Association of Patient English Proficiency and Diagnostic Imaging Acquisition in Emergency Department Patients with Abdominal Symptoms.

BACKGROUND: Patients with limited English proficiency (LEP) are at risk for communication barriers during medical care in the United States compared with English-proficient (EP) patients. It is unknown how EP affects the utilization of advanced diagnostic imaging (ADI) in the emergency department (ED). OBJECTIVE: The aim of this study was to compare the acquisition and findings of ADI in EP and LEP patients with abdominal symptoms. METHODS: We conducted a retrospective analysis of adult ED patients from January 2015 to January 2016. Patients were divided into EP and LEP cohorts. Logistic regression models incorporated language proficiency, interpretation method, and demographic characteristics. We determined crude and adjusted odds ratios (ORs) for the acquisition of ADI, defined as either computed tomography or ultrasound, and the proportion with actionable findings. RESULTS: In 3324 encounters (2134 EP; 1190 LEP), LEP patients were older (46.3 years vs. 43.8 years), more likely to be female (66.7% vs. 51.5%), and preferred Spanish (91.4%). ADI was obtained in 43.5% of EP and 48.1% of LEP. Adjusting for age, sex, and interpretation method, the OR was 1.09 (95% CI 0.90-1.32). There were no significant associations between interpretation type and acquisition of ADI. The proportion with actionable findings were similar in EP and LEP cohorts (29.6% vs. 26.7%). CONCLUSIONS: Accounting for demographic differences, ADI acquisition was similar for ED patients with and without LEP. Further research is needed to determine optimal interpretation modalities in this setting to prevent unnecessary imaging.

Previous exposure to violence among emergency department patients without trauma-related complaints: A cross sectional analysis.

INTRODUCTION: The Emergency Department (ED) is a critical setting for the treatment of acute violence-related complaints and violent victimization is associated with numerous long-term negative health outcomes. A trauma-informed care framework can prevent re-traumatization of victims within the healthcare setting, but currently there are insufficient mechanisms to detect previous exposures to community violence within the ED. The current study sought to determine the prevalence of community violence and characterize the types of violence exposures among adult ED patients without trauma-related complaints to determine if there may be a need for expanded screening for previous exposure to violence for ED patients. METHODS: This was a prospective cross-sectional observational study of adult ED patients without a trauma-related chief complaint at an urban public hospital. Adult patients were approached by trained research staff and answered questions adapted from the Survey of Exposure to Community Violence (SECV), which measures lifetime exposure to community violence, including both witnessing and victimization. The SECV was modified for clarity, brevity, and to assess exposure to violence within the previous 3 months and 3 years from enrollment, in addition to lifetime exposure. Enrollment occurred from June 2019 to September 2022 with a 19-month gap due to the COVID-19 pandemic. Demographics and results within SECV domains were analyzed using descriptive statistics. Comparisons between males and females in types of violence experienced during one's lifetime were made by fitting logistic regression models adjusting for age. RESULTS: A total of 222 respondents completed some or all of the modified SECV. Ages ranged from 19 to 88, with 47.7% of respondents identifying as female and 50.9% as male. Of all respondents, 43.7% reported directly witnessing violence during their lifetime, 69.4% being personally victimized by violence, and 55.4% personally knowing someone killed by a violent act. Of those personally victimized, 47.4% occurred within the preceding 3 years and 20.1% within 3 months. Among all respondents, lifetime victimization was reported in the following domains: slapping, hitting, or punching (45.9%); robbings or muggings (33.8%); physical threats (28.8%); verbal or emotional abuse (27.5%); being shot at (18.0%); uncomfortable physical touch (15.3%); forced entry while home (14.4%); sexual assault, molestation, or rape (13.5%); or being attacked with a knife (13.5%). Comparing male and female respondents, 63.5% of females and 76.6% of males reported any violent victimization over their lifetime (aOR 1.88; 95% CI 1.04-3.43). Additionally, 31.7% of females and 56.3% of males reported witnessing violence (aOR 2.86; 95% CI 1.64-5.06). Males were more commonly exposed to physical violence, violence with weapons, and threats while females more commonly reported sexual assault, molestation, and rape. CONCLUSION: Both lifetime and recent exposure to community violence was common among adult ED patients without trauma-related complaints. Broader adoption of a trauma-informed care framework and the development of efficient ED screening tools for previous exposure to trauma is reasonable in areas where community violence exposure is highly prevalent.

Prehospital Intranasal Glucagon for Hypoglycemia.

BACKGROUND: Prehospital hypoglycemia is usually treated with oral or intravenous (IV) dextrose in a variety of concentrations. In the absence of vascular access, intramuscular (IM) glucagon is commonly administered. Occupational needle-stick injury remains a significant risk while attempting to obtain vascular access or administer medications intramuscularly in the prehospital setting. We sought to determine if intranasal (IN) glucagon is effective in the prehospital treatment of hypoglycemia. METHODS: We performed a retrospective analysis of all consecutive cases where recombinant glucagon was administered IN by paramedics from January 1, 2015 through December 31, 2020. Excluded were cases without pre or post administration blood glucose documentation, and cases where another form of treatment for hypoglycemia was administered at any time during the EMS encounter. The primary outcome was clinical response to IN glucagon documented by paramedics; secondary outcomes included pre and post administration blood glucose values. RESULTS: Out of 44 cases that met study inclusion criteria, 14 patients (32%) had substantial improvement, 13 patients (30%) had slight improvement, and 17 patients (38%) had no improvement in mental status after administration of IN glucagon. In cases with substantial improvement (n = 14), the mean pre administration blood glucose was 33.8 mg/dl and the mean post administration blood glucose was 87.1 mg/dl (mean increase 53.3 mg/dl, 95% CI: 21.5 to 85.1). In cases with slight improvement (n = 13), the mean pre administration blood glucose was 23.9 mg/dl and the mean post administration blood glucose was 53.8 mg/dl (mean increase 29.9 mg/dl, 95% CI = 2.9 to 56.9). In case with no improvement (n = 17) the mean pre administration blood glucose was 30.1 mg/dl and the mean post administration glucose was 33.1 mg/dl (mean difference 3.1 mg/dl, 95% CI: -10.1 to 3.9). CONCLUSION: Intranasal administration of recombinant glucagon for hypoglycemia resulted in a clinically significant improvement in mental status and a corresponding increase in blood glucose levels in select cases in the prehospital setting.

Assessment of intimate partner violence abuse ratings by recently abused and never abused women.

BACKGROUND: There are a paucity of directly reported intimate partner violence survivors' experiences, especially in women of color. This study measures recently/currently abused women's ratings of varied abuse events compared to ratings from never abused women. METHODS: Women in a single, urban, public hospital emergency department (ED) were screened for intimate partner violence using the Abuse Assessment Screen (AAS). Two groups were identified - women abused within 1 year by an intimate partner or family member and those who screened negative for abuse. Using a two-group longitudinal survey and interview format, women completed visual analog scale ratings (0-100) for each of 20 abuse events/types. For analysis, each abuse type was placed on the 0-100 scale according to its designated rating. RESULTS: Average age of participants in the abuse group (n = 30) was 33. Never abused women averaged age 50 (n = 32). The majority of participants were African-American: abused 67% and never abused 94%. Abused women rated name-calling (p < 0.02) and put-downs (p < 0.01) as more severe than never abused women. Other non-physical and physical forms of abuse such as threats, control, burns or forced sex were perceived more similarly between groups. CONCLUSIONS: Abused women perceive verbal abuse events differently compared to never abused women.

Screening Electrocardiograms in Cocaine-Positive Chest Pain-Free Psychiatric Patients Requiring Medical Screening.

BACKGROUND: The current practice at a large urban academic emergency department (ED) is to obtain screening electrocardiograms (ECGs) as part of the medical screening on all psychiatric patients who test positive for cocaine. OBJECTIVE: We sought to examine the impact of an ECG in the medical screening of chest pain-free psychiatric patients who test positive for cocaine. METHODS: An institutional review board-approved retrospective chart review from January 2014 to December 2015 was performed on charts of adult ED patients requiring medical screening before transfer to a psychiatric facility. Patients who tested positive for cocaine on urine drug screens were included in this study. Patients with chest pain or those who did not have an ECG recorded were excluded. Outcomes evaluated included disposition and subsequent cardiac work-up. RESULTS: One thousand nine hundred sixty-eight ED patients were identified who tested positive for cocaine on a urine toxicology screen, and 853 met the inclusion criteria. ECGs were normal in 812 patients (95% [95% confidence interval 93-96%]) and abnormal in 41 patients (5% [95% confidence interval 4-7%]). Of 41 patients with abnormal ECGs, 4 were admitted for cardiac work-up. Two patients had positive troponin values in the ED, 2 had cardiology consultations, and 3 had further cardiac stress testing, all of which were negative or nondiagnostic. No cardiac catheterizations were performed. CONCLUSIONS: Most ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority with an abnormal ECG, no cases of acute myocardial ischemia or infarction were identified.

Decreased Nursing Staffing Adversely Affects Emergency Department Throughput Metrics.

INTRODUCTION: The effect of nurse staffing on emergency department (ED) efficiency remains a significant area of interest to administrators, physicians, and nurses. We believe that decreased nursing staffing adversely affects key ED throughput metrics. METHODS: We conducted a retrospective observational review of our electronic medical record database from 1/1/2015 to 12/31/2015 at a high-volume, urban public hospital. We report nursing hours, door-to-discharge length of stay (LOS) and door-to-admit LOS, and percentage of patients who left without being seen (LWBS). ED nursing hours per day was examined across quartiles with the effect evaluated using analysis of covariance and controlled for total daily ED volume, hospital occupancy and ED admission rate. RESULTS: From 1/1/15-12/31/15, 105,887 patients presented to the ED with a range of 336 to 580 nursing hours per day with a median of 464.7. Independent of daily ED volume, hospital occupancy and ED admission rate, days in the lowest quartile of nursing hours experienced a 28.2-minute increase per patient in door-to-discharge LOS compared to days in the highest quartile of nursing hours. Door-to-admit LOS showed no significant change across quartiles. There was also an increase of nine patients per day who left without being seen by a provider in the lowest quartile of nursing hours compared to the highest quartile. CONCLUSION: Lower nursing hours contribute to a statistically significant increase in door-to-discharge LOS and number of LWBS patients, independent of daily ED volume, hospital occupancy and ED admission rate. Consideration of the impact of nursing staffing is needed to optimize throughput metrics for our urban, safety-net hospital.

Correction to: The Effect of a Change Agent on Use of Evidence-Based Mental Health Practices.

The original version of this article unfortunately contained a mistake.

Comparison of Result Times Between Urine and Whole Blood Point-of-care Pregnancy Testing.

INTRODUCTION: Point-of-care (POC) pregnancy testing is commonly performed in the emergency department (ED). One prior study demonstrated equivalent accuracy between urine and whole blood for one common brand of POC pregnancy testing. Our study sought to determine the difference in result times when comparing whole blood versus urine for the same brand of POC pregnancy testing. METHODS: We conducted a prospective, observational study at an urban, academic, tertiary care hospital comparing the turnaround time between order and result for urine and whole blood pregnancy tests collected according to standard protocol without intervention from the investigators. After the blood was collected, the nurse would place three drops onto a Beckman Coulter ICON 25 Rapid HCG bedside pregnancy test and set a timer for 10 minutes. At the end of the 10 minutes, the result and time were recorded on an encoded data sheet and not used clinically. The same make and model analyzer was also used for urine tests in the lab located within the ED. The primary outcome was the difference in mean turnaround time between whole blood in the ED and urine testing in the adjacent lab results. Concordance between samples was assessed as a secondary outcome. RESULTS: 265 total patients were included in the study. The use of whole blood resulted in a mean time savings of 21 minutes (95% CI 16-25 minutes) when compared with urine (p<0.001). There was 99.6% concordance between results, with one false negative urine specimen with a quantitative HCG level of 81 mIU/L. CONCLUSION: Our results suggest that the use of whole blood in place of urine for bedside pregnancy testing may reduce the total result turnaround time without significant changes in accuracy in this single-center study.

Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation.

INTRODUCTION: Most emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified. METHODS: We conducted a retrospective chart review using appropriate International Classification of Diseases, 9(th) Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type. RESULTS: We identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management. CONCLUSION: Post-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.

The Effect of a Change Agent on Use of Evidence-Based Mental Health Practices.

Children's service systems are faced with a critical need to disseminate evidence-based mental health interventions. Despite the proliferation of comprehensive implementation models, little is known about the key active processes in effective implementation strategies. This proof of concept study focused on the effect of change agent interactions as conceptualized by Rogers' diffusion of innovation theory on providers' (N = 57) use of a behavioral intervention in a child welfare agency. An experimental design compared use for providers randomized to training as usual or training as usual supplemented by change agent interactions after the training. Results indicate that the enhanced condition increased use of the intervention, supporting the positive effect of change agent interactions on use of new practices. Change agent types of interaction may be a key active process in implementation strategies following training.

Agency Culture and Climate in Child Welfare: Do Perceptions Vary by Exposure to the Child Welfare System?

Organizational culture and climate play a critical role in worker retention and outcomes, yet little is known about whether perceptions of culture and climate vary depending on the demands of particular roles. In this study, 113 staff from a child welfare agency completed Organizational Social Context profiles. Staff were divided into three groups according to their proximity to child welfare tasks to assess whether involvement in higher stress child welfare tasks is related to perceptions of the social context. Findings suggest possible differences across groups, with those involved in core child welfare tasks appearing to perceive higher resistance to new ways of providing services and those with the least involvement in traditional child welfare perceiving a more positive social context overall.

Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography?

OBJECTIVES: The goal of this study was to determine if emergency physicians (EPs) can correctly perform a bedside diastology examination (DE) and correctly grade the level of diastolic function with minimal additional training in echocardiography beyond what is learned in residency. We hypothesize that EPs will be accurate at detecting and grading diastolic dysfunction (DD) when compared to a criterion standard interpretation by a cardiologist. METHODS: We conducted a prospective, observational study on a convenience sample of adult patients who presented to an urban emergency department with a chief concern of dyspnea. All patients had a bedside echocardiogram, including a DE, performed by an EP-sonographer who had 3 hours of didactic and hands-on echocardiography training with a cardiologist. The DE was interpreted as normal, grade 1 to 3 if DD was present, or indeterminate, all based on predefined criteria. This interpretation was compared to that of a cardiologist who was blinded to the EPs' interpretations. RESULTS: We enrolled 62 patients; 52% had DD. Using the cardiology interpretation as the criterion standard, the sensitivity and specificity of the EP-performed DE to identify clinically significant diastolic function were 92% (95% confidence interval [CI], 60-100) and 69% (95% CI, 50-83), respectively. Agreement between EPs and cardiology on grade of DD was assessed using κ and weighted κ: κ = 0.44 (95% CI, 0.29-0.59) and weighted κ = 0.52 (95% CI, 0.38-0.67). Overall, EPs rated 27% of DEs as indeterminate, compared with only 15% by cardiology. For DEs where both EPs and cardiology attempted an interpretation (indeterminates excluded) κ = 0.45 (95% CI, 0.26 to 0.65) and weighted κ = 0.54 (95% CI, 0.36-0.72). CONCLUSION: After limited diastology-specific training, EPs are able to accurately identify clinically significant DD. However, correct grading of DD, when compared to a cardiologist, was only moderate, at best. Our results suggest that further training is necessary for EPs to achieve expertise in grading DD.

Accuracy of a novel ultrasound technique for confirmation of endotracheal intubation by expert and novice emergency physicians.

INTRODUCTION: Recent research has investigated the use of ultrasound (US) for confirming endotracheal tube (ETT) placement with varying techniques, accuracies, and challenges. Our objective was to evaluate the accuracy of a novel, simplified, four-step (4S) technique. METHODS: We conducted a blinded, randomized trial of the 4S technique utilizing an adult human cadaver model. ETT placement was randomized to tracheal or esophageal location. Three US experts and 45 emergency medicine residents (EMR) performed a total of 150 scans. The primary outcome was the overall sensitivity and specificity of both experts and EMRs to detect location of ETT placement. Secondary outcomes included a priori subgroup comparison of experts and EMRs for thin and obese cadavers, time to detection, and level of operator confidence. RESULTS: Experts had a sensitivity of 100% (95% CI = 72% to 100%) and specificity of 100% (95% CI = 77% to 100%) on thin, and a sensitivity of 93% (95% CI = 66% to 100%) and specificity of 100% (95% CI = 75% to 100%) on obese cadavers. EMRs had a sensitivity of 91% (95% CI = 69% to 98%) and of specificity 96% (95% CI = 76% to 100%) on thin, and a sensitivity of 100% (95% CI = 82% to 100%) specificity of 48% (95% CI = 27% to 69%) on obese cadavers. The overall mean time to detection was 17 seconds (95% CI = 13 seconds to 20 seconds, range: 2 to 63 seconds) for US experts and 29 seconds (95% CI = 25 seconds to 33 seconds; range: 6 to 120 seconds) for EMRs. There was a statistically significant decrease in the specificity of this technique on obese cadavers when comparing the EMRs and experts, as well as an increased overall time to detection among the EMRs. CONCLUSION: The simplified 4S technique was accurate and rapid for US experts. Among novices, the 4S technique was accurate in thin, but appears less accurate in obese cadavers. Further studies will determine optimal teaching time and accuracy in emergency department patients.