Academic and Professional Outcomes of Participants in an Emergency Department Research Associate Program.

OBJECTIVES: Studies have found that participation in emergency department research associate (EDRA) programs is associated with medical school acceptance. However, little is known about the association between EDRA program participation and other academic and professional outcomes. We sought to characterize the academic and professional outcomes of EDRA program participants and their perception of program influence on academic and professional outcomes. METHODS: We conducted a cross-sectional study of University of Rochester EDRA program participants who graduated from the program May 2010 to May 2017. EDRAs were sent a secure, deidentified, survey. Standard descriptive statistics were used to characterize participant demographics and outcomes. National acceptance rates were referenced from sources. RESULTS: A total of 56 graduates completed the survey (64% response rate). Forty (71%) identified as female, 12 (21%) identified as Asian, one (2%) identified as Black or African American, and three (5%) identified as Hispanic or Latino. Acceptance rates to MD programs, DO programs, PhD programs, and master's programs were 88% (22/25), 92% (12/13), 100% (2/2), and 100% (9/9), respectively. Rates were significantly higher compared to national rates (all p < 0.001). Eighty-three percent (30/36 responses) and 74% (37/50) spoke about the EDRA program during postgraduate program and job interviews, respectively, and 78% (35/45 responses) included the EDRA program in their personal statements. Twenty-five percent (14/55) changed their career goals after participating in the EDRA program, of which 36% (5/14) left medicine and 21% (3/14) were undecided and chose to become a physician. CONCLUSIONS: An EDRA program can help develop and support a career in medicine and science. EDRA graduates used their experiences directly in their postgraduate program applications and job interviews. Acceptance rates of EDRA program graduates to postgraduate programs were higher than national averages. An EDRA program can help clarify career goals after program participation.

Emergency Medicine Residency Curricular Innovations: Creating a Virtual Emergency Medicine Didactic Conference.

Currently, there is a pandemic forcing social distancing and, consequently, traditional in-person education must shift to a virtual curriculum to protect all parties and continue professional development. Recognizing that not all emergency medicine (EM) content can be taught through a virtual platform, we propose a model for nearly all EM resident didactic conference adaptation to a virtual format to meet the needs of the adult learner while protecting all participants from the current coronavirus pandemic.

Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization.

OBJECTIVE: Homelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness. METHODS: We conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized. RESULTS: Over the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years. CONCLUSIONS: Compared to non-homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.

Depression symptomology groups among middle and older adult emergency department patients.

INTRODUCTION: Middle and late life adults may present depression symptomology differently than the expected symptoms of depression. Clusters of common symptoms may be overlooked when determining the most appropriate treatment options, leading to a less than effective treatment. Investigation of these clusters is needed to better understand patterns of depressive symptomology among middle and late life adults. METHODS: Consent, demographics, self-report items and PHQ-9 items were administered to subjects. Latent class analysis (LCA), was used to determine groupings of patients based on PHQ-9 items. Demographics were compared across classes for additional information. RESULTS: A total of 252 subjects aged 45-85 years old were enrolled. An LCA indicated that a 3 class solution explained the clusters endorsed: Low Concerns (35%), Many Concerns (34%), and Sleep and Fatigue Concerns (31%). Patients in the Low Concerns class were more likely to have private insurance compared to those in the Many Concerns class (57% vs 34%, p = 0.003). They also reported better general health (M = 2.39 vs M = 1.58, p < 0.001), and visited their PCP less frequently (M = 1.64 visits vs M = 3.31 visits, p = 0.004). LIMITATIONS: Recall bias may have been present due to self-report of symptoms which was a report based on a low threshold for endorsement of items. Future larger studies should utilize more response options. CONCLUSION: LCA suggests there are three unique groupings of symptoms as reported by the PHQ-9. These clusters may be valuable in determining treatment options and designing interventions.

Depression and Anxiety Among Emergency Department Patients: Utilization and Barriers to Care.

BACKGROUND: Anxiety and depression rates among emergency department (ED) patients are substantially higher than those in the general population. Additionally, those with mental health issues often have difficulty accessing care. Unfortunately, issues of anxiety and depression are frequently not addressed in the ED due to competing care priorities. This may lead to increased burden and overcrowding in EDs. OBJECTIVE: This study related anxiety and depression with ED utilization and perceived barriers to care. METHODS: To limit the impact of insurance coverage on ED utilization and access to care, a convenience sample of adults 45 to 85 years of age in the ED were surveyed. The Generalized Anxiety Disorder 7 and Patient Health Questionnaire 9 were used to measure anxiety and depression. RESULTS: A total of 251 subjects were enrolled. Severe anxiety was observed in 10% of patients, while moderately severe or severe depression was observed in 12%. Patients who were both severely anxious and depressed visited the ED nearly twice as often as nonanxious and nondepressed patients. The majority of patients cited at least one moderate barrier to care, and greater anxiety and depression scores were related to greater perceived barriers to care. Perceived barriers to care were more than three times higher among patients who were both anxious and depressed compared to those in patients who were neither depressed nor anxious and twice as high as in those who were either depressed or anxious (p < 0.001). CONCLUSION: Patients identified with internalizing mental health concerns utilize the ED at elevated rates while also reporting the greatest difficulties accessing care. These findings highlight the need for ED interventions aimed at identifying patient mental health concerns, as well as perceived barriers to care, to design interventions to effectively improve continuity of care.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine.

BACKGROUND: Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. METHODS: We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS: An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS: Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

A novel internet-based geriatric education program for emergency medical services providers.

Despite caring for large numbers of older adults, prehospital emergency medical services (EMS) providers receive minimal geriatrics-specific training while obtaining their certification. Studies have shown that they desire further training to improve their comfort level and knowledge in caring for older adults, but continuing education programs to address these needs must account for each EMS provider's specific needs, consider each provider's learning styles, and provide an engaging, interactive experience. A novel, Internet-based, video podcast-based geriatric continuing education program was developed and implemented for EMS providers, and their perceived value of the program was evaluated. They found this resource to be highly valuable and were strongly supportive of the modality and the specific training provided. Some reported technical challenges and the inability to engage in a discussion to clarify topics as barriers. It was felt that both of these barriers could be addressed through programmatic and technological revisions. This study demonstrates the proof of concept of video podcast training to address deficiencies in EMS education regarding the care of older adults, although further work is needed to demonstrate the educational effect of video podcasts on the knowledge and skills of trainees.

The outcomes of emergency pharmacist participation during acute myocardial infarction.

BACKGROUND: Current guidelines recommend door-to-balloon times of 90 min or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction (STEMI). OBJECTIVES: To determine if a clinical pharmacist for the ED (EPh) is associated with decreased door/diagnosis-to-cardiac catheterization laboratory (CCL) time and decreased door-to-balloon time. METHODS: A retrospective observational cohort study of ED patients with STEMI requiring urgent cardiac catheterization was conducted. Blinded data collection included timing of ED and CCL arrival, diagnostic electrocardiogram (ECG), and balloon angioplasty. For cases diagnosed after ED arrival, diagnosis time was substituted for door time. Diagnosis was the time ST elevations were evident on serial ECG. EPh present and not-present groups were compared. During the study period there were two EPhs and presence was determined by their scheduled time in the ED. Univariate and multivariate analyses was used to detect differences. RESULTS: Multivariate analysis of 120 patients, controlled for CCL staff presence and arrival by pre-hospital services, determined that EPh presence is associated with a mean 13.1-min (95% confidence interval [CI] 6.5-21.9) and 11.5-min (95% CI 3.9-21.5) decrease in door/diagnosis-to-CCL and door-to-balloon times, respectively. Patients were more likely to achieve a door/diagnosis-to-CCL time≤ 30 min (odds ratio [OR] 3.1, 95% CI 1.3-7.8) and≤ 45 min (OR 2.9, 95% CI-1.0, 8.5) and a door-to-balloon time≤ 90 min (OR 1.9, 95% CI 0.7-5.5) more likely when the EPh was present. CONCLUSIONS: EPh presence during STEMI presentation to the ED is independently associated with a decrease in door/diagnosis-to-CCL and door-to-balloon times.

Iodide mumps: a case report of complicated radioactive iodine causing sialadenitis.

Radiation sialadenitis is an uncommon adverse reaction to radioactive iodide therapy. Sialadenitis due to radiation exposure has a dose-related damage that can follow an acute or chronic inflammatory nature. We present a case of a patient who developed radiation sialadenitis after radioactive iodide therapy for papillary thyroid cancer resulting in severe parotid swelling and swelling, which resulted in an emergency department visit and had complete resolution with conservative management.

Pitfalls in first-trimester bleeding.

The focus of this article is first-trimester bleeding. Vaginal bleeding during the first 3 months of pregnancy is a common event. It is important that the emergency physicians recognize patients with vaginal bleeding who may have an adverse outcome if misdiagnosed or not treated appropriately in the emergency department. Causes of first-trimester vaginal bleeding include implantation bleeding, spontaneous abortions, ectopic pregnancy, and lesions involving the female reproductive system and perineal area infections.

Emergency Department Ultrasound Credentialing: a sample policy and procedure.

Emergency physician use of bedside ultrasound has increased dramatically over the last two decades. However, many emergency departments find it difficult to gain formal hospital credentialing for bedside sonography. We present the Emergency Department (ED) Ultrasound Credentialing Policy from the University of California, San Francisco. Although the American College of Emergency Physicians has published formal guidelines on this subject, they are not written in such a way that they are readily transcribed into a document suitable for review by credentialing committees and executive medical boards. Our policy details the background of emergency bedside ultrasound, the goals of its use, the scope of emergency physician sonography, credentialing criteria, and an example of a quality assurance program. We have not changed the components of the previously published guidelines. Rather, this document has withstood the rigor of our own credentialing process and is presented as an example in the hopes that it may help other EDs who seek credentialing in their institutions. This document is intended as a guideline for credentialing committees and will require alteration to meet the needs of each different hospital; however, the overall framework should allow for a less time-consuming process.

An unusual case of subterfuge in the emergency department: covert administration of antipsychotic and anxiolytic medications to control an agitated patient.

Pediatric, nursing home, and institutionalized psychiatric patients frequently receive medications covertly or against their will. Surreptitious medicating of emergency department (ED) psychiatric patients may occur but has not been reported. We discuss competing ethical, therapeutic, and legal issues in potential conflict during the treatment of an acutely psychotic patient who had homicidal and suicidal ideation and presented to a busy, urban ED. The practice of covertly medicating may not be uncommon in EDs, but fear of professional censure probably inhibits open discussion and documentation of such events. No specific statutory, ethical, or case law in the United States seems to control this type of situation.

A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients.

OBJECTIVES: To determine if midazolam is superior to lorazepam or haloperidol in the management of violent and severely agitated patients in the emergency department. Superiority would be determined if midazolam resulted in a significantly shorter time to sedation and shorter time to arousal. METHODS: This was a randomized, prospective, double-blind study of a convenience sample of patients from an urban, county teaching emergency department. Participants included 111 violent and severely agitated patients. Patients were randomized to receive intramuscular midazolam (5 mg), lorazepam (2 mg), or haloperidol (5 mg). RESULTS: The mean (+/-SD) age was 40.7 (+/-13) years. The mean (+/-SD) time to sedation was 18.3 (+/-14) minutes for patients receiving midazolam, 28.3 (+/-25) minutes for haloperidol, and 32.2 (+/-20) minutes for lorazepam. Midazolam had a significantly shorter time to sedation than lorazepam and haloperidol (p < 0.05). The mean difference between midazolam and lorazepam was 13.0 minutes (95% confidence interval [95% CI] = 5.1 to 22.8 minutes) and that between midazolam and haloperidol was 9.9 minutes (95% CI = 0.5 to 19.3 minutes). Time to arousal was 81.9 minutes for patients receiving midazolam, 126.5 minutes for haloperidol, and 217.2 minutes for lorazepam. Time to arousal for midazolam was significantly shorter than for both haloperidol and lorazepam (p < 0.05). The mean difference in time to awakening between midazolam and lorazepam was 135.3 minutes (95% CI = 89 to 182 minutes) and that between midazolam and haloperidol was 44.6 minutes (95% CI = 9 to 80 minutes). There was no significant difference over time by repeated-measures analysis of variance between groups in regard to changes in systolic and diastolic blood pressure (p = 0.8965, p = 0.9581), heart rate (p = 0.5517), respiratory rate (p = 0.8191), and oxygen saturation (p = 0.8991). CONCLUSIONS: Midazolam has a significantly shorter time to onset of sedation and a more rapid time to arousal than lorazepam or haloperidol. The efficacies of all three drugs appear to be similar.