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As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.

Reperfusion is critical for improving outcomes of patients experiencing ischemic stroke. Increasing evidence supports tenecteplase as an alternative to alteplase, with many potential benefits. This article discusses the current state of the evidence for intravenous reperfusion and considers strategies for improving access, including possible modifications to efficacy-related regulatory updates.

Introduction Our objective was to determine whether acute ischemic stroke (AIS) patients' language preference is associated with differences in time from symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DTI), and door-to-needle (DTN) time. Methods We identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003–05/2014 for whom language preference was available. Data were abstracted from the institution's Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DTI, and 4) DTN time. Results Of 3190 AIS patients, 300 (9.4%) were non-English preferring (NEP). Comparing NEP to English preferring (EP) patients in unadjusted or adjusted analyses, time from symptom discovery to arrival and rate of EMS utilization were not significantly different (overall median time 157 min, IQR 55–420; EMS utilization: 65% vs. 61.3% p = 0.21). There was also no significant differences in DTI or in likelihood of guideline-recommended DTI ≤ 25 min (overall median 59 min, IQR 29–127; DTI ≤ 25 min 24.3% vs. 21.3% p = 0.29) or DTN time or in likelihood of guideline-recommended DTN ≤ 60 min (overall median 53 min, IQR 36–73; DTN ≤ 60 min 62.5% vs. 58.2% p = 0.60). Conclusion Consistent with prior reports examining disparities in care, a systems-based approach to acute stroke prevents differences in hospital-based metrics. Reassuringly, NEP and EP patients also had similar speed of symptom recognition and EMS utilization.

Study objective There has been increasing attention to screening for health-related social needs. However, little is known about the screening practices of emergency departments (EDs). Within New England, we seek to identify the prevalence of ED screening for health-related social needs, understand the factors associated with screening, and understand how screening patterns for health-related social needs differ from those for violence, substance use, and mental health needs. Methods We analyzed data from the 2018 National Emergency Department Inventory–New England survey, which was administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening. Results Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one health-related social need, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder, and 159 (96%) for mental health needs. EDs reported a wide range of social work resources to address identified needs, with 155 (93%) reporting any social worker availability and 41 (27%) reporting continuous availability. Conclusion New England EDs are screening for health-related social needs at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address health-related social needs. We encourage research on the development of scalable solutions for identifying and addressing health-related social needs in the ED.

Study objective Telemedicine has potential to add value to the delivery of emergency care in rural emergency departments (EDs); however, previous work suggests that it may be underused. We seek to understand barriers to telemedicine implementation in rural EDs, and to describe characteristics of rural EDs that do and do not use telemedicine. Methods We performed a secondary analysis of data from the 2016 National Emergency Department Inventory survey, identifying rural EDs that did and did not use telemedicine in 2016. All rural EDs that did not use telemedicine were administered a follow-up survey asking about ED staffing, transfer patterns, and perceived barriers to telemedicine use. We used a similar instrument to survey a sample of EDs that did use telemedicine, but we replaced the question about barriers with questions related to telemedicine use. Data are presented with descriptive statistics. Results We identified 977 rural EDs responding to the 2016 National Emergency Department Inventory–USA survey; 453 (46%; 95% confidence interval 43% to 50%) did not use telemedicine. Among rural nonusers, 374 EDs (83%; 95% confidence interval 79% to 86%) responded to our second survey. Of the 177 rural EDs using telemedicine that we surveyed, 153 responded (86%; 95% confidence interval 80% to 91%). Among rural EDs not using telemedicine, 235 (67%) reported that their ED, hospital, or health system leadership had considered it. Cost was the most commonly cited reason for lack of adoption (n=86; 37%). Conclusion Among US rural EDs, cost is a commonly reported barrier that may be limiting the extent of telemedicine adoption.

Objectives Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency. Materials and methods A commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ β nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics. Results Among 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0–6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p