelyreasonsforLSBuse. Theycategorizedcasesbasedonwhattheydeterminedtobe themostlikelyreasonforapplyingaLSBandfornot removingitpriortotransport.Weusedsimpledescriptive statisticstoanalyzethisqualitativeanalysis,withcalculation ofkappastatistictoevaluatethereliabilityofthe tworaters’ determination.

Thefollowingpossiblereasonsforinitialandcontinued LSBuseweredeﬁnedapriori:

• Toimprovetheeaseofliftingduetothelocationofthe injuredpatientrelativetotheambulancegurneyorsize ofthepatient.

• LSBwasplacedbyanon-transportingagencyonscene.

• LSBwasrequiredforextricationofthepatientfroma difﬁcult-to-accesslocation.

• Casesinwhichthereviewerswereunabletodetermine thereasonforplacingthepatientonaLSB.

ThefollowingpossiblereasonsfornotremovingtheLSB onceinthetransportvehicleweredeﬁnedapriori:

• Documentedneurologicsymptomsorother documented ﬁndingmakingthepatienthigh probabilityofhavingSCI.

• PatientrequiredLSBformultipletransfersfromone agencytoanotherfortransportpurposes.

• Documentedmedicallycomplicatedpatientwith criticalillness,whohadalteredlevelofconsciousnessor wasintubated.

• Casesinwhichthereviewerswereunabletodeterminea clearreasonformaintainingLSBimmobilization throughouttransport.

HumanSubjectsCommitteeReview

ThisstudywasreviewedbytheArizonaDepartmentof HealthServicesHumanSubjectsReviewBoardand approvedforpublicationonMarch17,2016.

RESULTS

Therewere1,123,178EMStransportsenteredintothe AZ-PIERSdatasetduringthestudyperiod,andatotalof 1,005,978(89.6%)weresuccessfullylinkedtoHDDcases. Weincluded63EMSagencieswithaknownSMR implementationstatusintheanalysis.Ofthese,52 transitionedtoanSMRprotocol,resultinginidentification of417,979EMSencountersinthefullstudypopulation. Fromthose,weidentifiedacohortofpatientswithany diagnosisofspinaltrauma,totaling5,178encounters.Within thispopulation,225uniqueSCIcaseswereidentified. Narrativereportsofthoserecordswereexaminedbytwo independentreviewerstodeterminethemethodof immobilization.Seventy-fourcaseswereexcludedfromthe analysisforbeingSCIofnontraumaticcause(21), interfacilitytransfers(11),andthosethatdidnotcontain enoughinformationtodeterminethemethodof immobilization(42).Thestudygroupincluded151cases, whichweredividedintopre-(64cases)andpostimplementation(87cases)cohorts.(Figure1)

63EMS Agencies implementing SMR 52EMS Agencies Transitioned toSMR

87Cases Post-SMR 49with LSBuse Post-SMR

74casesExcluded (42)NotenoughInformation (11)InterfacilityTransport (21)non-traumatic

Figure1. Flowchartofspinalcordinjurycasesandlongspinal boardusebeforeandafterimplementionofaspinalmotion restrictionprotocol.

EMS,emergencymedicalservices; SMR,spinalmotionrestriction.

Thedistributionofdemographic,mechanism/intentof injury,andoutcomeinformationweresimilarbetweenthe pre-andpost-SMRcohortsasillustratedin Table1.The

Table1. Demographics.

resultsoftheprimaryanalysiscanbeseenin Table2.Ofthe 151SCIcasesincluded,LSBswereusedin52pre-SMR (81%)and49post-SMR(56%)cases.TheoddsofLSBuse afterSMRimplementationwere70%lowerthanitwas beforeimplementation(OR0.297,95%CI0.139–0.643; P = 0.002).C-collaruseafterSMRimplementation wasnotsigniﬁcantlychanged(OR = 0.51,95%CI: 0.23–1.143; P = 0.10).

ThesecondaryanalysisidentifyingreasonsforLSBuse afterSMRprotocolimplementationareillustratedin Table3.Ofthe49cases,themostcommonreasonsforLSB placementwereasfollows:easeoflifting(63%);placement bynon-transportingagency(18%);andextrication(16.3%). HighsuspicionofSCIwasthoughttobetheprimaryor secondaryreasonfornotremovingLSBafterassessmentin themajority(53%)ofcases,followedbymultiple transfersrequired(10%),andcriticalillness(10%).In26%of cases,therewasnotaclearreasonformaintainingfull

Medianage(Q1,Q3)70(48,83)70(50,84)0.09 ISS,n(%)

<151,631(84.4%)2,715(83.6%)0.46 >= 15301(15.6%)531(16.4%)

Missing0(0.0%)0(0.0%)

Gender,n(%)

Female1,072(55.5%)1,811(55.8%)0.83

Male860(44.5%)1,435(44.2%)

Missing0(0.0%)0(0.0%)

Race/ethnicity,n(%)

White1,557(80.6%)2,680(82.6%) <0.001

Black28(1.4%)72(2.2%)

Hispanic/Latino232(12.0%)373(11.5%)

AsianorPaciﬁcIslander22(1.1%)46(1.4%)

NativeAmericanorAlaskanNative57(3.0%)44(1.4%)

Refused/unknown36(1.9%)31(1.0%)

Mechanismofinjury,n(%)

Fall1,015(52.5%)1,715(52.8%)0.25

Motorvehicletrafﬁc523(27.1%)874(26.9%)

Struckby/against42(2.2%)67(2.1%)

Cut/pierce1(0.1%)2(0.1%)

Overexertion48(2.5%)49(1.5%)

Other224(11.6%)351(10.8%)

Missing79(4.1%)188(5.8%)

Intentofinjury,n(%)

(Continuedonnextpage)

Table1. Continued.

Pre-SMRPost-SMR P-value (N = 1,932)(N = 3,246)

Unintentional1,855(96.0%)3,076(94.8%)0.91

Suicide6(0.3%)10(0.3%)

Homicide31(1.6%)49(1.5%)

Other4(0.2%)4(0.1%)

Undetermined36(1.9%)107(3.3%)

Hospitaldischargestatus,n(%)

Home1,028(53.2%)1,609(49.6%) <0.001

SNF/ALF/rehab/longterm673(34.8%)1,312(40.4%)

Expired/hospice68(3.5%)142(4.4%)

Other163(8.4%)183(5.6%)

ISS,InjurySeverityScore; SNF,skillednursingfacility; ALF,assistedlivingfacility; rehab,rehabilitationfacility.

Table2. Ratesoflongspinalboardandcervical-collarusepre-andpost-implementationofaspinalmotionrestrictionprotocol. Pre-SMRimplementation (n = 64) Post-SMRimplementation (n = 87)

PatientswithLSBplacedfortransport(%)52(81.25)49(56.32)0.297(0.139–0.643)

PatientswithC-collarplacedfortransport(%)53(82.81)62(71.26)0.51(0.23–1.143)

LSB,longspinalboard; SMR,spinalmotionrestriction; CI,conﬁdenceinterval; C-collar,cervicalcollar.

Table3. Reasonsforlongspinalboarduseinpatientswithdiagnosedspinalcordinjury.

ReasonforLSBinitialplacement(n = 49)

PrimaryreasonLSBwasnotremoved priortotransport(n = 49)

Extrication(%)8(16.33)Highsuspicionofspinalcordinjury(%)26(53.06)

Easeofliftingnon-ambulatorypatientfrom theground(%) 31(63.27)Requiredtransferbetweenagencies(%)5(10.20)

Placedbynon-transportingagency(%)9(18.37)Criticalillness(ie,unconscious,intubated)(%)5(10.20)

Other(%)1(2.04)Otherorunclearreasoning(%)13(26.53)

LSB,longspinalboard.

spinalprecautionsthroughouttransport.Therewasastrong levelofagreementbetweentheraters’ determinationsofthe reasonsforLSBplacementandreasonsforno discontinuation(kappa,0.8209and0.8108,respectively).

DISCUSSION

Resultsofthisstudysuggestthatimplementationofa selectiveSMRprotocol,whichfocusedonreducingLSBuse, wasassociatedwithastatisticallysigniﬁcantdecreaseinbut noteliminationofLSBuseamongprehospitalpatientswith

acutetraumaticSCI.Itisnotablethattherewassucha signiﬁcantdecreaseinLSBuseevenintheveryhighestrisk cohortoftraumapatientsstudiedhere thosewithhospitaldiagnosedSCI.Asexpected,therateofC-collarusewasnot affectedbytheseprotocolchangesastheprotocol implementeddidnotmakethemoptional.Thisdatasupports thattheadoptionofSMRprotocolsbyprehospitalagencies doesleadtodecreasedratesofLSBuse,eveninpatientswith high-riskinjuries,andmaysubsequentlyreducethe secondarycomorbidityassociatedwiththesedevices.

TheuseofC-collarsdidnotdeclinesigniﬁcantlyasaresult oftheprotocolchanges,asEMSprofessionalswererequired tousethedeviceforpatientsmeetinghigh-riskcriteria.This ﬁndingwasexpectedgiventhattheSMRprotocolrequires continueduseofthesetoolstolimitspinalmotion.The observationthatratesofC-collarusedidnotdecreaselends additionalsupporttotheconclusionthattheSMRprotocol resultedinadecreaseinLSBuseratherthanothersystemrelatedchangesorconfoundersresultinginthischange.

ThemostpracticalandleastcontroversialuseofLSBin traumacareisforextrication.Itdoesseemthatthiswasa factorinasmallnumberofcases.Similarly,themost commonreasonforLSBuseafterSMRprotocol implementation(63%ofcaseswhereLSBswereused)was thatEMSprofessionalsappearedtousetheLSBtoliftanonambulatorypatientfromthegroundtothegurney. PerhapsmorecontroversialislimitingtheuseofLSBfor patientswithexam ﬁndingssuggestiveofSCI.Inthisstudy, inmorethanhalfofcaseswithLSBplacement,clinicians documentedaconcerningorabnormalneurologicalexam ﬁndinganddocumentedthataLSBhadbeenusedduetoa possibleSCI.Inthesecases,perhapsimprovededucational outreachwouldlimitLSBusetothepracticalneedto liftapatientandencourageLSBremovalprior totransportation.

InpatientswhohadaLSBplacedfortheirmovementtoa gurney,frequentlynoreasonwascitedastowhythe patientwasnotrolledoffthespineboardpriorto transportation.Insomecases,thepatient’scarerequired multipletransfersbetweenagencies,orthepatientwas intubatedorhadothersignsofcriticalillnessorairway compromise,whichmayhavemaderemovingthespine boardchallengingorsimplywasnotapriorityintreatmentat thetime.

LIMITATIONS

Limitationsofthisstudyincludetheretrospectivecollection ofthedatafromprehospitalEMSdocumentation. Additionally,theAZ-PIERSdatabaselacksdata ﬁeldsthat wouldhaveprovidedspeciﬁcreasonsEMSusedaLSB,and limitedinformationwasavailablefromthenarrativesto qualitativelyassesswhytheychosetouseaLSB.As mentionedabove,thereasonsforLSBusewerenotclearin someofthenarratives,andwhileprovidinginsightintothe thoughtprocessoftheEMSprofessionals,thenarrativesmay notrepresenttheactualprimarymotivationfor placingandnotremovingpatientsfromLSBs.Neitherwere weabletoguaranteethateachEMSagencyimplementedtheir SMRprotocolinthesamemanner.WhilemanyoftheEMS agencies’ selectiveSMRprotocolswerereviewedforthe presenceofcertaincriticalelements,theywerenotidentical; andalthoughstandardizededucationalmaterialwas available,theuniformityoftheeducationgiventothethe EMSprofessionalscouldnotbeevaluated.

CONCLUSION

Prehospitaluseofalongspinalboardinhigh-riskpatients andthosewithahospital-diagnosedspinalcordinjury, signiﬁcantlydecreasedafterimplementationofspinal motionrestrictionprotocols.Continueduseofthelong spinalboardafterSMRprotocolimplementationappeared tobemostcommonwhenEMSprofessionalsperceiveda practicaldifﬁcultyoruneasewithbeingabletolift,move, andcarryinjuredpatientswithouttheuseofaLSB.Aswith allparadigmsshiftsinpolicy,itdoestaketimeforcomplete adherencetonewpracticesandprocedures.Thisiswhere visualfeedbackandqualityimprovementprogramsplaya largerole,highlightingtheneedtoprovideguidance regardingwhenaLSBshouldbeusedandtheoptimaltiming ofremovingpatientsfromaLSBtominimizecomplications.

AFFILIATIONSCONTINUED

#McGovernMedicalSchoolatTheUniversityofTexasHealth ScienceCenteratHouston,Houston,Texas

** TowerHealth-ReadingHospital,PhiladelphiaCollegeof OsteopathicMedicine,Reading,Pennsylvania

AddressforCorrespondence:AmberD.Rice,MD,TheUniversityof Arizona,DepartmentofEmergencyMedicine,P.O.Box245057, Tucson,AZ5057.Email: arice@aemrc.arizona.edu

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

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15.ChanD,GoldbergR,TasconeA,etal.Theeffectofspinal immobilizationonhealthyvolunteers. AnnEmergMed. 1994;23(1):48–51.

16.ChanD,GoldbergRM,MasonJ,etal.Backboardversusmattresssplint immobilization:acomparisonofsymptomsgenerated. JEmergMed. 1996;14(3):293–8.

17.CordellWH,HollingsworthJC,OlingerML,etal.Painandtissueinterfacepressuresduringspine-boardimmobilization. AnnEmergMed. 1995;26(1):31–6.

18.BauerDandKowalskiR.Effectofspinalimmobilizationdeviceson pulmonaryfunctioninthehealthy,nonsmokingman. AnnEmergMed. 1988;17(9):915–8.

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20.UniversityofArizonaEMSProgram.Spinalmotionrestriction procedure.2022.Availableat: https://emergencymed.arizona.edu/ sites/default/ﬁles/ems-public/uag_2022_spinal_motion_restriction.pdf AccessedMarch1,2023.

ORIGINAL RESEARCH

AssociationofGenderandPersonalChoiceswithSalariesof NewEmergencyMedicineGraduates

FionaE.Gallahue,MD*

LouisJ.Ling,MD†

LeoQuigley,PhD,MPH‡

DianDowlingEvans,PhD,ENP-C§

EdwardSalsberg,MPA‡

RobertE.Suter,DO,MHA∥¶

CatherineA.Marco,MD#

SectionEditor:MarkI.Langdorf,MD,MHPE

*TheUniversityofWashington,DepartmentofEmergencyMedicine, Seattle,Washington

† UniversityofMinnesota,DepartmentofEmergencyMedicine, Minneapolis,Minnesota

‡ GeorgeWashingtonUniversityFitzhughMullanInstituteforHealthWorkforce Equity,Washington,DC

§ EmoryUniversityNellHodgsonWoodruffSchoolofNursing,Atlanta,Georgia

∥ SamHoustonStateUniversityCollegeofOsteopathicMedicine,Ofﬁ ceofthe Dean,Conroe,Texas

¶ UniformedServicesUniversityoftheHealthSciences,DepartmentofMilitary Medicine,Bethesda,Maryland

# PennStateHealthMiltonS.HersheyMedicalCenter,Departmentof EmergencyMedicine,Hershey,Pennsylvania

Submissionhistory:SubmittedAugust13,2024;RevisionreceivedAugust22,2024;AcceptedAugust23,2024

ElectronicallypublishedSeptember9,2024

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

DOI: 10.5811/westjem.33606

Objective: Themedicalliteraturehasdemonstrateddisparitiesandvariabilityinphysiciansalariesand, speciﬁcally,emergencyphysician(EP)salaries.Wesoughttoinvestigateindividualphysician characteristics,includingsexandeducationalbackground,togetherwithindividualpreferencesof graduatingEPs,andtheirassociationwiththesalaryoftheir ﬁrstjob.

Methods: TheAmericanCollegeofEmergencyPhysiciansandtheGeorgeWashingtonUniversity MullanInstitutesurveyed2019graduatingEPs.Thesurveyincludedrespondents’ demographicand educationalbackground,post-trainingjobcharacteristicsandlocation,hospitalcharacteristics, importanceofdifferentpersonalpriorities,andstartingsalaries.Weperformedamultivariableregression analysistodeterminehowsalarieswereassociatedwithjobtypesandindividuals’ characteristics.

Results: Wesentsurveysto2,192graduatingresidentsin2019.Ofthese,487(22.2%)responded,and 270(55.4%)accepted first-timeclinicaljobsandincludedsalarydata(12.3%ofallsurveyssent).Male sex,osteopathictraining,andfull-timeworkweresignificantlyassociatedwithhighersalary.Menand womenprioritizeddifferentfactorsintheirjobsearch.Womenweremorelikelytoconsidersuchfactors asparentalleavepolicy,proximitytofamily,desiredpracticesetting,typeofhospital,anddesired locationasimportant.Salary/compensationwasconsideredveryimportantby51.8%ofmenand29.6% ofwomen.Men’smediansalarywas$30,000morethanwomen’s(p = 0.01,95%CI +$6,929 +$53,071),asignificantpaydifferential.

Conclusion: Salariesofgraduatingemergencymedicineresidentsareassociatedwiththeresident’s sexanddegreetype:doctorofosteopathicmedicineordoctorofallopathicmedicine.Multiplefactors maycontributetomenhavinghighersalariesthanwomen,andsomeofthisdifferencereﬂectsdifferent prioritiesintheirjobsearch.Womenweremorelikelytoconsiderjobconditionsandsettingtobe moreimportant,whilemenconsideredsalaryandcompensationmoreimportant.[WestJEmergMed. 2024;25(5)800–808.]

INTRODUCTION

Background

Previousreportshavedemonstrateddisparitiesand variabilityinphysiciansalariesand,speciﬁcally,emergency physician(EP)salariesbyavarietyoffactors.1–7 Disparities bysexwithmenearningmorethanwomeniswell documented,3,5–7 butthepossiblecausesofthisdisparity alongwiththeassociationofotherfactorswithsalary differencesisnotaswelldescribed.Wereviewpossible associationswiththisvariabilityinstartingsalariesofnew EPresidencygraduatesin2019.

Importance

Graduatingemergencymedicineresidentphysicianshave personalcharacteristicsthatmayinfluencetheselectionof theirvery firstjob.Theseincludepersonalpreferencesthat influencetheirjob-selectiondecisionsandmayimpactthe finalsalaryofthejobtheyultimatelyselect.Individualsmay havepreferencesinselectingtheirjob.Thechoicesmadeby womenandmenmaybedifferent.Unfortunately,verylittle isknownaboutthesefactorstoguideyoungEPsastheygo throughtheprocessofjobselection.

GoalsofThisInvestigation

WepresenttheresultsofananalysisofasurveyofEPs completingtheirresidencytrainingthatincludedawide rangeofquestionsaboutthetypeofjobstheyconsidered, theirpersonalandprofessionaldemographics,factorsthat impactedtheirjobselectiondecisionand, finally,thejobthat waschosenandresultingsalary.Ourgoalwastodescribethe associationofpersonaltraitsandjobcharacteristicswiththe salaryofthe firstjob,includingtheimpactofthegraduate’ s sex.Wecomparedandcontrastedtheprioritiesofwomen andmenintheirjobhunt.Weperformedasecondary regressionanalysistoinvestigatetheimpactofsexaloneon salary,independentofthesepreferences.Byfocusingon individualsobtainingtheirvery firstjobposttraining,we eliminatedtheimpactofmid-careerjobchangesorjob changesforcareeradvancementinassessingtheimpactof suchfactorsastheEP’ ssex.

METHODS

SurveyInstrument

Aspartofalargerinitiativetostudytheworkforceneeds forEPsinthenearfuture,theAmericanCollegeof EmergencyPhysicians(ACEP)andtheGeorgeWashington UniversityMullanInstitute ﬁeldedasurveytoall2019 graduatingEMresidents,approximately4–8weekspriorto graduation.8 ThisstudyreviewedasubsetofgraduatingEM residents’ personalcharacteristics,educationalbackground, andcharacteristicsoftheirjobchoices.Weuseda multivariablequantileregressionanalysistoestimatethe possibleimpactofsomeofthesefactorsonthesalariesof their ﬁrstpost-residencyclinicaljob.

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Physiciansalarieshavedemonstrated disparitiesandvariability.Multiplefactors maybeassociatedwithsalarydifferences.

Whatwastheresearchquestion?

Whatfactorsimpactsalariesofemergency medicinegraduates?

Whatwasthemajor ﬁndingofthestudy?

Men ’ smediansalarywas$30,000more thanwomen ’ s(p = 0.01,95% CI + $6,929 + $53,071).

Howdoesthisimprovepopulationhealth?

Thisstudysuggeststhatthesalariesofnew EMgraduatesareimpactedbymultiple factorsincludinggender.

Theresearchdesignandsurveywereapprovedbythe GeorgeWashingtonUniversityInstitutionalReviewBoard. Weadaptedthesurveytoolfromsimilarsurveysusedbythe MullanInstituteforstudiesofotherphysicianspecialty graduatesandfurtheradjusteditbasedonfeedbackfrom subjectexpertsandpilot-testingamongEPs.Thesurvey questionsofferedafour-pointLikertscale(veryimportant, important,oflittleimportance,notimportantatall),witha not-applicableoption,forpriorityfactorsinajob.(See SupplementaryMaterial.)

SurveyDissemination

ThesurveywasdistributedviaemailinMayandJune 2019,approximately4–8weekspriortotheirgraduation,to 2,192residentswithintheACEPdatabasewhoreportedthey wouldcompletetheirtrainingprogramin2019.The2,192 residentsrepresentedapproximately97.3%ofthe2,253 residentsintheir ﬁnalyearoftrainingonDecember31,2018, asreportedbytheAmericanBoardofEmergencyMedicine.9 Anoriginalemailwasfollowedbyuptothreeremindersfor non-respondents.Asanincentive,10giftcardswithavalue of$150weredistributedrandomlytorespondents.The onlinesurveyusedREDCap(ResearchElectronicData Capture)software,hostedatGeorgeWashingtonUniversity MullanInstitute.10

OutcomeandMeasures

Wecollecteddataincludingrespondents’ demographic andeducationalbackground,educationaldebt,post-training jobs,jobmarketexperiences,andfactorsinﬂuencingpost-

trainingjobplans.Welookedatthesefactorsandtheir associationwiththesalariesofthe ﬁrstjobselectedbythe270 graduatesofEMresidencieswhohadacceptedaclinical positionpost-residencyandsuppliedtheirbasesalary.

StatisticalAnalysis

Physicianincomeisassociatedwithfactorssuchas specialty,sex,race,ethnicity,academicpractice,boardcertificationstatus,andworkintensity.2–6 Theprimary statisticalanalysisinvolvedanoverviewofthesefactors.11 In asecondaryanalysisweusedquantileregressionina multivariableanalysisestimatingtheremainingsalary differencesbysexwhenmultiplefactorswerecontrolledfor. Selectionofvariablesforthemodelwasguidedbyasimilar regressionanalysisinasurveyofallUS-basedACEP membersinwhichthevariablesusedwerechosento representincome-associatedfactorsincludingspecialty,sex, race,ethnicity,academicpractice,board-certificationstatus, andworkintensity.1–7 Thevariablesincludedinthemodel wereasfollows:age;workingfullvsparttime;racial minoritystatus(Black,AmericanIndianorAlaskanNative vsWhiteorAsian);ethnicity(Hispanicvsnon-Hispanic); urbanvsruralorsemi-ruralpractice(where “urban” means beinglocatedinacityof50,000ormoreresidents, “semirural” refersto “urbanclusters” of2,500to49,999residents asdefinedforthe2010census,and “rural” referstoareas withfewerthan2,500residents);employmentinanacademic medicalcenter;countryofmedicalschool(international medicalgraduatevsgraduateofUSandCanadianmedical school);medicaldegreetype(doctorofallopathicmedicine vsdoctorofosteopathicmedicine[MDvsDO]);whether workingasecondaryjob;andworkingforafor-profitvsa non-profitorganization.

Allrespondentswereaskedtoself-definetheirsituation accordingtothestatedcriteria.Fortheregressionmodelwe treatedthecategoricalincomevariableasapointvariableby definingannualincomeasthemid-pointofthe$10,000 rangesusedinthesurveyquestionaire,whileagewastreated asacontinuous(wholenumberofyears)variable.Allother variablesweredichotomouswithvaluesderivedfromyes/no surveyresponses,withtheexceptionofwhetherworkingfor for-profitornon-profitorganizationswheretheresponse optionswereyes/no/don’tknow.Toavertthelossof51 respondentswhostatedthattheydidnotknowthefor-profit ornon-profitstatusoftheiremployingorganization,the valueofthisvariablefor “don’tknow” respondentswas imputedasthemeanoftheyes/noresponsevalueacross respondentswhodidrespondyesorno;itwasassumedthat notknowingfor-profitornon-profitorganizationalstatus wasrandomlydistributedacrossbothsexes.

Quantileregressionistypicallyusedwhentheassumptions ofnormaldistributiondonothold,asisoftenthecasein salarydistributions.12 Thismethodenabledustogenerate resultsatthelower(25%)andhigher(75%)incomequartiles

oftheincomedistributionaswellasatthedistribution’ s center(median).Theresultsofthelowerandhigherquantile regressionanalysisarenotseparatelyreportedastheyclosely resembledtheresultatthemedian.Theyareavailablefrom theauthors.

Owingtomissingdataamongthe270respondents,the finalregressionanalysisincluded258observations.The13 independentvariablesusedinthemodeland258 observationsallowedtheregressionmodeltoadheretothe generaloverfittingguidelineofapproximately20 observationsperoutcomevariable.11 Wecarriedoutatest foroverfittingoutusingtheStata “ overfit” command,which reportsbothin-sampleandout-of-sampleshrinkage statistics,foreachregressionresult.13 Datawereanalyzed usingStata1614 (StataCorp,LLC,CollegeStation,TX).

RESULTS

Atotalof487graduatingresidentsreturnedthesurvey.Of these,the270respondentswhoaccepted first-timeclinicaljobs andincludedsalarydatacomprisedthegroupthatwas analyzed.Threeofthe270respondentswhodidnotidentifya binarygenderwereexcludedfromthesex-specificanalysis.Of the270respondents,258hadcompletedatathatcouldbe analyzedfortheregression.Ofthe270,169(62.6%)selfidentifiedasmen,98(36.3%)aswomen,andthree(1.1%) preferredtoself-describeornotanswer.Of262whogavetheir age,234(89.3%)wereunder36yearsold.Of268respondents, 211(78.7%)wereWhite,35(13.1%)wereAsian, five(1.9%) wereBlack,and17(6.4%)were “other” ormorethanonerace. Ofthe270graduates,171(63.3%)hadthreeyearsoftraining, 94(34.8%)hadfouryearsand five(1.9%)had ≥5years.

ComparedtoABEMdata,theproportionofrespondents whoreportedcompletingthree-yearprogramswaslessthan thepercentageofthosecompletingthree-yearprograms nationallyattheendofcalendaryear2018(63.6%vs70.2%) andskewedmoreWhitethanEMresidentsnationally(78.7% vs63%),andlessBlack(1.9%vs4%)thanresidentsin trainingduring2018–2019.9 Of264respondentswithdata, 93(35.2%)hadeducationaldebtexceeding$300,000,while themedianeducationaldebtwas$237,500.Almostthree quarters(72.4%)reported “quiteabit” or “agreatdeal” of salaryvariabilityintheirjobsearch(Table1).

Table1. Perceivedvariabilityofphysicians’ salaries.*

Howmuchsalaryvariability(intermsof totalannualincome)wasthere?NumberPercent Quiteabit13851.5% Agreatdeal5620.9% Verylittleornone5119.0% Onlygotoneoffersocan’tsay238.6% Total268100

*268ofthe270respondedtothisquestion.

MultivariableAnalysisofSalaryDifferences

Toassessthemultiplefactorsthatappearedlinkedtothe salariesearnedbynewlygraduatingresidentsweuseda quantileregressionanalysistocontrolformanyofthese factorstogetheratdifferentquantilesoftheincome distribution.Theassessmentaccountedforbothpart-time andfull-timework.Themoststatisticallysigniﬁcantfactor wasgendergap,withmenmakingamedian$30,000more thanwomen($244,200vs$214,200),followedbyDO graduateswhomadeamedian$30,000morethantheirMD counterparts(median$274,200formenvs$244,200for womenwhoareDOgraduates),andfull-timeworkers makingamedianof$43,000morethanthoseworkingparttime($287,349formenvs$257,349forwomenwhoare full-timeworkers)(Table3).

Otherfactorsthatwerenotsigniﬁcantbuttrendedtoward apositiveimpactonsalarywerenon-academiccenter employmentcomparedtoacademicandsemi-rural/rural comparedtourbanjobs.Twothirdsofgraduatesaccepted jobsatsitesincitiesdespitelowersalaries.Menwere morelikelytoacceptjobsassociatedwithhigherpay insmallercommunities,non-academicsettings,and smallerhospitals.

Sensitivityanalysisincludedrunningthemodelwithand withoutthefor-profitvariable.Withandwithoutimputation ofthevaluesofthefor-profitvariabledidnotsignificantly altertheresults,whichappearedtoberobusttominor variationsinthemodel.Similarly,theresultsdidnotchange substantiallybetweenlinearregressionandquantile regression,likelybecausetheincomedistributioninthis sampleappearedtocloselyfollowanormaldistribution basedonShapiro-WilkandShapiro-Franciatestsof normalityandStata’ s “sktest” forskewnessandkurtosis.

FactorsConsideredbyWomenandMeninTheir JobSearch

Respondentsratedfactorstheyconsideredinselectinga jobwithresponseoptionsrangingfrom “veryimportant” to “notimportantatall.” Wefocusedonfactorsratedas “ very important” comparedtootherresponses(excluding “not applicable”),reportedin Table2A,and “veryimportant” and “important” togethercomparedtoof “littleimportance” and “notimportant,” reportedin Table2B.Therationale behindthisisthat “veryimportant” factorscouldbe consideredcriticalinthejobselectiondecisionandtheir absencecouldeliminateapossiblejob,while “important” factorscouldbeconsiderednicetohaveand,therefore,only aswingfactorinjobselectionifthe “veryimportant” criteria weremet.Thefactorsarelistedinorderofthepercent differenceofpreferencesofwomenovermen.Factorsatthe topof Tables2A and 2B havethegreatestdifferenceinwhat womenconsideredimportantcomparedtomen;factorsat thebottomarethosethatmenconsideredmoreimportant thanwomen.

Generally,womenconsideredlifestyleandwork-life balancefactorsintheirjob-seekingchoicesmorethanmen. Parentalleavepolicy,proximitytofamily,thepractice setting,thetypeofhospital,andlocationofthehospital werestatisticallymoreoftencitedbywomenas “ very important ” factors,whilesalary/compensationwas statisticallymorefrequentlynotedformen.Whenadding “nicetohave”“important ” factorstothe “veryimportant ” factors,adifferentlistofprioritieswasstatisticallydifferent forwomenandmen.Forwomen,theparentalleavepolicy, meetingvisarequirements,thepatientpopulation, employmentoptionsforthespouse,stayinginthesame regionasthetrainingprogram,availabilityofmentors, supportiveacademicenvironment,andurbanvsrural settingcouldbeconsidered “nicetohave ”.Salary/ compensationwastheonlyfactorstatisticallymore importantformenthanforwomen.

DISCUSSION

Therearemanyfactorsassociatedwiththesalariesthat graduatesreceive.1–6 Threefactorsarestatistically significant.Themostsignificantfactorresultingingreater payisthegendergap,followedbyaDOdegreeand,not surprising,thatfull-timeemploymentpaysmorethanparttimeemployment.15 Incomparison,asimilarrecentsurveyof allACEPmembersfoundsexwassignificantlyassociated withbasesalarybuttypeofdegreewasnot.1 New osteopathicgraduatesarereportedinotherstudiestobe moreinclinedtochoosepositionsinnon-academicsettingsin smallercommunities,bothofwhichappearassociatedwith highersalaries.16,17 Apredominanceofallgraduates acceptedjobsatsitesincitiesdespitethelowersalaries.This isnotsurprisingwhenconsideringthe “veryimportant” preferencesthataresummarizedin Table2A

Thereareannualsurveysofemployersthatcollectdataon averagesalaryandcompensationbyspecialtysuchasthe ModernHealthcarePhysicianCompensationDatabaseand theMedicalGroupManagementAssociation.18,19 Most surveysincludealljobsfornewandexperiencedphysciansin differentphasesoftheircareersandusuallydonot differentiatebetweentypeofhospital,hospitalsite,andother factorsthatareinherenttotheirlocalcommunity.Thejobs mayhavedifferentproportionsofclinicalandadministrative orleadershipresponsibilities,whichmaymakeitdifficutto comparebetweenjobs.ThisACEP-MullenInstitutesurveyis uniqueinthatitfocusedspecificallyonstartingsalariesof graduatestakingtheirvery firstentry-leveljob.Evenforthis well-definedtypeofposition,therewas “quiteabit” or “ a greatdeal” ofvarianceinthejobstheywereoffered,(Table1) asnotedbygraduates.

Apersistentgendergaphasbeenidentiﬁedinnumerous studies,despitemanyyearsofattentioninmanyprofessions, manyotherspecialties;EMappearstobeno different.5,6,7,15,20,21,22 Wefoundagapattributabletosex

Parentalleavepolicy207925.361424.221.121.7520 <

Proximitytofamily419344.14216425.618.59.26530.002*

Jobs/practiceindesired practicesetting 529853.16816840.512.63.95910.05*

Typeofhospital229822.4161649.812.67.97000.01*

Jobs/practiceindesiredlocation769877.611016765.911.74.030.05*

Employmentforspouse/partner267534.73314223.211.53.23730.07

Patientpopulationtobeserved249724.72216213.611.15.17530.02* Weather259626.03116618.77.31.96430.16

Availabilityofmentors169317.21716310.46.82.42040.12

Supportiveacademicenvironment139214.1121607.56.62.87360.09

Frequencyofweekendduties239823.53216719.24.30.69680.40

Sortedinorderofthedifferenceinpercentageofwomenrespondingas “veryimportant” comparedtomen(column7).

*P < .05signiﬁcance.

**Sincenoteveryrespondentansweredeveryquestion,Nisthetotalnumberofwomenandmenrespondingtothequestion. EM,emergencymedicine; NP,nursepractitioner; PA,physicianassistant.

aloneof$30,000atthemedian,whichwasconsistentacross theincomedistribution.Reisdorffetalfoundasigniﬁcant gendergapof$43,565forasampleofallACEPmembers, andMadsenetalfoundasmallerbutstillsigniﬁcant differenceof$19,418foracademicEMfaculty.1,22 The impactofsexinphysicianpayseemspersistentthroughouta careerandcouldtranslatetoanover$2millionnetincome

differenceovera40-yearcareer.23 Ourresultsondifferencein jobpreferencesbysexsuggestthatthereasonsforthegap maynotbeentirelysystemicbutmaybeatleastpartly associatedwiththedifferentlocationsandtypeofjobsthat menandwomenselect.

Graduatingresidentshavemanyfactorstoconsiderand eachindividualwillhavedifferentpersonalprioritiesaswell

Table2B. “Veryimportant” and “important” vsof “littleimportance” and “notimportantatall”:factorsinﬂuencingjobselectionformenand womensortedbydifferenceinpercent.*

Factoris

Parentalleavepolicy517964.6%3114221.842.8%39.7066 <

Job/practicemeets visarequirements

92634.6%75413%21.6%5.14250.02*

Patientpopulationtobeserved729774.2%9116256.2%18.0%8.47760.004* Employmentforspouse/partner537570.7%7514252.817.9%6.46360.01*

Availabilityofpart-timeposition327642.1%3413724.8%17.3%6.83170.01*

Stayinginsamecity/region asEMtraining

Availabilityofmentors619365.6%8216350.3%15.3%5.61060.02*

Supportiveacademicenvironment419244.6%5016031.2%13.4%4.48890.03*

Ruralvsurban719773.2%10016560.6%12.6%4.27130.04*

Frequencyofweekendduties699870.4%9816758.7%11.7%3.64340.06

Typeofhospital709871.4%9816459.8%11.6%3.63300.06

Proximitytofamily689373.1%10216462.2%10.9%3.16220.08

Opportunitiesforteaching389440.4%5316232.7%7.7%1.54310.21

Frequencyofovernightshifts739874.5%11716570.5%4.5%0.39310.53

Opportunitiesforresearch7907.8%61603.75%4.05%1.89560.17

Jobsindesiredpracticesetting869887.8%14616886.9%0.9%0.04010.84 Costofliving639764.9%10516464%0.9%0.02270.88 Partnershipopportunity378245.1%6614944.3%0.8%0,01460.90

Jobs/Practiceindesiredlocation949895.9%15916795.2%0.7%0.07180.79

7.6%6.05950.01*

Sortedinorderofthedifferenceinpercentageofwomenrespondingas “veryimportantorimportant” comparedtomen(column7). *P < .05signiﬁcance.

**Sincenoteveryrespondentansweredeveryquestion,Nisthetotalnumberofwomenandmenrespondingtothequestion. EM,emergencymedicine; NP,nursepractitioner; PA,physicianassistant.

asdifferentcareergoals.Womenarestatisticallylesslikely thanmentoconsiderhighsalaryasveryimportantandmore likelytoconsidermorenon-salaryfactors,aslistedin Tables2A and 2B,asmoreimportantthanmen.The long-term ﬁnancialimpactofthesedecisionsareunknown andwerenotconsideredintheanalysis,butthesepersonal prioritiesmaycontributetotheunexplainedandpersistent salarydifferencesbysex.

Weconﬁrmedthatsalarymaybeimpacted,butlessso, basedonlocationofpractice,sizeofthecityandthesetting, withacademicandlargehospitalspayinglessthansmaller, ruralandcommunityhospitals.Menweremorelikelyto acceptjobsassociatedwithhigherpayinsmaller communities,non-academicsettings,smallerhospitals,or exclusivelyEMpracticeconsistentwithatleastoneother study.24 AsananticipatedsurplusofEPsisprojected,its

Table3. Quantileregressionresults(median). CategoryCharacteristicVariable

Non-minority255(98.8%)reference

Non-Hispanic246(95.3%)reference

AgeIncreasingageMean$ 1,246( 4,535 + 2,044) 0.46242,954212,954

TrainingTraining location3 International medical graduate 10(3.9%)$+48,096( 9,067 + 105,529) 0.10292,296262,296 USorCanadian graduate 248(96.1%)reference

Non-academic190(73.6%)reference

0.62237,936207,936

Nosecondary job 188(72.9%)reference

1Basesalaryonly.

2Under-representedminorityofBlack,NativeAmerican,andAlaskancomparedtoallothers.

3InternationalmedicalgraduatecomparedtoCanadianandAmericanschoolsaccreditedbytheLiaisonCommitteeonMedicalEducation andAmericanOsteopathicAssociation.

4DO,osteopathicphysicians,comparedto MD,allopathicphysicians.

*P > |t|: P-valueinregressiontable: P < .05signiﬁcance.

**Thisisthemediansalaryformales/femaleswithallothervariablessettotheirnullvalue,includingthecontinuousvariableforage.

†Thistableshowsresultsfor258respondents.

impactwillbefeltmostdirectlybygraduatingresidentswho arenewtothejobmarketandmostcloselyinvestedinthe supplyanddemand.25 Ofnote,thissurveywascompleted priortotheCOVID-19pandemic.

LIMITATIONS

Therewereseverallimitationstothestudy.Thesampleof 270residentsanalyzedandthe258whohadcomplete(or imputed)datafortheregressionanalysisrepresents

approximately12%ofallgraduatingresidentsin2019;thus, whileitcannotbeconsideredarepresentativesample,itdoes provideinsightintosomeofthefactorsconsideredby graduatingresidentsthatmaybeassociatedwiththeir salaries.Understandingsalarywasnottheprimarypurpose ofthelargerinitiative,buttheresultingdatasetincluded salarydataforrespondentswhohadacceptedapostresidencyjob.Theanalysiscomparedrespondents’ base salarieswithoutconsiderationofadditionalincomesources suchasincentivepaymentsandmaynotrepresentall anticipatedincome.Likeallsurveysrelyingonself-reported data,thepotentialexistsforinaccuraciesorrecallbias. Surveyrespondentswereaskedtoreporttheirsalarieswithin $10,000ranges;so,thepointvaluesusedintheanalysis presumethatactualsalarieswereevenlydistributedwithin eachsalaryrange,whichcouldhaveresultedinsome inaccuracyinsalaryreporting.

Althoughthereisvariabilityinsupplyanddemandof emergencyphysiciansbystate,ourintentwasanational scope;thus,analysisofthesalariesandjobopportunities withinspeciﬁcregionsorstateswasnotperformed.Whilethe originalsurveytoolhasbeenusedwidelywithgraduatesof otherspecialties,validationofthissurveytoolwaslimitedto content-expertcomments,pilot-testingwithinEM,and modiﬁcationbasedonfeedbackreceived.1 Wedidnot exploreanynumericalmeasuresoffactorloadingor surveyconsistency.

Theregressionmodelwaslimitedto13variablestoaddress overfitting,necessitatingdifficultchoicesastowhichvariables toincludeandhowbesttoconstructdummyvariablesfrom categoricalones.Nevertheless,theresultsofasensitivity analysisthatfoundonlyminorchangesintheresultswhen alternativevariablelistingswereexploredsuggestthatthe regressionmodelwasnotsensitivetochangesinmodel specification.Finally,theregressionanalysisusedasample thatwasslightlysmallerthanthemainsample(258vs270) owingtomissingdataonsomevariables.Itisassumedthatthe 258werecloselyrepresentativeofthelargersample,giventhe smalldifferenceinnumbersbetweenthetwosamples.

CONCLUSION

Asampleof2019graduatingEMresidentsreported varianceinsalariesthatdependedonseveralvariables.Men andosteopathicphysicianswerepaidsigniﬁcantlymorein their ﬁrstjobsthanwomenandallopathicphysicians.In exploringpossiblereasonsforthegapinpaybetweenmen andwomen,womenarestatisticallymorelikelythanmento considerlifestylefactorssuchasparentalleavepolicy, proximitytofamily,joblocation,practicesetting,andtypeof hospitalaspriorities.Menarestatisticallymorelikelyto considersalaryandcompensationmoreimportantthan women.Nevertheless,thegapinpaybetweenmenand womenEMgraduatesisnotfullyexplainedbythefactors

wewereabletoincludeinouranalysis,andother explanationsmustbesoughtfortheportionofthegendergap thatremainsunexplained.

AddressforCorrespondence:FionaE.Gallahue,MD,TheUniversity ofWashington,DepartmentofEmergencyMedicine,3259th Ave., Box359702,Seattle,WA,206-744-2556.Email: ﬁogal@uw.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsourcesand financialormanagementrelationshipsthatcouldbeperceivedas potentialsourcesofbias.Financialsupportwasprovidedbythe AmericanCollegeofEmergencyPhysicians(ACEP),AmericanBoard ofEmergencyMedicine(ABEM),AmericanCollegeofOsteopathic EmergencyPhysicians(ACOEP),AmericanOsteopathicBoardof EmergencyMedicine(AOBEM),CouncilofEmergencyMedicine ResidencyDirectors(CORD),EmergencyMedicineResidents’ Association(EMRA),andSocietyforAcademicEmergencyMedicine (SAEM).ESandLQreceivedfundingfromtheAmericanCollegeof EmergencyPhysicians(ACEP),AmericanBoardofEmergency Medicine(ABEM),AmericanCollegeofOsteopathicEmergency Physicians(ACOEP),AmericanOsteopathicBoardofEmergency Medicine(AOBEM),CouncilofEmergencyMedicineResidency Directors(CORD),EmergencyMedicineResidents’ Association (EMRA),andSocietyforAcademicEmergencyMedicine(SAEM)for thedataacquisitionandanalysis.Therearenootherconflictsof interestorsourcesoffundingtodeclare.

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ORIGINAL RESEARCH

EquityintheEarlyPainManagementofLongBoneFractures inBlackvsWhitePatients:WeHaveClosedtheGap

DietrichJehle,MD*

KrishnaK.Paul,BS* StanleyTroung,BA*

JacksonM.Rogers,BS*

BlakeMireles,MBS*

JohnJ.Straub,BS* GeorgiyGolovko,PhD†

MatthewM.Talbott,DO* RonaldW.Lindsey,MD‡

CharlesP.Mouton,MS,MBA,MD§

SectionEditor:DavidThompson,MD

*UniversityofTexasMedicalBranch,DepartmentofEmergencyMedicine, Galveston,Texas

† UniversityofTexasMedicalBranch,DepartmentofPharmacologyand Toxicology,Galveston,Texas

‡ UniversityofTexasMedicalBranch,DepartmentofOrthopaedicSurgeryand Rehabilitation,Galveston,Texas

§ UniversityofTexasMedicalBranch,DepartmentofFamilyMedicine, Galveston,Texas

Submissionhistory:SubmittedOctober27,2023;RevisionreceivedApril19,2024;AcceptedApril26,2024

ElectronicallypublishedAugust1,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18531

Introduction: Patientswithlongbonefracturesoftenpresenttotheemergencydepartment(ED)with severepainandaretypicallytreatedwithopioidandnon-opioidanalgesics.Historicaldatarevealsracial disparitiesinanalgesicadministration,withWhitepatientsmorelikelytoreceiveanalgesics.Withthe diversifyingUSpopulation,healthequityisincreasinglycrucial.Inthisstudyweaimedtoevaluatethe earlyadministrationofopioidandnon-opioidanalgesiaamongBlackandWhitepatientswithlongbone andfemurfracturesinEDsoverdifferenttimeframesusingasubstantialdatabase.

Methods: WeretrospectivelyextractedInformationfrom57UShealthcareorganizationswithinthe TriNetXdatabase,encompassing95millionpatients.TheEDrecordsfrom2003–2023weresubjectedto propensityscorematchingforageandgender.Wefocusedonfourcohorts:twocomprisingBlackand Whitepatientsdiagnosedwithlongbonefractures,andanothertwowithBlackandWhitepatients diagnosedsolelywithfemurfractures.Weexaminedanalgesicadministrationratesover20years (2003–2023)at ﬁve-yearintervals(2003–2008;2008–2013;2013–2018;2018–2023),andfurther analyzedtheratesforthemostrecenttwo-yearperiod(2021–2023).

Results: Disparitiesinanalgesicadministrationsigniﬁcantlydiminishedoverthestudyperiod.For patientswithlongbonefractures(1,095,052),theopioidadministrationgapnarrowedfrom6.3%to1.1%, whilenon-opioidadministrationdisparitiesreducedfrom4.4%to0.3%.Similartrendswerenotedfor femurfractures(265,181).By2021–2023,nosigniﬁcantdifferencesinanalgesicadministrationwere observedbetweenracialgroups.

Conclusion: Overthepast20years,thegapinearlyadministrationofopioidandnon-opioidanalgesics forBlackandWhitepatientspresentingwithlongbonefracturesorfemurfractureshasbeen disappearing.[WestJEmergMed.2024;25(5)809–816.]

INTRODUCTION

Background

Patientswithlongbonefracturesroutinelypresenttothe emergencydepartment(ED)withseverepain,requiring effectivepainmanagementstrategies.Over178millionnew fractureswererecordedworldwidein2019,and approximately60%ofthosewerelongbonefractures.1,2 Standardmanagementprinciplesusenon-opioidandopioid analgesicstotreattheseverepainoftenassociatedwithlong bonefractures.3 Therehavebeen ﬁndingssuggestingthatnot allpatients’ painwasbeingtreatedequitably.Anational studypublishedin2008thatcovereda13-yearperiodshowed thatnon-HispanicWhitepatientswere8%(31%vs23%) morelikelythanBlackpatientstoreceiveopioidsforpainrelatedconditionsincludingnephrolithiasisandlongbone fractures.4 Severalsubsequentstudieshaveshownthesame trend,showingthatnon-HispanicWhitepatientsweremore likelytobetreatedwithpainmedicationsthanotherracesfor longbonefractures.4–10

Incontrast,somerecentsmallerstudieshavereportedno statisticallysigniﬁcantracialdifferencesinanalgesic prescribingforpatientswithlongbonefractures.11–14 Forexample,astudypublishedin2021with6,441pediatric visitsshowedtherewasnosigniﬁcantdifferenceinthe rateofopioidsprescribedtochildrenwhowereBlack, Hispanic,orotherracevsnon-HispanicWhitechildrenwho weretreatedforlongbonefracturesatmultiplehospitals from2012–2019.15

AsthepopulationoftheUnitedStatesgrows,itsdiversity isexpectedtoincreaseaswell.Minoritygroupsareprojected toexceedover50%oftheUSpopulationby2044.16 Thus,healthequityandawarenessofdifferentialtreatment basedonraceorethnicitybecomesmoresigniﬁcant. Thefundamentalidealinmedicineistoensureahealthcare systemthatdoesnotproduceinequitablehealth treatmentandoutcomesbasedonanindividual’ s demographiccharacteristics.

GoalsofInvestigation

Ourprimaryobjectivewastoinvestigatepotentialracial inequalitiesintheadministrationofopioidandnon-opioid analgesicsforpatientswithlongboneandfemurfracturesin theED.

METHODS

StudyDesignandSetting

Thisstudyemployedapropensity-matched,retrospective designtoevaluatealargenationaldatabase,TriNetX,over varioustimeperiods.Usingthe “UnitedStatesCollaborative Network” withintheplatform,containingde-identiﬁed electronichealthrecordsofapproximately95million patientsfrom57healthcareorganizations,wecreatedtwo setsofcohortsonDecember27,2022.Theseorganizations arelargelytertiaryacademiccentersandtheirsatellite

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Effectivepainmanagementforlongbone fracturesiscrucial.Disparitiesinanalgesic prescribingbasedonracehighlighttheneed forhealthequity.

Whatwastheresearchquestion?

Arethereinequitiesinadministrationof analgesiaforlongbonefracturesofBlackvs Whitepatients?

Whatwasthemajor ﬁndingofthestudy?

From2003to2023,theopioidadministration gapnarrowedfrom6.3%(P < 0.001,CI 0.65 – 0.75)to0.2%(P = 0.78,CI0.98 – 1.03).

Howdoesthisimprovepopulationhealth?

Racialdisparitiesareasigni ﬁ cantbarrierto equitabletreatment,andthisstudyhelpsshed lightonthecurrentstateofhealthcare.

facilities.Thereisrepresentationfromallgeographicregions oftheUnitedStates.

CohortSelection

Weselectedpatientsfromallagegroups.Toprotect patientprivacy,thosewhowere ≥90yearsofagewere groupedas90withintheTrinetXdatabase.Inthe firstsetof cohortsstudied,Cohort1.1containedBlackpatientswith longbonefractures,whileCohort1.2containedWhite patientswithlongbonefractures.Longbonefracturesare definedusingtheInternationalClassificationofDiseases, 10th Rev,procedurecodingsystem(ICD-10)fordiagnosisof fracturesoftheshaftofthetibiaandfemur,lowerendof ulna,upperendofradius,shaftofulnaand fibula,lowerend ofradius,forearm,andshoulderandupperarm.TheICD-10 codesarelistedin Table1.Ofnote,multiplefracture diagnosesmaybepresentinonevisit.Inthesecondsetof cohorts,Cohort2.1hadBlackpatientswithonlyfemur fracturesandCohort2.2hadWhitepatientswithonlyfemur fractures.Inthesecohorts,patientshadcomethrough emergencydepartmentservices(CPT:1013711)withinthe prior20years.

Wefurtherexploredthecohortsbylookingatasubgroup analysisover ﬁve-yearintervalsrangingfrom2003–2008, 2008–2013,2013–2018,and2018–2023.Theserounded cutoffswerechosenforeaseofinterpretation.Weanalyzed eachintervalfromJanuaryofthestartingyeartoJanuary1 ofthe ﬁnalyear.Bothlongboneandfemurfracturecohorts

Table1. InternationalClassiﬁcationofDiseases,10th Rev,for fracturediagnosisindatabase.

FracturediagnosisICD-10-CM

No.offractures indatabase

ShoulderandupperarmS421,073,481

ForearmS521,072,733

LowerradiusS52.5679,479

FemurS72597,633

LowerulnaS52.6346,093

ShaftoftibiaS82.2290,731

UpperradiusS52.1259,067

ShaftofulnaS52.2228,245

Unspeciﬁedshaftof ﬁbula, initialencounter,closed S82.409A57,426

ICD-10-CM,InternationalClassiﬁcationofDiseases,10th Rev, ClinicalModiﬁcation.

werechoseninparttocontrolforconfoundersincaseswith multiplefractures,butalsobecausefemurfracturescomprise amorehomogeneousgroupthatmoreconsistentlyneeds analgesia.Institutionalreviewboardapprovalwasnot requiredforthisstudy,asTriNetXprovidesdatathathas beende-identiﬁed,whichrestrictsaccesstoprotectedhealth information(forusersofthedatabase).17

Measures

Demographicsincludedself-reportedgenderrace, ethnicity,andmaritalstatus,whichmaptoHealthLevel7 administrativestandards.Genderwascodedasmaleor female.RaceandethnicitywererecodedintoHispanic,nonHispanicWhite,andnon-HispanicBlack.

Outcomes

Fromeachcohort,twodifferentoutcomeswereevaluated: treatmentwithopioidanalgesics(VA:CN101)andtreatment withnon-opioidanalgesics(VA:CN103).Theadministration datapresentedwasbinary:whetherthepatienthadreceived

anyamountofanalgesiaornot.Thetimewindowwas adjustedfortheoutcometooccuronthesamedayorupto onedayfromtheindexeventforeachcohort.Patientswere excludedfromthecohortiftheyreceivedtheoutcomeprior tothevisit,suchasthosewhomayhavehadadocumented acuteorchronicopioid/non-opioidprescriptionprior toarrival.

StatisticalAnalysis

UsingtheTriNetXdatabase,a1:1propensityscorematch wasproducedwithlinearandlogisticregression.Weused greedynearestneighbormatchingwithtoleranceof0.1and differencebetweenpropensity ≤0.1.18 Balanceoncovariates wasassessedusingstandardizedmeandifference,and absolutevaluesof >0.1wereconsideredpositiveforresidual imbalance.TheTriNetXplatformusesinputmatricesof user-identiﬁedcovariatesandconductslinearandlogistic regressionanalysistoobtainpropensityscoresforindividual subjects.TriNetXrandomizestheorderofrowstoeliminate biasresultingfromthenearestneighboralgorithms.This studymethodologyhasbeenpreviouslyvalidated.17

Wecomparedcohortsbeforeandafterpropensity matching.Propensitymatchingwasdonethroughthe “BalanceCohorts” toolinTriNetXtocontrolforageatthe diagnosisofthefractureandgender.Therewerestatistically signiﬁcantdifferencesinthedemographicsforallcompared cohortspriortopropensitymatching.Demographicsbefore andafterpropensitymatchingforthecohortswithlongbone fracturesorfemurfracturesinthelast20yearsareshownin Table2.Duetorecentincreasesinsocietalawarenessfor differentialtreatmentbasedonracialdisparities,asecond subgroupanalysiswasalsocompletedonJanuary1,2023,to analyzethesameoutcomes(opioidanalgesicsandnonopioidanalgesicsonthesamedaytoonedayafteremergency care)forBlackcomparedtoWhitepatientsoverthemost recenttwoyears(2021–2023).

Weusedthemeasure-of-associationtoolinTriNetXto performunivariateanalysiswhereriskratio(RR),95% conﬁdenceinterval(CI),andprobabilityvalues(P )were

Table2. DemographicsforBlackpatientsvsWhitepatientsfrom2003–2023beforeandafterpropensityscorematching.

LongbonefracturesBlackpatientsbeforeWhitepatientsbeforeBlackpatientsafterWhitepatientsafter Totalpatients172,411901,998172,411172,411

FemurfracturesBlackpatientsbeforeWhitepatientsbeforeBlackpatientsafterWhitepatientsafter

Male22,441(57%)91,567(41.5%)22,441(57%)22,441(57%)

calculatedtoshowcomparisonsofoutcomesforthetime intervalscorrespondingtoeachcohortstudied.Thedatawas reportedasRRswith95%CIfromthe ﬁnalanalysis,which wascompletedonDecember29,2022.Statisticalsigniﬁcance wassetatatwo-sidedalpha <0.05.

RESULTS

CharacteristicsofStudySubjects

Inthisstudyweanalyzed94,990,854patientsfrom57 healthcareorganizationsintheUnitedStatesCollaborative NetworkdatabaseinTriNetX.Therewere2,477,404 patientsidentiﬁedwithlongbonefractures(272,690Black and1,716,194White)and597,833patientswithonlyfemur fractures(67,905Blackand431,613White)beforerestricting toEDvisits.AfterrestrictingthestudytotheED,175,354 Blackand919,698Whitepatientswerefoundwithlongbone fractures.Usingthe ﬁve-yearintervalsfromthesubgroup analysisoflongbonefractures,thenumberofBlackpatients foundwere9,917(2003–2008);27,294(2008–13);67,767 (2013–18);and82,008(2018–23)whilethenumberofWhite patientsfoundwere44,864(2003–2008);147,130(2008–13); 340,320(2013–18);and459,479(2018–23),respectively.

ForpatientswhocamethroughtheEDintheprior 20yearswithfemurfractures,therewere40,084Blackand 225,097Whitepatients.Lookingatthesame ﬁve-year intervalsforthesubgroupanalysisoffemurfractures,there were2,092(2003–2008)5,827(2008–13);15,521(2013–18); and19,677(2018–23)Blackpatients,whiletherewere9,301 (2003–2008);33,098(2008–13);82,390(2013–18);and 117,103(2018–23)Whitepatients,respectively.Wedeﬁned raceas “unknown” in19%ofthepatientpopulation.The geographicdistributionofpatientsinthecohortsofED patientswithlongbonefractureswas25%fromthe

Northeast,20%fromtheMidwest,39%fromtheSouth,and 13%fromtheWesternUS.

MainResults

Opioidanalgesiaforpatientswithlongbonefractures increasedforbothcohorts,shiftingfrom14.4%ofBlackand 20.7%(RR0.697,95%CI0.647–0.751)ofWhitepatients between2003–2008to45.8%ofBlackand46.9%(RR0.978, 95%CI0.964–0.992)ofWhitepatientsbetween2018–2023. Similarincreasesareseenwithnon-opioidanalgesia,going from13.1%ofBlackand17.5%ofWhitepatients(RR0.751, 95%CI0.692–0.815)between2003–2008to42.0%forBlack and41.7%ofWhitepatients(RR1.007,95%CI0.991–1.024) between2018-2023.Additionaldatacanbefoundin Table3 and Table4.Thedifferencebetweenopioidanalgesics prescribedforBlackvsWhitepatientswithlongbone fractureshasoveralldecreasedfromasigniﬁcant6.3%gapto 1.1%gapfromthetimeintervalsof2003–2008to2018–2023, asseenin Figure1.Forpatientswithlongbonefracturesin theEDintheprior20years(80%arefromthemostrecent 10years),37.7%ofBlackpatientsreceivedopioidanalgesia comparedto39.8%ofWhitepatients(RR0.947,95%CI 0.937–0.957),while34%ofBlackpatientsreceivednonopioidanalgesiacomparedto35.6%ofWhitepatients(RR 0.955,95%CI0.944–0.967).

Opioidanalgesiaforpatientswithfemurfractureshas beenincreasingforbothcohorts,goingfrom17.8%ofBlack and22.6%ofWhitepatients(RR0.786,95%CI0.667–0.926) between2003–2008to68.1%ofBlackand69.4%ofWhite patients(RR0.982,95%CI0.961–1.003)between 2018–2023.Thisincreaseisalsoseeninnon-opioidanalgesia, increasingfrom16.3%ofBlackand18.7%ofWhitepatients (RR0.876,95%CI0.732–1.047)between2003–2008to

Table3. OpioidanalgesicadministrationforBlackpatientsvsWhitepatientsfrom2003–2023afterpropensityscorematching.

LongbonefracturesBlackpatients%(n)Whitepatients%(n)RR(95%CI)

2003–200814.4%(997)20.7%(1,346)0.697(0.647,0.751)

2008–201319.5%(3,318)24.6%(4,210)0.792(0.761,0.824)

2013–201838.8%(14,250)40.1%(15,392)0.969(0.952,0.986)

2018–202345.8%(19,178)46.9%(21,168)0.978(0.964,0.992)

2021–202345.0%(7,223)44.8%(7,643)1.003(0.981,1.028)

2003–202337.7%(37,412)39.8%(41,408)0.947(0.937,0.957)

FemurfracturesBlackpatients%(n)Whitepatients%(n)RR(95%CI)

2003–200817.8%(213)22.6%(248)0.786(0.667,0.926)

2008–201329.9%(839)29.7%(806)1.006(0.928,1.091)

2013–201854.1%(3,495)53.0%(3,401)1.021(0.989,1.055)

2018–202368.1%(5,196)69.4%(5,511)0.982(0.961,1.003)

2021–202369.6%(2,186)70.1%(2,228)0.993(0.962,1.026)

2003–202354.8%(9,726)54.4%(9,777)1.008(0.989,1.027)

RR,relativerisk; CI,conﬁdenceinterval;timeintervalsfrominitialJan1to ﬁnalJan1.

Table4. Non-opioidanalgesicadministrationforBlackpatientsvsWhitepatientsfrom2003–2023afterpropensityscorematching. LongbonefracturesBlackpatients%(n)Whitepatients%(n)RR(95%CI)

2003–200813.1%(886)17.5%(1,072)0.751(0.692,0.815)

2008–201319.0%(3,109)23.6%(3,985)0.807(0.774,0.841)

2013–201834.8%(12,004)36.3%(13,774)0.957(0.939,0.976)

2018–202342.0%(15,044)41.7%(17,582)1.007(0.991,1.024)

2021–202341.0%(5,473)40.0%(6,270)1.025(0.996,1.054)

2003–202334.0%(30,735)35.6%(35,604)0.955(0.944,0.967) FemurfracturesBlackpatients%(n)Whitepatients%(n)RR(95%CI)

2003–200816.3%(196)18.7%(199)0.876(0.732,1.047)

2008–201325.4%(695)25.5%(722)0.995(0.910,1.089)

2013–201845.1%(2,817)45.0%(2,966)1.004(0.966,1.043)

2018–202358.6%(4,034)59.0%(4,464)0.994(0.967,1.021)

2021–202358.5%(1,668)59.1%(1,798)0.990(0.948,1.033)

2003–202346.3%(7,712)45.3%(8,120)1.023(0.999,1.046) RR,relativerisk; CI,conﬁdenceinterval;timeintervalsfrominitialJan1to ﬁnalJan1.

RateofopioidadministrationforBlackpatientsvsWhite patientswithlongbonefracturesafterpropensitymatching.

58.6%ofBlackand59%ofWhitepatients(RR0.994,95% CI0.967–1.021)between2018–2023.Additionaldatacanbe foundin Table3 and Table4.Thedifferencebetweenopioid analgesicsprescribedforBlackvsWhitepatientswithfemur fractureshasoveralldecreasedfroma4.8%gapto1.3%gap fromthetimeintervalsof2003–2008to2018–2023,asseenin Figure2.ForpatientswithfemurfracturesintheEDinthe prior20years(80%arefromthemostrecent10years),opioid analgesiawasgivento54.8%ofBlackvs54.4%ofWhite patients(RR1.008,95%CI0.989–1.027)whilenon-opioid analgesiawasgivento46.3%ofBlackvs45.3%ofWhite patients(RR1.023,95%CI0.999–1.046).

SubgroupAnalysis

InthesubgroupanalysisperformedJanuary5,2023, administrationofopioidanalgesicsandnon-opioid analgesicsforBlackpatientswascomparedtoWhitepatients

RateofopioidadministrationforBlackpatientsvsWhite patientswithfemurfracturesafterpropensitymatching.

forlongboneandonlyfemurfracturesduringEDvisitsfrom 2021–2023.Beforepropensitymatchingwasperformed,a totalof229,395patientswereidentiﬁedwithlongbone fracturesand62,761patientswithonlyfemurfractures duringthisperiod.Afterpropensitymatching,therewerea totalof69,668patientswithlongbonefracturesand18,992 patientswithonlyfemurfracturesduringthisperiod.The analysisafterpropensitymatchingshowedthatBlackand Whitepatientswerebothgivencomparableopioidanalgesics (45.0%vs44.8%,RR1.00,95%CI0.980–1.028)andnonopioidanalgesics(41.0%vs.40.0%,RR1.025,95%CI 0.996–1.054)forlongbonefracturesduringthistime interval.Whenevaluatingforonlyfemurfractures,the ﬁndingswerealsocomparable.BlackandWhitepatients weregivenequivalentopioidanalgesics(69.6%vs70.1%,RR 0.993,95%CI0.962–1.026)andnon-opioidanalgesics (58.5%vs59.1%,RR0.990,95%CI0.948–1.033).

Figure1.

Figure2.

ComparisonofGroups

Theoutcomesforprescribingofopioidanalgesicsand non-opioidanalgesicsforBlackvsWhitepatientspresenting totheEDinalltimeintervalsandsubgroupswereall collectedonthesamedayorwithin24hoursaftertheindex event.Duringtheperiod2003–2008,Whitepatientswere prescribedsigniﬁcantlymoreopioidanalgesicsthanBlack patients;however,thegaphasbeendecreasing,andbetween theyears2021–2023,wefoundnosigniﬁcantdifferenceinthe numberofopioidanalgesicsprescribedforeitherthelong bonefractureorfemurfracturecohorts.

DISCUSSION

Theobjectiveofthisstudywastoinvestigatethe relationshipbetweenracialdisparitiesandtheadministration ofbothopioidandnon-opioidanalgesicsfollowingvarious longboneandfemurfractures,andthetrendovera20-year timespantodeterminewhetherdisparitieshavediminished. Thesampleincludedover2.4millionpatientsacrosstheUS whowereevaluatedforpainassociatedwithlongbone fractures.Previousstudieshaveconcludedthatthepainfor thesefracturesisundermanagedfornon-Whitepatients.6 In the2003–2008cohort,the findingsofpreviousstudieswere confirmed,thatWhitenon-Hispanicpatientswerepreviously administeredanalgesiasignificantlymoreoftenthanother demographics.4–8,10 Theresultsofthisstudysuggestthatthe gapbetweenanalgesiaadministrationrateshasdiminished. Infact,therewasnostatisticalsignificanceinopioidsgivento BlackpatientswithlongbonefracturesoverWhitepatients overthemostrecentyears(2021–2023).Resultsweresimilar withandwithoutpropensitymatchingofthegiven populations.Thecohortsoffemurfracturesshowedsimilar findings;however,thegapinadministrationofopioids appearstohavenarrowedin2008andhasremained insignificantupto2023.

Employingpropensitymatchingbyageandgenderis importantinthisdatabase,giventhemarkeddifferencesinthe epidemiologyoflongboneandfemurfracturesacrossraces. Notably,racialdisparitiesinfractureincidenceareevident acrossvariousagegroups,frompreschoolto60yearsofage. Blackmalesshowasignificantlyhigherincidenceoffractures uptotheageof62,whileBlackfemalesexperienceamodestly elevatedrateoffracturesuntiltheageof40.Furthermore, fracturesattributedtoviolencearetenfoldhigheramong Blackindividualscomparedtootherracialgroups. Interestingly,despitepossessinggreaterbonedensity,Black individuals,includingbothchildrenandadults,exhibitan increasedsusceptibilitytofracturesacrossmostnon-fallrelatedinjurymechanisms.Thishighlightsthecomplexityof thefactorsinfluencingfracturerisksandthesignificanceof consideringage,gender,andraceintheanalysis.19

Thisstudydemonstratesthat,overall,opioid administrationhasincreasedoverthepast20years.Several factorscontributedtothistrend,includingrecent

misrepresentationsbydrugcompaniesabouttherisks associatedwithopioids,20 aswellaspolicyinitiativesfrom theJointCommissiononAccreditationofHealthcare Organizationswhichincentivizedhospitalsandphysicians formoreaggressivepainmanagement.Theresultsare consistentwitha2008studythatshowedanincreasein opioiduseduringtimesshortlyafterthelaunchofJoint Commissioninitiatives.4 In1997,painstandardswere developedthroughpoliciesdevelopedbytheJoint Commissionduetoaneedfororganizedpainassessment. Thepoliciesemphasizedpainasthe “5thvitalsign,” which resultedinanupwardtrendforadministrationand prescriptionofopioidmedicationsastreatment.21

Timetopainmanagementbecameacorequalitymetricby whichEDsweremeasuredformultipleyearsandwaslinked toMedicareCMSreimbursement.Physiciansandhospitals wereevaluatedbasedontheirpaintreatmentpractices,and ﬁnancialincentiveswereprovidedformeetingcertain criteria.This,inconjunctionwithincreasedsocietal awarenessregardingdisparitiesinhealthcare,mayhave playedaroleinnarrowingthegapinanalgesia administrationbetweenBlackandWhitepatients.The combinationofperformance-basedassessmentsand incentives,alongwithheightenedpublicconsciousness,likely contributedtochangesinpainmanagementpracticesthat addressedpreviouslyexistingdisparities.Therehasbeena morerecenttrendasaresultoftheopiatepandemicthat showsoverallopioidprescriptionsarenowdecreasingto allpatients.14

Theresultsofthisstudyhaveimportantimplicationsfor theacutemanagementofpatientswithlongbonefracturesin theUS.Inadequatelytreatedpainhasbeenfoundtobea majorpublichealthchallengeintheUS,andracialand ethnicminoritygroupshavehistoricallyappearedtobeata highriskofreceivinginadequatepaintreatmentintheED.4 Whilestudiesasrecentas2020haveconcludedthatracial andethnicminoritiesarelesslikelytoreceiveanalgesiafor acutetrauma,10 theresultsofthisstudyshowthatthe differentialintreatmenthasdisappeared.Weincorporateda largersamplesizethatisapproximately10timeslargerthan anypreviousstudyonthistopic,andthroughpropensity matchingsomeoftheconfoundingvariableswereeliminated thatmayhaveskewedpreviousdata.Futurestudiesshould aimtoaddressothervariablescontributingtothisdecreasein disparityandincorporatemorestratiﬁcationofraceand ethnicitytodeterminewhetherotherdisparitiesarepresent. Otherpossiblerelationships,suchasratesofanalgesicrefusal byrace,prehospitaladministrationofanalgesia,disparities inassessmentofpainscorebyemergencyclinicians,and languagebarriersshouldalsobeanalyzed.

LIMITATIONS

Becausethiswasaretrospectivestudy,causationbetween racialdisparitiesandopioidadministrationcouldnotbe

established.However,thesizeofthisstudy – 2.4millionvs 157,000-inconjunctionwithpropensitymatching,gaveus greaterpowertoidentifydifferencesinoutcomesbetween groupscomparedtopreviousstudies.3,11–15

Inthispropensity-matchedretrospectivestudyoutofthis nationaldatabase,itbecomesdifﬁculttoevaluateclinical detailsabouteachpatientencountersuchaspainscores, amountofanalgesia,compliancetomedicationsgiven, EmergencySeverityIndexacuitylevel,multitrauma,and informationabouttheprescriber.Thisleadstolackof objectivelymeasuringtheeffectivenessoftheanalgesia, whetheradditionaltreatmentwasneededaftertheinitial analgesia,and,overall,alimitationinjudgingthe effectivenessofthetreatmentitself.Thisstudy,however,was dedicatedtoamoreshort-termapproachregardingtheuseof medicationsintheED,notnecessarilytheeffectivenessof post-encounterormedicationsprescribedupondischarge.

Theremaybeanissuewithgranularityofthevisittypeand dateindatacollectedfromICD9/10-basedsystems.This differenceshouldnotbesigniﬁcantbetweenthegroupsor leadtoconfounding.Approximately80%ofthepatient populationisfromthepast10yearsasmanyadditional healthcareorganizationshaverecentlyjoinedtheTriNetX database.Asaresult,thedatasetthatincludesall20yearsis skewedtowardmorerecentpatients.Thiseffectisminimized bylookingattwo-and ﬁve-yearperiods.

Additionally,theinabilitytoobtaininsuranceinformation foreachpatientmayhaveposedaparticularchallengeasthis canaccountforcertainbiasesthataffect ﬁnancialaccessto treatmentandmaynotbemeasurableonthisscale.7 Ouraim wastoeliminateconfoundingvariablessuchasthis,and furtherinformationoninsuranceperpatientmayprovidedata allowingustobetterunderstandthedifferencesbeing measuredinthesesetsafterpropensitymatching.Although propensitymatchingwasperformedfordemographic information,theremaybepre-existingmedicalconditionsthat impactpainseverityandadministrationofanalgesiaforwhich thestudydidnotcontrol.Inaddition,racewasnotknownfor approximatelyone-ﬁfthofthepatientpopulation.

IntheTriNetXdatabase,theidentitiesordesignationsof thehealthcareorganizationsandtheirrespectivesitesarenot disclosedsincethedataisde-identified.Consequently,we couldnotconsideranyclusteringbyhospital.Thislimitation issignificantastheremaybeinherentdifferencesinthe populationcharacteristicsacrossvarioushospitalsystemsor sites,whichcouldinfluencetheadministrationpatternsof analgesiaandpotentiallyintroducebiasintotheresults. Moreover,ourdatabasedoesnotprovideinformationthat allowedustodiscernwhetheranalgesicswereadministered toindividualpatientsintheprehospitalsetting,whichmay haveservedasanadditionalconfoundingfactor.Thereis evidenceindicatingthatpriorto2020,disparitiesexistedin theadministrationofpainmedicationintheprehospital setting.Thiswasobservedincasesinvolvingbothnon-

traumaticandtraumaticpainfulconditions,wherethe probabilityofBlackpatientsreceivingpainmedicationwas lowerwhencomparedtoWhitepatients.22

CONCLUSION

Thisretrospectiveanalysisprovidesevidencefrom healthcarecentersacrosstheUSthatthereisnolongera signiﬁcantdifferenceintheadministrationofopioidand non-opioidanalgesicsbetweenBlackandWhitepatients diagnosedwithlongboneandfemurfractures.

AddressforCorrespondence:DietrichJehle,MD,Universityof TexasMedicalBranch,EmergencyBuilding,Room3.124H,301 UniversityBlvd.,Galveston,Texas77555.Email: dijehle@utmb.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisstudywasconductedwiththe supportoftheInstituteforTranslationalSciencesattheUniversityof TexasMedicalBranch,supportedinpartbyaClinicaland TranslationalScienceAward(UL1TR001439)fromtheNational CenterforAdvancingTranslationalSciences,NationalInstitutesof Health.Thecontentissolelytheresponsibilityoftheauthorsand doesnotnecessarilyrepresenttheofficialviewsoftheNational InstitutesofHealth.Therearenootherconflictsofinterestorsources offundingtodeclare.

REFERENCES

1.GBD2019FractureCollaborators.Global,regional,andnationalburden ofbonefracturesin204countriesandterritories,1990–2019:a systematicanalysisfromtheGlobalBurdenofDiseaseStudy2019. LancetHealthyLongev. 2021;2(9):e580–92.

2.BerghC,WennergrenD,MöllerM,etal.Fractureincidenceinadultsin relationtoageandgender:astudyof27,169fracturesintheSwedish FractureRegisterinawell-deﬁnedcatchmentarea. PLoSOne. 2020;15(12):e0244291.

3.AmbossIcon.Generalprinciplesoffractures.2022.Availableat: https:// www.amboss.com/us/knowledge/General_principles_of_fractures/ AccessedFebruary17,2023.

4.PletcherMJ,KerteszSG,KohnMA,etal.Trendsinopioidprescribingby race/ethnicityforpatientsseekingcareinUSemergencydepartments. JAMA. 2008;299(1):70–8.

5.MeghaniSH,ByunE,GallagherRM.Timetotakestock:ameta-analysis andsystematicreviewofanalgesictreatmentdisparitiesforpaininthe UnitedStates. PainMed. 2012;13(2):150–74.

6.MinickP,ClarkPC,DaltonJA,etal.Long-bonefracturepain managementintheemergencydepartment. JEmergNurs. 2012;38(3):211–7.

7.YoungMF,HernHG,AlterHJ,etal.Racialdifferencesinreceiving morphineamongprehospitalpatientswithblunttrauma. JEmergMed. 2013;45(1):46–52.

8.LeeP,LeSauxM,SiegelR,etal.Racialandethnicdisparitiesinthe managementofacutepaininUSemergencydepartments:metaanalysisandsystematicreview. AmJEmergMed. 2019;37(9):1770–7.

9.KennelJ,WithersE,ParsonsN,etal.Racial/ethnicdisparitiesinpain treatment:evidencefromOregonemergencymedicalservices agencies. MedCare. 2019;57(12):924–9.

10.BenzingAC,BellC,DerazinM,etal.Disparitiesinopioidpain managementforlongbonefractures. JRacialEthnHealthDisparities. 2020;7(4):740–5.

11.YenK,KimM,StremskiES,etal.Effectofethnicityandraceontheuse ofpainmedicationsinchildrenwithlongbonefracturesinthe emergencydepartment. AnnEmergMed. 2003;42(1):41–7.

12.DickasonRM,ChauhanV,MorA,etal.Racialdifferencesinopiate administrationforpainreliefatanacademicemergencydepartment. WestJEmergMed. 2015;16(3):372–80.

13.SinghalA,TienYY,HsiaRY.Racial-ethnicdisparitiesinopioid prescriptionsatemergencydepartmentvisitsforconditionscommonly associatedwithprescriptiondrugabuse. PLoSOne. 2016;11(8):e0159224.

14.RomanelliRJ,ShenZ,SzwerinskiN,etal.Racialandethnicdisparities inopioidprescribingforlongbonefracturesatdischargefromthe emergencydepartment:across-sectionalanalysisof22centersfroma healthcaredeliverysysteminNorthernCalifornia. AnnEmergMed. 2019;74(5):622–31.

15.GoyalMK,DrendelAL,ChamberlainJM,etal.Racial/ethnicdifferences inedopioidprescriptionsforlongbonefractures:trendsovertime. Pediatrics. 2021;148(5):e2021052481.

16.ColbySLandOrtmanJM.Projectionsofthesizeandcompositionofthe U.S.population:2014to2060.2021.Availableat: https://www.census. gov/library/publications/2015/demo/p25-1143.html AccessedFebruary17,2023.

17.MurphyLR,HillTP,PaulK,etal.Tenecteplaseversusalteplasefor acutestroke:mortalityandbleedingcomplications. AnnEmergMed. 2023;82(6):720–8.

18.HarrisonSL,Fazio-EynullayevaE,LaneDA,etal.Atrial ﬁbrillationand theriskof30-dayincidentthromboembolicevents,andmortalityin adults ≥ 50yearswithCOVID-19. JArrhythm. 2020;37(1):231–7.

19.PressleyJC,KendigTD,FrencherSK,etal.Epidemiologyofbone fractureacrosstheagespaninBlacksandWhites. JTrauma. 2011;71(5Suppl2):S541–8.

20.HaffajeeRLandMelloMM.Drugcompanies’ liabilityfortheopioid epidemic. NEnglJMed. 2017;377(24):2301–5.

21.BakerDW.TheJointCommission’spainstandards:originsand evolution.2017.Availableat: https://www.jointcommission.org/-/media/ tjc/documents/resources/pain-management/pain_std_history_web_ version_05122017pdf.pdf?db=web&hash=E7D12A5C3BE9DF031F3 D8FE0D8509580&hash=E7D12A5C3BE9DF031F3D8FE0D8509580 AccessedFebruary17,2023.

22.AcevesA,CroweRP,ZaidiHQ,etal.Disparitiesinprehospitalnontraumaticpainmanagement. PrehospEmergCare.2023(6):794–9.

ORIGINAL RESEARCH

ACross-SectionalReviewofHIVScreeninginHigh-Acuity EmergencyDepartmentPatients:AMissedOpportunity

JacquelineJ.Mahal,MD,MBA*† FernandoGonzalez,MD†

DeirdreKokasko,BS* AhavaMuskat,MD†

*JacobiMedicalCenter,DepartmentofEmergencyMedicine,Bronx,NewYork † AlbertEinsteinCollegeofMedicine,Bronx,NewYork

SectionEditor:IoannisKoutroulis,MD,MBA,PhD

Submissionhistory:SubmittedApril17,2023;RevisionreceivedApril24,2024;AcceptedMay3,2024

ElectronicallypublishedAugust1,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18067

Introduction: Emergencydepartment(ED)patientsrequiringimmediatetreatmentoftenbypassatriage processthatincludesHIVscreening.Inthisstudyweaimedtoinvestigatethepotentialmissed opportunitytoscreenthesepatientsforHIV.

Methods: Weconductedthiscross-sectionalstudyinamunicipalEDoverasix-weekperiodbetween June–August2019.ThepatientpopulationinthisstudyarrivedintheEDasapre-notiﬁcationfrom prehospitalservicesordesignatedbytheambulanceorwalk-intriagenurseasrequiringimmediate medicalattention.Medicalstudentresearcherscollecteddemographicdataandcategorizedpatients intothreeclinicalgroups(trauma,medical,psychiatric).Theydocumentedthepatient’seligibilityforHIV screeningasdeterminedbyaphysicianandconﬁrmedthatthepatientmetcriteriaofclearmentalstatus, controlledpain,stablevitalsigns,andabilitytocontributetoamedicalhistoryandphysicalexamination. Thestudentresearchersdidthisatinitialpresentationandthenagainduringthepatient’sEDstayofupto eighthours.Thestudyoutcomesmeasuredthepercentageoftotalpatientswithineachclinicalgroup (trauma,medical,psychiatric)abletoengageintheHIVscreeningprocessuponarrivalandduringan eight-hourEDstay.

Results: Onaverage,700patientspermonthareannouncedonarrivalviaoverheadpage,indicating thattheyrequireimmediatemedicalattention.Duringthesix-weekstudy,205patients(approximately 20%oftotal)wereenrolled:114trauma;56medical;and35psychiatricpresentations.Theaverage patientagewas53;60%ofpatientsweremale.Niney-eight(48%)patientswereeligibleforHIV screeningwithinaneight-hourEDstay;63(31%)wereabletobescreeneduponinitialpresentationand 35(17%)inthe firsteighthoursoftheirEDvisit.Withinmedicalandtraumasubgroups,therewasno significantdifferenceintheproportion(36%)ofpatientsthatcouldbescreeneduponpresentation. Amongthepsychiatricpresentations,only five(14%)wereabletobescreenedduringtheirhospitalstay.

Conclusion: Triageprotocolsforhigh-acuitymedico-surgicalpatientsresultedinamissedopportunity toscreen48%ofpatientsforHIV.Acutepsychiatricpatientsrepresentedaparticularmissedopportunity. WeadvocateforuniversalHIVscreening,facilitatedthroughelectronicbestpracticeadvisoriesanda modiﬁedtriagetailoredtohigheracuitypatients.ImplementingthesechangeswouldensurethatHIV screeningisnotoverlookedinhigh-acuityEDpatients,leadingtoearlydetectionandtimely interventions.[WestJEmergMed.2024;25(5)817–822.]

INTRODUCTION

TheUSCentersforDiseaseControlandPrevention (CDC)reported131.3millionvisitstoUnitedStates emergencydepartments(ED)in2020.1 In2014,7%of patientswhovisitedtheEDreportedalackofaccessto cliniciansratherthanseriousnessoftheirmedicalcondition asthereasonfortheirlastEDvisit.2 Approximately1.2 millionpeoplelivewithHIVintheUS,and13%areunaware ofthediagnosis.3 ThisincidenceofHIVinfections,coupled withsigniﬁcantEDvolumeanduseoftheEDforprimary care,continuestomaketheEDacriticalpointof engagementwiththemedicalsystemand,thus,an opportunitytoprovideHIVscreening.4–7

SincetheCDC’s2006recommendationforopt-outHIV screeningforpatientsinallhealthcaresettings,therehasbeen ampleliteratureonuniversalHIVscreeningintheED; however,acutelyillpatientsareoftenexcludedfromdata collection.8–10 OnestudyfocusingonHIVscreeningof acutelyillmedicalpatientsintheEDfoundthatthemajority ofthepatientsdiagnosedwithHIVwereadmittedwithAIDS andhadanaverageofthreeprevioushealthcarevisitspriorto HIVscreening.11 Whenconsideringtraumapatientsinthe ED,theliteraturereportsHIVscreeningratesthatrange from25.2–64.1%.12–14 Arecentpapercomparingscreening intraumatomedicinepatientsfoundthatscreeningin traumapatientswaslowerthaninmedicalpatients,yetHIV rateswerehigherintraumavsmedicalpatients.14 Both studiesdemonstratethatitisfeasibletotestthesehigher acuitypatientsandsuggestthathigh-acuitypatientsmaybe anothermissedopportunityintheEDtoidentifypreviously undiagnosedHIV.

Inoursetting,ifapatientisacutelyillorinjuredrequiring immediatemedicalattention,thepatientisannouncedviaan overheadintercomandismovedtoaresuscitationbay, bypassingthetriageprocessthatincludesrequiredHIV screening.PerNewYorkStatePublicHealthLaw(PHL),15 therearethreeexceptionstotherequiredHIVtestingoffer: life-threateningillness;recenttestingandnorecentrisk behaviors;andadeterminationbytheattendingthatthe patientdoesnothavementalcapacity.Wehypothesizethat ourtriageprocessofautomaticallyexcludingpatients identiﬁedviaoverheadpagepresentsmissedopportunitiesto screenotherwiseeligiblepatients.

METHODS Design

Thiswasasingle-site,cross-sectionalstudy.Ourobjective wastomeasurewhatpercentageofpatientsdeemedacute, andwhothusbypassedthetriageprocessthatincludesHIV screeninginordertoreceiveimmediatemedicalevaluation, wereabletobescreenedforHIVduringtheirEDstay.The protocolwasapprovedbytheAlbertEinsteinCollegeof MedicineandtheNewYorkCityHealth&Hospitals institutionalreviewboardsandwasdeemedexemptfrom

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

WhileuniversalHIVscreeningintheEDisa well-knownandreviewedclinicalactivity, acutelyinjuredandmedicallyillpatientsare oftenexcluded.

Whatwastheresearchquestion?

Dopatientswhopresentemergentlytoan urbanEDpresentamissedopportunityfor HIVscreening?

Whatwasthemajor ﬁndingofthestudy?

Ofthe205acutelyill,injuredorpsychiatric patientsinthisstudywhobypassedtypical HIVscreeningintriage,98(48%)were screenedforHIVduringtheireight-hour EDstay,with63(31%)screenedupon initialpresentation.

Howdoesthisimprovepopulationhealth?

ThisstudyhighlightsagapinHIVscreening andamissedopportunityfortestingHIVin EDpatients.

requiringconsent.Thisstudyisreportedusingthe StrengtheningtheReportingofObservationalStudiesin Epidemiology(STROBE)guidelines.16

Setting

Thisstudywasconductedinamunicipal,adultED withLevel1traumadesignationinNewYorkCitywithan annualcensusofapproximately73,000andapproximately 15%ofpatientsarrivingbyambulance.Enrollmentoccurred overasix-weekperiodfromJune–August2019.Three medicalstudentresearchers(SR)werepresentinthe EDforapproximately13hoursperday,5–7days perweek.

ResearchWorkﬂow

ThepatientpopulationinthisstudyarrivedintheEDasa pre-notiﬁcationfromprehospitalservicesorwasdesignated bytheambulanceorwalk-intriagenurseasrequiring immediatemedicalattention.Thesepatientswereeither EmergencySeverityIndex(ESI)1or2,wereannouncedvia anoverheadintercomsystem,andmovedtoaresuscitation bay.Inrealtime,SRsreportedtotheresuscitationbayto recorddemographicdataincludingage,gender,chief complaint,date,andtimeofpresentation.Theyassigned patientstooneofthreeclinicalgroups:trauma;medical;

orpsychiatric.Psychiatricpatientsincludedthosewith agitationsecondarytosubstanceuse,primarypsychiatric presentation,oradualdiagnosis.Theattendingorresident physiciandeterminedwhetherthepatientcouldengageinthe HIVscreeningprocess,andtheSRscheckedthatthepatient metcriteriaofclearmentalstatus,controlledpain,stable vitalsigns,andabilitytocontributetomedicalhistoryand physicalexamination.

IfapatientcouldnotengageintheHIVscreeningprocess, butanappropriatehealthcareproxy(HCP)waspresentto provideconsent,thepatientwasconsideredscreenable. Verbalconsentofthepatientorthepatientproxyisrequired priortoorderingtheHIVtestinaccordancewithNewYork StatePHL2781/2781a17;however,askingtheHCPfor consentforHIVtestingisnottypicallydoneinourED. Patientswhowerenotimmediatelyabletoparticipateinthe HIVscreeningprocesswerereassessedatfourandeight hoursafterpresentation.Eighthourswaschosensincethe averagelengthofstayinthisEDisapproximately sevenhours.

WewereunabletoreceiveHIVtestresultsforpatients whowerebotheligibleandoptedinfortesting.Thestudy periodstraddledahospital-widetransitiontoanew electronichealthrecordsystem(EHR),whichincludeda changeintheHIVtestingprotocol,leadingtolostand canceledbloodtests.

DataAnalysis

Theprimarystudyoutcomeswerethepercentagesof patientsineachoftheclinicalgroups(trauma,medical, psychiatric)whowereabletoengageintheHIVtest screeningprocessatarrivalandbyorbeforeeighthours. Meanagewithstandarddeviationwerereportedforeach clinicalgroupandcomparedtothemeanoftheentirecohort. SinceconsentviaHCPisatypicalinpractice,wereport thenumberofpatientsandtheaverageageofthis patientsubgroup.

Wecomparedtheproportionofpatientsineachclinical groupandtheproportionthatcouldengageintheHIV screeningatarrivalandbyorbeforeeighthoursusingthe

traumagroupasthereferencegroup.Weused χ 2 tocompare proportionsandtheStudent t -testtocomparemeanswiththe α at.05orlessfortwo-tailedtestsofsigniﬁcance.Analysis wascompletedinExcel2019(MicrosoftCorporation, Redmond,WA).

RESULTS

InourED,approximately700patientspermonthare calledoverheadonarrivalandmovedtotheresuscitation bay.Duringthesix-weekstudyperiod,205patientswere enrolled,capturingapproximately20%ofoverhead notifications.TheaveragetimeofdaytheSRrespondedto theoverheadpagewas3:40 PM with23%ofpatientsbeing seenafter8 PM ontheovernightshift.Ameanmaleageof 44.7vsameanfemaleageof66.6wasstatisticallysignificant inthetraumagrouponly(P < .001, Table1).Themedical andpsychiatricclinicalsubgroupshadnostatistically significantdifferenceinagebygender.Theproportionof patientsinthemedicalclinicalsubgroupdidnotdiffer statisticallyfromthetraumareferencegroup(Table1).Eight (4%)patientswereincludedasscreenablebecauseaHCP providedconsent;averageageoftheseeightpatientswas65 witharangeof23–91.

Ofthe205patients,98(48%)wereabletoengageinHIV screeningduringtheireight-hourEDstay.Ofthese98 patients,63(31%)wereabletobescreeneduponinitial presentationandanadditional35(17%)inthe firsteight hoursoftheirEDvisit.Whencategorizedbypresentation type,61(54%)of114traumapatients,32(57%)of56medical patients,and five(14%)of35psychiatricpatientswereableto engageinHIVscreeningduringtheireight-hourEDstay. Therewasnostatisticaldifferencebetweenabilityto participateinscreeningbetweentraumaandmedicalclinical presentations(Table2).Comparedtotraumaandmedical patients,psychiatricnotificationshadasignificantlylower abilitytobescreenedbytheeight-hourmark(P < .03).The patient’slevelofpsychiatricacuity,beinginpolicecustody, orleavinguponsobrietywerereasonsthat30(86%)ofthe35 psychiatricpatientswerenotabletobescreenedwithineight hoursintheED.

1Medicalandpsychiatricclinicalsubtypewerecomparedtothetraumagroupasareference. 2Meanagebygenderwerecomparedwithineachclinicalsub-type.

Table1. Patientcharacteristics:age,gender,clinicalpresentationassignment.

Table2. PercentageofpatientsbypresentationtypeandtimewhowereabletobescreenedforHIV.

Presentationsub-type Patients (totalN = 205) Screenedatpresentation (t = 0hours) P-valueScreened ≤ 8hours P-value Trauma11441(36%)20(18%) Medical5620(36%)0.9712(21%)0.52 Psychiatric352(6%) <0.0013(8%)0.03

DISCUSSION

Thissingle-site,cross-sectionalstudydemonstratedthat 36%ofpatientswhopresentedwithemergentmedicalor traumaclinicalpresentations,thusbypassingHIVscreening intriage,wereabletobescreenedatinitialpresentation.An additional21%whopresentedformedicaland18%for traumapresentationswereabletobescreenedbyeighthours intotheirEDstay.Theresultswerestatisticallyconsistent betweenpatientsinthemedicalortraumaclinical presentationgroupsandstatisticallylesslikelyforpsychiatric patients.Notably,86%ofpsychiatricpatientswereunableto bescreenedwithineighthoursintheED.

With1in7people,ornearly165,000intheUnited States,18 unawareoftheirHIVstatus,universal,nontargetedHIVscreeninginhigh-volumesettingslikeEDs remainsaneffectivestrategy.StudiesfrombothOaklandand Chicagoreportthatapproximately50%ofnewHIV diagnoseswouldhavebeenmissedhadtheyusedatargeted, symptom-andrisk-basedscreeningmethodology.19–23 Ina randomizedclinicalstudycomparingatargetedvsanontargetedscreeningapproach,Haukoosetalconcludedthat targetedscreeningwasnotsuperior,althoughitwasmore efﬁcientwithfewertestscompleted.24

Inadditiontothescreeningmethodology,thelocationof HIVscreeningmayinﬂuencethecompletionoftesting. ScreeningforHIVcanoccurduringtriage,registration,inthe waitingroomwithkiosksanddedicatedstaff,oratthebedside drivenbyaclinician.InTanetal,theauthorsreviewed20HIV testingprotocols.25 Theyfoundthatofferratesarehighest duringregistrationandattriage,attributedtosystematic questioning,reaching100%insomestudies.Theofferof testingdoesnot,however,equatetoacceptanceoftesting.The highestacceptancerateswerefoundatthebedsideandinthe waitingroom,oftenbecausethepersondoingthescreening wouldalsobeconductingthetest.25 Screeningandtesting protocolsdifferbysiteandresourcesavailable,making generalizabilityacrossallEDsettingsdifﬁcult.

TriageisoneofthemostimportantprocessesintheED. Toguideclinicianswiththistask,triagescoresareusedto provideanobjectivemeasureofpatientacuitytofocusonthe sickestpatients.TheEmergencySeverityIndex(ESI)triage scoreisthemostusedintheUS26 andistheoneusedinour institution.Studiesreportgreatvariabilitywithpoorto moderateaccuracy,27,28 especiallyinhigh-acuitypatients. TheAmericanCollegeofSurgeonsCommitteeonTrauma recommendsanover-triagerateof25–50%onactivationof

traumateamsattraumacenters,andtheliteraturereportsa rangeof18–91%.29–32 Thisvariabilitymaybenecessaryto ensureprompttreatmentoflife-threateninginjuriesand illnesses,whilealsoreducingthenumberofacutepatients treatedatnon-traumacenters.29

Over-triageandanemphasisonimmediateintervention presumesineligibilityforHIVscreeninginourtriage processthatwouldtypicallyincludeuniversal,nontargetedHIVscreening.Patientswithhighacuity(ESI1 and2)werenotinformedofHIVscreeninginourstudy,as wasthecaseinotherstudies. 15 , 33 Thefocusonidentifying, stabilizing,andtreatingacuteinjuryorillnesssensibly supersedestheHIVscreeningprocess.Atrueuniversal HIVscreeningprotocolshouldincludeallpatients regardlessofESIandincludeanindividualassessmentto determineabilitytoconsent,ratherthanpresumed ineligibility.Whileweha dthemanpowertoreassess patientsperiodically,thisresource-heavymodelisnot likelytobebroadlyreplicable.

Evenwiththeabilitytoreassessperiodically,wefoundthat 86%ofacutepsychiatricpatientswerenotabletobescreened forHIVatinitialpresentationorwithineighthoursintheED. InallstagesoftheHIVcarecascade,thepatientpopulation thatstruggleswithmentalhealthismetwithchallenges. MentalhealthdisordersincreasetheriskofHIVacquisitionby 4–10times34,35 and,atthesametime,interferewithHIV testingandlearningone’sHIVstatus.36 Thestrugglewith depression,anxiety,trauma,andsubstanceuseisasubstantial barriertoHIVpreventionmethods(ie,condoms,pre-exposure prophylaxis),andadultswithmentalhealthdisorderswere morelikelytobeinvolvedinbehaviorsassociatedwithHIV acquisitionortransmissionthanadultswithoutmental disorders.37,38 Struggleswithmentalhealthcontributetopoor retentionincareandanti-retroviraladherence.38,39 Without thebeneﬁtofviralsuppressionachievedwithanti-retroviral treatment,acute-carehospitalizationsforpatientswithHIV andmentalhealthdisordersarehigherthanforHIVpatients withoutmentalhealthdisorders.39,40 Oftheacutepatients presentingtotheED,our ﬁndingssuggestthatpatientswith mentalhealthpresentationsand,inparticular,acutemental healthcrisesmayrequireanalternativeoradditionalapproach toHIVscreeningandtesting.

TheEDisoneplacetostartthecarecascadewithuniversal testing.However,weseethattheacutepatient,andespecially thepatientwithacutementalhealthpresentations,may requireanalternativeapproach,otherthanduringinitial

triage,toensurethatscreeningoccurs.UsingtheEHRhas beenshowntooptimizescreeningandtestingandtoincrease identificationofnewHIVinfections.41,42 BuildinganESI1 and2ordersetthatincludesanHIVtestcouldbeonemeansto addressHIVscreeningintothecareofacutelyillpatients.The HIVtestintheordersetwouldrequiretheclinicianto acknowledgescreeningeligibilityandverbalconsentpriorto finalizingtheorder.Abestpracticeadvisorywithscriptsfor clinicianstouseopt-outlanguagecouldbeprogrammedto fire ifpatientshaven’tyetbeenscreenedduringthecurrentED encounterandhaven’treceivedHIVtestingina predeterminedlook-backperiod.Thisstrategycouldaddress anypatientwhomayhavemissedHIVscreeningortestingin theED,notjustouracutepatientswhomissourtriage screening.Anynewapproachorcombinationofapproaches wouldrequireimplementationplansandprocessesandfuture investigationbeforebeingacceptedassolutions.

LIMITATIONS

Thiswasnotacompletesampleofallacutepatients presentingtotheEDduringthestudyperiodsincewedidnot haveSRs24hoursaday.Thiswasasingle-sitestudyina LevelItraumacenterwithhighvolume,whichcontributesto problemswithgeneralizabilitymainlyfornon-urban hospitalsettings.TheapproachtoHIVscreeningislikelyto bevariableinotherEDsandmaynotoccuraspartofthe triageprocess.Differencesinlawsandregulationsfortesting andconsentmayalsocontributetothelackof generalizabilityofthese ﬁndings.Thedeterminationofbeing abletobescreenedisclinician-dependent,withpossiblebias towardHIVscreeningandtestingintheEDandwhether peopleshouldbeasked.Wearenotabletoreportthedisease prevalenceinthissmalldataset.TheHIVtestresultswerenot reportedduetoinconsistenttestingandlabprotocolsfor HIVtestingasthehospitalmigratedtoanewEHRsystem duringthetestingperiod.Whilenotthefocusofthestudy,we acknowledgethatthisdataandcollectionofHIVriskfactors forpatientswouldhavebeenavaluableadditiontothestudy.

CONCLUSION

ThisstudyhighlightsagapinHIVscreeninginEDsanda missedopportunityfortestingforHIVinEDpatients.We foundthatcloseto48%ofpatientswhopresentforemergent careandmissedtheHIVuniversalscreeningthatoccurs duringtriageinourinstitutioncouldengageinthescreening processeitheratpresentationorduringtheirEDstay.And weidentiﬁedanalreadyvulnerablegroup psychiatric patients thatappearstobeineligibleforscreeningwithin anEDstay,leavingustoconsiderwhetherthesepatientswill determinetheirHIVstatus.Futureresearchisneededto assesstheeffectivenessofelectronicbestpracticeadvisories andbuilt-inHIVscreeningandtestingordersetsinhigher acuitypatients,aswellasapproachestomeetingtheneedsof theacuteandvulnerablepsychiatricpatient.

AddressforCorrespondence:Dr.JacquelineJ.Mahal,Directorof EmergencyHIVServices,JacobiMedicalCenter,Departmentof EmergencyMedicine,1400PelhamParkwaySouth,Bronx,NY 10461.Email: mahalj@nychhc.org

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

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PreventiveHealthServicesOfferedinaSamplingofUS

EmergencyDepartments,2022–2023

ChristopherL.Bennett,MD,MSc,MA*

M.KitDelgado,MD,MS†

MelissaPasao,BS*

JaniceA.Espinola,MPH‡

KrislynM.Boggs,MPH‡

CarlosA.CamargoJr.,MD,DrPH‡§

*StanfordUniversitySchoolofMedicine,DepartmentofEmergency Medicine,Stanford,California

† UniversityofPennsylvania,DepartmentofEmergencyMedicine, Philadelphia,Pennsylvania

‡ MassachusettsGeneralHospital,DepartmentofEmergencyMedicine, Boston,Massachusetts

§ HarvardT.H.ChanSchoolofPublicHealth,DepartmentofEpidemiology, Boston,Massachusetts

SectionEditor:FaithQuenzer,DO,MPH

Submissionhistory:SubmittedSeptember28,2023;RevisionreceivedFebruary23,2024;AcceptedApril5,2024

ElectronicallypublishedJuly17,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18488

Introduction: IntheUnitedStates,morechronicandpreventivehealthcareisbeingdeliveredinthe emergencydepartment(ED)setting.Understandingtheavailabilityofpreventivehealthservicesinthe EDsettingiscrucial.Ourgoalwastounderstandtheavailabilityofasubsetofpreventivehealthservices inUSEDsandexplorehowthathaschangedovertime.

Methods: In2022–2023,usingtheNationalEmergencyDepartmentInventory(NEDI)-USA,we surveyedarandom20%(1,064)samplingofall5,613USEDs.WeaskeddirectorsoftheseEDsabout theavailabilityofandpreferencefor12preventivehealthservices,socialworkeravailability,selfreportedpercentageofuninsuredEDpatients,andmeasuresofEDcrowding.Wealsoaskedabout perceptionsofbarrierstoimplementingpreventivehealthservicesintheED.Weusedunadjustedand multivariablelogisticregressionmodelstocompareservicefrequencyin2022–2023toprior ﬁndings from2008–2009thatrepresenteda5.7%randomsamplingofallEDs.

Results: Among302responderstothe2022–2023survey(5.4%randomsampling,28.4%response rate),94%reportedofferingatleastonepreventivehealthservice,withamedianof ﬁveservices.The mostcommonserviceofferedwasintimatepartnerviolencescreening(83%),whiletheleastcommon wasroutineHIVscreening(19%).Sevenservices(eg,intimatepartnerviolence,alcoholrisk,and smokingcessationscreening)hadahigheroddsofbeingofferedin2022–2023thanin2008–2009; ﬁndingswereunchangedinsensitivityanalyses.Asmallproportionofdirectorsopposedoffering preventivehealthservices.However,manyexpressedconcernsthatpreventivehealthservicesinthe EDwouldleadtolongerlengthsofstay(56%),increasedcoststotheirED(58%),adiversionofstafftime fromprovidingacutecare(50%),orthattheirpatientswouldnothaveaccesstoadequatefollowup(49%).

Conclusion: NearlyallEDsofferatleastonepreventivehealthservice.Manyoffermultipleservices; rateswerehigherthanthoseidentiﬁedin2008–2009,inbothunadjustedandmultivariablemodels. Althoughlimitedbytheresponserate,thisworkprovidesthemostrecentandcomprehensivesnapshot ofthetypeandfrequencyofasubsetofpreventivehealthservicescurrentlyofferedinUSEDs.[WestJ EmergMed.2024;25(5)823–827.]

INTRODUCTION

AlargeproportionofUShealthcareisdeliveredinthe emergencydepartment(ED)setting.1 Asanentrypointinto thehealthcaresystem,EDsareprovidinganincreasing proportionofbothemergentandnon-emergent(ie,chronic andpreventive)care,1,2 inpartduetoinsufﬁcientaccessto primarycare,populationgrowth,andanagingpopulation withincreasinglycomplexmedicalneeds.Therecentendof thePublicHealthEmergencyforCOVID-19andsubsequent unwindingoftheMedicaidcontinuousenrollmentprovision likelyentailsgreaterEDutilizationforbothchronicand preventivehealthcareneeds.3 However,itremainsunclear whatpreventivehealthservicesarecurrentlybeingofferedin theEDsettingandhowthishaschangedovertime.Findings fromthisstudycouldhelpframethechanginglandscape aroundEDreimbursementsandincentivestructures.

Astudyconductedin2008–2009engagedEDdirectors, determinedtheavailabilityofasubsetofpreventivehealth servicesofferedinarandomsamplingofUSEDs,and characterizedperceivedbarrierstoimplementingthese services.4 Ourobjectivewastoprovideanupdated assessmentoftheavailabilityofasubsetofpreventivehealth servicesfollowingtheonsetofCOVID-19inEDs,giventhe expectationthatresourcesareincreasinglyallocatedto preventivecare.Theunderlyinggoalwastoofferinsightinto andcontributetotheknowledgebasesupportingeffortsto improveandoptimizehealthcaredeliverywithinthe EDsetting.

METHODS

WeusedtheNationalEmergencyDepartmentInventory (NEDI)-USAasasamplingframeworkforthisstudy.The NEDI-USAisacomprehensivedatabaseofallnon-federal, non-specialtyUSEDs;informationavailableattheED-level (eg,teachinghospitalafﬁliationandannualvisitvolume)is updatedannually.5 FromNEDI-USA,wegenerateda randomlistof1,064EDs(≈20%ofallUSEDs).5 Onthe basisofthisrandomlist,directorswerecontacteduptothree times(fromWinter2022toSpring2023)viae-mailormail. Non-responderswerecontactedbytrainedresearch assistantsviatelephone.4

Theinstrumentwasapreviouslyimplementedsurvey (2008–2009)thatcharacterizedtheavailabilityof(and preferencefor)11preventivehealthservices,ED-levelsocial workeravailability,self-reportedpercentageofEDpatients whowereuninsured,andmeasuresofEDcrowdingina5.7% randomsamplingofUSEDs(Appendix).4 Ifaservicewas notoffered,thesurveyaskedwhetheritcouldbeoffered givenexistingresources.Directorswerealsoaskedabout perceptionsofbarrierstoimplementingpreventivehealth servicesintheED.InlinewithupdatedUSCentersfor DiseaseControlandPrevention(CDC)recommendations encouraginghepatitisCscreening,the2022–2023surveyalso inquiredaboutavailabilityofroutinehepatitisscreening.6

PopulationHealthResearchCapsule

Whatdowealreadyknow?

AlargeproportionofallUnitedStates(US) healthcareisdeliveredintheemergency department(ED);thisincludesagrowing amountofpreventivecare.

Whatwastheresearchquestion?

Tounderstandhowtheprovisionofasubsetof preventivehealthservicesinUSEDshas changedovertime.

Whatwasthemajor ﬁndingofthestudy?

NearlyallEDsstudied(94%)reported offeringatleastonepreventivehealthservice, withamedianof ﬁ veservices.

Howdoesthisimprovepopulationhealth?

Thisworkprovidesthemostrecentsnapshot ofthetypeandfrequencyofasubsetof preventivehealthservicescurrentlyofferedin USEDs.

Otherwiseallotherdataelements,includingthedeﬁnitionof crowding(ie,atleastoneofthreeCDCcriteria:average waitingtimeofonehourorgreater;leftwithoutbeingseen rateof3%ormore;oranytimeonambulancediversion) wereunchanged.4

Ininitialanalyses,wesummarizeddatawithdescriptive statistics(eg,counts,proportions,andmedianswith interquartileranges[IQR]),andcomparisonswere conductedusingstatisticaltests(eg, χ2andKruskal-Wallis tests).Logisticregressionwasthenemployedtoassessthe oddsofpreventivehealthservicesbeingofferedmore frequentlyin2022–2023thanin2008–2009.Wealso conductedsensitivityanalyseswithmultivariablemodels adjustingforcriticalaccesshospitalstatus.Thesedatawere summarizedwithoddsratios(OR)and95%confidence intervals(CI).Atwo-tailed P < 0.05wasconsidered statisticallysignificant.AnalyseswerecompletedinStata 15.1(StataCorp,CollegeStation,TX)andRStudio(https:// www.R-project.org),and figureswerecreatedinRand Datawrapperrelease0.4.6(https://app.datawrapper.de/). ThisstudywasapprovedbytheStanfordUniversity InstitutionalReviewBoardandfollowedthe StrengtheningtheReportingofObservationalstudiesin Epidemiology(STROBE)guidelinesfor observationalstudies.7

Table. Characteristicsofresponders,non-responders,andtheNationalEmergencyDepartmentInventory-USA. NEDI-USA, N = 5,613%

*Responders, n = 302%(95%CI)

Non-responders, n = 762%(95%CI) P-value

Medianannualvisitvolume(IQR)20,000(7,300–42,350)14,216(5,000–37,000)16,572(7,300–38,000)0.07

Hospitaltype

Teachinghospital56(4–9)5(3–6)0.36

Traumacenter 0.85

No8385(80–88)84(81–86)

Basic87(5–11)7(6–9)

Advanced98(5–12)9(7–11)

Criticalaccesshospital2441(36–47)32(29–36) <0.01

Urbaninﬂuencecode <0.01

Urban6651(45–57)57(53–60)

Largerural1413(10–17)17(15–20)

Smallrural2036(31–42)26(23–29)

USregion

Northeast1112(9–16)14(11–16)

Midwest2734(29–40)36(32–39)

South4334(29–39)37(34–41)

West1920(16–25)14(11–16)

*ConfidenceintervalsnotcalculatedforNEDI-USAbecauseentireUSpopulationofEDsisincluded;valuesdonotrelyonanestimate.The 302responders(28.4%responserate)reflecta5.4%randomsamplingofall5,613EDsintheUS;NEDI-USAreflectsED-levelinformation fromthe2019NEDI-USA.

CI,conﬁdenceinterval; ED,emergencydepartment;IQR,interquartilerange; NEDI-USA,NationalEmergencyDepartmentInventory-USA.

RESULTS

Characteristicsofresponders,non-responders,and NEDI-USAoverallarepresentedinthe Table.The302 responders(28.4%responserate)reﬂecta5.4%random samplingofall5,613USEDs.Withtheexceptionofahigher proportionofrespondersrepresentingsmall,rural,critical accesshospitalEDs(comparedtoNEDI-USAandnonresponders),EDcharacteristicswereotherwisesimilar.For context,characteristicsofrespondersin2008–2009and 2022–2023arepresentedin SupplementalTable1;therewere asimilarnumberoftotalrespondersin2008–2009(277,5.7% randomsampleofallEDs).In2022–2023,responderswere similarlymoreoftenfromcriticalaccesshospitalsthanin 2008–2009;theyalsoreportedlessEDsocialworker availabilityand inthecontextofthepreviouspassageof theAffordableCareAct werelesslikelytoreporthaving morethan35%oftheirpatientsbeinguninsured.8

Nearlyall(94%)directorsreportedthattheirEDs routinelyofferatleastoneofthe12preventivehealth services,withamedian(IQR)of5(3–7)servicesoffered.The mostcommonserviceofferedwasintimatepartnerviolence screening,whiletheleastcommonwasroutineHIV screening.Nearlyallthepreventivehealthservices,except HIVandhypertensionscreening,weremorefrequently offeredin2022–2023thanin2008–2009(Figure1).Sevenof

theserviceshadhigheroddsofbeingofferedin2022–2023 thanin2008–2009; ﬁndingswereunchangedafter adjustmentforcriticalaccesshospitalstatus (SupplementalTable2).

Further,amongdirectorswhoreportedthattheirEDdid notofferaparticularpreventivehealthservice,manystill reportedthatresourceswereavailabletooffersuchservices (Figure2).Whenaskedabouttheir “ﬁrstchoice” ofservice theywouldmostliketooffer,alcoholriskscreening, counseling,andreferralwasmostcommon,whileroutine HIVandhepatitisscreeningwereleastcommon.Onlya smallproportionofEDdirectorsthoughtthatpreventive healthservicesshouldnotbeofferedintheED.However,as highlightedinthe SupplementalFigure,manyexpressed concern(ie,stronglyagreedoragreed)thatoffering preventivehealthservicesintheEDwouldleadtoeither longerlengthsofstay(56%)orincreasedcoststotheirED (58%),orwouldrequireadiversionofstafftimefrom providingacutecare(50%),orthattheirpatientswouldnot haveaccesstoadequatefollow-up(49%).

DISCUSSION

AmongarandomsamplingofUSEDs,nearlyalloffered atleastonepreventivehealthservice,manycurrentlyhave theresourcestooffermore,andonlyaminorityofdirectors

Figure1. Availabilityofpreventivehealthservices,2008–2009and2022–2023. Theindividualpreventivehealthservicesaresortedbymostfrequenttoleastfrequent.Hepatitisscreeningwasnotincludedinthe 2008–2009study;valuesreﬂect2022–2023data.Nearlyallthepreventivehealthservicesweremorefrequentlyofferedin2022–2023than in2008–2009.

expressedthebeliefthatpreventivehealthservicesshouldnot beofferedintheEDsetting.Theresultsrepresentanincrease inboththeoverallproportionofEDsofferingatleastone preventivehealthserviceandthemediannumberofservices offeredperEDsince2008–2009.4 This ﬁndingisconsistent withrecentworkdemonstratingthatEDsareprovidinga growingamountofchronicandpreventivecareintheUS.1,2 Acomponentoftheresultsmightbeexplainedbythehigh proportionofrespondersfromcriticalaccesshospitalsand theuniquemissiontheseEDshavewithintheirlocal communities.Reassuringly,adjustmentforcritical accesshospitalsdidnotmateriallyaltertheobserved temporaldifference.

Althoughweareunabletocommentontheunderlying reasonswhy(orwhynot)aparticularEDoffersaparticular preventivehealthservice,thereasonsarelikely

multifactorial.Servicesthataremandatedorstrongly encouraged,comparedtoservicesthatareneither,arelikely moreoftenoffered.Further,servicesthatarelesstime-and resource-intensive(eg,aseriesofscreeningquestions comparedtocheckingahemoglobinA1corperforminga HIVantigen/antibodytest)arealsomorelikelytobeoffered. AcomponentlikelyalsodependsonboththeEDandits availableresources,andtheuniqueneedsofthepatient populationsservedintheseEDs.

Theobservedchangesoccurredinthesettingoftherecent unwindingofMedicaid’scontinuousenrollmentprovision, withtheprospectthatmillionsofAmericanswilllose or havealreadylost Medicaidcoverage.3 Thislosswilllikely translateintoincreasedratesofEDutilizationforboth emergentandnon-emergent(eg,chronicandpreventive)care acrossthecountry.Giventhestafﬁng,crowding,and

Figure2. Abilitytoofferpreventivehealthserviceswithexistingstaffandfundingin2022–2023. Emergencydepartmentdirectorswereaskedwhethertheyhadasysteminplacetoroutinelyprovideaparticularpreventivehealthservice. Thosewhoreported “no” (ie,didnotofferaparticularservice)werefurtheraskedwhethertheycouldalreadyofferthatserviceroutinelygiven existingstaffandfunding.Theindividualpreventivehealthservicesaresortedbymosttoleastfrequentlyreportedasbeingpossibletooffer.

boardingcrisesinEDs,whichwereexacerbatedbythe COVID-19pandemic,EDresourcesareexpectedtobe furtherstrained.9

LIMITATIONS

Ourworkhasseveralimportantlimitations,amongthem oursurvey-basedapproachandresponserate.Asurveyisthe onlyfeasiblemeanstostudythistopic;theseservicesarenot typicallybilledforortrackableinanysystematicnational sampleofUSEDs.Reassuringly,ourgoalofobtaininga similarlysizedrandomsamplingofEDsasin2008–2009was met,andourresponserateisconsistentwithrecentwork demonstratingsurvey-fatigueamonghealthcareworkers duringCOVID-19andlowersurveyresponserates.10 For context,weprovidedetailedcomparisonsofhowresponders comparetonon-responders,NEDI-USA,andto2008–2009 responders.Giventhislimitation,andthatbothtimepoints reﬂectdistinctrandomsamplings,weintentionallyavoided formalpairwisecomparisonsbetween2008–2009and 2022–2023responders.Instead,weincorporateda conservativeapproachusingdescriptivestatisticsand conductedregressiontodemonstratethatadjustmentfor criticalaccesshospitalstatusdidnotmateriallychange our ﬁndings.

Second,wecanonlycommentonavailabilityforthe preventivehealthservicesweconsidered;neithercouldwe commentonthe fidelity,comprehensiveness,oreffectiveness ofanyofthepreventivehealthservicesstudied.Ourobjective wastoprovideanupdatedassessmentoftheavailabilityofa subsetofpreventivehealthservicesintheEDsetting,withthe goalofhighlightingtheincreasingamountofnon-emergent carebeingprovided.Third,givenourgoalofusingthesame surveyvehicletofacilitatecomparisonsagainstpriorwork wecannotcommentontheextentof,orED-leveldifferences in,theseservices.Theseissuesareimportantandmeritfuture investigationbutarebeyondthescopeofthecurrentwork. Theseissues,andworkfocusedoncosteffectiveness, reimbursements,and financialincentivesofpreventivehealth servicesofferedinEDsettings,arethefocusofcurrentand futureeffortsbyourgroup.Despitetheselimitations,our findingsrepresentthemostcurrentandcomprehensive snapshotoftheavailabilityandfrequencyofpreventive healthservicescurrentlyofferedinUSEDs.

CONCLUSION

Nearlyall.EDsintheUnitedStatesofferatleastone preventivehealthservice.ManyEDsoffermultipleservices, andrateswerehigherthanthoseidentiﬁedin2008–2009in bothunadjustedandmultivariablemodels.Althoughlimited bythelowresponserate,thisworkprovidesthemostrecent snapshotofthetypeandfrequencyofasubsetofpreventive healthservicescurrentlyofferedinUSEDs.

AddressforCorrespondence:ChristopherBennett,MD,MSc,MA, StanfordUniversitySchoolofMedicine, DepartmentofEmergency Medicine,3145PorterDr.,WingB-2ndFloor,PaloAlto,CA94304. Email: cleebennett@stanford.edu

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

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ORIGINAL RESEARCH

ExploringMedicalStudentExperiencesofTraumainthe

EmergencyDepartment:OpportunitiesforTrauma-informed MedicalEducation

GiselleAppel,BA*

AhmedT.Shahzad,BA*

KestrelReopelle,MD†

StephenDiDonato,PhD‡

FrancesRusnack,DO§

DimitriosPapanagnou,MD,EdD,MPH∥

*ThomasJeffersonUniversity,SidneyKimmelMedicalCollege, Philadelphia,Pennsylvania

† IcahnSchoolofMedicine,DepartmentofEmergencyMedicine, NewYork,NewYork

‡ ThomasJeffersonUniversity,CollegeofNursing,Philadelphia,Pennsylvania

§ NewYorkUniversityGrossmanLongIslandSchoolofMedicine, DepartmentofEmergencyMedicine,NewYork,NewYork

∥ ThomasJeffersonUniversity,SidneyKimmelMedicalCollege, DepartmentofEmergencyMedicine,Philadelphia,Pennsylvania

SectionEditor:AndrewPhillips,MD,MEd

Submissionhistory:SubmittedOctober6,2023;RevisionreceivedMarch20,2024;AcceptedMarch25,2024

ElectronicallypublishedJune28,2024

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

DOI: 10.5811/westjem.18498

Purpose: Duringthethird-yearemergencymedicine(EM)clerkship,medicalstudentsareimmersedin traumaticincidentswiththeirpatientsandclinicalteams.Trauma-informedmedicaleducation(TIME) appliestrauma-informedcare(TIC)principlestohelpstudentsmanagetrauma.Weaimedtoqualitatively describetheextenttowhichstudentsperceivedthesixTIMEdomainsastheynavigatedcriticalincidents duringtheirEMclerkship.

Methods: Weemployedaconstructivist,modiﬁedgroundedtheoryapproachtoexploremedical students’ experiences.Weusedthecriticalincidenttechniquetoelicitnarrativestobetterunderstandthe sixTIMEdomainsastheynaturallyappearintheclerkship.Participantswereaskedtodescribea traumaticincidenttheyexperiencedduringtheclerkship,followedbytheclerkship’sroleinhelpingthem managetheincident.Usingtheframeworkmethod,transcriptswereanalyzed1)deductivelybymatching transcriptexcerptstorelevantTIMEdomainsand2)inductivelybygeneratingdenovothemestocapture factorsthataffectedstudents’ handlingoftraumaduringcriticalincidents.

Results: TwelveparticipantswereenrolledandinterviewedinJuly2022. “Safety” wasthemost frequentlydescribedTIMEdomain,whereas “Gender,Cultural,andHistoricalissues” and “Peer Support” werediscussedleast.Inductiveanalysisrevealedthemesthathinderedorsupportedtheir abilitytomanagetraumaticexperiences,whichweregroupedintothreecategories:1)student interactionswiththelearningenvironment:complexsocialdeterminantsofhealth,inequalitiesincare, andovertdiscrimination;2)studentinteractionswithpatients:ethicallyambiguouscare,witnessing acutepatientpresentations,andreactivationofpasttrauma;and3)studentinteractionswithsupervisors: powerdynamics,invalidationofcontributions,role-modeling,andstudentempowerment.

Conclusion: ThesixTIMEdomainsarerepresentedinstudents’ perceptionsofimmediate,stressful criticalincidentsduringtheirEMclerkship,with “Safety” beingthemostcommonlydescribed;however, thedegreetowhichthesedomainsaresupportedinstudents’ experiencesoftheEMclerkshipdiffer,and instancesofinadequatelyexperienceddomainsmaycontributetostudentdistress.Understandingthe EMclerkshipthroughthespeciﬁclensofstudents’ experiencesoftraumamaybeaneffectivestrategyto guidecurricularchangesthatpromoteasupportivelearningenvironmentforstudentsintheemergency department.[WestJEmergMed.2024;25(5)828–837.]

INTRODUCTION

Overrecentyears,emergencydepartments(ED)across theUnitedStateshaveservedaspointsofcareforvictimsof wideninghealthdisparities,increasingsociopoliticalunrest, theCOVID-19virus,andincreasingnumbersofmass shootings.TheEDworkplacealsoservesasaclinical learningenvironmentforlearnersacrossmultiplehealth professions,routinelyexposingthemtotraumathatis intrinsictoemergencymedicine(EM)practiceandcare deliveryintheUS.Medicalstudentsareathighriskfor sustainingpsychologicalandemotionaltraumafromtheir encounterswithpatientsandinteractionswithmembersof theirEDcareteams oftenforthe ﬁrsttimeintheir professionalcareers.1–3

Studentshaveprevious lyreportedthattheir undergraduatemedicaleducation(UME)traininghasnot adequatelypreparedthemtocopewithsuchstressful events. 2 Aninabilitytopositivelycopewithstresscan negativelyimpactstudents ’ health,contributetoanxiety, depression,and/ordetachment. 4 – 6 Notonlycanthis stresshaveapsychologicalimpactonwell-being,but itcanalsoimpactstudents ’ abilitytoadvocatefor themselves,theirpeers,andtheirpatientsoverthecourse oftheirtraining.

Researchsuggeststhattheimpactofstressfuleventson studentscanbelessenedorampliﬁedbystructuralsupport embeddedinformalcurriculum.Frameworks,suchas trauma-informedmedicaleducation(TIME),haveoutlined whatstructuralsupportmaylooklikeinUME.Traumainformedmedicaleducationrepresentsanapproach thatappliestrauma-informedcare(TIC)principlestoUME tohelpstudentsrecognizeandaddresstraumainreal time.7 Itaimstocreatealearningcultureguidedbysix

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Medicalstudentsareimmersedintraumatic incidentswhentheyrotatethroughthe EDduringtheemergencymedicine (EM)clerkship.

Whatwastheresearchquestion?

Towhatextentdomedicalstudentsperceive thedomainsoftrauma-informedmedical education(TIME)astheynavigatetheED clinicalenvironment?

Whatwasthemajor ﬁndingofthestudy?

ThedegreetowhichTIMEdomainsare supportedinstudents ’ experiencesoftrauma differ,andinstancesofinadequately experienceddomainsmaycontributeto studentdistress.

Howdoesthisimprovepopulationhealth?

BetteridentifyingopportunitiesfortraumainformededucationintheEMclerkshipcan supportstudentsandtheirwell-being.

trauma-informeddomains:safety;trustandtransparency; peersupport;collaborationandmutuality;empowerment, voice,andchoice;andcultural,historic,andgender considerations(Table1).8

SafetyCouldthestudentexpresstheirthoughtsaboutthesituationopenly?Didthestudentwonderifthey wouldbenegativelyimpactediftheyvoicedtheiropinion?

TrustandtransparencyWasthestudentbriefedaboutthesituationbeforetheyexperiencedit?

PeersupportWereanyofthestudent’speersinthesituation,too?Howdidthestudentinteractwith thesepeers?

CollaborationandmutualityWasthestudentabletointeractwiththeirfaculty?

Didthestudentwitnessalackofprofessionalism?Whathappened?Howwasthislackof professionalismrespondedto?

Empowerment,voice,and choice

Cultural,historic,andgender considerations

Ifthestudenthadfeedbackforyourclerkshipand/orotherpeople,howdidtheydeliverthis feedback?

Ifthestudentneededtotaketimeawayfromthesituationorclerkship,wasthereroomintheir scheduletodoso?Howcouldtheyrequestthistimeiftheyneededit?

Werethereothersinthissituationwhohadasimilarracial,ethnic,orgenderidentityas thestudent?

Werethereotherswhoseracial,ethnic,orgenderidentitiesweredifferentfromthestudent’s?

Table1. Trauma-informedmedicaleducationdomains.

WhilesomemedicalcollegeshaveincorporatedTIME domainsintotheircurriculum,9 theextenttowhichTIME domainsinformthethird-yearEMclerkshipcurriculum remainsunclearandunexplored.Bybetterunderstandingthe studentexperienceofthethird-yearEMclerkship,educators couldtakepracticalstepstoadequatelypreparelearnersfor thechallengesposedbytheEDclinicallearning environment.Inthisqualitativestudy,weaimedtodescribe speciﬁcTIMEdomainsstudentsexperienceastheyare naturallyimmersedintheclinicalenvironment.Speciﬁcally, weaimedtoidentifytowhatextentstudentsperceivedTIME domainstobepresentwithinthethird-yearEMclerkship curriculumtosupporttheirabilitytonavigatehigh-stress criticalincidentsintheED.

MATERIALSANDMETHODS

Wetookamodifiedconstructivistgroundedtheory approachtocollect,describe,andanalyzethird-yearmedical students’ perceivedstressfulincidentsduringtheirEM clerkshipintheirthird-yearofmedicaltraining.We employedthecriticalincidenttechnique(CIT),adata collectionmethodthatguidesparticipantstodisclosevivid descriptionsofa “criticalincident.” Formally,perCITa criticalincidentisdefinedas “anyobservablehumanactivity thatissufficientlycompleteinitselftopermitinferencesand predictionstobemadeaboutthepersonperformingthe act.”10 AspartofourCITmethod,participantswereaskedto recountanddescribeaspecific,stressfulcriticalincidentthat theyexperiencedduringtheirEMclerkship.Itisimportant tonotethattwostudyinvestigatorshaveconsiderable experiencewithqualitativeresearchmethods(SD,DP),and onestudyinvestigatorhasextensiveexperiencewiththeCIT method(DP).Also,oneresearchteammember(SD)isa trainedtraumacounselorwithanextensiveTICbackground. Thestudyprotocolwasapprovedbytheinstitutionalreview boardofThomasJeffersonUniversity,anddatawas collectedinJuly2022.

PopulationandSamplingStrategy

Becausewesoughttounderstandtheexperiencesof medicalstudentsintheEMclerkship,weintentionallyand exclusivelysampledthird-yearmedicalstudents.We recruitedthird-yearmedicalstudentswhohadcompleted theirEMclerkshipatanurban,academic,tertiary-care medicalcenteratThomasJeffersonUniversityHospitalin Philadelphia,Pennsylvania.Twostudyinvestigators(KR, DP)arefacultyinthisdepartmentandarefamiliarwiththe practiceenvironment.

Studentparticipantswereidentiﬁedthroughpurposive conveniencesampling.InJuly2022,thestudyteamsent recruitmentemailstostudentlistservsatourrespective medicalschools.Criteriaforinclusionwerethatthe participantwasathird-yearmedicalstudentandhad successfullycompletedtherequiredEMclerkshipduringthe

studyperiod.Participantswereenrolledthroughtargeted emailsdescribingthestudyandassurancethatparticipation wasvoluntary.Studyparticipantsandtheirrespective narrativeswerede-identiﬁedusinganinternallydeveloped codingscheme.

DataCollection

Thestudyconsistedofaseriesofcriticalincident interviewswiththird-yearmedicalstudents,each30–45 minuteslong,thatwereconductedinAugust2022.Informed consentwasobtainedfromrecruitedstudents.Afterabrief demographicelectronicquestionnairewascompleted, interviewswerescheduledwithparticipants.Eachinterview wasconductedvirtuallyusingvideoconferencingsoftware (ZoomVideoCommunications,Inc,SanJose,CA)withtwo membersoftheresearchteamwhoweretrainedineliciting criticalincidentsthroughinterviews.Participantswere compensated$75fortheirparticipationinthestudy.

Interviewswereconductedusingadetailedinterview protocolwithquestionsthatwereinformedbytheTIME framework(Appendix).Theinterviewprotocolwas developedbythestudyinvestigatorsandwaspilotedwith twomedicalstudentstooptimizeinterviewquestions.Pilot interviewdatawereincludedintheanalysis.Student participantswereaskedtodescribeakeyincidentduring theirEMclerkshipwhentheyexperiencedasigniﬁcant trauma.AnaudiorecordingfromeachZoominterviewwas transcribedusingautomatedtranscriptionsoftware,which wasthenmanuallyreviewedbymembersofthestudyteam fortranscriptionaccuracy.Transcriptswerede-identiﬁed.

Analysis

Dataforeachparticipant’stranscriptwasreducedto captureacriticalstory.Foreachtranscript,theparticipant’ s narrativewasre-organizedchronologicallyintoacoherent, re-storiednarrative.Bytakingaconstructivistandmodiﬁed groundedtheoryapproach,weinductivelyanalyzedrestoriedcriticalincidents.Throughaseriesofseveraliterative conversations,andperCITbestpractices,wemanually developedassertions(organizedinExcel[MicrosoftCorp, RedmondWA])aboutthemeaningofeachincidentasit relatedtotheresearchquestion.Toorganizeoverarching themesfromassertions,weconductedaseriesofvirtualcardsortingactivitiesthatwerefacilitatedthroughseveralvirtual GoogleJamboardactivities.Iterativecross-incidentanalyses withthestudyteaminformedconnections,associations,and relationshipsforthemesthatemergedfromtheassertions. Thisallowedourteamtogenerateanoverarchingframework ofobservedthemesandrelationships.

Togroundourinductive ﬁndingsandmoredirectlyassess thedegreetowhichstudents’ perceivedTIMEdomains duringtheirclerkship,weundertookadeductiveapproachin whichexcerptsfromeachparticipant’snarrativewere matchedwiththemostrelevantTIMEdomaindiscussed

(ie,avividdescriptionoftheimpacttheEDlearning environmenthadonastudent’sabilitytoopenlyexpresstheir opinionswasmatchedtotheTIMEdomainof “Safety”). ForcriticalincidentswheremultipleTIMEdomainswere identiﬁed,weselectedthemostdominantTIMEdomain. Toensureinternalvalidityofdatainterpretation,theentire teamofinvestigatorsmettoreviewallinductiveassertions anddeductivecategorizations.Discrepancieswereresolved throughiterativeconversationsoverthe10-month studyperiod.

RESULTS

Weidentifiedandinterviewed12studentparticipants. Studysizewasinformedbydatasaturation,information power,andanalyticalanddatasufficiency.11 Theaverageage ofparticipantswas25.5yearsold;50%identifiedasmaleand 50%asfemale.Themajorityofparticipantsidentifiedas White(8of12participants)(Table2).Participants’ critical incidentsalignedwithdeductivecodesborrowedfromthe TIMEframework(Table3).Participantsdescribedelements of “Safety,” whetherpsychologicalorphysical,most frequentlyacrossall50interviews,whereas “Gender, Cultural,andHistoricalissues” and “PeerSupport” were discussedtheleast(13each).

Analysisofcriticalincidentswithcross-casecomparisons revealedthatthemeswereclassiﬁedintothreecategories:1) studentinteractionswiththeEDclinicallearning environment;2)studentinteractionswiththeirsupervisors; and3)studentinteractionswiththeirpatients(Table4).

StudentInteractionswiththeEDClinical LearningEnvironment

NavigatingSocialDeterminantsofHealth Studentsstruggledwithhavingtonavigateandreconcile thecomplexsocialdeterminantsofhealth(SDoH)for patientsseekingcareintheED.Thiswasoftenaccompanied byintenseemotionandstressinstudents.

So,Iobviouslywasalittlestressedoutbecause patientscryingobviouslyisnotsomethingIhave experienced ::: That’sjustsomethingthatIhadn’tdone onmyownyet.Andsobeinginthepatient’ srooms withthemcryingandmejusttryingtobelike, “What doIdo?DoIwantto ﬁxitrightaway?” SoIwaslike, “MaybeIshouldgogetsomeone.Maybehewantsto talkaboutwhyhe’sfeelingthisway.” Iwasn’treally toldhowtodealwiththat.

Studentsexperienceduncertaintywhennavigatingovert patientsuffering,psychosocialfactorsthatfurther complicatedcareplans,andhavingconversationswiththeir patients.Consequently,studentsdesiredmoresupport duringtheseencountersintheformofgreaterpreparationfor thepatientencounter,emotionalsupport,andeffectiverole-

Table2. Demographicsofparticipants.

CharacteristicN = 12

Age

21–244(33%)

25–275(42%)

27+ 3(25%)

Gender Man6(50%)

Woman6(50%)

Race

Asian/NativeHawaiian/PaciﬁcIslander3(25%) White8(67%) Hispanic1(8%)

modelingfromtheirsupervisors.Theyalsoexpressedan interestinopportunitiestodebriefandmakesenseofthese challengingencounters.

RespondingtoObservedInequitiesinCare

Studentsexperiencedhesitationanddistresswhen navigatinginstancesofperceivedcareinequitieswiththeir treatmentteams(eg,whenthereasonwhytwopatients withsimilarpresentationsreceivingdifferenttreatments wasunclear).

Andthispatientlooksexactlythesame. AndIwassort oflike,What’sthedifference?Theywerelike, “Youcould tellthisone’s[thepatient’s]uncomfortable.” Ithoughtthe otheronelookeduncomfortable,butwhatever.Weended updoingjustalotmoreforher,andIcouldn’treally identifyanydifferencebetweenthetwocases.Ithought theywereboththesame ::: “Hey,didthatjusthappen, though?” Ithoughtithappened.Orlike, “AmI hallucinating?”

Inequityincareisaconceptrepeatedlyintroducedinthe preclinicalyears;however,studentsfeltunpreparedto navigatediscussionswiththeircolleagueswhenthey recognizedinequitydirectlyinﬂuencingthecaretheywere delivering.Moreover,athird-yearmedicalstudent’srelative lackofexperienceintheclinicalrealmandunfamiliaritywith theuniqueenvironmentoftheirrotation(eg,teamdynamics, patientpopulation,location),addedfurtherambiguitytothe situation.Studentsfeltunabletocommunicatetheirconcern andadvocatefortheirpatients.

NavigatingRace,Gender,andSocioeconomic Discrimination

Discrimination(ie,racial,cultural,and/orgender-based) intheworkplacehinderedthepsychologicalsafetyof studentsbelongingtominoritygroupsthatwere

Table3. Frequencyofdeductivethemes.

TIMEdomainRepresentativequote(s)

Safety “Imadeanappointmentwithschoolcounselingservices.Ifelt fine. IkindofthoughtIwasgoingtohave,like,weirddreamsorfeel weird.AndIwastotallyunaffected,butIdon’tknow.Younever know.Idon’tthinkI’veeverseensomeone beentherewhen theypronouncesomeonedead.Itwaskindofmy firstexperience andeventhen,Iwasstillperiphery.[Counseling]waslike, ‘Iwas goingtoreachouttoyouanyway.Wemadealistofthosepeople whocameupattheschoolcounselingcenter’smeeting.’ Iwas feeling fine,soitwasn’tlike, ‘Wow,that’sgreat!’;butitwaskindof niceforsomeonetobe, ‘It’sokaythatyoufeel fine.Youshouldn’t feelbadthatyou’renot,like,hauntedbythis,’ ifthatmakessense.”

Empowerment, voice,choice

Collaborationand mutuality

Transparencyand trustworthiness

Frequencytable (asnumberof instancesacrossall transcripts) Percentageof allinstances (%)

“SoIreadtheattendingalittlebitonedge,listeningtowhatthey’re saying,andthentheysay, ‘Yeah,likeyoudidn’tevenlookintotheir mouth.Andyeah,itjustwasnot,notorganized.’ AndIwaslikein myhead,likethinking, “Wait,what?LikeI100%didaneuroexam, andIhadhimopenuphismouthandsay,checkfornineandten. AndthenIhadhimpointhistongueoutto,totherightandleft.” AndthenIwaslike, ‘Okay,whatdoIdonow?DoIcontradictmy attending?Orjustsay, ‘Sure?’” 3020

“Thephysicianbroughttheeventupquickly.Oncehewasonthe phone,consultedsurgeryandthenhungupandhesaid, ‘It’sreally importantthatwetakeownershipofwhathappenedhere.Instead oflyingand/ormakingexcuses,wetakeownershipandsaywhat happened.’ Butthenhestillhadtogodootherthings,andthenI wastheonewhoinitiated[moreconversationabouttheevent], whichIthinkwasappropriatefrommysenseandfromthe attendingsense,aconversationabouttheevent,mostlyfora learningexperienceformetotalkaboutwhathappened.”

“Ithinkitwouldhavebeennicetohavesomeacknowledgment becauselike,partofthefrustrationisfeelinglikeyou’retheonly personwhoseesitthisway,youknow?Andit’slike,itwouldhave beenniceifmyattendingturnedtomeandwaslike, ‘Hey,likethat waskindofproblematic.Ihopeyoudon’tthinkthatweallthinkthat waybecausewedon’tlikethatkindofthing.’ Ithinkitwouldhave counteractedalittlebitofthedisillusionmentIfeeltowards medicineingeneral.”

2517

1812

Gender,cultural,and historicalissues

“Ithinkthere’salwaysthatfeeling,especiallylikeasayoung femaletrainee,IfeellikeIkindofhavetoputonabravefaceand notshowthatmuchemotion.Idon’tknow.Likeit’sgoodtoappear investedinyourpatients,butit’snotgoodtobelike, ‘Oh,likethisis theworstthingthat’severhappened,blah,blah,blah.’ Because obviouslyallthesepeoplehaveseenworse.So,no,Idon’tthink thatanyonewouldhavewrittenmeabadreviewifIwasshowing thatIwasupset.ButIdothinkitsubconsciouslyimpactswhat peoplethinkofyou.Like,youknow,maybeshe’snotcutoutfor this ﬁeldorsomething.”

Peersupport “Andso,IthinkthatmademefeellikeIhadtobetheone responsibleforensuringthatthiswomanwasabletogethomeand avoidfurtherintimatepartnerviolence.IreallyfeltlikeIwastheone whodecided,like,whethershewouldbeundergoingmoreviolence thatnight.”

TIME,trauma-informedmedicaleducation.

138.7

OverarchinggroupingIndividualthemes

Students’ interactionswithpatientsReactivationofpasttrauma

Emotionaldiscomfortassociatedwithnavigatingethicsanduncertainty

Emotionaldiscomfortwhenwitnessinghighacutepatientcareforthe ﬁrsttime

Students’ interactionswithsupervisorsPowerdynamicsdiminishingstudentclinicalautonomy

Novalidationforstudentclinicalcontributions

Role-modelingasameanstosupportstudents

Empowermentandfeedbackasameanstocreatepsychologicalsafety

Students’ interactionwiththeEDclinical learningenvironment

ED,emergencydepartment.

Navigatingsocialdeterminantsofhealth

Respondingtoobservedinequitiesincare

Navigatingrace,gender,andsocioeconomicdiscrimination

discriminatedagainst evenwhentheseactswerenot directedtostudents(eg,atstafforpatientsbelongingtothe student’sminoritygroup).

It’salsodisappointingbecauseIfeltlikemyattending didn’treallysayanythingtogoagainstthat.Hewasn’t agreeingwithher,buthewaslike, “Ohyeah.” Hekind ofjustdismisseditanddidn’tengagetoomuch.

Adiscriminatoryexperiencecoupledwithsilent complacency(ie,alackofacknowledgmentofsuchevents fromclinicalteammembers,particularlyfacultyand supervisorswhoweretaskedwithadvocating,teaching,and protectingstudents)complicatedstudents’ responsestosuch eventsandmarginalizedtheirroleintheclinicalworkplace. Importantly,studentsofcolor(asintheabovecase)feltless empoweredontheteam,especiallywhenbeingtheirteam’ s onlymemberofcolor.

StudentInteractionswithSupervisingResidents andAttendings

PowerDynamicsDiminishingStudentClinicalAutonomy Powerdynamicsinterferedwithstudents’ abilityto advocatefortheirpatientsandcontributedtotheirstress whenimmersedintheclinicalenvironment.Thesepower dynamicshinderedtheirabilitytoclarifycomplexmedical andsocialcasesbecausetheyfearedbeingperceivedas unknowledgeable.Furthermore,theywerelesslikelytoask foradiscussionand/ordebrieﬁngtoresolvetheirfeelings surroundingpatientencountersastheydidnotwanttobe perceivedasemotionalor “weak” :

Ifeltsadandkindofdisappointedthatotherphysicians weren ’ttakingitseriously,thatweneededtogetherout ofthereandwecouldatleastprovideresources,orwe coulddomoretoacknowledgethatshe’sherefor

intimatepartnerviolence-relatedconcernsandthatno onereallycaredaboutwhathappenedaftersheleft.

Studentsoftenfoundthemselvestornbetweenthedesireto investmoretimeincaringforandadvocatingonbehalfof theirpatientsandtheneedtomaintainefﬁciency, subordination,andastrongperformanceforevaluatorswho assessedtheirclinicalskills,oftenoverlookingunassessedyet equallyvitalinterpersonalskills(ie,demonstratingempathy, advocatingforpatients).

AndIdidn’treallyfeellikeIcouldexplaintothe physician, “Hey,thisissomethingthatisreally importanttomethatIthinkshouldbehandled differently.” Ijustdidn’tfeelthatwasmyplacewith someonewhohadalotofcontrolovermygrade.Itwas thiswarbetweenwhatIfeelwasbestformyfuture gradesandwhatIfeltwasmorallyright.

NoValidationforStudentClinicalContributions

Alackofacknowledgmentofstudents’ contributionsto thecareteam,eitherinrealtimeorontheirevaluation, causedstudentstoexperiencedistress.Incomplexclinical situationswherestudentsfelttheyhadmeaningfully contributedtopatientcare,alackofvalidationofthe student’scomposure,adaptability,and/orjudgment hinderedtheirabilitytoassimilatetothecareteamand triggereddissociationfromanddisillusionmenttowardthe clerkshipexperience.

Yougetanevaluationforeverysinglestuffyouworkon. MyEMevaluationdidn’tsayanythingabout[themass shootingevent].Itwasn’tlikeIneededanyonetobe “Wow,shedidn’tfreakout” or “Shewascalm.” It didn’thavetobethat.Andmyevaluationwasn’tbad,

Table4. Frameworkofinductivethemes.

itwasfair Justtome,that’skindofalargeeventthat happened.Itjustfeltkindofweirdthatthatcontext wasmissing.

Role-ModelingtoSupportStudents

Modelingofintegrity,professionalism(ie, accountability),anddebrieﬁngbysupervisorshelped studentsprocesspoorclinicalperformanceandgainclosure duringiatrogeniccomplications.

Thephysicianbroughttheeventupquickly.Once[he[ hungupaftertalkingwithsurgery,hesaid, “It’sreally importantthatwetakeownershipofwhathappened here.Insteadoflyingandormakingexcuses,wetake ownership.” Thenhepersonallyaddressedmyfeelings andmypotentialblamingofmyselfforthesituation andreassuredthatitwasn’tmyfault.Andthesethings hesaid,whichisadmirable,andhowyoutakefull,full ownershipforthecomplication.

Participantnarrativessuggestedthattakingownership overastressfulortraumaticincidentofferedasenseof agencyandopenedopportunitiesforpositiveclinical learning,insteadofleavingthestudentfeelingpowerlessto speakoractontheevent.Thenegativeimpactofperforming aclinicalerrorwasmitigatedbasedonhownextactionsteps wereframed.

EmpowermentandFeedbacktoCreate PsychologicalSafety

Asstudentsworkedthroughavarietyofclinical encountersduringtheirrotation,onefactorthatwasoften describedassupportingstudents’ psychologicalsafetywas feelingempoweredbytheirteamandreceivingtimely feedbackbefore,during,and/orafteraclinicalsituation.

Themputtingthattrustinme mademewanttotryto dothebestthatIcouldinthissituationwithalimited numberofexperiences.

Inthisparticularincident,thestudentfoundthemselvesin anemergentencounterwithapatientincardiacarrestand wastaskedwithintubatingthepatient.Althoughthestudent feltuncertain,theteam’strustandempowermenttoperform acriticalroleimprovedtheirsenseofagencyandsecurityand helpedmotivatethemtoperformthetask.

StudentInteractionswithPatients ReactivationofPastTrauma

Clinicalsituationsinvolvingpatientswhowerevictims ofdomesticviolencereactivatedtraumainstudentswith similarexperiences.

[Listeningtoherdisclosure]wasdeﬁnitelyhardbecause I’vehadnotasextremebutsimilarexperiences.I resonatedwithher,andIthinkthatmadeitalotmore challenging.Wecouldatleastprovideresourcesordo moretoacknowledgethatshe’shereforintimate partnerviolence-relatedconcerns.Noonereallycared aboutwhathappenedaftersheleft,orpeoplewerenot eventotallyawareofit.

Theclerkshipcurriculumdidnotpreparethisstudentto managetheguiltassociatedwithtreatingdomesticabuse victims(orasenseof “notdoingenough”).Thestudentfelt disappointedthatothermembersoftheclinicalteamwere notacknowledgingconcernsforfuturedomesticviolence risk.Consequently,thestudentdidnotfeeltheycouldopenly expressthemselveswiththeirsuperiorswhohadcontrolover theirsummativeassessment(ie,grade).

EmotionalDiscomfortAssociatedwithNavigatingEthics andUncertainty

Ethicallyambiguoussituationsaboundinmedicine. However,theseethicallychallengingsituations suchas instancesinwhichpatientswerephysically/chemically restrained,proceduresthatwereperformedonpatientswith alteredmentalstates,orcriticalmedicaldecisionsthatwere madebypatientsurrogates causedstudentstoexperience emotionaldiscomfortthatmadeitdifﬁculttonavigatethese situationsinrealtime.

[Thefaciallaceration]neededtoberepaired.Butthe patient,understandably,whowasconfusedreallydidn’t wantustouchingheranddidn’twantitdone ::: What weendedupdoingisholdingthepatientdownwhile theresidentrepairedthefaciallaceration.Andduring theentiretime,shewasobviouslyveryunhappy,kept ontellingustostop,andtoldtheresidentthatshe wouldgether ﬁred.Wewereabletosuccessfully completetheprocedure,whichwasourgoal.

EmotionalDiscomfortWitnessingHigh-AcuityPatient CarefortheFirstTime

TheeducationalexperienceoftheEMclerkshipis primarilybasedonclinicalencounters.However,witnessing acutemanifestationsofpatients’ conditions,suchasphysical disfigurementorinabilitytocommunicate,overwhelmed studentsandimpededtheirabilitytoeffectivelymanagethe concernsoftheirpatients.Intheexamplebelow,while physicaldisfigurementwasexpected,thestudentfeltstunted byalackofpreparationonhowtonavigateanencounter withapatientwithalternativemethodsofcommunication andwasoverallunpreparedfortheeffectthatthepatient’ s physicaldisfigurementwouldhaveontheirowncomposure.

Ihaveneverseensomeonedisabledforawhile;Ifeellike wedohavepropertrainingonthat.ButthenwhenIsee, “Oh,myGod,hewasn’tlikethisatinybitago,andnowhe isbecauseofdisease.Theyusedtobefullyableandnow they’renot.” Iwastryingtowalkalineofthebestwayto communicate,whichwasadifferentexperiencethanIever hadbefore.Itwasreallyhardtoseeapersoninthatstate, especiallywhenyou’renotexpectingit.I’llremember whathewaslikeforever.

DISCUSSION

Studentexperiencesexploredinthisstudyreinforceprior literature’sunderstandingsoftheEDasastressful environmentandtheEMclerkshipasaneducationalsetting thatmayexposestudentstotraumathatexceedstheir existingcopingabilities.Thedeductiveandinductive analysesundertakeninthisstudyrevealinsightsaboutthe natureofthesestressorsthroughthelensofstudents’ experiencesduringtheirthird-yearEMclerkship.The deductiveapproachmatchedincidentssharedwithin12 students’ narrativestothesixTIMEdomains,whereasthe inductiveapproachofthisqualitativedatageneratedanovel groupof10overarchingthemes.

Overall,thedeductiveanalysisdemonstratedthatTIME domainswererepresentedinstudents’ perceptionsofEM clerkshipeducationalstructures(eg,mentors,policies,types ofpatientinteraction)astheynavigatedcriticalincidents. However,therearedifferencesinthefrequencyofandways inwhichcertaindomainsarerepresentedandsupportedin thestudents’ perceptionofexistingcurricularstructures. “Safety” wasbyfarthemostfrequentlymatchedTIME domaintoexcerptswithinstudents’ narratives(34%ofall identiﬁedinstances),followedby “Empowerment,Voice, andChoice” and “CollaborationandMutuality” (20%and 17%ofinstances,respectively).

Incontrast,theTIMEdomainsof “Transparencyand Trustworthiness,”“GenderCultural,andHistoricalIssues,” and “PeerSupport” werelesscommonlyidentiﬁedas dominantdomainsacrossstudents’ criticalincidents(12%, 8.7%,and8.7%ofinstances,respectively).Excerptsthatwere matchedtotheseTIMEdomainsoftendescribedinstancesin whichthesedomainswerediscussedbutnotpositively reinforcedinthecurrentclerkshipcurriculum(Table3).For example,anexcerptmatchedto “Safety” mayhaveexpressed anexperienceinwhichastudentfeltunabletovoicetheir opinionsopenlyduetoperceivednegativeconsequences.In contrast,otherexcerptsinstudentnarrativesreﬂected instancesinwhichaparticularTIMEdomainmayhavebeen wellrepresentedandsupportedbytheirclerkshipexperience. Forinstance,asdescribedin Table3,anexcerptthatwas matchedto “CollaborationandMutuality” demonstrated howthisdomainwassupportedbyasupervisor’srolemodelingofprofessionalism.

Often,instanceswhereTIMEdomainswerepositively reinforcedresultedinstrongerstudentresilienceand handlingofcriticalincidents,whereasthelackof positivereinforcementofTIMEdomainsresultedin studentdistress.Theprevalenceof “Safety” asadomain identiﬁedacrossincidents(oftenasadomainthatwasnot wellsupported)mayindicatethatstudentsexperience “Safety” asoneofthemostsalientdomainsthataffects theirabilitytomanagestressfulsituationscomparedto otherdomains.

Theinductiveapproachgenerated10denovothemesthat describestudents’ perceptionsoftraumaduringtheEM clerkshipandcanbebroadlyorganizedandunderstoodas emergingfromthreetypesofstudentinteractions:withthe clinicalenvironment;withsupervisors;andwithpatients (Table4). “Students’ interactionwiththeclinicallearning environment” describetheimmutablecontextual environmentoftheclerkshipexperience(eg,social,racial, and/orculturalfactors)thatinﬂuencestudents’ interactions withothersandincludesnavigatingSDoH,actingon perceivedinequities,andhandlingdiscriminationintheED. Incontrast, “Students’ interactionswithsupervisors” capturesthethemesofpowerdynamics,distressfrom invalidatedcontributionstotheteam,role-modeling, feedback,andempowerment.

Finally,thethirdcategory, “Students’ interactionswith patients,” encompassesthemesofemotionaldiscomfortwith ethicalambiguity,emotionaldistressfromacutepatientcare conditions,andreactivationofpreviouspersonaltrauma. Overall,thesethreefamiliesofthemespaintapictureofthe third-yearEMclerkshipinwhichstudentsperceive themselvestobeatthecenterofthecomplexlearning environmentoftheED,continuouslyinterfacingwith patientsandsupervisorsinapre-existing, ﬁxed, socioeconomic,political,andculturalcontextthatshapesthe learningexperience.The10themesthatdescribethis complexsettinghavepotentialtoeither “enable” or “disable” effectivestudentmanagementoftheir criticalincidents.

Whencomparingtheinductivelygeneratedframework withtheTIMEframeworkinhowtheycapturestudents’ experiencesofthethird-yearEMclerkship,bothframeworks demonstrateaconsiderabledegreeofoverlapbutdifferin howtheycategorizestudents’ responsestocriticalincidents. Bothframeworksdescribetheinﬂuenceofpowerstructures, debriefs,transparencyofexpectations,genderandcultural issuesonstudents’ experiences.However,wheretheTIME frameworkcategorizestheseideasbasedonthetypeof stressor,theinductiveframeworkcategorizesthesameideas basedonwhomthestudentwasinteractingwith.Thus,one ofthelargestdifferencestoemergebetweenthedeductive andinductiveanalysiswasnotthecontentofthemesbutthe overallprinciplesbywhichtheapproachesorganizedand understoodthecontentofstudentnarratives.

WefeltthattheTIMEframeworkyieldedabroader,less specificpictureofstudents’ experienceswithcriticalincidents thatwerenotaseffectiveatcapturingthenuancesand complexitiesofstudents’ experiencesandspecificstressors (eg,SDoH,patientdisfigurement,inequitiesinpatientcare, ethicaldilemmas,lackofautonomyandvalidation)asthe inductiveframework.Thisdiscrepancymaystemfromthe factthattheTIMEdomainsarenotbasedspecificallyonthe third-yearEMclerkshipbutinsteadongeneralideasfound throughoutUME.Inaddition,theTIMEdomainsas envisionedbyBrownetaldrawonstructures,suchas institutionalpolicies,counselingservices,andself-care techniques,thatextendbeyondthestructures(ie,mentors, patients)thatstudentsactivelyinteractwithwhencritical incidentsoccur.7

Bycomparison,becauseour findingsoriginateentirely fromstudentexperiencesduringtheseincidents,this frameworkmaybebetterabletocaptureamoredetailedand student-informedunderstandingofthetrauma-informed structuresinthethird-yearEMclerkshipthatmost significantlyimpacttheirabilitytonavigateacutestress. Accordingly,ourobservedthemesmayofferamorerelevant lenstoassessforeducationalandenvironmentalstructures specifictothethird-yearEMclerkshipthathinderor promotestudents’ responsestocriticalincidents,while TIMEdomainsmayoffernon-specificrelevanceincapturing experiencesoftraumaacrossvariousclerkships.

LIMITATIONS

Severallimitationsofthisstudyareworthnoting.Asthis studywasconductedasaninterviewseriesusingconvenience samplingatoneinstitution,the findingsmaynotbefully generalizable.However,the findingsofourstudymayserve asafoundationforfuturestudies,whichmaybeableto betterassessthegeneralizabilityoftheir findingsinthe contextofthisstudy’s.Ourlimitedsamplesizeraises concernsabouttheextenttowhichour findingsare generalizableacrossEMclerkshipsintheUSortoa broaderpopulationofmedicalstudentsacrossvarious geographiclocations.

Somedegreeofrecallbiasalsolikelyaffectedourstudyas participantsweremorelikelytorememberthemostsalient elements,positiveornegative,oftheirexperiencesintheED whileomittingdescriptionsofotherfactorsthataidedor impededtheirabilitytomanagethesituation.Weattempted tolimittheeffectofrecallbiasbyusingacriticalincident technique-guidedquestionnairethataskedparticipantsto activelyrecallasmanyelementsofthesituationas possible(eg,location,timeofday,surroundings,involved people,etc)toavoidomission.Also,thedegreeofsafetythat participantsfeltindisclosingtheirtruefeelingstothe interviewermayhaveaffecteddisclosureoftraumatic incidentsacrossourparticipantpool,whichmight havebeenreducedbyaneutral,third-partyinterviewernot

afﬁliatedwithouracademicinstitution.Futurestudiesmight employacross-sectionalqualitativeapproachin whichrepresentativesitesacrossthecountrycan besampled.

CONCLUSION

Atpresent,studentsexperienceallsixTIMEdomains duringtheirthird-yearEMclerkship,withsomedomains experiencedmorethanothers.Thedomainsof “Safety,” “Empowerment,Voice,andChoice,” and “Collaboration andMutuality” arefrequentlydescribedinstudentaccounts ofrespondingtoimmediate,stressfulcriticalincidentsduring theclerkship.TheinadequateperceptionofcertainTIME domainsinEMundergraduatemedicaleducationduring criticalincidentsmaycontributetostudentdistressand hinderstudents’ abilitytorespondtotheirperceivedtrauma. Consideringthe ﬁndingslaidforthbythisstudy,thespeciﬁc natureofstudents’ experiencesoftraumaduringtheEM clerkshipmaybeaneffectivetooltoguidecurricularchanges thatimprovestudents’ abilitytomanageimmediatestressors intheclinicalenvironment.

AddressforCorrespondence:DimitriosPapanagnou,MD,EdD, MPH,ThomasJeffersonUniversity,SidneyKimmelMedical College,DepartmentofEmergencyMedicine,1025WalnutSt., CollegeBuilding,Suite100,Room101,Philadelphia,PA19107. Email: Dimitrios.Papanagnou@jefferson.edu

REFERENCES

1.PessagnoR,FooteCE,AponteR.Dealingwithdeath:medical students’ experienceswithpatientloss. Omega-JDeathDying. 2014;68(3):207–28.

2.Al-MateenCS,LinkerJA,DamleN,etal.Vicarioustraumatization andcopinginmedicalstudents:apilotstudy. AcadPsychiatr. 2014;39(1):90–3.

3.Rhodes-KropfJ,CarmodySS,SeltzerD,etal. “Thisisjusttoo awful;Ijustcan’tbelieveIexperiencedthat ”:medicalstudents’ reactionstotheir “mostmemorable” patientdeath. AcadMed. 2005;80(7):634–40.

4.BatleyNJ,BakhtiR,ChamiA,etal.Theeffectofpatientdeathon medicalstudentsintheemergencydepartment. BMCMedEduc. 2017;17(1):110.

5.CookAF,AroraVM,RasinskiKA,etal.Theprevalenceofmedical studentmistreatmentanditsassociationwithburnout. AcadMed. 2014;89(5):749–54.

6.ScaerRC. TheBodyBearstheBurden:Trauma,dissociation,and Disease.London,UK:Taylor&FrancisGroup,2014.

7.BrownT,BermanS,McDanielK,etal.Trauma-informedmedical education(TIME):advancingcurricularcontentandeducational context. AcadMed. 2021;96(5):661–7.

8.SubstanceAbuseandMentalHealthServicesAdministration. SAMHSA’sconceptoftraumaandguidancefortraumainformed approach.2014.Availableat: https://ncsacw.acf.hhs.gov/userﬁles/ﬁles/ SAMHSA_Trauma.pdf.AccessedAugust11,2022.

9.McClintonAandLaurencinCT.JustinTIME:Trauma-informedmedical education. JRacialEthnHealthDisparities. 2020;7(6):1046–52.

10.ButterﬁeldLD,BorgenWA,AmundsonNE,etal.Fiftyyearsofthe criticalincidenttechnique:1954–2004andbeyond. QualRes. 2005;5(4):475–97.

11.GuestG,MacQueenKM,NameyEE. AppliedThematicAnalysis ThousandOaks,CA:SAGEPublications,Inc,2012.

ORIGINAL RESEARCH

DrowningAmongChildren1–4YearsofAge inCalifornia,2017

PhyllisF.Agran,MD,MPH*†‡

DianeG.Winn,RN,MPH†

SoheilSaadat,MD,MPH,PhD‡ JayaR.Bhalla,BS†

VanNguyenGreco,MD*† NakiaC.Best,PhD,RN§ ShahramLot ﬁpour,MD,MPH‡

SectionEditor:CristinaM.Zeretzke,MD

–2021

*UniversityofCaliforniaIrvineSchoolofMedicine,DepartmentofPediatrics, Irvine,California

† AmericanAcademyofPediatricsOrangeCounty,NewportBeach,California ‡ UniversityofCaliforniaIrvineSchoolofMedicine,DepartmentofEmergency Medicine,Irvine,California

§ UniversityofCaliforniaIrvine,SueandBillGrossSchoolofNursing, Irvine,California

Submissionhistory:SubmittedMarch17,2024;RevisionreceivedJuly8,2024;AcceptedAugust23,2024

ElectronicallypublishedSeptember9,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.20356

BackgroundandObjectives: Drowning,theleadingcauseofunintentionalinjurydeathamong Californiachildrenlessthan ﬁveyearsofage,averaged49annualfatalitiesfortheyears2010–2021.The CaliforniaPoolSafetyActaimstoreducefatalitiesbyrequiringsafetymeasuresaroundresidentialpools. ThisstudywasdesignedtoanalyzeannualfatalityratesanddrowningincidentsinCaliforniaamong children1–4yearsofagefrom2017–2021.

Methods: Weidentiﬁedfatalities,injuryhospitalizations,andemergencydepartment(ED)visitsfrom CaliforniastatevitalstatisticsdeathdataandstatehospitalandEDdischargedatausingtheEpiCenter CaliforniaInjuryDataOnlinewebsite.

Results: Overthe five-yearstudyperiod,4,166drowningincidentswereidentified:234werefatalities, 846werehospitalizations,and3,086wereEDvisits.Theobserveddifferenceinfatalityratesfrom2017 to2021failedtoachievestatisticalsignificance(P = 0.88).Location-basedanalysisofthe234fatal drowningincidentsrevealedthatpoolswerethemostcommoninjurysite,accountingfor65%of thecases.

Conclusion: Drowningremainstheleadingcauseofunintentional,injury-relateddeathamong Californiachildren1–4yearsofage,astheannualrateoffatalityoverthe ﬁve-yearstudyperioddidnot decline.WhiletheEpiCenterCaliforniaInjuryDataOnlinewebsiteisexcellentforanalyzingannual ratesofdrowningincidentsamongCaliforniaresidentsovertime,itislimitedinprovidinginsightinto modiﬁableriskfactorsandeventcircumstancesthatcanfurtherinformprevention.Thedevelopmentof robustintegratedfatalandnon-fatallocal,state,andnationalsystematicdatacollectionsystemscould aidinmovingtheneedleindecreasingpoolfatalitiesamongyoungchildren.[WestJEmergMed. 2024;25(5)838–844.]

INTRODUCTION

Drowningistheleadingcauseofunintentional,injuryrelateddeathamongchildren1–4yearsofageintheUSand California,andthesecondleadingcauseofunintentional, injury-relateddeathamongchildren5–9yearsofage.1,2,3 For theyears2010–2021,therewasanaverageof49child

fatalitiesamongthoselessthan ﬁveyearsold.California’ s populationisnearly40millionlivingin58counties.4 The CaliforniaDepartmentofPublicHealth(CDPH)EpiCenter onlinedatabaserevealsthatdrowninghasbeentheleading causeofinjurydeathamongCaliforniaresidents1–4yearsof agefornearly25years.4 Amongchildrenwhosurvive

drowning,alargenumberexperiencelifelongdisabilitiesthat rangefromminortosevere.TheCaliforniaDepartmentof DevelopmentalServices2022ClientDevelopmentand EvaluationReportdocumentsacaseloadofmorethan 700personswhorequirelifelongservicesasaresultof nonfataldrowning.5

Californiaisoneoffourstatesthataddresstheprevention ofresidentialpooldrowningthroughstatelegislation.The ﬁrstCaliforniaPoolSafetyActwentintoeffectonJanuary1, 1997,andwasupdatedin2017.Inpart,theCaliforniaPool SafetyLawincreasedthenumberofrequiredsafetyfeatures aroundresidentialpoolsfromonetotwo,expanded allowablesafetydevices,andexpandedtheinspection process. 6 Thelawcoverspoolsandspasatprivate,singlefamilyresidencesatthetimeofsale,transferofproperty, orremodel.

PurposeofAnalysis

Thepurposeofthisdataanalysiswastoexaminethe annualfatalityratesandcharacterizedrowningincidents amongCaliforniachildren1–4yearsofage(Universityof CaliforniaIrvineIRB#1735.)

METHODS

WeobtainedthedataforthisstudyfromtheEpiCenter CaliforniaInjuryDataOnlinewebsite.Thisisa comprehensivesourceofinjurydatalimitedtoCalifornia residents.EpiCenterdataincludesfatalities,injury hospitalizations,andemergencydepartment(ED)visits.4 DrowningfatalitieswereidentifiedfromtheCDPHusing InternationalClassificationofDiseases,10th Rev,Clinical Modification(ICD-10-CM)cause-of-deathcodesappearing intheunderlyingcause-of-death fieldasfollows:W65–W74; X71;X92;Y21;W65–W74;X71;X92;andY21.We calculatedfatalityratesfromtheCaliforniaDepartmentof FinanceReportP-3:CompleteStateandCountyProjections Dataset(Baseline2019PopulationProjections;Vintage 2020Release).4

InjuryhospitalizationsandEDvisitswereidenti fied fromtheCaliforniaDepartmentofHealthCareAccessand Information(HCAI)PatientDischargeDataset(PDD)and theEDdataset,respectively.ThePDDincludesrecordsof inpatientdischargesfromCalifornia-licensedhospitals, includinggeneralacutecare,acutepsychiatric,chemical dependencyrecovery,andpsychiatrichealthfacilities.The EDdataincludesrecordsofpatientface-to-faceencounters withcliniciansathospitalslicensedtoprovideemergency medicalcare.IfanEDencounterresultedinasamehospitaladmission,theEDencounterwouldbecombined withthePDDrecordandonlyappearasahospitalization. Weidenti fi eddrowninghospitalizationsandEDvisits usingICD-10-CMcodesappearinginanyof25diagnosis fi eldsand12externalcause-of-morbidity fi elds. 7 On theEpiCenterinteractivewebsite,weselected

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Drowningistheleadingcauseof unintentional,injury-relateddeathamong children1 – 4yearsofageintheUS andCalifornia.

Whatwastheresearchquestion?

Weexaminedrecentfatalityratesand characterizeddrowningincidentsamong Californiachildren1 – 4-yearsofage.

Whatwasthemajor ﬁndingofthestudy?

Annualdrowningfatalityrates(2017 – 2021) didnotdecline(P = 0.88),and65%of fatalitiesoccurredinpools.

Howdoesthisimprovepopulationhealth?

Thisstudyoffersanewperspectiveontheneed forrobustdatacollectionsystemsthataidin movingtheneedleindecreasingpoolfatalities amongyoungchildren.

“drowning/submersion” undertheInjuryMechanism drop-downmenufordeaths,hospitalizations,andED visits.Thisincludedunintentional,intentional,and undeterminedintentdrownings.

ConsistentwithCaliforniaHealthandHumanServices De-IdentificationGuidelines,EpiCenterdoesnotprovide dataforresultswithfewerthan11cases.Becauseofthedeidentificationguidelines,wewereonlyabletodeterminethat lessthan4%offatalcaseswereintentunknownor intentional.Lessthan1%ofhospitalizedand~0.3%ofED caseswereclassifiedasintentional.

Welookedattheoverallincidenceofcasesamong Californiachildren1–4yearsofagefortheyears2017–2021 andtheratesoffatalities,hospitalizations,andEDvisits. Dataelementsreviewedincludedageinyears,sexofchild, race/ethnicity,locationofincident,outcome(fatal, hospitalization,EDvisit),disposition,andlengthofstay. Incidentlocationisdefinedasthebodyofwater,basedon ICD-10/ICD-10-CMcodedescriptions(eg,pool,bathtub,or openbodyofwater).Race/ethnicityiscategorizedasfollows: Hispanic;White;Asian;Black;multiracial;andPacific Islander.Wecalculatedincidenceratesand95%confidence intervalsassumingaPoissondistributionofdrowningdata. P -valueswerecalculatedbasedonthechi-squaretestby exactcalculationmethod.WeusedStata17.0SE(StataCorp LLC,CollegeStationTX)forstatisticalanalysis.

RESULTS

Incidence

Duringthestudyperiod,2017–2021,atotalof4,166 drowningincidentsweredocumented. Table1 showsthe annualincidenceofdrowningbyfatality,hospitalization, andEDvisit. Table2 showstheincidencerate(IR)of drowningbyageandsex.Theincidenceofdrowningwas highestamongthe2-year-oldagegroup(P < 0.01). Table3 showstheIRofdrowningpermonthanddayoftheweek during2017–2021.DrowningwasmostprevalentinJune andJulyandleastprevalentinDecemberandJanuary (P < 0.001).Similarly,drowningwasmoreprevalenton weekendscomparedtoweekdays(P < 0.001).

Drowningincidentsamong234(5.62%)caseswerefatal. Ofthenonfatalcases,2,438(58.52%)patientsweretreated andreleasedfromtheED;628(15.07%)required hospitalizationforlessthanadayorovernight;136(3.26%) stayedinthehospitalfor2–4days;82(1.97%)hadhospital staysexceedingfourdays;and648(15.55%)wereeither transferredfromtheEDorhadunknowndispositions.

Fatality

Thefatalityratesvariedfrom2.2per100,000population in2017to2.5per100,000in2021,buttheobserveddifference failedtoattainstatisticalsigniﬁcance(P = 0.88).Thisis contrarytothedecreaseinEDvisitsandhospitalization

duringthesameperiod.Thecasefatalityratioforthe1-yearoldagegroupstoodat7.86%(6.32–9.64%),whichwashigher thanforotheragegroups(P < 0.001).Similarly,thecase fatalityratioformaleswas6.48%(5.52–7.54%),exceeding thefatalityratioforfemales,whichwas4.47%(3.56–5.53%) (P = 0.005).Theanalysisoffataldrowningincidentsamong 234childrenaged1–4years,basedonthelocation,showed thatpoolswerethemostcommonsite,accountingfor65% (152cases).Bathtubsfollowedat14%(32cases),natural bodiesofwaterat11%(27cases),and10%(23cases) occurredatotherorunspeciﬁedwatersources.

Fataldrowningratesbyrace/ethnicitywerehighest amongBlackandmultiracialchildren(3.3/100,000), followedbyWhitechildren(3.0/100,000),Hispanic children(2.1/100,000),andthelowestratewasamongAsian children(1.8/100,000).

DISCUSSION

Drowningremainstheleadingcauseofdeathamong Californiachildren1–4yearsofage.Theannualrateof fatalityoverthe ﬁve-yearstudyperioddidnotdecline.

Incidence

Overthe ﬁve-yearstudyperiod(2017–2021),4,166 drowningincidentswerereportedamongCaliforniachildren 1–4yearsofage,anannualaverageof833incidents.Of

Table1. AnnualdrowningratesofCaliforniachildren1–4yearsofage:2017–2021.

= 234)Hospitalizations(N = 846)EDvisits(N = 3,086)Total(N = 4,166)

*Rate:Incidencerateper100,000person-year. ED,emergencydepartment.

Table2. DemographicsofthedrowningincidenceofCaliforniachildren1–4yearsofage:2017–2021.

*Rate:Incidencerateper100,000person-year. ED,emergencydepartment.

Table3. TimingofthedrowningincidenceinCaliforniachildren1–4yearsofage:2017–2021.

Fatalities (N = 234)

Hospitalizations (N = 846)

EDvisits (N = 3,086)

Total (N = 4,166)

Month17.75*9.1%2023.6%5764.8%88 21311.5%2824.8%7263.7%113 37.75*5.4%3121.6%10571.4%147 4247.5%7022.0%22470.4%318 5286.8%9723.6%28669.6%411 6384.3%17219.7%66476.0%874 7434.5%16817.4%75478.1%965 8294.9%11819.8%44875.3%595 9175.4%5718.0%24276.6%316 107.75*4.6%3923.0%12371.1%173 117.75*7.7%2524.8%6865.4%104 121114.7%2128.0%4357.3%75

DayofweekSunday374.2%18320.6%66975.3%889 Monday244.8%10521.1%36874.0%497 Tuesday347.6%9821.9%31670.5%448 Wednesday306.7%7917.7%33875.6%447 Thursday327.4%8720.1%31372.5%432 Friday387.8%10120.8%34671.3%485 Saturday394.0%19319.9%73676.0%968

*Thenumberofincidentswasrecordedas “<11,” andwearbitrarilyreplacedthemwith7.75,contributingtothegrandtotalof4,166. ED,emergencydepartment.

these,nearly6%werefataland94%werenonfatal drownings.ThehighestIRwasamongchildrentwoyearsof age.Incidentsinthesummermonths(JuneandJuly)andon weekendsweremostprevalent.Racial/ethnicratesareonly availableforfatalitiesdueto2019modiﬁcationstoraceand ethnicitycodingintheHCAIhospitaldischargeandEDvisit data.FatalityrateswerehighestamongBlackand multiracialchildren.ThehighestratesamongBlackchildren havebeendocumentedinotherstudiesaswell,indicatingthe needtoaddressdisparities.3,8,9,10,11,12

Fatal

Apreviousanalysisfoundthatannualratesof unintentionalfataldrowningsfrom1999–2020among Californiachildren1–4yearsofageatalllocationsandat swimmingpoolsdidnotdeclinesigniﬁcantly.13 Fortheyears 2017–2021,ofthe234fatalitiesamongchildren1–4yearsof age,65%occurredatpools,similartothe ﬁndingsinother studies.Thecodingdoesnotdifferentiatethelocationof pools(eg,residentialorcommunity),whicharegovernedby differentregulations.However,itiswelldocumentedthat fatalincidentsamongyoungchildrenaremostcommonat residentialpools.TheNationalCenterforFatalityReview

andPrevention(NCFRP)reportedthat52%offatal drowningsoccurredinahomeorresidentialpool.The ConsumerProductSafetyCommissionPoolorSpa Submersion2023Reportalsorevealedthatamongthe fatalities,84%wereataresidentialpool.2,3,11,12,14 Thisdata highlightstheneedtoprioritizepreventioneffortsthattarget pooldrownings.Fornonfatalcases,wecouldnotdetermine whetherthelocationwasapoolorotherbodyofwater becauseofthelargeproportionofT75.1ICD-10-CMcodes correspondingto “Unspeciﬁedeffectsofdrowningand nonfatalsubmersion.”

Fatal/Nonfatal

Foreveryfatalityamongthe1–4-yearagegroupinthis study,therewere18nonfatalincidents.This ﬁnding highlightstheneedtoincludeandcomparefatalandnonfatal incidentstobetterunderstandthecircumstancesand modiﬁableriskfactors,suchassubmersiontimebefore rescueandinitiationofcardiopulmonaryresuscitationatthe site.15,16,17,18 ThecurrentCaliforniapoolsafetylawisSB-442 PublicHealth:Pools:Drownings2017.6 Basedonits provisions,coverage,andinspectionrequirements,wewould notexpecttoseeareductioninadrowningfatalitybecause

1)fatalityisarareevent;2)wehavenodocumentation ofthedegreetowhichpoolownersremaincompliantafter theone-timeinspection;and3)althoughtwo “safety features” arerequired,onlyoneoftheoptionsisabest practice anenclosurethatisolatesthepoolfromaccess tothehomemeetingCaliforniaBuildingStandards Codespeciﬁcations.

AddressingDataGaps

Basedonthese findings,robustintegratedfataland nonfatallocal,state,andnationalsystematicdatacollection systemsthatenhanceourunderstandingoftheepidemiology andmodifiableriskfactorsincludingregionaldifferencesare necessarytomovetheneedleindecreasingpoolfatalities amongyoungchildren.Comprehensivesurveillancesystems wouldalsoincludeallportalsofdataentry,beginningwith firstresponderssuchaslifeguards,emergencymedical services,andlawenforcement.Standarddefinitionsand codingusingICD-10andIC1-10-CM,datasourcelinkages, real-timeelectronicdataentry,timelyanalysisandreporting, andstate-of-the-arttechnologytoimprovedatavariable capturewillincreaseourknowledgeand filldatagaps.19,20,21 PreliminaryresultsfromtheDrowningDeathScene InvestigationandtheChildDeathReview(CDR)Projectof theNCFRPalsoindicatethatthewidespreaduseofa standardizedtoolwill fillasignificantdatagapinknowledge toinformprevention.22

LocalCDR,aprocessthatallowsforamultidisciplinary comprehensivereviewofchildfatalitiesusingdatacollected frommultiplesources,hasbeenusedeffectivelyforboth surveillanceandtoinformprevention.23,24,25 TheHaddon Matrixmodelasappliedtodrowningcapturesthemultiple layersofprotectionandinterventionstointerruptthe progressiontoadeathbydrowningandcanbeintegrated intocasefatalityreview.9,26 TheInjuryEquityFramework theoreticmodelprovidesfurtherguidanceonsystematicdata collectionandanalysisthatcanbeconsideredinthelocal childdeathreviewprocess.27

Inadditiontopediatricians(childabuse,intensivists, primarycare),localCDRteamsideallyinclude representativesfromthecountychildprotectivesocial services,lawenforcement,publichealthandschoolnursing, andthecoroner’sormedicalexaminer’sofﬁces.The coroner ’sofﬁce(andoftenlawenforcement)conducts detailedinvestigationsincasesofunexpectedchilddeath, especiallythosewhodiewithoutbeingtransportedto hospitals.Otherteammembersmayalsohaveadditional interactionwiththechildorfamily.28 Theavailabilityof guidelinesonthetypeofinformationtogatherinfatal drowningcasesshouldimprovedatacapturebyCDR teammembers.

Physicianinvolvementinimprovingthequalityand quantityofdatainhealthrecorddocumentationandthe subsequentCDRprocessfurtherdetailsthecircumstances

andprovidesinsightintofutureprevention recommendations.Further,reportingtocountychild protectiveservicesifthereareconcernsforlackof appropriatesupervisionorsafeguardscanresultin additionalresourcesorservicesforthefamilytoprevent futureincidents.Childdeathreviewasasurveillancetool withactionrecommendationsiseffective.23,24,25 Pediatricianscanadvocateforintegratingnon-fatal drowningintothefatalityreview.

TheAmericanAcademyofPediatrics(AAP)strongly recommendsthatstatesestablishsystematicreportingonthe circumstancesofdrowning.9 Arobuststatewidedata collectionandanalysissystemprovidesinformationto developbestpractices,communityinterventions,and relevantpublicpolicies.TheCaliforniaLegislaturefounda solutiontothestatewidedrowningdatacollectiongapin reportingfatalandnonfatalincidentswhenCalifornia SenateBill855(Newman,Ch.817,Stat.2022:Child DrowningDataCollectionPilotProgram)waschaptered intolaw.Implementationofadatacollectionsystembythe CDPHmovesusclosertotheAAPrecommendationthat statesestablishsystematicreporting.Strengtheningour countyCDRteamsinreviewingdrowningcasesand includingnonfatalcasesforanalysisshouldcontributetoa robuststatewidesurveillancesystemandcanbeamodelfor otherstates.9,10,29

LIMITATIONS

Thereareseverallimitationstothisstudy.TheCDPH EpiCenteronlinepubliclyavailabledatabase,basedonvital statisticsandhospital/emergencydischargedata,enablesan analysisofannualratesofdrowningincidentsonlyamong Californiaresidentsovertime.ChildrenwhovisitCalifornia andourpopulartouristattractionsarenotcountedifthey sustainafatalornonfataldrowning.Moreover,thedatabase islimitedinidentifyingmodiﬁableriskfactorsandevent circumstancesthatcanfurtherinformdata-driven preventionstrategiesandpolicies.

TheratiosoffataltohospitalizationtoEDvisitsmay includedoublecountsassomeEDencountersmayalsobe includedinthehospitaldata.Wedonothaveexposuredata. Additionally,wecouldnotdeterminetheextentof unreportedincidents.AsKoonpointedout,theCDPH publiclyaccessibledatarelatedtodrowningwasnotdesigned forresearch.14 Finally,asigniﬁcantdatagaprelatesto thelocationofthepoolforhospitalandEDvisitsdueto ICD-10-CMcodingvariability.

CONCLUSION

Drowningremainstheleadingcauseofunintentional, injury-relateddeathamongCaliforniachildren1–4yearsof age,astheannualrateoffatalityoverthe ﬁve-yearstudy perioddidnotdecline.WhiletheEpiCenterCaliforniaInjury DataOnlinewebsiteisexcellentforanalyzingannualratesof

drowningincidentsamongCaliforniaresidentsovertime,it islimitedinprovidinginsightintomodiﬁableriskfactorsand eventcircumstancesthatcanfurtherinformprevention. Currently,inconsistentandincompletedatahamperthe identiﬁcationandmonitoringoftrends,riskfactors,and preventionrecommendations.Incorporatingdataelements inthecontextoftheinjuryequityframeworkwillfurther guideinterventions.27 Systematicchilddeathreview, combinedwithallchilddrowningincidentinvestigationscan informevidence-basedbestpractices,community interventionsandtheimplementatonofeffectiveand impactfulpublicpolicies.

ACKNOWLEDGMENTS

ThankyoutoOrionStewart,PhD,researchscientist, CaliforniaDepartmentofHealth,InjuryandViolence PreventionBranchforreviewingandcontributingtothis study.WealsothanktheCaliforniaKids’ PlatesProgram, CaliforniaDepartmentofPublicHealthInjuryandViolence PreventionBranchforsupportingthisprojectwith partialfunding.

AddressforCorrespondence:PhyllisAgran,MD,MPH,Universityof CaliforniaIrvineSchoolofMedicine,DepartmentofEmergency Medicine,3800W.ChapmanAve.,Suite3200,Orange,CA92868. Email: pagran@hs.uci.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisstudywassupportedbypartial fundingfromtheCaliforniaKids’ PlatesProgram,California DepartmentofPublicHealthInjuryandViolencePreventionBranch. TheCaliforniaKids’ PlatesProgram,CaliforniaDepartmentofPublic HealthInjuryandViolencePreventionBranchhadnoroleinthe designandconductofthestudy.Therearenootherconflictsof interestorsourcesoffundingtodeclare.

REFERENCES

1.CentersforDiseaseControlandPrevention.WISQARS(Web-based InjuryStatisticsQueryandReportingSystem).2019.Availableat: https://www.cdc.gov/injury/wisqars/index.html AccessedMarch2,2024.

2.CunninghamRM,WaltonMA,CarterPM.Themajorcausesofdeath inchildrenandadolescentsintheUnitedStates. NEnglJMed. 2018;379(25):2468–75.

3.SpencerM,HedegaardH,WarnerM.Unintentionaldrowningdeaths amongchildrenaged0–17years:UnitedStates,1999–2019. NCHS DataBrief. 2021;(413).

4.CaliforniaDepartmentofPublicHealth.EpiCenter:Californiainjurydata online.2021.Availableat: https://skylab4.cdph.ca.gov/epicenter/ AccessedMarch2,2024.

5.CaliforniaDepartmentofDevelopmentalServices.Drowning prevention.Availableat: https://www.dds.ca.gov/initiatives/ drowning-prevention.AccessedMarch2,2024.

6.NewmanJ.CaliforniaStateSenate.SenatebillSB-442PublicHealth: Pools:Drownings.(2017–2018).2017.Availableat: https://leginfo. legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180 SB442&search_keywords=pool+safety.AccessedMarch2,2024.

7.HedegaardH,JohnsonRL,GarnettMF,etal.TheInternational ClassiﬁcationofDiseases,10thRevision,ClinicalModiﬁcation (ICD–10–CM)externalcause-of-injuryframeworkforcategorizing mechanismandintentofinjury.2019.Availableat: https://www.cdc.gov/ nchs/data/injury/nhsr136-508.pdf.AccessedMarch2,2024.

8.ClemensT,MorelandB,LeeR.Persistentracial/ethnicdisparities infatalunintentionaldrowningratesamongpersonsaged ≤29years UnitedStates,1999–2019. MorbMortalWklyRep. 2021;70(24):869–74.

9.DennySA,QuanL,GilchristJ,etal.Preventionofdrowning.Policy Statement. Pediatrics. 2019;143(5):e20190850.

10.DennySA,QuanL,GilchristJ,etal.Preventionofdrowning.Techincal Report. Pediatrics. 2021;148(2):e2021052227.

11.NationalCenterforFatalityReviewandPrevention.Drowningcase registry.Availableat: https://ncfrp.org/cdr/drowning-case-registry/ AccessedMarch2,2024.

12.YangT.Poolorspasubmersion:Estimatednonfataldrowninginjuries andreporteddrownings,2023report.2023.Availableat: https://www. cpsc.gov/s3fs-public/Pool-or-Spa-Submersion-Estimated-NonfatalDrowning-Injuries-and-Reported-Drownings-2023-Report.pdf? VersionId=aKdoue0fOpavlEc1E6FBLzYzIAKO8lyW AccessedMarch2,2024.

13.AgranP,WinnD,NguyenGrecoV,etal.Californiachilddrowning: anewperspective.2023.Availableat: https://www.aap-oc.org/ wp-content/uploads/2023/10/CA-Child-Drowning-AbstractPosterNCE-AAP-2023_QR-Code.pdf.AccessedOctober23,2023.

14.KoonW,StewartO,BranderR,etal.Burdenoffataldrowningin California,2005–2019. InjPrev. 2023;29(5):371–7.

15.PeriF,LauraDeNardi,CanutoA,etal.Drowninginchildrenand predictiveparameters. PediatrEmergCare. 2023;39(7):516–23.

16.RaessL,DarmsA,Meyer-HeimA.Drowninginchildren:retrospective analysisofincidentcharacteristics,predictingparameters,andlongtermoutcome. Children. 2020;7(7):70.

17.QuanL,BierensJJLM,LisR,etal.Predictingoutcomeofdrowningat thescene:asystematicreviewandmeta-analyses. Resuscitation. 2016;104:63–75.

18.LouxT,MansuriF,BrooksSE,etal.Factorsassociatedwithpediatric drowningadmissionsandoutcomesatatraumacenter,2010–2017. AmJEmergMed. 2021;39:86–91.

19.AgranP,WinnD,BhallaJ.PartnersforChildhoodDrowningPrevention: 2023–2024.2023.Availableat: https://www.aap-oc.org/wp-content/

uploads/2023/09/Partners-For-Childhood-Drowning-Prevention2023-2024-92023.pdf.AccessedMarch2,2024.

20.MeddingsDR,ScarrJP,LarsonK,etal.Drowningprevention: turningthetideonaleadingkiller. LancetPublicHealth. 2021;6(9):e692–5.

21.PedenAE,SarramiP,DinhM,etal.Descriptionandpredictionof outcomeofdrowningpatientsinNewSouthWales,Australia:protocol foradatalinkagestudy. BMJOpen. 2021;11(1):e042489.

22.CollierA,JoyS,FraleyG.P2A002:Usingenhanceddeathscene investigationandchilddeathreviewtobetterunderstandandprevention drowningamongchildrenandyouth.2023.Availableat: https:// aapexperience23.eventscribe.net/fsPopup.asp?PosterID=620497& mode=posterInfo.AccessedOctober23,2023.

23.QuanL,PilkeyD,GomezA,etal.Analysisofpaediatricdrowningdeaths inWashingtonstateusingthechilddeathreview(CDR)forsurveillance: whatCDRdoesanddoesnottellusaboutlethaldrowninginjury. Inj Prev. 2011;17Suppl1:i28–33.

24.WirtzSJ,FosterV,LenartGA.Assessingandimprovingchilddeath reviewteamrecommendations. InjPrev. 2011;17Suppl1:i64–70.

25.DesapriyaE,SonesM,RamanzinT,etal.Injuryprevention inchilddeathreview:childpedestrianfatalities. InjPrev. 2011;17Suppl1:i4–9.

26.HaddonW.Thechangingapproachtotheepidemiology,prevention, andameliorationoftrauma:thetransitiontoapproachesetiologically ratherthandescriptivelybased. AmJPublicHealthNationsHealth. 1968;58(8):1431–8.

27.KendiSandMacyML.Theinjuryequityframework establishing auniﬁedapproachforaddressinginequities. NEnglJMed. 2023;388(9):774–6.

28.AgranP,WinnD,AndersonC,etal.(2010).Drowningof1–4-year-old childreninswimmingpoolsandspassurveillancehandbook.2010. Availableat: https://www.aap-oc.org/wp-content/uploads/2022/10/ Drowning-Surveillance-Handbook-Final-2011.pdf AccessedMarch2,2024.

29.NewmanJ.CaliforniaStateSenate.SB-855ChildhoodDrowningData CollectionPilotProgram.(2021–2022).2022.Availableat: https:// leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id= 202120220SB855.AccessedMarch2,2024.

EXPERT COMMENTARY

ChatGPT’sRoleinImprovingEducationAmongPatientsSeeking

EmergencyMedicalTreatment

FarisF.Halaseh,BS*

JustinS.Yang,BA*

CliffordN.Danza,BS*

RamiHalaseh,MD†

LindseySpiegelman,MD,MBA‡

SectionEditor:ChrisBaker,MD

*UniversityofCalifornia,Irvine,SchoolofMedicine,Irvine,California † KaiserPermanenteSanFrancisco,DepartmentofInternalMedicine, SanFrancisco,California ‡ UniversityofCalifornia,Irvine,DepartmentofEmergencyMedicine, Irvine,California

Submissionhistory:SubmittedDecember21,2023;RevisionreceivedJune21,2024;AcceptedJune21,2024

ElectronicallypublishedAugust13,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18650

Providingappropriatepatienteducationduringamedicalencounterremainsanimportantareafor improvementacrosshealthcaresettings.Personalizedresourcescanofferanimpactfulwaytoimprove patientunderstandingandsatisfactionduringorafterahealthcarevisit.ChatGPTisanovelchatbot computerprogramdesignedtosimulateconversationwithhumans thathasthepotentialtoassistwith care-relatedquestions,clarifydischargeinstructions,helptriagemedicalproblemurgency,andcould potentiallybeusedtoimprovepatient-cliniciancommunication.However,duetoitstraining methodology,ChatGPThasinherentlimitations,includingtechnicalrestrictions,riskofmisinformation, lackofinputstandardization,andprivacyconcerns.Medicolegalliabilityalsoremainsanopenquestion forphysiciansinteractingwiththistechnology.Nonetheless,carefulutilizationofChatGPTinclinical medicinehasthepotentialtosupplementpatienteducationinimportantways.[WestJEmergMed. 2024;25(5)845–855.]

INTRODUCTION

Effectivecommunicationandcounselingbetween cliniciansandpatientsiscrucialforhigh-qualityhealthcare, particularlyintheemergencydepartment(ED)wheretime constraintsandevolvingdiagnosticscancomplicate discussionsaboutcurrentandpost-hospitalcare.Thismakes patienteducationanimportantgaptoaddress.Theurgency andcomplexityofemergencycasesoftenhinder comprehensiveinformationdelivery,leavingpatients’ questionsunanswered.Inquiriesabouttheircondition, treatmentoptions,andprognosisarevitalforpatient understandingandengagementindecision-making.A systematicreviewexaminingthefactorsthatinﬂuencethe patientexperienceintheEDhighlightedphysician-patient communicationasthemostcommonfactoraffecting patientsatisfaction.1 Addressingtheseconcernsnotonly boostssatisfactionbutalsoempowerspatients,improving healthoutcomes.

Effectivedischargeinstructionsareessentialforapatient’ s post-emergencycare,asambiguityorinadequate explanationcanresultinconfusion,noncompliance,and

subsequentreadmission.2,3 Arecentstudyrevealedthat24% ofpatientsdonotfullyunderstandtheirfollow-upplan,64% struggletocomprehendtheirreturn-to-EDinstructions,and 42%donotreceivecompletedischargeinstructions.3 Improvingdischargecommunicationcanenhancetransition tofollow-upcare,therebyimprovingpatientcareoutcomes andreducingavoidablereadmission.Inadditionto communicationchallenges,patientsmaystruggletoidentify themostappropriatetypeofcarefortheirconditions.The EDoftenseescasesthatcouldbemoreeffectivelymanaged inprimarycareorurgentcaresettings.About13–27%ofall EDvisitsareconsiderednon-urgentinnature,resultingin approximately$4.4billionannualcost.4 Identifyingfactors thatcontributetounnecessaryemergencycareutilizationcan aidthedevelopmentoftargetedinterventionsand educationalinitiativesaimedatredirectingpatientstomore appropriateavenuesoftreatment.

Furthermore,increasinglydiversepatientpopulations bringlanguagebarrierstotheforefrontofcareintheED. PatientswithlimitedEnglishproﬁciencyoftenfaceobstacles inunderstandingtheirdiagnosesandtreatmentplans.One

studiedshowedonly52%ofnon-Englishspeakerswere satisﬁedwiththeirEDvisit,comparedto71%ofEnglish speakers.5 Strategiestoreducetheinequitableimpactof languagebarriershasobviousbeneﬁtsforpatientsafetyand outcomesintheED.

Onemethodtoaddresstheselimitationscouldbeclinical applicationofamachinelearning(ML)largelanguage model(LLM),suchasChatGPT(OpenAI,LP,San Francisco,CA).AnML-basedchatbotcanlearnfromavast arrayoftrainingdataanduserinteractionstoimprove performanceandefﬁcacyofitsdeliveredcommunication.In recentperformanceevaluations,ChatGPTscoredabovethe nationalaverageonpubliclyavailablerenditionsofStep1, Step2-ClinicalKnowledge,andStep3oftheUnitedStates MedicalLicensingExam(USMLE).6 Themodel’sUSMLE performancecontinuestoimprovewithnewupdates,suchas GPT-4,whichadditionallyoffersimage-analysis capabilities.7 Modelsarealsobeingusedtotrainmedical studentsandpreparethemforclerkships.8–10 These benchmarksdemonstrateChatGPT’ s ﬂuencywithbasic medicalinformationattheknowledgelevelofamedical schoolgraduate.

Patientsoftenundertakeaninternetsearchofmedical topicsbeforeorafterspeakingwithaphysician.However, withavastarrayofinformationandmisinformation availableontheinternet,physiciansandotherhealthcare professionalsremainanimportantinterfacetosource reliablemedicalknowledge.Here,weevaluatethepotential rolethatLLMslikeChatGPTcouldhaveasapersonalized educationalresourceforpatientsseekingemergency medicaltreatment.

CHATGPT:HOWITWORKS

ChatGPTisatext-basedchatbotthatfacilitatesuser interactionthroughnaturallanguage.TheMLmodelforthe publiclyavailableversions,GPT-3.5andGPT-4,were trainedonwrittentextdrawnfromavastspectrumofonline databases.Pretrainingenablesthemodelstoconstructa robustlinguisticframework.Furtherconditioningincludes assignment-speciﬁcadjustments,humanfeedbackthatcan bolsteritsconversationalabilities,andrigoroustestingto ensureresilienceagainstchallenginguserqueries.This processiscriticalforaligningthemodel’soutputwith nuancedhumandialogue,enhancingitscapacitytoprovide preciseandcontextuallyappropriateresponses.10

GPT-4isthelatestiterationofthisLLM,withan enhancedarchitecturethatnotonlyunderstandsand generatestextualcontentbutalsointerpretsandrespondsto visualinput.11 Furthermore,whileexperimentalfeaturesin GPT-4includethepotentialforcurrentinternetdata,such capabilitieshavenotbeenbroadlyreleasedtousers.The broaderimplicationsofthislimitation,includingthebalance betweenmodelautonomyandthenecessityforhuman oversight,areexaminedfurtherinthesectionontechnical

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

CurrentpatienteducationintheEDis inadequate,oftenleadingto misunderstandingandnoncompliancewith post-careinstructions.

Whatwastheresearchquestion?

HowcanthechatbotChatGPTimprove patienteducationintheEDsetting?

Whatwasthemajor ﬁndingofthestudy?

ChatGPThelpstriage,clarifydischarge,and providecareinstructions.

Howdoesthisimprovepopulationhealth?

ChatGPTcanenhancepatienteducation, improvingcomprehensionandadherenceto follow-upcare,reducingunnecessaryED visitsandenhancingoveralloutcomes.

restrictions.Nevertheless,thecurrentcapabilitiesof ChatGPTareanimportantleaptowardacollaborativerole thathumansandAIsystemswillshareinnavigatingcomplex real-worldapplications.12

PATIENTEDUCATIONBENEFITS

TheEDisasettingwithaparticularlyhighdemandfor efﬁcientandclearpatienteducationatdischargegiventhe potentialreappearanceorsequelaeofconditionsrequiring emergentevaluation.However,theEDalsooftenimposesa highdegreeofconstraintonpatient-clinicianinteraction time.Eveninthesettingoflow-acuityconditions,an observationalstudyshowedthecombinedamountoftime physicians,nurses,andtechniciansspentwithpatientsonce theyareassignedtoabedwasabout25%oftotalpatient lengthofstay.13 Thefactorsunderlyinglimitedinteraction timearemultifactorial,butoften-citedcontributingreasons includepatientvolumeandhighloadofdocumentation requirements.Offeringaresourcethatisadaptiveand responsivetopatientconcernsrelevanttotheirspeciﬁc situationisanimportantgapintheED.ChatGPTcan provideaninteractivemodalitythatispersonalizedtomeet thisgapforthehealthcareeducationneedsofpatientsand theirclinicians.

Care-RelatedQuestions

ChatGPTmayoffermultiplebeneﬁtsforpatientsinthe ED.Itcanquicklygivepersonalizedresponsestoqueriesona widerangeofhealthcaretopics.Forexample,thesoftware

canprovidepurpose-andrisk-basedinformationabout proceduresapatientortheirfamilymembermayundergo duringanEDencounter(Figure1A).ChatGPToffers

backgroundinformationabouttheprocedureandrefersto thecareteamforfurtherencounter-basedquestionsand concerns.Theinformationprovidedaboutaprocedure,such

Figure1. (A–B)SelectedQ&Arelatingtomedicalcare.InputsarehumanquestionsandoutputsweregeneratedbyChatGPT.

ascomputedtomographyangiographyinthisexample, describesaninitialdepthofresponsethatislikelyadequate foralayperson’sintroduction.Incontrasttoconductinga generalinternetsearchforthepurposesandrisksofthis procedure,ChatGPTsummarizesthepertinentinformation inaconversationalformatthatiseasilyaccessibletotheuser.

AnotherexampledemonstratesChatGPT’ssensitivityto slightalterationsofmeaningwhenaskedaboutmedical conditionsandmedications.Theuser ﬁrstasksaquestion aboutthepurposeofthemedicationmilrinoneforastated conditionofheartfailure(Figure1B).Thesoftware’ s responseexplainsashortsummaryforboththecondition andthemedication.

Giventhesamesetofprompts,thereareseveral differencesbetweenGPT-3.5andGPT-4outputs.GPT-4 outputsarelengthier,withclearerstructuretotheanswer approach.Intheseexamples,thereappearstobeatendency towarditemizinglists.Thereisalsoanobservedempathetic bentwithapparentself-anthropomorphizationbystarting sentenceswith “I.” Whilefurtherstudyontheend-user impactofthismodeliterationiswarranted,GPT-4appears tooffermorecomprehensiveinformationthanGPT-3.5for selecthealthcare-associatedqueries(Figure1).

DischargeInstructions

DischargeinstructionsforpatientsleavingtheEDare importantforpatientsafetyandsatisfaction.However, studiesshowthatpatientsoftendonotfullyunderstandthe after-careinstructionsprovidedtothem.2,14,15 Poor adherencetomedicaladviceorfollow-upmaybe attributableinparttoagapinmedicalunderstanding. Personalizedeffortstoincreasepatientadherenceto dischargeinstructionshavefocusedonstafffollow-upvia phonecallorSMSmessaging,buttheseinterventionsbear relativelyhightimeandmonetaryrequirements,anddonot alwaysprovidepositiveresults.16–18 ChatGPTcanbeusedto improvepatientunderstandingofinstructionsgivenbya clinician.Itsnatural-languageinterfaceallowspatientstoask questionsasiftheywereconversingwithahuman (Figure2A, 2B).Similartendenciesareobservedcomparing theGPT-4modeltoGPT-3.5,withlongeranswers,increased listcreation,andgreateruseof ﬁrst-orsecond-person writingstyle.

SeekingCare

NavigatingtheUShealthcaresystemtodeterminethe appropriateentityfromwhichtoseekcareisoftena signiﬁcantchallengeforpatients.TheEDremainsoneofthe onlysettingsinwhichrelativelytimelyevaluationandcareis availableandisoftenusedasasafetynetforpatientswithno healthinsurance.However,evenpatientswithinsuranceand adesignatedprimarycarephysiciansometimesoptforan EDvisitduetobarriersaccessingtheirphysician.Beneﬁtsof comprehensiveevaluationandservices,withimaging,labs,

andpharmacyprovidedinonelocationisacompetitive convenienceforpatients.19,20 Dueinparttothesefactors, annualEDutilizationratescontinuetorisedisproportionate todemographicfactors,increasingburdenonEDresources forconditionsthatarebetteraddressedinpreventivecaresettings.21

ChatGPTcanprovideguidanceinseekingurgentvs emergentcare.Inoneexample,apatientwithsymptoms typicalofaurinarytractinfectionasksifavisittothe emergencyroomisadvisable( Figure3A ).Theresponse indicatesthatcareshouldbesoughtbutsuggestsurgent careorprimarycaresettingsfor ﬁ rst-lineevaluation,given thestatedsymptoms.Theresponsealsoprovidesexamples ofmoreserioussymptomsthatindicateneedforemergent evaluation.Guidingapatient ’ sdecisionmatrixina personalized,interactivemannermaybeanimpactfulway toencouragethemtoseekanappropriatelevelof care.ReducinginstancesofEDutilizationforlow-acuity healthconcernsassistseffortstoreduceEDcrowding, whichcanhavewide-rangingbene ﬁ tsforhealthcare systemsbyimprovingpatientoutcomes.22 Futurestudy couldexaminetheusefulnessofChatGPTintriage scenarios,comparedtocurrentmodalitiessuchasnurse advicephonelines.

ChatGPTcanalsoofferguidanceduringprehospital emergencies,detailingstep-by-stepinstructionsto respondersandadvisinghowtoseekanappropriatelevelof care.Forexample,ChatGPTdescribesrecommended actionsuponencounteringasyncopalpatient(Figure3B). Prehospital-interventioneducationgearedtoward laypersonshasbeenakeyfocusinpublichealth,particularly forconditionssuchascardiacarrest,stroke,andmajor hemorrhage.Whilecertainpracticesarebesttaughtina hands-ondemonstrationsetting,ChatGPTmaybea valuablereferenceresourceforlaypersonsactinginthe capacityofanemergencyresponder.23

PatientCommunication

ChatGPTcanofferreal-timetranslationforlanguages includingEnglish,Spanish,French,German,Italian, Portuguese,Chinese,Japanese,Korean,Arabic,Dutch, Polish,Russian,andmore.Whilereal-timetranslationisof crucialimportanceforEDhistory-taking,translatorservices arebecomingubiquitousduetothegrowingpopularityof tele-healthconsultationdevices.Thebeneﬁtsofusing softwarewithtranslationcapabilitytoaddresspatient questionsisapparentinprehospitalandpost-disposition settings.Forexample,ChatGPToffersthesameresponsefor aquestionasked ﬁrstinEnglish,andtheninSpanish (Figure4).ComparedtoGPT-3.5,GPT-4’sEnglishresponse takesamorecautiousapproachtoprovidingmedical guidance.However,GPT-4’sSpanishresponseappearsmore likeGPT-3.5intheunhedgedencouragementforfurther medicalcare.Thisdifferencemaybeduetoavarietyof

factors:modellanguagetraining;translation ﬁlters;or underlyingdifferencesintrainingdataitself.Further discussionoftechnicallimitationsisdiscussedinthesection ontechnicalrestrictions.Futurestudiesshouldinvestigate

Figure2. (A–B).SelectedquestionsrelatingtodischargeinstructionsandChatGPToutput. Volume25,No.5:September2024WesternJournal

theaccuracyofChatGPTtranslationsandcomparethe resultstoalternativemodalitieslikecertiﬁedmedical translators,orothertext-onlymodalitieslikeGoogle Translate,inaclinicalhealthcareenvironment.24,25

Figure3. (A–B).ChatGPTinputandoutput.TopoutputdemonstratesChatGPTtriagerecommendationsandbottomoutputsigniﬁesurgent responseinstructions.

Costs

ChatGPTiscurrentlyeasilyaccessibleandoffersano-cost useraccountforthepublic.Asubscription-basedupgradeis alsooffered,whichprovidesquickerresponsetimesandearly accesstonewfeatures.7 UtilizationofChatGPTtoassist

patienteducationforvariousaspectsofcare,including understandinghealthconditions,dischargeinstructions,and whentoseekemergencymedicalcaremaysavehospitaltime, money,andresources.Emergencydepartmemtspendingisa growing ﬁnancialconcernonanationallevelbutmaybe

alleviatedbyreducingthefrequencyofpresentationsfor preventablecausesandavoidablevisits.26 Byproviding personalguidanceonwhentoseekemergencycare, ChatGPThasthepotentialtomakeimportantcontributions toloweringhospitalburden.

RISKSANDLIMITATIONSOFCHATGPT

TechnicalRestrictions

UsingChatGPTinemergencymedicinecarriescertain risks.Onemajorconcernisthatthemodelcanprovide

differentresponsestothesameorsimilarquestions,which affectsitsreliabilityandusefulness.BecauseChatGPTis basedonaMLalgorithm,itmaygeneratedifferentresponses tosimilarquestionsdependingonavarietyoffactors,suchas theorderorcontextofwordsusedasinput.Inarecentstudy onChatGPT’sresponses,identicalquestionsregarding cirrhosisandhepatocellularcarcinomaweresubmittedtwice andindependentlygraded.ChatGPTwasabletoproduce twosimilarresponses90.48%ofthetime.Althoughthis numbermayberegardedashighreproducibility,itraises

Figure4. ChatGPTresponsesinEnglish(top)andSpanish(bottom).

concernsoverthepotentialconsistencyofofferingmedical advicetolaypersons.Althoughmostinstanceswillprovide theuserwiththesameinformation,ChatGPT’ sresponsesare basedonprobability.27 Futurestudiesshouldanalyzethis variabilitytodeterminetheimpactonresponse appropriatenessfortheuser.

Inadditiontooutputvariability,thereisalsoapotential fordifferencesinusercomprehension.Thisunderscores anotherrisk:thepotentialfordifferencesincomprehension andinterpretationoftheinformationprovidedtolaypersons. Althoughthislimitationiscommonamongmanydifferent technologies,thesedifferencesincomprehensioncanleadto potentiallyadverseoutcomesforpatients.Giventhese considerations,itiscrucialtoexercisecautionandapply criticalthinkingwhenusingChatGPTasasourceof informationinhealthcareinteractions.Itisessentialtobe awareofthepotentialfordevelopingoverconﬁdencein ChatGPT’srecommendations,andtheriskforanchoring onaspeciﬁcdiagnosisorimpressionforbothpatients andclinicians.

Responsevariabilityandinterpretationofresponsescan impacttheconsistencyandreliabilityofthismodel.Itis importantforcliniciansandpatientstobeawareofthese risks,andtouseChatGPTasasupplementarytoolrather thanaprimarysourceofinformation.Therefore,ongoing improvementsinthetechnologyandcontinuedtrainingof thealgorithmshouldbepursued.Effortstoincorporate currentmedicalliteratureintothetrainingdatacould enhancethereliabilityandrelevanceofChatGPT’ s responses.However,itremainsessentialtorecognizethe dynamicnatureofclinicalpracticeandtheimportanceof relyingonevidence-basedguidelinestoensurepatientsafety andwell-being.

Misinformation

Ensuringaccurateandtruthfulinformationiscrucial whenusingChatGPT,asmisinformationcanhaveserious consequencesforpatientcare.ChatGPT’strainingdatais limitedtoinformationavailablebefore2021.Medical knowledgeandpracticeshaveevolvedsincethisknowledge cutoffpoint,andChatGPTmayreferenceinformationthatis outdatedornolongerapplicabletocurrentmedical practices.AccordingtotheChatGPTstudyforcirrhosisand hepatocellularcarcinoma,ChatGPT’sanswerscontaineda mixofcorrectandincorrectinformation.Thepercentageof responsesthatwereclassiﬁedashavingbothcorrectand incorrectoroutdatedanswerswas22%inbasicknowledge, 33%indiagnosis,25%intreatment,18%inlifestyle,and50% inpreventivemedicine.28 However,whilethisstudy highlightspotentiallimitationsofChatGPT’saccuracyin respondingtoquestionsabouthepatocellularcarcinoma,itis importanttorecognizethatfurtherresearchisneededto comprehensivelyevaluatetheaccuracyofChatGPT’ s responsesacrossallmedicaldomains.Physiciansand

patientsmustremaincautiouswhenusingChatGPTand seekconﬁrmationfromotherreliablesourcesbeforemaking decisionsbasedontheinformationprovided.

Anotherconcernisthemodel’sopaquealgorithm,which cangenerateplausiblesoundingbutinaccurateor nonsensicalanswers,aphenomenonknownas “hallucinations” 29 Evidenceofthiscanbeseeninfabricated sourceswhenChatGPTisaskedtoprovidereferencesfora givenresponse.30 ChatGPT’strainingmayhaveincluded scientiﬁcliteraturecitationdatasets,butitsgenerative algorithmdoesnotallowforone-to-onedatasource matching,resultinginaresponsethatprovidescompletely fabricatedsources.Patientsmaybelesslikelytoquestionthe accuracyofChatGPT’sresponsesiftheyarepresentedwitha sourceandsimplyassumethattheinformationhasbeen veriﬁed.Thiscanultimatelyleadtopatientsmaking decisionsthatarenotintheirbestinterestandmayeven resultinharm.

Thereiscurrentlyunavoidableriskofmisinformation whenusingChatGPTforpatienteducationinemergency medicine.Tomitigatethisrisk,itisimportanttomanage expectationsandriskthresholds.Physiciansandpatients shouldbeadvisedoftherisksandbeneﬁtsofthistechnology. Additionally,regularevaluationandimprovementof themodelwillhelpminimizetheriskofinaccuracies andmisunderstandings.

PrivacyandSecurity

Ensuringpatientprivacyandsecurityisanotherconcern whenusingChatGPTforpatientencounters.Unauthorized accesstoprotectedhealthinformation(PHI)canleadto identitytheft,insurancefraud,andothertypesofharmtothe patient.Forphysicians,unauthorizeddisclosuresviolatethe HealthInsurancePortabilityandAccountabilityAct (HIPAA)andcanleadtodisciplinaryaction,lossof licensure,andlegalliability.OpenAI,thecreatorsof ChatGPT,havestatedthatdatausedwithChatGPTwill remainsecuredbydefault,withanopt-outoptiontoshare dataforresearchandqualityimprovement.Nevertheless, majorcorporationssuchasVerizonandJPMorgan&Co. haverestrictedemployeesfromaccessingChatGPTdueto concernsoverpossibledatabreaches.31 Sensitivehealthcare informationcouldbeatasimilarrisk.

WhilethepublicavailabilityoftheChatGPTapplication programminginterfacemakesiteasytointegrateinto websitesandapplications,italsoraisesconcernsaboutthe securityandprivacyofpatientinformation.Astheuseof artiﬁcialintelligence(AI)chatbotsbecomemorewidespread, itisincreasinglyimportanttoensurethatthesetechnologies areusedinawaythatprotectspatientprivacyandcomplies withregulationssuchasHIPAA.IntegratingChatGPTinto aHIPAA-compliantframeworkmayhelpaddressthese concerns.Healthcaretechnologyleadersmusttakenecessary measurestoprotectPHI.

MedicolegalandOtherEthicalConsideration

IntegrationofChatGPTintoemergencymedicine presentsacomplexlandscapeofmedicolegalandethical implications.32 Wehavepreviouslydiscussedlimitations withthesoftware:potentialformisdiagnosisanddelayed treatmentisasignificantconcern.Artificialintelligence systems,whileadvanced,maynotalwaysaccurately interpretpatientsymptoms,whichisdependentuponthe qualityofuserinputandthesoftware’sunderstanding.This haspotentialtoinfluencepatientoutcomes,andthereare numeroussituationsthatcoulddothesame.

Considerthefollowinghypothetical,ethicalscenarios:

• ChatGPTrecommendsagainstseekingcare,which resultsinaharmfulorlife-threateningpatientoutcome.

• ChatGPTprovidesfalseinformationtoapatient.

• Patientsinadequatelyadvisedontherisks/beneﬁtsof ChatGPTmisinterpretitsanalysis.

• PatientPHIisaccessedduringadatabreachorduring theperformanceimprovementprocess.

• ChatGPTprovidesinformationthatisnotuptodateor conﬂictswithcurrentguidelines.

Intheunfortunatecircumstancewhereoneormoreofthese eventsoccurandlegalactionistaken,whoshouldbeheld responsible OpenAI,clinicians,orboth?Thisisacurrent challengethatnecessitatesfurtherinterdisciplinarydiscussion betweenstakeholders.33 Nonetheless,therearestepsthatmust betakentohelpminimizeriskforallpartiesinvolved.For example,thereshouldberestrictionsplacedonLLMspriorto ofﬁcialimplementationinthe ﬁeld.Whetherthrough legislationoranindependentbody,ChatGPTmustadhereto regulatorystandardsthatensureHIPAA-complianceand informedconsent.34 PhysiciansandOpenAImustalsowork towardeducationonpotentialrisksofthesoftware.Physicians andotherhealthcareprofessionalsshouldalsoimplement legalformsandliabilitywaiversintothecareprocesstoensure protectionininstanceswheretheseregulationsfail.

TRANSITIONINGINTOCLINICALSTUDIES

Thenextmajorstepthatmustbetakenistovalidate ChatGPT’sefficacyandsafetyinclinicalsettings.32 Oneofthe majorbarriersthatresearchersmayfaceistheever-changing updatestothesoftware,whichisalsoalimitationofthispaper. NotonlyisChatGPTcontinuallybeingupdated,butthe protocolsbywhich fine-tuning,updates,andfurthertraining occurareconfidential.10 ThisinherentlymakesChatGPT difficulttostudy.However,potentialfuturestudieswith ChatGPTaremanyandshouldassesstheaccuracy,safety, readability,andsemanticanalysisofthesoftware.Onesuch futurestudycouldconsidertheefficacyofpatienttriagefor ChatGPTandtriagenursephonecalls.Futurestudiesshould alsoinvestigatethecostbenefitofimplementingsuchasystem intoEDworkflow,eitherfortriage,dischargeinstructions,or

both.Thisshouldbecorroboratedbyexaminingpotential algorithmbiasintherealworld.32,34,35

THEPHYSICIAN’SROLEINCHATGPT

Asstatedpreviously,ChatGPTcannotreplaceaphysician. AlthoughOpenAIhasmadesigniﬁcantstridesindevelopinga softwarethatcommunicatesina morehuman-like,empathetic mannercomparedtopreviouschatbots,currenttechnology stilllackstheoversightandnuanceofferedbyahuman.This technologycannotreplaceanin-depthhistory,physicalexam, orclinicalreasoning.However,giventhecurrentrateof progressonthesetechnologies,itwouldbenaivetoconsidera futureindependentoftechnology-assistedpatientencounters. Forthisreason,physiciansandhealthcareprofessionalsmust beinvolvedinresearchanddevelopmentoversighttoensure accuratedataisavailableontheseplatforms,andthatthese technologiesarebeingdevelopedwiththerightintentions. PhysiciansshouldalsocontinuetobeinformedonAI developments,sothattheycanplayaproactiverolein educatingpatientsonthebeneﬁts,limitations,andliabilityof thesoftware.Furtherstudiesmustalsoexaminethelegal implicationsforphysicians,patients,andOpenAI,as ChatGPTandhealthcarecontinuetointersect.

CONCLUSION

ThispaperdescribestheuseofChatGPTasan educationalresourceforpatientsseekingemergencymedical treatment.Althoughlimitationssuchastechnicalissues, misinformationrisk,lackofinputstandardization,and privacyconcernsexist,thissoftwareofferscompelling benefitsforpatienteducation.Thesoftwarecananswer questionsspecifictopatientsandtheirpresentations, allowingforapersonalizededucationalresource.ChatGPT canalsoclarifydischargeinstructions,helptriageurgentvs emergentconditions,anditcanrespondinmultiple languages.Physiciansmustunderstandthesebenefitsand limitationstobestguidepatientsandconductfurther researchinnewAItechnologies.

AddressforCorrespondence:FarisF.Halaseh,BS,Universityof California,IrvineSchoolofMedicine,1001HealthSciencesRd., Irvine,CA92617.Email: fhalaseh@hs.uci.edu

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

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13.McCarthyDM,EngelKG,BuckleyBA,etal.Talk-timeinthe emergencydepartment:durationofpatient-providerconversations duringanemergencydepartmentvisit. JEmergMed. 2014;47(5):513–9.

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15.ZavalaSandShafferC.Dopatientsunderstanddischargeinstructions? JEmergNurs. 2011;37(2):138–40.

16.SuffolettoB,CalabriaJ,RossA,etal.Amobilephonetextmessage programtomeasureoralantibioticuseandprovidefeedbackon adherencetopatientsdischargedfromtheemergencydepartment. AcadEmergMed. 2012;19(8):949–58.

17.SuffolettoBandYealyDM.Thetroublewithmedicationadherenceafter emergencycare. AnnEmergMed. 2013;62(3):235–6.

18.vanLoon-vanGaalenM,vanderLindenMC,GusseklooJ,etal. Telephonefollow-uptoreduceunplannedhospitalreturnsforolder emergencydepartmentpatients:arandomizedtrial. JAmGeriatrSoc. 2021;69(11):3157–66.

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Commentson “AShorterDoor-in-Door-outTimeIsAssociated withImprovedOutcomeinLargeVesselOcclusionStroke”

GillianCooper,BS§

VainaviGambhir‡

ZoeGasparotti,BSN∥

SamanthaCamp,BA§

WilliamGum,BS§ RobinsonOkolo,BS§ RiyaRaikar‡

ChadSchrier,MSN,RN¶ JessicaDowning,MD*†‡

QuincyK.Tran,MD,PhD*†‡

*UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, Baltimore,Maryland

† UniversityofMarylandSchoolofMedicine,TheRAdamsCowleyShockTrauma Center,Baltimore,Maryland

‡ UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, TheResearchAssociatePrograminEmergencyMedicineandCriticalCare, Baltimore,Maryland

§ UniversityofMarylandSchoolofMedicine,Baltimore,Maryland

∥ UniversityofMarylandMedicalCenter,TheCriticalCareResuscitationUnit, Baltimore,Maryland

¶ UniversityofMarylandMedicalCenter,DepartmentofStrokeNeurology, Baltimore,Maryland

SectionEditor:MarkI.Langdorf,MD,MHPE

Submissionhistory:SubmittedJanuary3,2024;RevisionreceivedMarch21,2024;AcceptedMarch25,2024 ElectronicallypublishedJune28,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18668

DearEditors:

Wereadwithgreatinterest, “AShorterDoor-in-Door-out TimeIsAssociatedwithImprovedOutcomeinLargeVessel OcclusionStroke,” bySigaletal.1 Firstly,wewouldliketo congratulatetheauthorsontheir WestJEM publicationthat highlightsimportantconceptsformanagementofpatients withischemicstrokefromlargevesselocclusion(LVOS)in theemergencydepartment(ED).However,wehadafew commentsregardingtheirconclusionsaboutdoor-in-doorout(DIDO)timeandstrokeoutcomes.Notably,thetitle statesthatshorterDIDOtimecorrelatestoimprovedstroke outcomes,buttheirmultivariablelogisticregressionanalysis demonstratedthatDIDOwasnotstatisticallysigniﬁcant (Table4,OR1.13,95%CI0.99–1.30).Whiletheunivariate analysissuggestedthatEDpatientswithgoodoutcomehad shortenedDIDO,thisconclusionshouldnotbemadewhen theirmultivariateregressionsuggestedotherwise.

Theauthors’ findingsanddiscussionalsosuggestthatED DIDOtimesarenotrelevanttostrokeoutcomes.Thisis controversialbecausetherewerealsoconflictingreportsfrom previousstudies.2,3 Inthispresentpaper,theauthorslooked atspecifictimeintervalsforDIDOthresholds(≤60minutes, >60minutes, ≤90minutes, >90minutes, ≤120minutes, >120minutes),whichtheyincludedintheirunivariate analysisbutnottheirmultivariablelogisticregression analysis.Bycategorizingcontinuousvariables,the authorsriskedlosingthegranularityofthevariablesand perhapsstatisticalpower;however,itisunknownwhether theseintervalswouldhaveshownsignificanceon multivariablelogisticregressionanalysis,asopposedto

assessingDIDOsolelyasacontinuousvariableinthe logisticregression.

Ontheotherhand,theauthorsreportedthatthey calculated90-daymodiﬁedRankinScale(mRS)viaelectronic healthrecords(EHR)andalsoretrospectivelycalculated 90-daymRSvaluesfor77(18%)oftheirpatients.However, retrospectivecalculationsofmRSareinherentlybiased,as clinicianstendtoscoreapatient’sdisabilityashigherthan whatwasexperiencedbythepatient,andtheirqualityoflife lower.4,5 Therefore,itispossiblethatoutcomemeasureswere moresubjectiveandcouldaffecttheauthors’ analyses.

Additionally,datafromourcomprehensivestrokecenter (CSC),forwhichpatientswithLVOSandthrombectomy undergoprospective90-daymRSassessmentaspartofthe clinicalcareforallstrokepatients,reportedthatdifferenttime intervalsareassociatedwithimprovedoutcomeforpatients withLVOS.Weanalyzedthedataof203patientswithLVOS whopresentedtoourCSCviaourcriticalcareresuscitationunit (CCRU)betweenJanuary2019–May2021forthrombectomy, usingamachinelearningalgorithm(classiﬁcationand regressiontree[CART]).TheCARTalgorithmusesrecursive partitioningtoidentifyimportantpredictorsandassignthese predictorswithrelativevariableimportance(RVI).Themost importantpredictorswouldbegivenaRVIof100%;other predictorswouldsubsequentlybeassignedRVIvaluesas percentageofthemostimportantfactor.

SimilarlytoSigaletal’sstudy,ouranalysisfoundthatwhile NationalInstitutesofHealthStrokeScaleandagewere signiﬁcantfactorsassociatedwithpatientoutcomes (Appendix1),theEDDIDOtimewasalsoasigniﬁcantfactor

withaRVIof27.6%(Appendix1).Furthermore,theDIDO timeatourCSC’sresuscitationunitwasalsoanimportant factorwithaRVIof62.7%.Allthetimeintervalsinour analysiswereenteredintheCARTascontinuousvariables. Nevertheless,wehypothesizethatthelackofsignificancein theauthors’ multivariablelogisticregressionmaybebecause theirpatients’ 90-daymRSvalueswereobtainedviaEHR,in contrasttoourdata,whichresultedfromprospectively collected90-daymRSvalues.However,theresultthatthe CCRU’sDIDOwasasignificantfactorwithhigherRVI valuesthanEDDIDOforpatients’ outcomecouldalso provideanotherpossibleexplanationforthe findingsinSigal etalandSchevingetalthatEDDIDOmightnotbea significantfactor.ItcouldbethatwhatwasdelayedinED DIDOtimewaslatermadeupbytheteamsattheCSConce patientsweretransferredfromtheEDs.However,further studiesarenecessarytoconfirmorrefuteourobservation. Despiteourconcerns,wewholeheartedlyagreewiththe authorsthatcliniciansneedtoexpeditepatientswhohave LVOStoundergothrombectomy,regardlessofwherethey areduringthecriticaltimeperiod.

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

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AddressforCorrespondence:QuincyK.Tran,MD,PhD,University ofMarylandSchoolofMedicine,DepartmentofEmergency Medicine,22SouthGreeneSt.,SuiteT3N45,Baltimore,MD21201. Email: qtran@som.umaryland.edu

4.SucharewH,KleindorferD,KhouryJC,etal.Derivingplaceof residence,modiﬁedRankinscale,andEuroQol-5Dscoresfromthe medicalrecordforstrokesurvivors. CerebrovascDis. 2021;50(5):567–73.

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