Search

BACKGROUND: Digitization (using novel digital tools and strategies) and consumerism (taking a consumer-oriented approach) are increasingly commonplace in clinical trials, but the implications of these changes are not well described. METHODS: We assembled a group of trial experts from academia, industry, non-profit, and government to discuss implications of this changing trial landscape and provide guidance. RESULTS: Digitization and consumerism can increase the volume and diversity of trial participants and expedite recruitment. However, downstream bottlenecks, challenges with retention, and serious issues with equity, ethics, and security can result. A click and mortar approach, combining approaches from novel and traditional trials with the thoughtful use of technology, may optimally balance opportunities and challenges facing many trials. CONCLUSION: We offer expert guidance and three click and mortar approaches to digital, consumer-oriented trials. More guidance and research are needed to navigate the associated opportunities and challenges.

OBJECTIVE: The objective of this qualitative study is to gauge physician sentiment about an emergency department (ED) clinical decision support (CDS) system implemented in multiple adult EDs within a university hospital system. This CDS system focuses on predicting patients likelihood of ED recidivism and/or adverse opioid-related events. METHODS: The study was conducted among adult emergency physicians working in three EDs of a single academic health system in Rhode Island. Qualitative, semistructured interviews were conducted with ED physicians. Interviews assessed physicians prior experience with predictive analytics, thoughts on the alerts placement, design, and content, the alerts overall impact, and potential areas for improvement. Responses were aggregated and common themes identified. RESULTS: Twenty-three interviews were conducted (11 preimplementation and 12 postimplementation). Themes were identified regarding each physician familiarity with predictive analytics, alert rollout, alert appearance and content, and on alert sentiments. Most physicians viewed these alerts as a neutral or positive EHR addition, with responses ranging from neutral to positive. The alert placement was noted to be largely intuitive and nonintrusive. The design of the alert was generally viewed positively. The alerts content was believed to be accurate, although the decision to respond to the alerts call-to-action was physician dependent. Those who tended to ignore the alert did so for a few reasons, including already knowing the information the alert contains, the alert offering information that is not relevant to this particular patient, and the alert not containing enough information to be useful. CONCLUSION: Ultimately, this alert appears to have a marginally positive effect on ED physician workflow. At its most beneficial, the alert reminded physicians to deeply consider the care provided to high-risk populations and to potentially adjust their care and referrals. At its least beneficial, the alert did not affect physician decision-making but was not intrusive to the point of negatively impacting workflow.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities.As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments—communicable diseases, non-communicable conditions, and injuries—and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Introduction: During the COVID-19 pandemic, as society struggled with increasing disease burden, economic hardships, and with disease morbidity and mortality, governments and institutions began implementing stay-at-home or shelter-in-place orders to help stop the spread of the virus. Although well-intentioned, one unintended adverse consequence was an increase in violence, abuse, and neglect.Methods: We reviewed the literature on the effect the pandemic had on domestic violence, child and elder abuse and neglect, human trafficking, and gun violence. In this paper we explore common themes and causes of this violence and offer suggestions to help mitigate risk during ongoing and future pandemics. Just as these forms of violence primarily target at-risk, vulnerable populations, so did pandemic-related violence target marginalized populations including women, children, Blacks, and those with lower socioeconomic status. This became, and remains, a public health crisis within a crisis. In early 2021, the American College of Emergency Physicians (ACEP) Public Health and Injury Committee was tasked with reviewing the impact the pandemic had on violence and abuse as the result of a resolution passed at the 2020 ACEP Council meeting.Conclusion: Measures meant to help control the spread of the COVID-19 pandemic had many unintended consequences and placed people at risk for violence. Emergency departments (ED), although stressed and strained during the pandemic, remain a safety net for survivors of violence. As we move out of this pandemic, hospitals and EDs need to focus on steps that can be taken to ensure they preserve and expand their ability to assist victims should another pandemic or global health crisis develop.Keywords: pandemic; elder abuse; human trafficking; COVID-19; gun violence; intimate partner violence; child abuse; fear.

Introduction: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention.The aim of this study was to describe EPs’ beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED).Methods: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons’ Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate.Results: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home.Conclusions: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

ObjectiveThis study examined emergency department (ED) and behavioral health (BH) provider attitudes and behaviors related to lethal means screening and counseling of patients with suicide risk, specifically examining differences by provider type and whether providers had firearms in their own home.MethodsEmergency department providers (physicians and mid-level practitioners) and behavioral health (BH) providers at four Colorado EDs completed an anonymous, web-based survey.ResultsFewer ED providers (35%) than BH providers (81%) felt confident in their ability to counsel patients about lethal means (p

A recommended component of suicide prevention is encouraging at-risk individuals to voluntarily and temporarily reduce access to firearms and other lethal methods. Yet delivering counseling on the topic can be difficult, given the political sensitivity of firearm discussions. To support such counseling, we sought to identify recommended framing and content of messages about reducing firearm access for suicide prevention. Through qualitative interviews with firearm owners and enthusiasts, we identified key points for use in framing (identity as a gun owner, trust, voluntary and temporary storage, and context and motivation) and specific content (preference for "firearm" over "gun," and legal issues such as background checks for transfers). These findings build on prior work and should enhance efforts to develop and deliver effective, acceptable counseling and-ultimately-prevent firearm suicide.

ObjectivesIn the United States, emergency medicine (EM) researchers hold proportionately fewer federal career development awards than researchers in other specialties. Others hypothesize that this deficit may partly be attributed to lack of mentors, departmental resources, and qualified applicants. Our objectives were to examine the association between departmental and institutional resources and career development awards and to describe the barriers to conducting research and btaining grants in EM.MethodsWe conducted an online, cross-sectional survey study of vice chairs for research and research directors at academic emergency departments in the United States in January and February 2016. Participants provided quantitative information regarding their department's demographics, available research resources, number of funded independent investigators, and number of career development awards. They were also asked about the perceived adequacy of departmental and institutional resources and perceived barriers to research and grant success. Data were analyzed using descriptive statistics and multivariable linear regression, as appropriate.ResultsOf 178 eligible participants, 103 (58%) completed the survey. Most departments reported some infrastructure for research and grant submission, including research coordinator(s) (n = 75/99; 76%, 95% confidence interval [CI] = 66%-84%), research associates (69/99; 70%, 95% CI = 60%-79%), and administrative/secretarial research support (79/101; 78%, 95% CI = 69%-86%). The majority of departments (56/103; 49%, 95% CI = 44%-64%) had no R01-funded researchers, and only 15 (15%, 95% CI = 8%-23%) had three or more R01-funded researchers. The most frequently reported challenge to junior faculty applying for grants was low motivation for applying (62/103; 60%, 95% CI = 50%-70%), followed closely by insufficient mentorship (50/103; 49%, 95% CI = 39%-59%) and discouragement from low funding rates (50/103; 49%, 95% CI = 39%-59%). In the multivariable model, only the number of departmental R-level-funded researchers was associated with the number of departmental career development awards (coefficient = 0.75, 95% CI = 0.39-1.11; R2  = 0.57).ConclusionsWhile more multiple departmental and institutional resources correlated with a greater number of funded career development awards, the single greatest predictor was the number of R-level-funded researchers in the department. Low motivation and insufficient mentorship were the most frequently reported barriers to junior faculty applying for career development awards. Further studies are needed to describe junior faculty perspectives on these issues and to explore strategies for overcoming these barriers.

Study objectiveTo identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda.MethodsNational content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated.ResultsFifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings.ConclusionThe technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Introduction: Medical and public health societies advocate that healthcare providers (HCPs) counselat-risk patients to reduce firearm injury risk. Anonymous online media comments often contain extremeviewpoints and may therefore help in understanding challenges of firearm safety counseling. To helpinform injury prevention efforts, we sought to examine commenters’ stated opinions regarding firearmsafety counseling HCPs.Methods: Qualitative descriptive analysis of online comments posted following news items (in May-June, 2016) about a peer-reviewed publication addressing when and how HCPs should counsel patientsregarding firearms.Results: Among 871 comments posted by 522 individuals, most (57%) were generally negative towardfirearm discussions, 17% were positive, and 26% were neutral/unclear. Two major categories andmultiple themes emerged. “Areas of agreement” included that discussions may be valuable (1) whenaddressing risk of harm to self or others, (2) in pediatric injury prevention, and (3) as general safetyeducation (without direct questioning), and that (4) HCPs lack gun safety and cultural knowledge. “Areasof tension” included whether (1) firearms are a public health issue, (2) counseling is effective preventionpractice, (3) suicide could/should be prevented, and (4) firearm safety counseling is within HCPs’ purview.Conclusion: Among this set of commenters with likely extreme viewpoints, opinions were generallynegative toward firearm safety conversations, but with some support in specific situations. Providingeducation, counseling, or materials without asking about firearm ownership was encouraged. Engagingfirearm advocates when developing materials may enhance the acceptability of prevention activities.[West J Emerg Med. 2017;18(5)903-912.]

Introduction: Youth seen in the emergency department (ED) with injuries from youth violence (YV) have increased risk for future violent injury and death. Pediatric emergency medicine (PEM) physicians rarely receive training in, or perform, YV screening and intervention. Our objective was to examine effects of a Web-based educational module on PEM physicians’ knowledge, attitudes, and behaviors regarding YV screening and interventions in the ED.Methods: All PEM fellows and attendings at an urban Level I pediatric trauma center were invited to complete an interactive Web-based education module (and 1-month booster) with information on YV’s public health impact and how to screen, counsel and refer YV-involved patients. Consenting subjects completed electronic assessments of YV prevention knowledge and attitudes (using validated measures when possible) before and after the initial module and after the booster. To measure behavior change, chart review identified use of YV-specific discharge instructions in visits by YV-injured PEM patients (age 12-17; identified by E codes) 6 months before and after the intervention. Survey data were analyzed with Fisher’s exact for binary outcomes and Kruskal-Wallis for Likert responses. Proportion of patients given YV discharge instructions before and after the intervention was compared using chi-square.Results: 18 (67%) of 27 PEM physicians participated; 1 was lost at post-module assessment and 5 at 1 month. Module completion time ranged from 15-30 minutes. At baseline, 50% of subjects could identify victims’ re-injury rate; 28% were aware of ED YV discharge instructions. After the initial module and at 1 month, there were significant increases in knowledge (p

Introduction: Technology-based interventions offer an opportunity to address high-risk behaviors inthe emergency department (ED). Prior studies suggest behavioral health strategies are more effectivewhen gender differences are considered. However, the role of gender in ED patient preferences fortechnology-based interventions has not been examined. The objective was to assess whether patientpreferences for technology-based interventions varies by gender.Methods: This was a secondary analysis of data from a systematic survey of adult (18 years of age),English-speaking patients in a large urban academic ED. Subjects were randomly selected during apurposive sample of shifts. The iPad survey included questions on access to technology, preferencesfor receiving health information, and demographics. We defined ‘‘technology-based’’ as web, textmessage, e-mail, social networking, or DVD; ‘‘non-technology-based’’ was defined as in-person,written materials, or landline. We calculated descriptive statistics and used univariate tests to comparemen and women. Gender-stratified multivariable logistic regression models were used to examineassociations between other demographic factors (age, race, ethnicity, income) and technology-basedpreferences for information on specific risky behaviors.Results: Of 417 participants, 45.1% were male. There were no significant demographic differencesbetween men and women. Women were more likely to use computers (90.8% versus 81.9%; p¼0.03),Internet (66.8% versus 59.0%; p¼0.03), and social networks (53.3% versus 42.6%; p¼0.01). 89% ofmen and 90% of women preferred technology-based formats for at least type of health information;interest in technology-based for individual health topics did not vary by gender. Concern aboutconfidentiality was the most common barrier to technology-based use for both genders. Multivariateanalysis showed that for smoking, depression, drug/alcohol use, and injury prevention, gendermodified the relationship between other demographic factors and preference for technology-basedhealth information; e.g., older age decreases interest in technology-based information for smokingcessation in women but not in men (aOR 0.96, 95% CI 0.93-0.99 versus aOR 1.00, 95% CI 0.97-1.03).Conclusion: Our findings suggest ED patients’ gender may affect technology preferences. Receptivityto technology-based interventions may be a complex interaction between gender and otherdemographic factors. Considering gender may help target ED patient populations most likely to bereceptive to technology-based interventions. [West J Emerg Med. 2014;15(5):593–599.]