Theater for Healthcare Equity; A Model for Inclusion and Anti-Bias Training in Academic Medicine.

There are no standardized methods for training medical personnel in antiracist action, such as how to be an upstander or how to use micro-resistance. Roleplay and drama-based pedagogy can empower and educate healthcare professionals by providing experiential training and a safe space for antiracist practice and discussion. The Theater for Healthcare Equity (THE) is an innovative methodology that explores upstander techniques in real time with facilitated instruction. We implemented eight THE sessions at our institution and assessed participant responses via a voluntary survey. Forty-one participants completed a REDCap survey, and 32 participants completed the Continuing Medical Education survey. Participants appreciated the creation of safe spaces, the practice format, and the learning experience, which provided an honest and open environment for the sharing of experiences, addressing race-based bias, and practicing responses to real-life scenarios. Constructive feedback included changes to session duration, participant discomfort with improvisation, and lack of printed tools.

Implicit Bias and Patient Care: Mitigating Bias, Preventing Harm.

Introduction: Simulation is a valuable and novel tool in the expanding approach to racism and bias education for medical practitioners. We present a simulation case focused on identifying and addressing the implicit bias of a consultant to teach bias mitigation skills and limit harm to patients and families. Methods: Learners were presented with a case of a classic toddler's fracture in an African American child. The learners interacted with an orthopedic resident who insisted on child welfare involvement, with nonspecific and increasingly biased concerns about the child/family. The learners were expected to identify that this case was not concerning for nonaccidental trauma and that the orthopedic resident was demonstrating bias. They were expected to communicate with both the resident and the parent effectively to defuse the situation and prevent harm from reaching the family. A debrief and an anonymous survey followed the case. Results: Seventy-five learners participated, including pediatric and emergency medicine residents, fellows, attendings, and medical students. After the case, the majority of learners expressed confidence that they could recognize racial bias in the care of a patient (90%), ensure patient care was not influenced by racial bias (88%), and utilize a tool to frame a concern about bias (79%). Discussion: Participants felt that this simulation was relevant and effective and overall left the experience feeling confident in their abilities to identify and manage racially biased patient care. This anti-racist simulation offers an important skill-building opportunity that has been well received by learners.

Prevalence and correlates of experiencing drug-related discrimination among people who use drugs presenting at emergency department at high risk of opioid overdose.

Objectives: Our objective is to determine if specific sociodemographic characteristics were associated with perceived drug-related discrimination among people who use drugs (PWUD) presenting for care in the emergency department (ED). Methods: We conducted a secondary analysis of data from the Navigator trial, a randomized control trial of two behavioral interventions in the ED for people at risk of an opioid overdose. Participants included adult patients presenting to two Rhode Island EDs. Eligible participants included those high risk for an opioid overdose, resided or received most of their healthcare in Rhode Island, and were able to provide consent. The primary outcome of this analysis was self-reported feelings of drug-related discrimination by the medical community. The independent variables of interest included race/ethnicity, gender identity, and sexual orientation. Log-binomial multivariable regression models were constructed with all three independent variables of interest and a selection of sociodemographic covariates. Results: Of 620 eligible participants, 251 (40.5%) reported ever experiencing drug-related discrimination in their lifetime. In the adjusted model, participants who identified as women and participants who identified as LGBQIA+ were more likely to report experiencing drug-related discrimination from the medical community in EDs. Racial/ethnic minority groups were less likely than White (non-Hispanic) participants to report drug-related discrimination. Discussion: In this study population, White participants reported more drug-related discrimination than their minority counterparts, although female and LGBQIA+ patients reported more discrimination. Future studies should further assess the significance of these intersecting identities on self-reported discrimination. This knowledge could improve ED-based interventions, policies, and services for PWUD.

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006-2015.

BACKGROUND: Acute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED. METHODS: This cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006-2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting. RESULTS: When evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8-2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55-8.68) compared to female patients, 7.4 (95% CI 6.7-8.12). CONCLUSIONS: In this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.

Race, ethnicity, and emergency department post-overdose care.

BACKGROUND: Emergency department (ED) visits for opioid-related overdoses continue to rise across the United States, particularly among Black, Latinx, and American Indian/Alaskan Native communities. A minority of people with opioid use disorder (OUD) engages in formal addiction treatment and there are racial disparities in treatment access. ED visits for opioid overdose are crucial opportunities to link individuals with OUD to harm reduction and treatment services. However, we know little about whether racial inequities exist in ED treatment after opioid overdose. METHODS: This observational, cross-sectional study examined differences in services provided to overdose patients who were discharged after an ED visit for opioid overdose by patient race-ethnicity. Primary outcomes included provision of take-home naloxone, ED-based behavioral counseling, and linkage to treatment. Race-ethnicity differences in post-overdose ED services were evaluated using chi-square analyses, and multivariable logistic regression analyses were conducted to examine associations of race-ethnicity with receiving post-overdose services, controlling for other institutional-, provider-, and patient-level factors. RESULTS: From September 2017 to February 2020, 734 patients were discharged from the ED for an opioid-related overdose. Most patients were White non-Latinx (70.0%), 8.9% were Black non-Latinx, 3.3% were Other race non-Latinx, and 18.0% were Latinx. Take-home naloxone was the most frequent intervention provided to patients while behavioral counseling was the lowest across all race-ethnicity categories. There were no statistically significant differences in provision of take-home naloxone and treatment referral based on patient race-ethnicity. However, a lower proportion of discharged Black non-Latinx patients received behavioral counseling compared to patients of other race-ethnicities, and the odds of receiving behavioral counseling was significantly higher for White non-Latinx (OR: 1.75; 95% CI: 1.00, 3.06); Latinx (OR: 2.06; 95% CI: 1.05, 4.06); and Other race non-Latinx (OR: 3.29; 95% CI: 1.18, 9.15) patients compared to Black non-Latinx patients. CONCLUSION: Black non-Latinx patients discharged from the ED for an opioid-related overdose were less likely to receive behavioral counseling compared to non-Black patients. Possible reasons for this decreased provision of behavioral counseling include provider bias, patient mistrust of the medical and behavioral health care systems, and limited provider training in addiction medicine and motivational interviewing. These inequities add to the known racial disparities in ED patient care. Further research should elucidate barriers to behavioral counseling within ED settings and factors contributing to racial inequities in post-overdose emergency care.

Association Between Emergency Medicine Clerkship Diversity Scholarships and Residency Diversity.

OBJECTIVE: To improve resident diversity, emergency medicine (EM) residencies across the United States have implemented financial scholarships to attract visiting medical students underrepresented in medicine (URiM). The impact of these scholarships on changes in residency racial and ethnic diversity is currently unknown. In this study, we describe characteristics of these visiting elective scholarships for underrepresented students and evaluate changes in residency racial and ethnic diversity after program implementation. METHODS: From 2018 to 2019, we conducted a cross-sectional survey of EM residency programs with a visiting clerkship rotation scholarship for medical students URiM. Programs were identified for study inclusion using the Society for Academic Emergency Medicine's online directory of Visiting Elective Scholarship Programs for Underrepresented Minorities. Program characteristics were analyzed descriptively. Changes in residency racial and ethnic diversity were evaluated using an interrupted time series analysis. RESULTS: Of 34 programs contacted, 20 responded. While there was some variability in funding sources, scholarship amounts, and application review, most scholarships were similar in implementation practices. Of the 20 program respondents, nine were able to provide complete data on residency race and ethnicity and were included in the time series analysis. After program implementation, the time series analysis showed a significant increase in both underrepresented minority EM residents overall and Black and Latinx EM residents in particular. CONCLUSION: Emergency medicine visiting clerkship scholarship programs for medical students URiM vary in funding type and application review but had similar implementation practices. Residency programs increased their racial and ethnic diversity after program implementation. Future investigations are needed to determine specific factors contributing to the successful implementation of scholarship programs.

Efficacy of Computed Tomography Utilization in the Assessment of Acute Traumatic Brain Injury in Adult and Pediatric Emergency Department Patients.

BACKGROUND: Computed tomography (CT) is commonly used to assess traumatic brain injury (TBI) in the emergency department (ED). Radiologists at a Level 1 trauma center implemented a novel tool, the RADiology CATegorization (RADCAT) system, to communicate injuries to clinicians in real time. Using this categorization system, we aimed to determine the rates of positive head CTs among pediatric and adult ED patients evaluated for TBI. METHODS: We performed a retrospective analysis of all patients who received a head CT to assess for TBI. We classified head CTs using the RADCAT tool. On a 5-point scale, scores of 3 or less are considered normal or routine. Scores of 4-5 are considered high priority, representing findings such as intracranial bleeding. RESULTS: Of the 5,341 head CT's obtained during the study period, 992 (18.5%) had high priority results (scores 4-5). A large number of pediatric studies, 30.8%, were positive for high priority results. Among the adult population, 18.0 % contained high priority results. CONCLUSION: The pediatric population had a higher rate of high priority reads among those undergoing non- contrast head CT for TBI compared to adult patients.

Emergency Department-Provided Home Blood Pressure Devices Can Help Detect Undiagnosed Hypertension.

INTRODUCTION: Emergency departments (EDs) are critical sites for hypertension (HTN) screening. Home blood pressure (BP) monitoring (HBPM) is used routinely in outpatient settings, yet its utility after the ED visit for those with elevated BP in the ED is unclear. AIM: In this pilot study, we assessed if HBPM could detect HTN in patients with elevated in-ED BP. METHODS: From September 2014 to July 2017, we recruited adult patients at an urban, academic ED with a triage BP ≥ 120/80 mmHg and no history of HTN into this prospective cohort observational study. After their ED visit, participants obtained BP measurements for two weeks using a validated HBPM. HTN was considered probable if the average HBPM BP was ≥ 135/85 mmHg. We calculated the proportion of participants whose ED BP measurement accurately predicted HTN using HBPM after discharge. RESULTS: Of 136 participants enrolled, 93 (68%) returned the HBPM with at least four home BP measurements [mean number of measurements obtained: 29 (SD: 17, range 4-59)]. Participants' median age was 40 years-old (IQR 34-48); 55% were female, 19% were black, and 58% were white. Forty-six percent of participants with elevated in-ED BP had HTN in follow-up. CONCLUSIONS: For patients with elevated BP in the ED, HBPM could be valuable for determining which patients have HTN and require expedient follow-up.

Elevated blood pressure and illness beliefs: a cross-sectional study of emergency department patients in Jamaica.

BACKGROUND: Elevated blood pressure (BP) is common among emergency department (ED) patients. While some data exist on the association between ED BP and hypertension (HTN) in the USA, little is known about this relationship in Afro-Caribbean nations. The aim of the study was to evaluate the relationship between elevated systolic BP in the ED and a previous diagnosis of HTN, accounting for potential factors that could contribute to poor HTN control among those with a previous diagnosis: socioeconomic status, health-seeking behavior, underlying HTN illness beliefs, medication adherence, and perceived adherence self-efficacy. METHODS: This was a cross-sectional survey over 6 weeks, from November 19 through December 30, 2014. Those surveyed were non-critically ill or injured adult ED patients (≥ 18 years) presenting to an Afro-Caribbean hospital. Descriptive statistics were derived for study patients as a whole, by HTN history and by presenting BP subgroup (with systolic BP ≥ 140 mmHg considered elevated). Data between groups were compared using chi-square and t tests, where appropriate. RESULTS: A total of 307 patients were included: 145 (47.2%) had a prior history of HTN, 126 (41.4%) had elevated BP, and 89 (61.4%) of those presenting with elevated blood pressure had a previous diagnosis of HTN. Those with less formal education were significantly more likely to present with elevated BP (52.1 vs. 28.8% for those with some high school and 19.2% for those with a college education; p = 0.001). Among those with a history of HTN, only 56 (30.9%) had a normal presenting BP. Those with a history of HTN and normal ED presenting BP were no different from patients with elevated BP when comparing the in duration of HTN, medication compliance, location of usual follow-up care, and HTN-specific illness beliefs. CONCLUSIONS: In this single-center study, two out of every five Jamaican ED patients had elevated presenting BP, the majority of whom had a previous diagnosis of HTN. Among those with a history of HTN, 60% had an elevated presenting BP. The ED can be an important location to identify patients with chronic disease in need of greater disease-specific education. Further studies should evaluate if brief interventions provided by ED medical staff improve HTN control in this patient population.

Achieving the BpTRUth: emergency department hypertension screening and the Centers for Medicare & Medicaid Services quality measure.

In 2012, the Centers for Medicare & Medicaid Services (CMS) instituted a Physician Quality Reporting System measure for screening and referring patients with elevated blood pressure (BP). The aims of this study were to (1) assess the reliability of ED triage BP as a metric to establish when the CMS threshold (≥120/80 mm Hg), and other clinically relevant BP thresholds (≥140/90 and ≥160/100 mm Hg) have been met, using BP measured with a highly accurate device (BpTRU) in the emergency department as the gold standard; and (2) determine whether correct identification varies by gender, race, or triage acuity. Using the BpTRU, we calculated the proportion of patients whose triage BP accurately indicated a need for further referral and treatment for hypertension according to three suggested BP thresholds (≥120/80, ≥140/90, and ≥160/100 mm Hg). Of 354 patients, the median age was 39 years, 48.9% were women, and 66.4% were White. At the three suggested BP thresholds (≥120/80, ≥140/90, and ≥160/100 mm Hg), 66.1%, 74.0%, and 88.8% of patients were confirmed to meet the CMS threshold, respectively. There were no differences by gender, race, or triage acuity. Emergency department triage BP would reliably identify elevated BP using the CMS threshold in up to two-thirds of those without known hypertension.

A profile of freestanding emergency departments in the United States, 2007.

BACKGROUND: Freestanding Emergency Departments (FSEDs) have emerged as an alternative to traditional hospital-based emergency care. STUDY OBJECTIVE: We sought to determine the number, basic types, distribution, and characteristics of United States (US) FSEDs in 2007. METHODS: Combining data from the 2007 National Emergency Department Inventory-USA database, the 2007 American Hospital Association Annual Survey of Hospitals, Internet searches, and telephone calls, we established an inventory of FSEDs. We define FSEDs as emergency care facilities physically distinct from a hospital. FSEDs include "satellite" Emergency Departments (EDs), which are owned by a parent hospital, and "autonomous" EDs, which lack such an affiliation. RESULTS: We identified 80 FSEDs operating in 2007, representing 1.6% of all US EDs; 73 (91%) in 20 states were satellite EDs, and seven (9%) in three states were autonomous EDs. Most FSEDs (92%; 95% confidence interval 83-97%) were located in urban areas, which is considerably higher than the proportion for hospital-based EDs (58%). The median distance from a satellite ED to a parent hospital ED was 10.6 miles. In 2007, FSED annual visit volumes ranged from 700 to 56,545 visits. The 2007 median visit volume was 18,769 (interquartile range 11,106-23,504; n = 52). This value did not vary by geographic region and is almost identical to the 2007 median visit volume for hospital-based EDs (18,776 visits). CONCLUSIONS: FSEDs represent <2% of US EDs, with satellite EDs comprising a majority of all FSEDs. Most (92%) FSEDs are located in urban areas.