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Introduction: The Philadelphia Department of Public Health (PDPH) declared a public health emergency due to hepatitis A in August 2019.1 Our emergency department (ED) serves a population with many of the identified risk factors for hepatitis A transmission. This study examines the impact of an ED-based hepatitis A vaccination program, developed in partnership with the PDPH, on incidence of hepatitis A infection and hospital admission.Methods: We conducted a retrospective review of all ED visits in the 12-week period centered around the implementation of the ED-based hepatitis A vaccination program. All adult patients presenting to the ED were offered vaccination, with vaccines supplied free of charge by the PDPH. We compared the incidence of diagnosis and of hospital admission for treatment of hepatitis A before and after implementation of the program.Results: There were 10,033 total ED visits during the study period, with 5009 of them prior to the implementation of the vaccination program and 5024 after implementation. During the study period, 669 vaccines were administered. Before the vaccination program began, 73 patients were diagnosed with hepatitis A, of whom 67 were admitted. After implementation of the program, 38 patients were diagnosed with hepatitis A, of whom 31 were admitted.Conclusion: A partnership between an ED and the local public health department resulted in the vaccination of 669 patients in six weeks in the midst of an outbreak of a vaccine-preventable illness, with a corresponding drop in ED visits and hospital admission for acute hepatitis A.

Introduction: Academic Emergency Medicine (EM) departments are not immune to natural disasters, economic or political forces that disrupt a training program’s operations and educational mission. Due process concerns are closely intertwined with the challenges that program disruption brings. Due process is a protection whereby an individual will not lose rights without access to a fair procedural process. Effects of natural disasters similarly create disruptions in the physical structure of training programs that at times have led to the displacement of faculty and trainees. Variation exists in the implementation of transitions amongst training sites across the country, and its impact on residency programs, faculty, residents and medical students.Methods: We reviewed the available literature regarding due process in emergency medicine. We also reviewed recent examples of training programs that underwent disruptions. We used this data to create a set of best practices regarding the handling of disruptions and due process in academic EM.Results: Despite recommendations from organized medicine, there is currently no standard to protect due process rights for faculty in emergency medicine training programs. Especially at times of disruption, the due process rights of the faculty become relevant, as the multiple parties involved in a transition work together to protect the best interests of the faculty, program, residents and students. Amongst training sites across the country, there exist variations in the scope and impact of due process on residency programs, faculty, residents and medical students.Conclusion: We report on the current climate of due process for training programs, individual faculty, residents and medical students that may be affected by disruptions in management. We outline recommendations that hospitals, training programs, institutions and academic societies can implement to enhance due process and ensure the educational mission of a residency program is given due consideration during times of transition.

PURPOSE: Early-phase clinical trials (EP-CTs) are designed to determine optimal dosing, tolerability, and preliminary activity of novel cancer therapeutics. Little is known about the time that patients spend interacting with the health care system (eg, time toxicity) while participating in these studies. METHODS: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs from 2017 to 2019 to obtain baseline characteristics and number of health care–associated days, defined as all inpatient and outpatient visits while on trial. We used univariable and multivariable analyses to identify predictors of increased time toxicity, defined as the proportion of health care–associated days among total days on trial. For ease of interpretation, we created a dichotomous variable, with high time toxicity defined as ≥20% health care–associated days during time on trial and used regression models to evaluate relationships between time toxicity and clinical outcomes. RESULTS: Among 408 EP-CT participants (mean age, 60.5 years [standard deviation, SD, 12.6]; 56.5% female; 88.2% White; 96.0% non-Hispanic), patients had an average of 22.5% health care–associated days while on trial (SD, 13.8%). Those with GI (B = 0.07; P =.002), head/neck (B = 0.09; P =.004), and breast (B = 0.06; P =.015) cancers and those with worse performance status (B = 0.04; P =.017) and those receiving targeted therapies (B = 0.04; P =.014) experienced higher time toxicity. High time toxicity was associated with decreased disease response rates (odds ratio, 0.07; P <.001), progression-free survival (hazard ratio [HR], 2.10; P <.001), and overall survival (HR, 2.16; P <.001). CONCLUSION: In this cohort of EP-CT participants, patients spent more than one-fifth of days on trial with health care contact. We identified characteristics associated with higher time toxicity and found that high toxicity correlated with worse clinical outcomes. These data could help inform patient-clinician discussions about EP-CTs, guide future trial design, and identify at-risk patients. EP-CT patients spent 20% of days on trial with health care contact. High time toxicity correlated with worse outcomes. [ABSTRACT FROM AUTHOR]

BackgroundMaternal resuscitation in the emergency department requires planning and special consideration of the physiologic changes of pregnancy. Perimortem cesarean delivery (PMCD) is a rare but potentially life-saving procedure for both mother and fetus. Emergency physicians should be aware of the procedure's indications and steps because it needs to be performed rapidly for the best possible outcomes.ObjectiveWe sought to review the approach to the critically ill pregnant patient in light of new expert guidelines, including indications for PMCD and procedural techniques.DiscussionThe prevalence of maternal cardiac arrest and survival outcomes of PMCD in the emergency department setting are difficult to estimate. Advanced cardiovascular life support protocols should be followed in maternal arrest with special considerations made based on the physiologic changes of pregnancy. The latest recommendations for maternal resuscitation are reviewed, including advance planning, rapid determination of gestational age, emergent delivery, and postprocedure considerations for PMCD.ConclusionsMaternal resuscitation requires knowledge of physiologic changes and evidence-based recommendations. PMCD outcomes are best for both mother and fetus when the procedure is performed rapidly and efficiently in the appropriate setting. Emergency physicians should be familiar with this unique clinical scenario so they are adequately prepared to intervene in order to improve maternal and fetal morbidity and mortality.

IntroductionThe objective of this study was to develop a process to maximize the safety and effectiveness of disclosing Positron Emission Tomography (PET) amyloid imaging results to cognitively normal older adults participating in Alzheimer's disease secondary prevention studies such as the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4) Study.MethodsUsing a modified Delphi Method to develop consensus on best practices, we gathered and analyzed data over three rounds from experts in two relevant fields: informed consent for genetic testing or human amyloid imaging.ResultsExperts reached consensus on (1) text for a brochure that describes amyloid imaging to a person who is considering whether to undergo such imaging in the context of a clinical trial, and (2) a process for amyloid PET result disclosure within such trials. Recommendations included: During consent, potential participants should complete an educational session, where they receive verbal and written information covering what is known and unknown about amyloid imaging, including possible results and their meaning, implications of results for risk of future cognitive decline, and information about Alzheimer's and risk factors. Participants should be screened for anxiety and depression to determine suitability to receive amyloid imaging information. The person conducting the sessions should check comprehension and be skilled in communication and recognizing distress. Imaging should occur on a separate day from consent, and disclosure on a separate day from imaging. Disclosure should occur in person, with time for questions. At disclosure, investigators should assess mood and willingness to receive results, and provide a written results report. Telephone follow-up within a few days should assess the impact of disclosure, and periodic scheduled assessments of depression and anxiety, with additional monitoring and follow-up for participants showing distress, should be performed.ConclusionsWe developed a document for use with potential study participants to describe the process of amyloid imaging and the implications of amyloid imaging results; and a disclosure process with attention to ongoing monitoring of both mood and safety to receive this information. This document and process will be used in the A4 Study and can be adapted for other research settings.

PURPOSE: To identify early-phase clinical trial (EP-CT) participants at risk for experiencing worse clinical outcomes and describe receipt of supportive care services. METHODS: A retrospective review of the electronic health records of consecutive patients enrolled in EP-CTs from 2017 to 2019 examined baseline characteristics, clinical outcomes, and receipt of supportive care services. The validated Royal Marsden Hospital (RMH) prognosis score was calculated using data at the time of EP-CT enrollment (scores range from 0 to 3; scores = 2 indicate poor prognosis). Differences in patient characteristics, clinical outcomes, and receipt of supportive care services were compared on the basis of RMH scores. RESULTS: Among 350 patients (median age = 63.2 years [range, 23.0-84.3 years], 57.1% female, 98.0% metastatic cancer), 31.7% had an RMH score indicating a poor prognosis. Those with poor prognosis RMH scores had worse overall survival (hazard ratio [HR], 2.00; P < .001), shorter time on trial (HR, 1.53; P < .001), and lower likelihood of completing the dose-limiting toxicity period (odds ratio, 0.42; P = .006) versus those with good prognosis scores. Patients with poor prognosis scores had greater risk of emergency room visits (HR, 1.66; P = .037) and hospitalizations (HR, 1.69; P = .016) while on trial, and earlier hospice enrollment (HR, 2.22; P = .006). Patients with poor prognosis scores were significantly more likely to receive palliative care consultation (46.8% v 27.6%; P < .001), but not other supportive care services. CONCLUSION: This study found that RMH prognosis score could identify patients at risk for decreased survival, shorter time on trial, and greater use of health care services. The findings underscore the need to develop supportive care interventions targeting EP-CT participants' distinct needs. [ABSTRACT FROM AUTHOR]

Objectives: Emergency medicine (EM) residents are currently evaluated via The Milestones, which have been shown to be imperfect and subjective. There is also a need for residents to achieve competency in patient safety and quality improvement processes, which can be accomplished through provision of peer comparison metrics. This pilot study aimed to evaluate the implementation of an objective peer comparison system for metrics that quantified aspects of quality and safety, efficiency and throughput, and utilization. Methods: This pilot study took place at an academic, tertiary care center with a 3‐year residency and 14 residents per postgraduate year (PGY) class. Metrics were compared within each PGY class using Wilcoxon signed‐rank and rank‐order analyses. Results: Significant changes were seen in the majority of the metrics for all PGY classes. PGY3s accounted for the significant change in EKG and X‐ray reads, while PGY1s and PGY2s accounted for the significant change in disposition to final note share. Physician evaluation to disposition decision was the only metric that did not reach significance in any class. Conclusions: These preliminary data suggest that providing objective metrics is possible. Peer comparison metrics could provide an effective objective addition to the milestone evaluation system currently in use. [ABSTRACT FROM AUTHOR]

The article presents the discussion on value of a trauma informed approach to the ethics consultation. Topics include value of incorporating community engagement informing the creation of a TIEC being sensitive to historical context, oppression, and marginalization; and providing trauma informed care due to community disinvestment, structural racism, and short-sighted incentive structures in medicine.

Starting in 2021, the 21st Century Cures Act mandated that patients have free access to their medical records. In this era of OpenNotes, we continue to uncover ways our written communication affects patient experiences, physician-patient relationships, and clinical care. For example, our documentation can cause patients to feel judged or offended and can affect their likelihood of seeking future care.1,2 Language can also influence us, as shown through studies that measure clinician attitudes and medical decision-making.3,4 Family physicians are well positioned to model best practices to decrease stigma and bias and increase clinician empathy through the language used in the medical record (Table 15). [ABSTRACT FROM AUTHOR]

1. Recognize the uniqueness of the early-phase clinical trial (EP-CT) patient population 2. Apply the concept of early intervention of supportive care services for patients with advanced cancer in EP-CTs Early-phase clinical trials (EP-CTs) investigate novel therapeutic approaches for people with cancer. Little is known about the use of supportive care (SC) services and timing of goals-of-care (GOC) discussions in EP-CTs. Analyze utilization of supportive care services and documentation of advance care planning by EP-CT participants. Retrospective review of electronic health records of consecutive patients enrolled in EP-CTs at Massachusetts General Hospital from 2017 to 2019. We collected information via electronic medical record to obtain baseline characteristics, receipt of SC services (palliative care [PC], social work [SW], physical therapy [PT], and nutrition), and documentation of GOC and code status discussions (before/during EP-CT vs after/never). Among 425 patients (median age 63.0; 56.0% female; 97.4% metastatic cancer, 22.1% gastrointestinal cancer), less than half received SC services before or during the trial (PC: 33.2% before/during, 66.8% post/never; SW: 41.9% before/during, 58.1% post/never; PT: 38.4% before/during, 61.6% post/never; and nutrition: 33.2% before/during, 62.1% post/never). Patients with gastrointestinal cancer were more likely to receive PC and SW before/during EP-CT (PC: 29.8% vs 18.3%, p = 0.009; SW: 27.5% vs 18.2%, p = 0.025), Earlier PC was associated with earlier hospice referral (HR = 1.95, p = 0.014) and shorter survival (HR = 1.54, p < 0.001). Patients receiving earlier SC services were more likely to have GOC discussions documented earlier (PC: 65.2% vs 13.0%, p < 0.001; SW: 41.0% vs 22.7%, p < 0.001; PT: 38.7% vs 25.2%, p = 0.005; nutrition: 39.1% vs 25.0%, p = 0.002). Patients with earlier PC were more likely to have earlier documented code status (46.8% vs 24.3%, p < 0.001) but not for any other service. Less than half of patients received SC services before or during their participation in EP-CTs. Those who received earlier SC services were more likely to have earlier documentation of GOC discussions. PC before or during EP-CT was associated with earlier code status, earlier hospice use, and shorter survival. Findings underscore the utility of supportive care services in EP-CTs. [ABSTRACT FROM AUTHOR]

Expanding the Safety Net: Emergency Department-Based Gun Lock Distribution for Violence Prevention. [Extracted from the article]