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PURPOSE: To determine whether breastfeeding behaviors, skin temperature, and blood glucose values could be influenced through the use of kangaroo care at the time of birth in healthy full term infants. METHOD: Descriptive study with nine full term neonates given kangaroo care beginning within 1 minute of birth and continuing until completion of the first breastfeeding by mothers who intended to breastfeed. Infant skin temperature was taken at 1 and 5 minutes after birth and every 15 minutes thereafter. Blood glucose level was taken 60 minutes after birth, the time at which the infant latched onto the breast was recorded, and breastfeeding behaviors were observed during the first breastfeeding. RESULTS: Skin temperature rose during birth kangaroo care in eight of the nine infants, and temperature remained within neutral thermal zone for all infants. Blood glucose levels varied between 43 and 85 mg/dL for infants who had not already fed and between 43 and 118 mg/dL for those who had fed. All but one infant spontaneously crawled to and latched onto a breast by 74 minutes after birth. Physicians noted that mothers were distracted from episiotomy or laceration repair discomfort during birth kangaroo care. CLINICAL IMPLICATIONS: In this institution, birth kangaroo care was integrated into routine delivery room care, with nurses noting no change in nursing workload. Nurses have noted observing the crawling, latching, and successful breastfeeding of most infants. Because of the results of this pilot study, birth kangaroo care has been implemented successfully with all women who wish to participate. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to examine the effects of Tai Chi Inspired Exercise (TCIE) as compared to Strength training on dynamic standing balance, static standing balance, and fall efficacy in a well elderly population. Method,: The study included two pre-existing groups of elderly retired community dwellers. One group of 10 subjects (mean age = 78 years) participated in Strength Training, and the other group of 12 subjects (mean age = 80.3 years) participated in TCIE. The Limits of Stability (LOS) was used as a pre-test and post-test measure for both groups. The Berg Balance Scale, Single Leg Stance (SLS), and the Survey of Activities and Fear of Falling in the Elderly (SAFFE) were administered post-test for both groups. These assessments quantified differences between the two groups based on static and dynamic standing balance, movement characteristics, fear of falling, and activity restriction. Results: Subjects of the TCIE group scored significantly higher in the post-test scores of the SLS with eyes open. TCIE and Strength Training pre-test and post-test scores of the LOS indicated significant differences in reaction time, velocity, endpoint excursion, maximum excursion, and directional control. Conclusion: Both Strength Training and TCIE positively impact balance. The Strength Training Group demonstrated greater balance during repetitive movements in one direction. The TCIE group demonstrated greater balance during functional tasks, showing generalization of fall prevention strategies into activities of daily living. [ABSTRACT FROM AUTHOR]

Introduction: The last national emergency department (ED) inventory was performed in 2007, and major changes in population demographics, healthcare needs and infrastructure have since occurred. We sought to obtain an updated inventory of EDs in Singapore to identify and describe changes in their characteristics and capabilities across the years., Methods: In 2021, the National Emergency Department Inventories (NEDI) instrument was administered to the leadership of Singapore EDs. Emergency departments in Singapore are opened round the clock, have no restrictions on who can access care and are equipped to handle general medical emergencies. The questionnaire comprises 16 items across three categories: (a) general characteristics, (b) patient volume and (c) medical capabilities., Results: We achieved 100% response rate from all 17 EDs - nine EDs in public hospitals and eight in private hospitals. In 2021, the EDs saw a total of 1,140,388 visits, an increase of 27% from 2007, with the median number of visits almost doubling (from 39,450 to 77,989); 41% and 59% of the EDs reported over 20% of visits arriving by ambulance and over 20% of visits resulting in inpatient admission, respectively. A clear distinction between public and private EDs across these metrics remained. Medical capabilities grew: 59% had access to a dedicated computed tomography scanner (up from 46%) and 82% had negative pressure isolation facilities (up from 54%). Overall, 41% of EDs self-assessed to be operating above their capacity., Conclusion: Singapore EDs have progressed in capabilities and capacity. Despite this, the increasing volume, complexity and acuity of patients are imposing strains on the emergency care system, signalling potential for systems improvement., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

Importance: Nearly 30 million predominantly rural US residents lack timely access to trauma care expertise available at level I or II trauma centers. Telehealth is an established approach to improve access to health care expertise using remote consultation; however, the prevalence of use of telehealth in trauma (teletrauma) across the US is not known., Objective: To examine the prevalence of, trends in, and factors associated with teletrauma use and adoption among US emergency departments (EDs)., Design, Setting, and Participants: This survey study included data from the National Emergency Department Inventory (NEDI)-USA survey from January 1, 2016, to December 31, 2020. Each year, a 1-page survey was sent to the directors of nonfederal, nonspecialty EDs by mail and email up to 3 times; nonresponders were further contacted via telephone to complete the survey. Data were analyzed from January to March 2023., Main Outcomes and Measures: The primary outcome was self-reported ED use of teletrauma for each year studied. Additional measures included data regarding self-reported use of any other telehealth service and ED characteristics. Multivariable logistic regression analyses were performed to assess ED characteristics associated with teletrauma use in 2020 and teletrauma adoption between 2017 and 2020., Results: Of 5586 EDs in the US in 2020, 4512 had available teletrauma survey data (80.8% response rate); 379 (8.4%) of these EDs reported teletrauma use. In contrast, 2726 (60.4%) reported use of any other telehealth service. Teletrauma use (among EDs with any telehealth use) ranged between 0% in Alabama; Connecticut; Washington, DC; Indiana; New Jersey; Nevada; Oklahoma; Oregon; Rhode Island; and South Carolina to more than 60% in Arkansas (39 of 64 [60.9%]), South Dakota (31 of 41 [75.6%]), and North Dakota (30 of 35 [85.7%]). Factors associated with teletrauma use included rural location (odds ratio [OR], 2.44; 95% CI, 1.77-3.36), critical access hospital (OR, 2.67; 95% CI, 1.83-3.88), and basic stroke hospital vs nonstroke hospital (OR, 1.74; 95% CI, 1.32-2.30) designations. Factors associated with adoption of teletrauma by 2020 included critical access hospital (OR, 1.98; 95% CI, 1.35-2.90) and basic stroke hospital vs nonstroke hospital (OR, 1.42; 95% CI, 1.04-1.94) designation., Conclusion and Relevance: This survey study found that teletrauma use lagged significantly behind use of other telehealth services in US EDs in 2020. While most EDs using teletrauma were located in rural areas, there was significant state-level variation in teletrauma use. Future research is needed on how teletrauma is being used and to identify barriers to its wider implementation.

Introduction: In the United States, more chronic and preventive healthcare is being delivered in the emergency department (ED) setting. Understanding the availability of preventive health services in the ED setting is crucial. Our goal was to understand the availability of a subset of preventive health services in US EDs and explore how that has changed over time., Methods: In 2022-2023, using the National Emergency Department Inventory (NEDI)-USA, we surveyed a random 20% (1,064) sampling of all 5,613 US EDs. We asked directors of these EDs about the availability of and preference for 12 preventive health services, social worker availability, self-reported percentage of uninsured ED patients, and measures of ED crowding. We also asked about perceptions of barriers to implementing preventive health services in the ED. We used unadjusted and multivariable logistic regression models to compare service frequency in 2022-2023 to prior findings from 2008-2009 that represented a 5.7% random sampling of all EDs., Results: Among 302 responders to the 2022-2023 survey (5.4% random sampling, 28.4% response rate), 94% reported offering at least one preventive health service, with a median of five services. The most common service offered was intimate partner violence screening (83%), while the least common was routine HIV screening (19%). Seven services (eg, intimate partner violence, alcohol risk, and smoking cessation screening) had a higher odds of being offered in 2022-2023 than in 2008-2009; findings were unchanged in sensitivity analyses. A small proportion of directors opposed offering preventive health services. However, many expressed concerns that preventive health services in the ED would lead to longer lengths of stay (56%), increased costs to their ED (58%), a diversion of staff time from providing acute care (50%), or that their patients would not have access to adequate follow-up (49%)., Conclusion: Nearly all EDs offer at least one preventive health service. Many offer multiple services; rates were higher than those identified in 2008-2009, in both unadjusted and multivariable models. Although limited by the response rate, this work provides the most recent and comprehensive snapshot of the type and frequency of a subset of preventive health services currently offered in US EDs., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Objectives: Pediatric readiness varies widely among emergency departments (EDs). The presence of a pediatric emergency care coordinator (PECC) has been associated with improved pediatric readiness and decreased mortality, but adoption of PECCs has been limited. Our objective was to understand factors associated with PECC implementation in general EDs., Methods: We conducted semistructured qualitative interviews with a purposively sampled set of EDs with and without PECCs. Interviews were completed, transcribed, and coded until thematic saturation was reached. Themes were identified through a consensus process and mapped to the Consolidated Framework for Implementation Research (CFIR)., Results: Twenty-four interviews were conducted and mapped to themes related to innovation, individuals and implementation process, outer setting (health system), and inner setting (hospital/ED). Addressing innovation, individuals, and implementation process, the primary theme was variability in how the PECC role was defined and who was responsible for implementing it. Regarding the outer setting, participants reported that limited system resources affected their ability to implement the PECC role. Key inner setting themes included concerns about limited visit volume, a lack of systems for measuring pediatric quality of care, and significant tension around change., Conclusions: Implementation of the PECC role appears to be limited by heterogeneous interpretations of the PECC, de-prioritization of pediatrics, and limited system resources. However, many participants described motivation to improve pediatric care and implement the PECC role in context of increasing pediatric visits; they offered strategies for future implementation efforts., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs., Methods: Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions., Results: In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar., Conclusions: Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care., (© 2023 Society for Academic Emergency Medicine.)

Objectives: Prior research suggests that the presence of state-specific pediatric emergency medical facility recognition programs (PFRPs) is associated with high emergency department (ED) pediatric readiness. The PFRPs aim to improve the quality of pediatric emergency care, but individual state programs differ. We aimed to describe the variation in PFRP characteristics and verification requirements and to describe the availability of pediatric emergency care coordinators (PECCs) in states with PFRPs., Methods: In mid-2020, we collected information about each PFRP from 3 sources: the state Emergency Medical Services for Children (EMSC) website, the EMSC Innovation and Improvement Center website, or via communication with the state's EMSC program manager. For each state with a PFRP, we documented program characteristics, including program start date, number of tiers, whether participation was required/optional, and requirements for verification., Results: Overall, we identified 17 states with active PFRPs. Five states had only 1 tier or level of recognition whereas the others had multiple. All programs did require presence of a PECC for verification. However, some PRFPs with multiple verification tiers did not require presence of a PECC to achieve each level of verification. In states with PFRPs, EDs with higher total visit volumes, a separate pediatric ED area, located in the Northeast, and earlier program start date were all more likely to have a PECC., Conclusions: There is variation in state PFRPs, although all prioritize the presence of a PECC. We encourage further research on the effect of different aspects of PFRPs on patient outcomes., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Telehealth capacity may be an important component of pandemic response infrastructure. We aimed to examine changes in the telehealth use by the US emergency departments (EDs) during COVID-19, and to determine whether existing telehealth infrastructure or increased system integration were associated with increased likelihood of use. Methods: We analyzed 2016-2020 National ED Inventory (NEDI)-USA data, including ED characteristics and nature of telehealth use for all US EDs. American Hospital Association data characterized EDs' system integration. An ordinary least-squares regression model obtained one-step-ahead forecast of the expected proportion of EDs using telehealth in 2020 based on growth observed from 2016 to 2019. Among EDs without telehealth in 2019, we used logistic regression models to examine whether system membership or existing telehealth infrastructure were associated with odds of innovation in telehealth use in 2020, accounting for ED characteristics. Results: Of 4,038 EDs responding to telehealth questions in 2019 and 2020 (73% response rate), 3,015 used telehealth in 2020. Telehealth use by US EDs increased more than expected in 2020 (2016: 58%, 2017: 61%, 2018: 65%, 2019: 67%, 2020: 74%, greater than predicted 71%, p = 0.004). Existing telehealth infrastructure was associated with increased telehealth innovation (OR = 1.88, 95% CI: 1.49-2.36), whereas hospital system membership was not (odds ratio [OR] = 1.00, 95% confidence interval [CI]: 0.80-1.25). Conclusions: Telehealth use by US EDs in 2020 grew more than expected and preexisting telehealth infrastructure was associated with increased innovation in its use. Preparation for future pandemic responses may benefit from considering strategies to invest in local infrastructure to facilitate technology adoption and innovation.

Background: Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S., Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12-50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics., Results: Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20-34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p  < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p  < 0.001)., Conclusion: In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations.

Background: Pediatric hospital care is becoming increasingly regionalized, and previous data have suggested that insurance may be associated with transfer. The aims of the study are to describe regionalization of pediatric care and density of the interhospital transfer network and to determine whether these varied by insurance status., Methods: Using the New York State ED Database and State Inpatient Database from 2016, we identified all pediatric patients and calculated regionalization indices (RI) and network density, overall and stratified by insurance. Regionalization indices are based on the likelihood of a patient completing care at the initial hospital. Network density is the proportion of actual transfers compared with the number of potential hospital transfer connections. Both were calculated using the standard State ED Database/State Inpatient Database transfer definition and in a sensitivity analysis, excluding the disposition code requirement., Results: We identified 1,595,566 pediatric visits (emergency department [ED] or inpatient) in New York in 2016; 7548 (0.5%) were transferred and 7374 transferred visits had eligible insurance status (Medicaid, private, uninsured). Of the transfers, 24% were from ED to ED with discharge, 28% from ED to ED with admission, 31% from ED to inpatient, 16% from inpatient to inpatient, and 1.2% from inpatient to ED. The overall RI was 0.25 (95% confidence interval [95% CI], 0.20-0.31). The overall weighted RI was 0.09 (95% CI, 0.06-0.12) and was 0.09 (95% CI, 0.06-0.13) for Medicaid-insured patients, 0.08 (95% CI, 0.05-0.11) for privately insured patients, and 0.08 (95% CI, 0.05-0.11) for patients without insurance. The overall network density was 0.018 (95% CI, 0.017-0.020). Network density was higher, and transfer rates were lower, for patients with Medicaid insurance as compared with private insurance., Conclusions: We found significant regionalization of pediatric emergency care. Although there was not material variation by insurance in regionalization, there was variation in network density and transfer rates. Additional work is needed to understand factors affecting transfer decisions and how these patterns might vary by state., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: In 2007, the US Institute of Medicine recommended that every emergency department (ED) appoint pediatric emergency care coordinators (PECCs). Despite this recommendation, our national surveys showed that few (17%) US EDs reported at least 1 PECC in 2015. This number increased slightly to 19% in 2016 and 20% in 2017. The current study objectives were to determine the following: percent of US EDs with at least 1 PECC in 2018, factors associated with availability of at least 1 PECC in 2018, and factors associated with addition of at least 1 PECC between 2015 and 2018., Methods: In 2019, we conducted a survey of all US EDs to characterize emergency care in 2018. Using the National ED Inventory-USA database, we identified 5514 EDs open in 2018. This survey collected availability of at least 1 PECC in 2018. A similar survey was administered in 2016 and identified availability of at least 1 PECC in 2015., Results: Overall, 4781 (87%) EDs responded to the 2018 survey. Among 4764 EDs with PECC data, 1037 (22%) reported having at least 1 PECC. Three states (Connecticut, Massachusetts, and Rhode Island) had PECCs in 100% of EDs. The EDs in the Northeast and with higher visit volumes were more likely to have at least 1 PECC in 2018 (all P < 0.001). Similarly, EDs in the Northeast and with higher visit volumes were more likely to add a PECC between 2015 and 2018 (all P < 0.05)., Conclusions: The availability of PECCs in EDs remains low (22%), with a small increase in national prevalence between 2015 and 2018. Northeast states report a high PECC prevalence, but more work is needed to appoint PECCs in all other regions., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Little is known about the recent usage of pediatric telehealth across all emergency departments (EDs) in the United States. Building upon our prior work, we aimed to characterize the usage of ED pediatric telehealth in the pre-COVID-19 era. Methods: The 2019 National ED Inventory-USA survey characterized all U.S. EDs open in 2019. Among EDs reporting receipt of pediatric telehealth services, we selected a random sample ( n  = 130) for a second survey on pediatric telehealth usage (2019 ED Pediatric Telehealth Survey). We also recontacted a random sample of EDs that responded to a prior, similar 2017 ED Pediatric Telehealth Survey ( n  = 107), for a total of 237 EDs in the 2019 ED Pediatric Telehealth Survey sample. Results: Overall, 193 (81%) of the 237 EDs responded to the 2019 Pediatric Telehealth Survey. There were 149 responding EDs that confirmed pediatric telehealth receipt in 2019. Among these, few reported ever having a pediatric emergency medicine (PEM) physician (10%) or pediatrician (9%) available for emergency care. Although 96% of EDs reported availability of pediatric telehealth services 24 h per day, 7 days per week, the majority (60%) reported using services less than once per month and 20% reported using services every 3-4 weeks. EDs most frequently used pediatric telehealth to assist with placement and transfer coordination (91%). Conclusions: Most EDs receiving pediatric telehealth in 2019 had no PEM physician or pediatrician available. Most EDs used pediatric telehealth services infrequently. Understanding barriers to assimilation of telehealth once adopted may be important to enable improved access to pediatric emergency care expertise.

Introduction: Although many emergency departments (EDs) receive telehealth services for psychiatry, or telepsychiatry, to manage acute psychiatric emergencies, national research on the usage of ED telepsychiatry is limited. To investigate ED telepsychiatry usage in the pre-COVID-19 era, we surveyed a sample of EDs receiving telepsychiatry in 2019, as a follow-up to a survey targeted to similar EDs in 2017. Methods: All U.S. EDs open in 2019 ( n  = 5,563) were surveyed to characterize emergency care. A more in-depth second survey on telepsychiatry use (2019 ED Telepsychiatry Survey) was then sent to 235 EDs. Of these EDs, 130 were randomly selected from those that reported telepsychiatry receipt in 2019, and 105 were selected based on their participation in a similar survey in 2017 (2017 ED Telepsychiatry Survey). Results: Of the 235 EDs receiving the 2019 Telepsychiatry Survey, 192 (82%) responded and 172 (90% of responding EDs) confirmed 2019 telepsychiatry receipt. Of these, five were excluded for missing data (analytic sample n  = 167). Telepsychiatry was the only form of emergency psychiatric services for 92 (55%) EDs. The most common usage of telepsychiatry was for admission or discharge decisions (82%) and transfer coordination (70%). The most commonly reported telepsychiatry mental health consultants were psychiatrists or other physician-level mental health professionals (74%). Discussion: With telepsychiatry as the only form of psychiatric services for most telepsychiatry-receiving EDs, this innovation fills a critical gap in access to emergency psychiatric care. Further research is needed to investigate the impact of the COVID-19 pandemic on usage of ED telepsychiatry.

Background: Despite the potential protective effect of a plant-based diet against chronic obstructive pulmonary disease (COPD), it remains unknown whether intake of different types of plant foods is beneficial for COPD. Our aims were to determine whether adherence to the healthful version of a plant-based diet (healthful Plant-based Diet Index (hPDI)) is associated with a lower COPD risk, whereas adherence to the unhealthful version (unhealthful Plant-based Diet Index (uPDI)) is associated with a higher COPD risk., Methods: 46,948 men from the Health Professionals Follow-up Study, 73,592 women from the Nurses' Health Study, and 85,515 women from the Nurses' Health Study II who completed biennial questionnaires from 1984-2018. We derived diet scores from repeated validated food frequency questionnaires. Among 5,661,994 person-years of follow-up, we documented 2605 validated COPD cases between 1984-2018., Results: After tight control for smoking and other potential confounders, COPD risk was 46% lower among participants with the highest hPDI score compared to those with the lowest score. Conversely, COPD risk was 39% higher among participants with the highest uPDI. Further adjustment for processed meat intake led to similar results., Conclusions: These findings provide further evidence for consuming a diet that emphasizes healthful plant foods to optimize lung health.

Objective: Trauma center certifications across the United States (U.S.) are not unified. Participation in the national trauma certification program established through the American College of Surgeons (ACS) is not universal, and many states maintain unique trauma certification systems with varying criteria. We investigated degree of similarity between the ACS national trauma certification program and state trauma certifications, then combined these distinct certifications into a unified national trauma center database., Methods: We performed a cross-sectional study of all non-specialty, non-federal emergency U.S. departments (EDs) open in 2018 to determine availability and levels of trauma centers. We created a "Standard" definition of trauma levels using ACS criteria as a benchmark. ACS similar trauma levels were then assigned to state levels I-III by comparing trauma receiving protocol, maximum response times, and general surgical coverage; through this process, levels across distinct systems established through different criteria were standardized., Results: In 2018, ACS certifications spanned 47 states and DC; 3 states did not participate in ACS (Mississippi, Pennsylvania, and Washington). A distinct, non-ACS state certification system was present in 47 states and DC; 3 states had no ongoing state certification system in 2018 (Maine, Rhode Island, and Vermont). Among 5,514 US EDs open in 2018, we identified 2,132 associated with adult and pediatric trauma centers (39%) holding certification (ACS, state, or both); 1,083 (51%) were certified levels I-III, and the rest (1,049, 49%) were levels IV-V. Of the 1,083 centers with any level I-III certification, 498 (46%) held ACS certification, and 1,059 (98%) held state certification. Applying ACS-similar criteria to centers with state levels I-III (n=1,059) resulted in a level change for 124 centers (12%). Using our "Standard" definition of a trauma level based on ACS criteria, our unified level I-III database included 959 (89%) adult and pediatric centers, with 24 (3%) ACS-certified only, 461 (48%) state-certified only, and 474 (49%) certified by both., Conclusions: Discrepancies exist between ACS and state trauma certification systems. The differences in level I-III state criteria confirm discrepant standards for a given trauma "level" across the U.S. We combined these certifications into a unified national trauma center database available to researchers and the public., Competing Interests: Declaration of Competing Interest The authors have no declarations or conflicts of interest to report., (Copyright © 2022. Published by Elsevier Ltd.)

Objectives: To describe first author gender differences and characteristics in 1) Society for Academic Emergency Medicine (SAEM) Annual Meeting abstracts and 2) resulting manuscript publications., Methods: We performed cross-sectional evaluation of SAEM abstracts from 1990, 1995, 2000, 2005, 2010, 2015, and 2020, compiling and reviewing a random sample of 100 abstracts for each year (total n = 700 abstracts). We documented abstract characteristics, including first author gender, and used the 2020 SAEM scoring rubric. We then searched PubMed to identify manuscript publications resulting from abstracts from 1990 to 2015 (n = 600). Finally, among abstracts that resulted in manuscript publication, we identified first and last author gender on both the abstracts and the resulting publication., Results: Overall, 29% (202/695; n = 5 missing gender) of abstracts had female first authors. Female first authors increased over time (e.g., 17% in 1990 to 35% in 2020). Abstract quality scores were similar (both median [interquartile range] of 11 ([9-12]). Overall, 42% (n = 254/600) of abstracts resulted in a manuscript publication, 39% (n = 65/202) with female and 44% (n = 189/493) with male first authors (p = 0.26). The median time (IQR) from abstract to manuscript publication was longer for abstracts with female first authors vs. those with male first authors (2 [1-3] years and 1 [1, 2] years, p < 0.02); 77% and 78% of publications resulting from abstracts with female and male first authors, respectively, had the same first author. Female first author abstracts more often converted to a male first author manuscript publication (18%, n = 12/65) compared to male first author abstracts converting to female first author publications (7%, n = 14/189)., Conclusions: A minority of SAEM abstracts, and manuscript publications resulting from them, had female first authors. Abstracts with female first authors took longer to achieve manuscript publication, and almost a fifth of female first author abstracts resulted in male first author manuscript publication., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Christopher L. Bennett reports a relationship with Society for Academic Emergency Medicine Foundation that includes: board membership. Ali S. Raja reports a relationship with Society for Academic Emergency Medicine that includes: board membership. CLB serves on the Society for Academic Emergency Medicine Foundation Board of Trustees. ASR serves on the Society for Academic Emergency Medicine Board of Directors., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Millions of people visit US national parks annually to engage in recreational wilderness activities, which can occasionally result in traumatic injuries that require timely, high-level care. However, no study to date has specifically examined timely access to trauma centers from national parks. This study aimed to examine the accessibility of trauma care from national parks by calculating the travel time by ground and air from each park to its nearest trauma center. Using these calculations, the percentage of parks by census region with timely access to a trauma center was determined., Methods: This was a cross-sectional study analyzing travel times by ground and air transport between national parks and their closest adult advanced trauma center (ATC) in 2018. A list of parks was compiled from the National Parks Service (NPS) website, and the location of trauma centers from the 2018 National Emergency Department Inventory (NEDI)-USA database. Ground and air transport times were calculated using Google Maps and ArcGIS, with medians and interquartile ranges reported by US census region. Percentage of parks by region with timely trauma center access-defined as access within 60 minutes of travel time-were determined based on these calculated travel times., Results: In 2018, 83% of national parks had access to an adult ATC within 60 minutes of air travel, while only 26% had timely access by ground. Trauma center access varied by region, with median travel times highest in the West for both air and ground transport. At a national level, national parks were unequally distributed, with the West housing the most parks of all regions., Conclusion: While most national parks had timely access to a trauma center by air travel, significant gaps in access remain for ground, the extent of which varies greatly by region. To improve the accessibility of trauma center expertise from national parks, the study highlights the potential that increased implementation of trauma telehealth in emergency departments (EDs) may have in bridging these gaps.

Background: Although primary percutaneous coronary intervention (pPCI) is the preferred intervention for ST-elevation myocardial infarction (STEMI), not all patients are admitted directly to an emergency department (ED) with 24/7/365 pPCI capabilities. This is partly due to a lack of a national system of known pPCI-capable EDs. Our objective was to create a unified, national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs., Methods: We compiled all hospitals designated as Chest Pain Centers with Primary PCI by the American College of Cardiology's (ACC) National Clinical Data Registry (NCDR), all STEMI Receiving Centers designated by the American Heart Association's (AHA) Mission: Lifeline registry, and all state-designated pPCI-capable hospitals and designation criteria from state departments of health. We matched ACC, AHA, and state-designated facilities to those in the 2019 National ED Inventory (NEDI)-USA database to identify all EDs in pPCI-capable hospitals., Results: Overall, 467 hospitals were recognized as Chest Pain Centers with Primary PCI by ACC, 293 hospitals were recognized as being STEMI Receiving Centers by AHA, and 827 hospitals were confirmed to be pPCI-capable by state designations and operated 24/7/365. Together, there were 1,178 EDs (21% of 5,587 total) co-located in pPCI-capable hospitals operating 24/7/365., Conclusions: There is substantial heterogeneity in cardiac systems of care, with large regional systems existing alongside local state-led initiatives. We created a unified national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs. This data set will be valuable for future cardiac systems research and improving access to pPCI., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: Since its founding in 1989, the Society for Academic Emergency Medicine (SAEM) has accepted thousands of abstracts for presentation at its annual meeting. We reviewed abstracts to characterize temporal changes in study design, abstract topics, quality scores, and proportion of abstracts published as manuscripts., Methods: In this serial cross-sectional study, we compiled accepted SAEM abstracts at 5-year intervals (1990, 1995, 2000, 2005, 2010, 2015, 2020) and then randomly selected 100 abstracts from each year for review by two investigators. We documented each abstract's study design, sample size, and whether it was a single-center or multicenter study. We assigned each abstract to the most appropriate topic category. Applying SAEM's abstract scoring system from 2020, we calculated the mean overall quality score per year. Finally, we searched PubMed to determine if abstracts from 1990-2015 meetings were published as manuscripts., Results: The number of accepted abstracts increased from 180 in 1990 to 879 in 2020 (+388%). The most common study design changed from laboratory study in 1990 (22%) to cohort study in 2020 (44%; p < 0.001). The median study sample size increased over time, from 105 (interquartile range [IQR] 25-389) in 1990 to 544 (IQR 102-2067) in 2020 (p < 0.001). Multicenter studies have become more common (19% in 1990 vs. 40% in 2020; p = 0.001). The most common topic categories also changed from cardiology/pulmonary/airway (40%) and orthopedic/trauma/burn (17%) in 1990 to health services research/health policy/operations (25%) and cardiology/pulmonary/airway (22%) in 2020. There was a 20% increase in overall quality scores (p < 0.001). Between 37% and 49% of the abstracts reviewed from each year were later published as manuscripts, with no significant change over time (p = 0.33)., Conclusions: Over the past 30 years, there have been significant changes to the study designs, topics, and quality scores of SAEM meeting abstracts. However, conversion of abstracts to published manuscripts remains a challenge., (© 2022 Society for Academic Emergency Medicine.)

The care of severely burned patients comes with unique requirements for specialized burn centers. The American Burn Association sets guidelines for burn centers and provides a voluntary program to verify their quality of care. However, not all burn centers are verified, and it is unclear which nonverified centers have met requirements set by their state health departments. To compile a complete database of all U.S. emergency departments in facilities with confirmed burn centers, we investigated state requirements to supplement data from the American Burn Association verification process. In 2020, only 13 states set requirements for burn centers; 3 states explicitly required American Burn Association verification, 4 used modified American Burn Association criteria, and 6 used alternate criteria. Only two states had separate requirements for pediatric burn centers. Based on adherence to state and American Burn Association criteria, we identified 90 confirmed burn centers in 2020, 85 of which had emergency departments. Of these 85, 45 (53%) were only verified, 17 (20%) were only state-confirmed, and 23 (27%) were both. Emergency departments in a confirmed burn center were more likely-than those without-to have higher adult and pediatric visit volumes, be academic, be a stroke or trauma (adult or pediatric) center, have a dedicated pediatric area, and have a pediatric emergency care coordinator. We compiled the first unified burn center database that incorporates state and American Burn Association lists. This database can be utilized in future health services research and is available to the public through a smartphone application., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Pediatric emergency care coordinators (PECCs) are associated with pediatric readiness of emergency departments (EDs). National organizations have called for PECCs in all EDs. Although the National Pediatric Readiness Program provides a list of suggested tasks for each PECC, little is known about implementation. Our objective was to describe the role of PECCs in EDs., Methods: We analyzed data from the 2019 National ED Inventory-USA to identify EDs with PECCs in 8 states (Arkansas, Florida, Iowa, Maryland, Nebraska, New York, Vermont, and Wisconsin). We called each ED that reported having a PECC to administer a standardized survey assessing NRPP tasks, specifically quality improvement (QI), education provision, skill verification, equipment responsibilities, and how many hours the PECC devoted to the role., Results: Of the 201 of 830 EDs (24%) that reported a PECC, 167 (83%) completed the survey, with >80% response rate in each state. Of these, 153 EDs (92%) confirmed a PECC, and during the past year, 81% participated in QI initiatives, 93% provided pediatric education, 90% verified staff skills, and 90% were responsible for ensuring medications, equipment, supplies, and resources for children. The median number of hours per week that PECCs devoted to this role was 12 (interquartile range, 5-40). There was wide variation between states (eg, 50% of PECCs in Vermont participating in QI activities, as compared with 100% in Nebraska)., Conclusions: Most PECCs report participating in the suggested National Pediatric Readiness Program tasks, although there was variation by state. Future directions for this work include assessing the association between PECC tasks and patient outcomes., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

Background: Telehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted., Objective: Our primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth., Methods: We used the 2016 National Emergency Department Inventory-USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both., Results: Of the 442 EDs surveyed, 378 (85.5%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1% (45/320) of EDs with telestroke services reported weekly use versus 2.9% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was "improving level of clinical care." Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8%) than for pediatric telehealth adoption (1/272, 0.4%; P=.003)., Conclusions: In 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care., (©Kori S Zachrison, Emily M Hayden, Krislyn M Boggs, Tehnaz P Boyle, Jingya Gao, Margaret E Samuels-Kalow, James P Marcin, Carlos A Camargo Jr. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.06.2022.)

Objectives: Emergency department (ED) data are often used to address questions about access to and quality of emergency care. Our objective was to compare one of the most commonly used data sources for national ED information, the American Hospital Association (AHA) Annual Survey, with a criterion database: the National Emergency Department Inventory (NEDI)-USA data set., Methods: We compared the 2015 and 2016 AHA surveys to the following 3 criterion standards: (1) the 2015 and 2016 NEDI-USA databases, which have information about all US EDs, including merged data from (2) Council of Teaching Hospitals (COTH) and (3) the Critical Access Hospital (CAH) program. We present descriptive results about the number of EDs in each data set; total and median visit volumes; locations in rural areas; and COTH, CAH, and freestanding ED (FSED) status., Results: The AHA survey identified 3893 US EDs in 2015. These EDs had a total annual visit volume of 129,197,493 visits, with a median of 22,772 visits (interquartile range, 8311-47,938). Compared with the NEDI-USA, the AHA included 1433 fewer EDs (-27%; 95% confidence interval [CI], -28% to -26%) and 23,615,163 (-15%) fewer visits. Specifically, AHA was missing 245 (-22%; 95% CI, -24% to -19%) of those located in rural areas, 268 (-20%; 95% CI, -22% to -18%) in a CAH, and 240 (-47%; 95% CI, -51% to -42%) FSEDs. We saw similar results using 2016 data., Conclusions: Although several aggregated results were similar between the compared data sources, the AHA data set excluded many US EDs, including many rural EDs and FSEDs. Consequently, the AHA underreported total ED visits by 15%. We encourage data users to be cautious when interpreting results from any 1 ED data source, including the AHA., Competing Interests: None of the authors report any potential conflicts of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Optimal care for patients with stroke relies on timely recognition and rapid transport to appropriate treatment, often by emergency medical services (EMS). Our primary objective was to describe EMS time intervals for patients with suspected stroke in the United States. We also sought to quantify the variation in EMS time intervals by geographic location and urbanicity., Methods: We conducted a cross-sectional evaluation of EMS 9-1-1 activations (ie, calls for service) included in the 2018 and 2019 National EMS Information System datasets. We included ground or air EMS activations for a 9-1-1 scene response where a patient aged ≥18 years with suspected stroke was treated and transported by EMS. Time intervals for dispatch, response, scene, transport, and total prehospital time (ie, from dispatch to hospital arrival) were calculated, stratified by ground and air transport type., Results: A total of 410 187 activations for suspected stroke were included, of which 98% were a ground transport. The median total prehospital time for ground transports was 35 minutes (interquartile range, 27-45, 90th percentile 58). Median total prehospital time for air transports was substantially longer at 56 minutes (interquartile range, 43-70, 90th percentile 86). Times varied by Census division and urbanicity with the shortest ground total prehospital times in the East North Central division and urban areas and longest times in the East South Central and rural and frontier areas., Conclusions: Timely EMS response and transport is critical for optimizing care of patients with suspected stroke. Using a large, national dataset of EMS activations, we found variations by geographic location and urbanicity in total prehospital time for ground and air EMS activations for patients with stroke.

Objectives: Stroke centers are essential for the optimal care of patients with acute stroke. However, there is no universally applied standard for stroke center certification/designation and no unified list of confirmed US stroke centers. Multiple national organizations, and some state governments, certify/designate hospitals as stroke centers of various levels, but discrepancies exist between these systems. We aimed to create a unified, easily accessible, national stroke center database., Methods: Lists of confirmed stroke centers were obtained from national certifying bodies (The Joint Commission [TJC], Det Norske Veritas, and Healthcare Facilities Accreditation Program) and each state government. Lists were reconciled to a common standard based on TJC requirements and incorporated into the 2018 National Emergency Department Inventory-USA database, which includes all emergency departments (EDs)., Results: Among 5533 US EDs, we confirmed 2446 (44%) as stroke centers, including 297 Comprehensive Stroke Centers, 14 Thrombectomy-capable Stroke Centers, 1459 Primary Stroke Centers, and 678 Acute Stroke Ready Hospitals. Compared with EDs without stroke centers, EDs with stroke centers had higher annual visit volumes, were more often academic, and were more often located in hospitals that had trauma or burn centers., Conclusion: We report the consolidation of multiple stroke center designation groups with varying criteria into a unified list of all confirmed US stroke centers linked to a comprehensive, national ED database. This data set will be valuable for future stroke systems research and improving access to emergency stroke care for patients. These data have the potential to further optimize the emergency care of patients with stroke., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objective: The aim of this study was to describe our expansion of a Massachusetts grassroots initiative-to increase the appointment of pediatric emergency care coordinators (PECCs) in emergency departments (EDs)-to all 6 New England states., Methods: We conducted annual surveys of all EDs in New England from 2015 to 2020 regarding 2014 to 2019, respectively. Data collection included ED characteristics. The intervention from 2018 to 2019 relied on principles of self-organization and collaboration with local stakeholders including state Emergency Medical Services for Children agencies, American College of Emergency Physician state chapters, and Emergency Nursing Association state chapters to help encourage appointment of at least 1 PECC to every ED. Most ED leadership were contacted in person at regional meetings, by e-mail and/or telephone. We reached out to each individual ED to both educate and encourage action., Results: Survey response rates were greater than 85% in all years. From 2014 to 2016, less than 30% of New England EDs reported a PECC. In 2017, 51% of EDs in New England reported a PECC, whereas in 2019, 91% of New England EDs reported a PECC. All other ED characteristics remained relatively consistent from 2014 to 2019., Conclusions: We successfully expanded a Massachusetts grassroots initiative to appoint PECCs to all of New England. Through individual outreach, and using principles of self-organization and creating collaborations with local stakeholders, we were able to increase the prevalence of PECCs in New England EDs from less than 30% to greater than 90%. This framework also led to the creation of a New England-wide PECC network and has fostered ongoing collaboration and communication throughout the region., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Telehealth is commonly used to connect emergency department (ED) patients with specialists or resources required for their care. Its infrastructure requires substantial upfront and ongoing investment from an ED or hospital and may be more difficult to implement in lower-resourced settings. Our aim was to examine for an association between ED payer mix and receipt of telehealth services., Methods: Using data from the National Emergency Department Inventory (NEDI)-USA 2016 survey, we categorized EDs based on receipt of telehealth services (yes/no). The NEDI-USA data for EDs in New York state was linked with data from state ED datasets (SEDD) and state inpatient data (SID) to determine EDs' payer mix (percent self-pay or Medicaid). Other ED characteristics of interest were rural location, academic status, and annual ED visit volume. We compared EDs with and without telehealth receipt, and used a logistic regression model to examine the relationship between ED payer mix and telehealth receipt after accounting for other ED characteristics., Results: Of the 162 New York EDs in the SEDD-SID dataset, 160 (99%) were linked to the NEDI-USA dataset and 133 of those responded (83%) to the survey. Telehealth receipt was reported by 48 EDs (36%, 95% confidence interval [CI], 28-44%). Emergency departments with and without telehealth receipt were similar (all P >0.40) with respect to rurality (6% vs 9%, respectively), academic status (13% vs 8%), and annual volume (median 36,728 vs 43,000). By contrast, median percent of Medicaid or self-pay patients was lower in telehealth EDs (36%) vs non-telehealth EDs (45%, P = 0.02). In adjusted analysis, increasing proportion of Medicaid and self-pay patients was associated with decreased odds of telehealth receipt (odds ratio 0.87 per 5% increase; 95% CI, 0.77-0.99). Rural location, academic status, and ED volume were not significantly associated with odds of ED telehealth receipt in the adjusted model., Conclusion: Among EDs in the state of New York, increasing proportion of self-pay and Medicaid patients was associated with decreased odds of ED telehealth receipt, even after accounting for rural location, academic status, and ED volume. The findings support the need for additional infrastructural investment in EDs serving a greater proportion of disadvantaged patients to ensure equitable access.

Objective: Physician assistant (PA) and nurse practitioner (NP) staffing is increasingly common in emergency departments (EDs), with variable physician supervision. We examined the feasibility of using publicly reported metrics as a measure of ED performance by staffing model., Methods: We classified a convenience sample of 915 EDs by staffing model using the National Emergency Department Inventory-USA 2016 and a follow-up survey. Staffing models included 24/7 attending coverage with PAs/NPs, 24/7 attending coverage without PAs/NPs, and PAs/NPs without 24/7 attending coverage. We linked EDs with Hospital Compare data to examine availability of metrics and compared metric performance by staffing model. We used regression modeling to examine the independent relationship between staffing model and ED performance after adjusting for ED characteristics., Results: Of 915 EDs surveyed, 767 (83%) responded and 436 (48%) had complete staffing data and any Hospital Compare data. The 216 EDs without any Hospital Compare data more frequently had no 24/7 attending coverage, were smaller, and were more often rural. Of 5 clinical metrics, 3 had data from < 100 EDs (range: 2%-21%), and 2 had data from 0 EDs. Of the 5 clinical metrics, only median time-to-ECG had enough data for analysis and found no difference among staffing models. Among the 3 process metrics, only time to discharge was significantly faster in EDs with any PA/NP staffing., Conclusion: Many EDs in our national sample lacked sufficient Hospital Compare data to evaluate performance, likely because of lower patient volumes for condition-specific metrics. Alternative strategies to measure quality of care delivery in these settings should be developed., Competing Interests: The authors declare conflict of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Telepsychiatry has made psychiatric care more accessible to emergency department (ED) patients. To date, most telepsychiatry studies have focused on specific populations or small groups of EDs. This study sought to examine the potential role of telepsychiatry across a wider range of EDs by comparing visit dispositions for psychiatric visits in EDs that did (versus did not) receive telepsychiatry services. ED telepsychiatry service status was identified from the 2016 National ED Inventory-USA and then linked to psychiatric visits from the 2016 New York State Emergency Department Databases/State Inpatient Databases. Unadjusted analyses and multivariable logistic regression models were used to evaluate associations between an ED's telepsychiatry service status and two clinical outcomes: use of observation services and ED visit disposition. Across all psychiatric ED visits, 712,236 were in EDs without telepsychiatry while 101,025 were in EDs with telepsychiatry. Most (99.8%) visits were in urban EDs. In multivariable logistic regression models, psychiatric visits in EDs with telepsychiatry services had lower odds (adjusted odds ratio 0.30) of using observation services compared to visits in EDs without telepsychiatry. The receipt of ED telepsychiatry is associated with lower usage of observation services for psychiatric visits, likely reducing the amount of time spent in the ED and mitigating the ongoing problem of ED crowding. An overwhelming majority of visits in EDs with telepsychiatry services were in urban hospitals with existing psychiatric services. Factors affecting the delivery and effectiveness of telepsychiatry services to hospitals lacking in psychiatric resources merit further investigation., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Importance: Employment in operating rooms (ORs) may involve exposure to several inhaled agents, including surgical smoke and disinfectants, which are associated with adverse respiratory health effects. However, the association of long-term employment in ORs and chronic obstructive pulmonary disease (COPD) remains unknown., Objective: To examine the association of working in an OR with incidence of COPD among female nurses in the US., Design, Setting, and Participants: This cohort study used data from the Nurses' Health Study for US female registered nurses who provided information on questionnaires regarding OR employment history in 1984 and job type in 1982 and who had no history of COPD in 1984 (baseline). Data analyses were conducted from April 1, 2020, to January 31, 2021., Exposures: Duration of nursing in the OR and job type., Main Outcomes and Measures: The associations of any employment as an OR nurse, duration of employment, and duration and job type with incidence of self-reported, physician-diagnosed COPD. Hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards regression models stratified by age and calendar year. Models were adjusted for covariates, with model 1 adjusting for age, model 2 also adjusting for cigarette smoking status and pack-year of smoking, and model 3 also adjusting for race and ethnicity, US Census region, and body mass index., Results: Among 75 011 female nurses included in the analyses, the mean (SD) age at baseline was 50.5 (7.2) years; 29% had a history of employment in an OR, and 3% had 15 or more years of OR experience. In model 3, employment in an OR for 15 or more years was associated with a 46% increased risk of developing COPD compared with no history of OR employment (HR, 1.46; 95% CI, 1.10-1.93). Compared with nurses who never worked in an OR and had an administrative or nursing education function or a nonnursing job in 1982, the risk of developing COPD was greater among nurses who provided outpatient care (HR, 1.24; 95% CI, 1.04-1.47) and nurses employed in inpatient units (HR, 1.31; 95% CI, 1.07-1.59) who had no history of OR employment and was 69% greater among nurses with OR experience of 15 years or more (HR, 1.69; 95% CI, 1.25-2.28)., Conclusions and Relevance: In this cohort study, OR employment of 15 years or more was associated with an increased risk of developing COPD among female nurses. Additional studies with more recent and direct environmental monitoring data of multiple occupational exposures are needed to assess the relative role of exposure to surgical smoke and disinfectants in the observed association.

Objective: To determine the availability of pediatric emergency care coordinators (PECCs) in US emergency departments (EDs) in 2015, and to determine the change in availability of PECCs in US EDs from 2015 to 2017., Study Design: As part of the National Emergency Department Inventory-USA, we administered a survey to all 5326 US EDs open in 2015; all 5431 in 2016; and all 5489 in 2017. Through these surveys, we assessed the availability of PECCs. Descriptive statistics characterized EDs with and without PECCs; multivariable logistic regressions identified characteristics independently associated with PECC availability., Results: Among the 4443 (83%) EDs with 2015 data, 763 (17.2%) reported the availability of at least 1 PECC. The states with the largest proportion of EDs with PECCs were Delaware (78%, 7/9 EDs) and Maryland (48%, 20/42 EDs), and no PECCs were reported in Mississippi, North Dakota, or Wyoming. Availability of a PECC was associated (P < .001) with larger annual total ED visit volume and a dedicated pediatric ED area. Compared with the 17.2% of EDs reporting a PECC in 2015, 833 (18.6%) reported 1 in 2016, and 917 (19.8%) reported 1 in 2017 (P < .001)., Conclusions: Availability of at least 1 PECC increased slightly (2.6%) between 2015 and 2017, but ∼80% of EDs continue without one., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To determine whether frequency of interfacility transfer varied by insurance status among pediatric emergency department (ED) patients. Secondarily, we tested for an association between insurance status and odds of transfer with discharge from the second ED without observation or admission., Methods: We used the 2016 New York State ED and Inpatient Databases to identify all patients <18 years. ED and hospital characteristics were from American Hospital Association and National ED Inventory-USA. Among all ED patients, we calculated the proportion transferred stratified by insurance status (private, public, none). Among ED-to-ED transfers, we identified transfers without subsequent observation or admission, and used hierarchical logistic regression modeling (adjusting for patient and transferring ED/hospital characteristics) to determine whether insurance status was associated with odds of discharge from the second ED without observation or admission., Results: Of 1,303,575 pediatric ED visits, 6086 (0.5%) were transferred. Transfers were less frequent among patients with public or no insurance. Of 3801 ED-to-ED transfers, 1451 (38%) were without subsequent observation or admission. In bivariate and multivariable analysis, transferred patients with public and with no insurance were less likely to be discharged without observation or admission relative to privately insured patients., Conclusion: Among ED-to-ED transfers, pediatric patients with public or without insurance were more often kept for observation or admission at the second hospital after transfer. Differences in disease acuity or in providers' perception of follow-up availability may play a role in explaining these patterns. This disparity merits further investigation., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Health services research on the differences in care between pediatric and general emergency departments (EDs) is limited by ambiguity regarding the definition of a pediatric ED. Our goal was to determine the proportion of EDs captured by commonly used definitions of pediatric ED., Methods: We linked data for 2016 from two databases from New York State - the State Emergency Department Database and State Inpatient Database (SEDD/SID) and the National Emergency Department Inventory-USA (NEDI-USA). We examined the following 4 common definitions of pediatric ED: (1) admission capability, (2) physically distinct pediatric area in the ED, (3) membership in the Children's Hospital Association, and (4) volume of pediatric ED visits (patients <18 years ). We calculated the proportion of EDs that would be defined as pediatric for each criterion. We also examined the differences in patient demographics among pediatric EDs based on each criterion., Results: A total of 160 New York EDs were included in the linked databases. Across the 4 criteria, the proportion of EDs meeting the definition of pediatric ranged from 0% to 86%. Of the EDs, 86% had pediatric admission capability, 27%-38% had a physically distinct pediatric ED, and 8% were members of the Children's Hospital Association. No hospitals met the SEDD/SID criterion of ≥70% visits for patients <18 years., Discussion: The number of EDs and characteristics of patients seen varied widely based on the criterion used to define pediatric ED. Database linkage may make it challenging to identify pediatric hospitals in administrative data sets. A valid, standard definition of pediatric ED is critically needed to advance health services research., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Importance: Given the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however., Objective: To describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US., Design, Setting, and Participants: This national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020., Main Outcomes and Measures: The Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates., Results: A total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population., Conclusions and Relevance: This study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.

Background: Emergency care is an essential part of a health system. Ecuador has recognized emergency medicine as a specialty and has two emergency medicine residency training programs. However, little has been published about emergency department characteristics and capabilities in Ecuador., Objective: We described the characteristics and capabilities of emergency departments (EDs) in Quito, Ecuador, in 2017, using the National Emergency Department Inventory (NEDI) survey., Methods: The 23-item survey included questions pertaining to ED characteristics, including: visit volume, physical and administrative structure, clinical capabilities, technological resources, and consult personnel availability. This study included all EDs in Quito operating 24 hours/day, 7 days/week, and serving all patients seeking care. One representative from each ED was asked to complete the survey based on calendar year 2017., Findings: Thirty EDs met the inclusion criteria, and 26 completed the survey (87% response). The median number of ED beds was 17 (range 2-61). Median annual visit volume was 22,580 (range 1,680 to 129,676). All but two EDs provided care for both children and adults. Cardiac monitors were available in 88% of EDs, CT scanners in 68%, and rooms for respiratory isolation in 31%. Most EDs could manage patients with general medicine (92%), general surgery (92%), and gynecology (88%) emergencies 24/7. Fewer were able to provide hand surgery (45%) and dental (28%) care 24/7. Typical length of stay was 1-6 hours in 65% and >6 hours in 31% of EDs. Half of EDs reported operating at full capacity and 27% reported operating over their capacity. When compared to private EDs, government EDs (public and social security) had a higher mean number of visits per year (50,090 government vs. 13,968 private, p < 0.001), higher mean number of ED beds (36 government vs. 9 private, p = 0.002), and higher length of stay (58% of patient stays > 6 hours in government EDs vs. 86% of patient stays 1-6 hours in private EDs, p = 0.009)., Conclusions: EDs in Quito varied widely with respect to annual visit volume, ability to treat different pathologies 24/7, and resources. Most EDs are functioning at or over capacity, and a substantial number have long lengths of stay. Further research and investment in emergency care could help increase the capacity and efficiency of EDs in Ecuador., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Objectives: Occupational use of disinfectants among healthcare workers has been associated with asthma. However, most studies are cross-sectional, and longitudinal studies are not entirely consistent. To limit the healthy worker effect, it is important to conduct studies among early- to mid-career workers. We investigated the prospective association between use of disinfectants and asthma incidence in a large cohort of early- to mid-career female nurses., Methods: The Nurses' Health Study 3 is an ongoing, prospective, internet-based cohort of female nurses in the USA and Canada (2010-present). Analyses included 17 280 participants without a history of asthma at study entry (mean age: 34 years) and who had completed ≥1 follow-up questionnaire (sent every 6 months). Occupational use of high-level disinfectants (HLDs) was evaluated by questionnaire. We examined the association between HLD use and asthma development, adjusted for age, race, ethnicity, smoking status and body mass index., Results: During 67 392 person-years of follow-up, 391 nurses reported incident clinician-diagnosed asthma. Compared with nurses who reported ≤5 years of HLD use (89%), those with >5 years of HLD use (11%) had increased risk of incident asthma (adjusted HR (95% CI), 1.39 (1.04 to 1.86)). The risk of incident asthma was elevated but not statistically significant in those reporting >5 years of HLD use and current use of ≥2 products (1.72 (0.88 to 3.34)); asthma risk was significantly elevated in women with >5 years of HLD use but no current use (1.46 (1.00 to 2.12))., Conclusions: Occupational use of HLDs was prospectively associated with increased asthma incidence in early- to mid-career nurses., Competing Interests: Competing interests: CAC reports grants from NIOSH/CDC and NIH during the conduct of the study. JEC reports grants from National Institute of Occupational Safety and Health, grants from National Institute of Environmental Health Sciences and grants from National Heart, Lung and Blood Institute during the conduct of the study., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Telemedicine is a valuable tool to improve access to specialty care in emergency departments (EDs), and states have passed telemedicine parity laws requiring insurers to reimburse for telemedicine visits. Our objective was to determine if there is an association between such laws and the use of telemedicine in an ED., Methods: As part of the 2016 and 2017 National ED Inventory-USA surveys, directors of all 5404 EDs in the United States were surveyed on the use of telemedicine. States were divided into those with any form of telemedicine parity law and those without (as of January 2016). We investigated the association between a telemedicine parity law and the use of telemedicine controlling for ED characteristics; state was included as a random intercept., Results: In 2016, among the 50 states and the District of Columbia (DC), 21 (41%) had a telemedicine parity law, whereas 30 (59%) did not. Among the 4418 ED respondents to the telemedicine question (82% response rate), 2352 (53%) received telemedicine. The proportion of EDs receiving telemedicine varied widely across the states and DC, ranging from 13% in DC to 89% in Maine. Neither the presence nor duration of state telemedicine parity laws were independently associated with ED receipt of telemedicine in 2016 nor the adoption of telemedicine from 2016 to 2017., Conclusion: Telemedicine parity laws were not associated with use of telemedicine in the ED. These results suggest that other factors are driving the wide variation in ED use of telemedicine across states., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Objectives: Our objective was to estimate the emergency medicine board-certified emergency physician (EMBC EP) workforce supply and demand by U.S. state., Methods: To estimate state demand, we applied the methodology from our 2005 analysis to calculate full-time equivalent (FTE) EMBC EP demand for each emergency department (ED). The 2017 National Emergency Department Inventory-USA provided visit volumes for all EDs, while the American Board of Medical Specialties supplied the 2017 number of EMBC EPs per state. Assuming that at least one EMBC EP should be present 24/7 in each ED (requiring 5.35 FTEs minimum), we calculated the total FTEs required by dividing each ED's visit volume by the estimated average visits seen by an EMBC EP (3,548 visits per year) and then summed FTEs by state. The U.S. Census Bureau provided state demographic characteristics. We used multivariable linear regression to examine the association between state demographics and the density of EMBC EPs per state and compared 2017 results to our prior 2005 analysis., Results: There were 40,716 total EMBC EPs in 2017, fulfilling 77% of the estimated national demand. This was a substantial increase from 23,035 total EMBC EPs fulfilling 58% of demand in 2005. The 2017 supply ranged from 24% of demand in North Dakota to 142% in Hawaii. A lower density of EMBC EPs was associated with states in the Midwest and South (p < 0.001) and with a more rural population (p = 0.02). The absolute shortage of EMBC EPs worsened or remained the same in one-fourth of states., Conclusion: While the total number of EMBC EPs nearly doubled between 2005 and 2017, a shortage of full-time coverage persists. The supply and demand vary greatly by state. Worsening absolute shortages in several states show that the distribution of EMBC EPs is not meeting demand across the United States, particularly in rural areas., (© 2020 by the Society for Academic Emergency Medicine.)

Study Objective: The number of freestanding emergency departments (EDs) has increased rapidly in the United States, and there is concern that such entities are located near existing EDs rather than in areas lacking emergency care. In 2018, the Medicare Payment Advisory Commission recommended a reduction in Medicare reimbursement rates to freestanding EDs located within 6 miles of the nearest hospital-based ED. We aim to assess the potential effect of this proposal., Methods: Using the 2016 National Emergency Department Inventory-USA database, we identified the locations and visit volumes of all US freestanding EDs. Using QGIS, we mapped the distances from all freestanding EDs to both the nearest hospital-based ED and to the nearest ED (either hospital-based or freestanding ED)., Results: We collected location information for all 5,375 EDs open in 2016. Of these EDs, 609 (11%) were freestanding. Few freestanding EDs (1.4%) were located in rural areas and only 11% were located in areas with a median household income of less than $43,000. Overall, 460 freestanding EDs (76%) were within 6 miles of the nearest hospital-based ED, and these had 5.3 million total patient visits, whereas those greater than 6 miles away had 2.6 million visits., Conclusion: We found that most freestanding EDs (76%) are within 6 miles of the nearest hospital-based ED, and most visits (67%) to freestanding EDs are to those within that proximity, indicating that many freestanding EDs would be affected by this Medicare Payment Advisory Commission proposal, if implemented., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination., Methods: We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination., Results: Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination., Conclusion: Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)