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Policy Points Clarifications to Senate Bill (SB)1152 are necessary to address the differences between inpatient and emergency department (ED) discharge processes, determine how frequently an ED must deliver the SB1152 bundle of services to a single patient, and establish expectations for compliance during off-hours when social services are unavailable. Because homelessness cannot be resolved in a single ED visit, the state should provide funding to support housing-focused case workers that will follow patients experiencing homelessness (PEH) through the transition from temporary shelters to permanent supportive housing. Medi-Cal could fund the delivery of the SB1152 bundle of services to defray the costs to public hospitals that provide care for high numbers of PEH. California legislators should consider complementary legislation to increase funding for shelters so that sufficient capacity is available to accept PEH from EDs and hospitals, and to fund alternative strategies to prevent poverty and the upstream root causes of homelessness itself.ContextPrompted by stories of "patient dumping," California enacted Senate Bill (SB) 1152, which mandates that hospitals offer patients experiencing homelessness (PEH) a set of resources at discharge to ensure safety and prevent dumping.MethodsTo evaluate interventions to meet the requirements of SB1152 across three emergency departments (EDs) of a Los Angeles County public hospital system with a combined annual census of 260,000 visits, we used an explanatory sequential mixed methods approach, focusing first on quantitative evaluation and then using information from qualitative interviews to explain the quantitative findings.FindingsIn total, 2.9% (1,515/52,607) of encounters involved PEH. Documentation of compliance with the eight required components of SB1152 was low, ranging from 9.0% to 33.9%. Twenty-five provider interviews confirmed support for providing assistance to PEH in the ED, but the participants described barriers to compliance, including challenges in implementing universal screening for homelessness, incongruity of the requirements with the ED setting, the complexity of the patients, and the limitations of SB1152 as a health policy.ConclusionsDespite operationalizing universal screening for homelessness, we found poor compliance with SB1152 and identified multiple barriers to implementation.

OBJECTIVES A paucity of point-of-care ultrasound (POCUS) databases limits machine learning (ML). Assess feasibility of training ML algorithms to visually estimate left ventricular ejection fraction (EF) from a subxiphoid (SX) window using only apical 4-chamber (A4C) images. METHODS Researchers used a long-short-term-memory algorithm for image analysis. Using the Stanford EchoNet-Dynamic database of 10,036 A4C videos with calculated exact EF, researchers tested 3 ML training permeations. First, training on unaltered Stanford A4C videos, then unaltered and 90° clockwise (CW) rotated videos and finally unaltered, 90° rotated and horizontally flipped videos. As a real-world test, we obtained 615 SX videos from Harbor-UCLA (HUCLA) with EF calculations in 5% ranges. Researchers performed 1000 randomizations of EF point estimation within HUCLA EF ranges to compensate for ML and HUCLA EF mismatch, obtaining a mean value for absolute error (MAE) comparison and performed Bland-Altman analyses. RESULTS The ML algorithm EF mean MAE was estimated at 23.0, with a range of 22.8-23.3 using unaltered A4C video, mean MAE was 16.7, with a range of 16.5-16.9 using unaltered and 90° CW rotated video, mean MAE was 16.6, with a range of 16.3-16.8 using unaltered, 90° CW rotated and horizontally flipped video training. Bland-Altman showed weakest agreement at 40-45% EF. CONCLUSIONS Researchers successfully adapted unrelated ultrasound window data to train a POCUS ML algorithm with fair MAE using data manipulation to simulate a different ultrasound examination. This may be important for future POCUS algorithm design to help overcome a paucity of POCUS databases.

While much is known about governance models for research informatics programs in academic medical centers and similarly situated cancer centers, community and public health systems have been less well-characterized. As part of implementing an enterprise research governance framework, leaders in the Los Angeles County Department of Health Services established a research informatics program, including research data warehousing. The strategy is focused on high-priority, patient-centered research that leverages the investment in health IT and an efficient, sustained contribution from 2 affiliated Clinical Translational Sciences Institutes. This case study describes the foundational governance framework and policies that were developed. We share the results of several years of planning, implementation, and operations of an academically funded research informatics service core embedded in a large, multicenter county health system. We include herein a Supplementary Appendix of governance documents that may serve as pragmatic models for similar initiatives.

Background Early administration of convalescent plasma obtained from blood donors who have recovered from coronavirus disease 2019 (Covid-19) may prevent disease progression in acutely ill, high-risk patients with Covid-19. Methods In this randomized, multicenter, single-blind trial, we assigned patients who were being treated in an emergency department for Covid-19 symptoms to receive either one unit of convalescent plasma with a high titer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or placebo. All the patients were either 50 years of age or older or had one or more risk factors for disease progression. In addition, all the patients presented to the emergency department within 7 days after symptom onset and were in stable condition for outpatient management. The primary outcome was disease progression within 15 days after randomization, which was a composite of hospital admission for any reason, seeking emergency or urgent care, or death without hospitalization. Secondary outcomes included the worst severity of illness on an 8-category ordinal scale, hospital-free days within 30 days after randomization, and death from any cause. Results A total of 511 patients were enrolled in the trial (257 in the convalescent-plasma group and 254 in the placebo group). The median age of the patients was 54 years; the median symptom duration was 4 days. In the donor plasma samples, the median titer of SARS-CoV-2 neutralizing antibodies was 1:641. Disease progression occurred in 77 patients (30.0%) in the convalescent-plasma group and in 81 patients (31.9%) in the placebo group (risk difference, 1.9 percentage points; 95% credible interval, −6.0 to 9.8; posterior probability of superiority of convalescent plasma, 0.68). Five patients in the plasma group and 1 patient in the placebo group died. Outcomes regarding worst illness severity and hospital-free days were similar in the two groups. Conclusions The administration of Covid-19 convalescent plasma to high-risk outpatients within 1 week after the onset of symptoms of Covid-19 did not prevent disease progression. (SIREN-C3PO ClinicalTrials.gov number, NCT04355767.)

Conversational User Interfaces (CUI) are becoming increasingly utilized in Health applications due to their ability to engage patients and support clinical workflows. Yet recent reviews show that our understanding of CUI performance and user preferences towards them is still lacking. This work examines factors that explain people’s preference for engaging with a social needs screening CUI in a clinical context with 41 emergency department visitors. We demonstrate that people with low health literacy and high attitude towards emotional interaction (AEI) prefer responding to questions via CUI rather than a form-based survey. Specifically, participants with low health literacy appreciate the improved understandability offered by the CUI, whereas participants with high AEI appreciate the added level of engagement offered through conversational interactions. Our work advances the understanding of the benefits of CUI for different user groups in health contexts and beyond.

Objective Because higher parental psychosocial stress is associated with worsened asthma outcomes in children, we sought to determine if a parent-focused stress management intervention would improve outcomes among their at-risk African American children. Methods We enrolled self-identified African American parent-child dyads (children aged 4-12 years old with persistent asthma, no co-morbidities, on Medicaid) in a prospective, single-blind, randomized clinical trial with follow-up at 3, 6, and 12 months. All children received care based on the guidelines of the National Institutes of Health. Developed with extensive local stakeholder engagement, the intervention consisted of four individual sessions with a community wellness coach (delivered over 3 months) supplemented with weekly text messaging and twice monthly group sessions (both delivered for 6 months). The main outcome was asthma symptom-free days in the prior 14 days by repeated measures at 3 and 6 months follow-up. Results We randomized 217 parent-child dyads and followed 196 (90.3%) for 12 months. Coaches completed 338/428 (79%) of all individual sessions. Symptom-free days increased significantly from baseline in both groups at 3, 6, and 12 months, but there were no significant differences between groups over the first 6 months. At 12 months, the intervention group sustained a significantly greater increase in symptom-free days from baseline [adjusted difference = 0.92 days, 95% confidence interval (0.04, 1.8)]. Conclusion The intervention did not achieve its primary outcome. The efficacy of providing psychosocial stress management training to parents of at-risk African American children with persistent asthma in order to improve the children's outcomes may be limited. Clinicaltrials.gov NCT02374138.

Author(s): Yadav, Kabir; Meeker, Daniella; Mistry, Rakesh D; Doctor, Jason N; Fleming-Dutra, Katherine E; Fleischman, Ross J; Gaona, Samuel D; Stahmer, Aubyn; May, Larissa | Abstract: BackgroundAntibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.MethodsThis study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).ResultsThere were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI]n= 4.5% to 7.9%) to 2.4% (95% CIn= 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CIn= 1.0% to 3.4%) to 1.5% (95% CIn= 0.7% to 2.3%) with an odds ratio of 0.67 (95% CIn= 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.ConclusionImplementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.

BACKGROUND Subdissociative-dose ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is effective in relieving acute exacerbations of chronic pain. METHODS This study was a randomized double-blind placebo-controlled trial conducted May 2017 to June 2018 at a public teaching hospital (ClinicalTrials.gov #NCT02920528). The primary endpoint was a 20-mm decrease on a 100-mm visual analog scale (VAS) at 60 minutes. Power analysis using three groups (0.5 mg/kg ketamine, 0.25 mg/kg ketamine, or placebo infused over 20 minutes) estimated that 96 subjects were needed for 90% power. Inclusion criteria included age > 18 years, chronic pain > 3 months, and acute exacerbation (VAS ≥ 70 mm). Pain, agitation, and sedation were assessed by VAS at baseline and 20, 40, and 60 minutes after initiation of study drug. Telephone follow-up at 24 to 48 hours used a 10-point numeric rating scale for pain. RESULTS A total of 106 subjects were recruited, with three excluded for baseline pain

Introduction Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. Methods Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." Results Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). Conclusion The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis that has quickly overwhelmed our healthcare system. It has led to significant shortages in personal protective equipment (PPE), ventilators, and intensive care unit beds across the nation. As the initial entry point for patients with suspected COVID illness, emergency departments (ED) have had to adapt quickly to prioritize the safety of patients and providers while still delivering optimal, timely patient care. COVID-19 has presented many challenges for the ED that also extend to all inpatient services. Some of these key challenges are the fundamental tasks of communicating with patients in respiratory isolation while minimizing PPE usage and enabling all patients who have been affected by hospitals' visitor restrictions to connect with their families. We discuss the design principles behind implementing a robust in-hospital telehealth system for patient-provider and patient-family communication, provide a review of the strengths and weaknesses of potential videoconferencing options, and deliver concise, step-by-step guides for setting up a secure, low-cost, user-friendly solution that can be rapidly deployed.

Accessing patients’ social needs is a critical challenge at emergency departments (EDs). However, most EDs do not have extra staff to administer screeners, and without personnel administration, response rates are low especially for low health literacy patients. To facilitate engagement with such low health literacy patients, we designed a chatbot - HarborBot for social needs screening. Through a study with 30 participants, where participants took a social needs screener both via a traditional survey platform and HarborBot, we found that the two platforms resulted in comparable data (equivalent in 87% of the responses). We also found that while the high health literate participants preferred the traditional survey platform because of efficiency (allowing participants to proceed at their own pace), the low health literate participants preferred HarborBot as it was more engaging, personal, and more understandable. We conclude with a discussion on the design implications for chatbots for social needs screening.

The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.

Asthma remains the most prevalent chronic illness among children. Despite the substantial body of literature examining children with asthma, few studies have examined parents’ perspectives of the condition and experiences of caregiver stress. Parents of children with chronic illnesses experience elevated stress and may have limited opportunities to cope with complex emotions while caring for children with asthma. Drawing from focus groups and interviews with African American and Hispanic parents of children with asthma, this qualitative study was conducted as part of a patient-centered engagement process to inform the refinement of an intervention aimed at reducing stress among parents of children with asthma. All data were transcribed and underwent three waves of inductive analysis. The content analysis indicated that the unpredictable nature of asthma and the caregiving burden associated with managing children’s asthma contributed to parents’ stress, and external contexts compounded the impact of these stressors. Parents also reported having difficulty identifying how they coped with stress and employed approaches to coping with stress that they applied intermittently but encountered several barriers to enacting known or available coping strategies. Analyses also revealed that parents desired a multimodal stress reduction intervention that emphasized building relationships, allowed for flexibility, and encouraged staff-parent communication. Whereas African American and Hispanic parents’ experiences of stress and coping strategies were similar, their preferences differed in regards to incorporating technology into the intervention, the credentials of facilitators, and the salience of language preferences. Understanding the complexities of stressors facing caregivers is important for developing interventions to support parents and children coping with asthma, and in particular when working with families from diverse backgrounds.

Background Antibiotic stewardship efforts have expanded focus from inpatient to include outpatient settings. However, stewardship is urgently needed in acute care ambulatory settings: emergency departments (EDs) and urgent care centers (UCCs). Implementation of antibiotic stewardship in acute ambulatory care settings has been limited. Two major barriers to effective implementation exist: 1) lack of adaptation of successful outpatient stewardship interventions to the acute care ambulatory setting and 2) absence of rigorous measurement of implementation processes in EDs and UCCs in a manner that informs future scale and spread. Objectives Our objective was to apply an implementation science approach to address antibiotic overuse and inappropriate use in EDs and UCCs. Methods This study was a redesign of an evidence-based outpatient antibiotic stewardship intervention at participating EDs and UCCs using an innovative implementation science framework (dynamic adaptation process), adaptable for local clinical workflow and local champion provision. We evaluated multiple implementation outcome metrics throughout a cluster-randomized comparative effectiveness clinical trial of two approaches to the adapted antibiotic stewardship interventions. Results Our preimplementation phase included 21 in-depth interviews and online provider surveys (52% response rate). For the postimplementation survey, we had a 39% response rate. We identified common themes including patient expectations, lack of knowledge of existing guidelines, and maintenance of education over time. Additional themes indicated differences in modifications needed by type of clinical setting. Adoption of public commitment was high, with 79% of providers signing a commitment log, and 84% received public commitment flair. Signing of public commitment posters rate was 62%, as several sites chose not to use this component. Acceptability, fidelity, and appropriateness were also measured. Conclusions We demonstrate that implementation science approaches can help address the problem of unnecessary antibiotic use in EDs and UCCs with high acceptability and adoption. Similar approaches could be used to tailor quality improvement interventions in these settings.

Objective To compare the efficacy of buccally absorbed prochlorperazine (BAP) to intravenous prochlorperazine (IVP) for the abortive treatment of migraine headaches. Methods Randomized double-blind trial. Eighty subjects aged 18-65 presenting with migraines to the ED of a safety-net, urban hospital. Subjects were randomized to receive either 6 mg BAP plus 2.25 mL saline IV placebo or 10 mg IVP and buccally absorbed saccharine pill placebo. A 100 mm visual analog scale (VAS) was used to assess pain, nausea, and sedation. Comparisons between groups were analyzed by the Mann-Whitney U test or Fisher's exact test. Results Eighty subjects were recruited from November 2016 to December 2017; 79 completed the study. Demographics: 60 women and 19 men with a mean age of 38 ± 12.2 years. Initial mean VAS pain scores were similar between groups (BAP: 78.5 ± 19.9 mm vs IVP: 76.9 ± 19.5 mm). The improvement in mean VAS pain scores over 60 minutes for the BAP group was not significantly different from the IVP group (-54.9 ± 29.7 mm vs -66.7 ± 23.2 mm, respectively; P = 0.08). No significant differences were found in rates of nausea or sedation. Nine subjects in the BAP group required rescue treatment compared to 1 in the IVP group. Five subjects reported symptoms consistent with akathisia in the IVP group while no adverse effects were reported in the BAP group. Conclusion Buccally absorbed prochlorperazine (BAP) is an effective, non-invasive treatment for migraine headaches when compared to intravenous prochlorperazine (IVP).

Stakeholder engagement has the potential to develop research interventions that are responsive to patient and provider preferences. This approach contrasts with traditional models of clinical research in which researchers determine the study's design. This article describes the effect of stakeholder engagement on the design of a randomized trial of an intervention designed to improve child asthma outcomes by reducing parental stress. The study team developed and implemented a stakeholder engagement process that provided iterative feedback regarding the study design, patient-centered outcomes, and intervention. Stakeholder engagement incorporated the perspectives of parents of children with asthma; local providers of community-based medical, legal, and social services; and national experts in asthma research methodology and implementation. Through a year-long process of multidimensional stakeholder engagement, the research team successfully refined and implemented a patient-centered study protocol. Key stakeholder contributions included selection of patient-centered outcome measures, refinement of intervention content and format, and language framing the study in a culturally appropriate manner. Stakeholder engagement was a useful framework for developing an intervention that was acceptable and relevant to our target population. This approach might have unique benefits in underserved populations, leading to sustainable improvement in health outcomes and reduced disparities.

Shared decision-making (SDM) is essential to advancing patient-centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient-engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care. This article is protected by copyright. All rights reserved.

Objectives . To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients. Design . Secondary analysis of retrospective cohort study. Setting . Five EDs (four academic, one community) in the United States. Participants . Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]). Measurements . Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type. Results . A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P

“Expected practice” is a recently described method to alter clinical behavior. We implemented an expected practice around short-course antibiotic therapy, which was associated with decreased antibiotic utilization for multiple bacterial infections. Thus, we describe this expected practice as a novel, simple, and inexpensive tool to enhance antibiotic stewardship.

Utilization of ultrasound in the evaluation of patients with undifferentiated hypotension has been proposed in several protocols. We sought to assess the impact of an ultrasound hypotension protocol on physicians' diagnostic certainty, diagnostic ability, and treatment and resource utilization.Prospective observational study.Emergency department in a single, academic tertiary care hospital.A convenience sample of patients with a systolic blood pressure less than 90 mm Hg after an initial fluid resuscitation, who lacked an obvious source of hypotension.An ultrasound-trained physician performed an ultrasound on each patient using a standardized hypotension protocol. Differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. Blinded chart review was conducted for management and diagnosis during the emergency department and inpatient hospital stay.The primary endpoints were the identification of an accurate cause for hypotension and change in physicians' diagnostic uncertainty. The secondary endpoints were changes in treatment plan, use of resources, and changes in disposition after performing the ultrasound. One hundred eighteen patients with a mean age of 62 years were enrolled. There was a significant 27.7% decrease in the mean aggregate complexity of diagnostic uncertainty before and after the ultrasound hypotension protocol (1.85-1.34; -0.51 [95% CI, -0.41 to -0.62]) as well as a significant increase in the absolute proportion of patients with a definitive diagnosis from 0.8% to 12.7%. Overall, the leading diagnosis after the ultrasound hypotension protocol demonstrated excellent concordance with the blinded consensus final diagnosis (Cohen k = 0.80). Twenty-nine patients (24.6%) had a significant change in the use of IV fluids, vasoactive agents, or blood products. There were also significant changes in major diagnostic imaging (30.5%), consultation (13.6%), and emergency department disposition (11.9%).Clinical management involving the early use of ultrasound in patients with hypotension accurately guides diagnosis, significantly reduces physicians' diagnostic uncertainty, and substantially changes management and resource utilization in the emergency department.

Pain is highly prevalent in health care settings; however, disparities continue to exist in pain care treatment. Few studies have investigated if differences exist based on patient-related characteristics associated with aging. The objective of this study was to determine if there are differences in acute pain care for older vs younger patients. This was a multicenter, retrospective, cross-sectional observation study of 5 emergency departments across the United States evaluating the 2 most commonly presenting pain conditions for older adults, abdominal and fracture pain. Multivariable adjusted hierarchical modeling was completed. A total of 6,948 visits were reviewed. Older (⩾ 65 years) and oldest (⩾ 85 years) were less likely to receive analgesics compared to younger patients (

Objectives The primary individual research career development awards for emergency medicine (EM) investigators are the K08 and K23 awards. To the best of the authors’ knowledge, postaward productivity of EM K08 and K23 awardees has not been previously described. The objectives were to describe EM researchers who have received K08 or K23 awards and to evaluate their postaward federal funding and publications. Methods This was a cross-sectional study, conducted during January 2012, of clinician-scientists who previously completed EM residency or fellowship programs and have received K08 or K23 awards from the National Institutes of Health (NIH) or Agency for Healthcare Research and Quality (AHRQ) between fiscal years 2000 through 2011. Awardees were identified through the NIH reporting tool (NIH RePORTER). Postaward funding was abstracted, including R01-equivalent funding for K awardees who completed their K training by the end of the 2011 fiscal year. Postaward publications (with journal impact factor) were tabulated for all K awardees using PubMed and Journal Citation Reports. An e-mail survey was also conducted during September and October 2012 to describe the awardee characteristics (demographics and research background) of all EM K awardees using REDCap electronic data captures tools. Simple descriptive statistics are reported. Results Sixty-three EM awardees were identified; 24 (38%) were K08 awardees, and 39 (62%) were K23 awardees. Of the 38 (60%) awardees who completed their K training, 16 (42%) obtained subsequent federal funding, with six (16%) obtaining R01 funding (median time from end of K award to R01 award was 4.5 years). Overall, EM awardees published a mean (±SD) of 4.0 (±1.3) manuscripts per year (after the start of their K awards); the mean (±SD) impact factor of the journals in which these manuscripts were published was 4.5 (±5.7). Forty-five (71%) of EM K awardees responded to the survey. Respondents had a median age of 36 years (interquartile range [IQR] = 35 to 38 years), and 33 were male (73%). The median time from completion of residency to start of the K award was 6 years (IQR = 4 to 7 years), with 27 (60%) completing a research fellowship prior to the K award. Conclusions Over 40% of EM K awardees who completed their career development training subsequently obtained federal funding as principal investigator (PI) or co-PI, while approximately one in six obtained R01 equivalent funding. Given the numerous barriers facing emergency care researchers, EM K awardees demonstrate good postaward productivity. Resumen Descripcion y Productividad de los Investigadores de Medicina de Urgencias y Emergencias que Recibieron Becas de Formacion de Carrera Investigadora Supervisada K23 o K08 Objetivos Las principales becas individuales de formacion para la carrera investigadora en medicina de urgencias y emergencias (MUE) son las becas K08 y K23. Segun el conocimiento de los autores, no se ha descrito previamente la productividad tras las becas K08 y K23. Los objetivos fueron describir los investigadores de MUE que recibieron una beca K08 o K23, y evaluar sus publicaciones y ayudas publicas tras la beca. Metodologia Estudio transversal de investigadores clinicos que completaron previamente una residencia en MUE o una beca de investigacion y que habian recibido una beca K08 o K23 de los National Institutes of Health (NIH) o de la Agency for Healthcare Research & Quality (AHRQ) durante los anos 2000 a 2011, y que se llevo a cabo en enero del 2012. Los becados se identificaron a traves de las tablas publicadas por los NIH (NIH RePORTER). Se resumio la ayuda tras la beca, que incluyo la ayuda equivalente al R01 para becados K que completaron sus formacion K al final del ano 2011. Las publicaciones tras la beca (con el factor impacto de la revista) se tabularon para todos los becados K mediante PubMed y Journal Citation Reports. Se llevo a cabo tambien una encuesta a traves de correo electronico durante septiembre y octubre de 2012 para describir las caracteristicas (demograficas y experiencia investigadora) de todos los becados K de MUE usando las tablas de captura de datos electronicas REDCap. Se presentaron las estadisticas descriptivas. Resultados Se identificaron 63 becados de MUE, 24 (38%) fueron recibieron becas K08, y 39 (62%) becas K23. De los 38 (60%) becados que completaron su formacion K, 16 (42%) obtuvieron ayudas publicas posteriormente y 6 (16%) obtuvieron ayudas R01 (mediana de tiempo entre el final de la beca K y la beca R01 de 4,5 anos). De todos, los becados de MUE publicaron una media de 4,0 (desviacion estandar [DE] ±1.3) articulos por ano (tras el inicio de su beca K), con una media de puntuacion de factor de impacto de la revista a 5 anos de 4,5 (DE ±5,7) por publicacion. Cuarenta y cinco (71%) de los becados K de MUE respondieron a la encuesta. Los respondedores tenia una mediana de edad de 36 anos (RIC 35 a 38 anos) y 33 fueron varones (73%). La mediana de tiempo desde que se finalizo la residencia hasta el inicio de la beca K fue de 6 anos (RIC 4 a 7 anos), con 27 (60%) que completaron un programa de una beca de investigacion previamente a la obtencion de la beca K. Conclusiones Mas del 40% de los becados K de MUE que completaron su formacion obtuvieron ayudas publicas como investigador principal o coinvestigador, mientras que aproximadamente uno de cada seis obtuvo ayudas equivalentes a R01. Dadas las numerosas barreras para los investigadores en MUE, los becarios de MUE demuestran una buena productividad tras la beca.

Study objective We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program. Methods We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. Results During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. Conclusion The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.

Shared decision making (SDM) is a patient-centered communication skill that is essential for all physicians to provide quality care. Like any competency or procedural skill, it can and should be introduced to medical students during their clerkships (undergraduate medical education), taught and assessed during residency training (graduate medical education), and have documentation of maintenance throughout an emergency physician's career (denoted as continuing medical education). A subgroup representing academic emergency medicine (EM) faculty, residents, content experts, and patients convened at the 2016 Academic Emergency Medicine Consensus Conference on SDM to develop a research agenda toward improving implementation of SDM through sustainable education efforts. After developing a list of potential priorities, the subgroup presented the priorities in turn to the consensus group, to the EM program directors (CORD-EM), and finally at the conference itself. The two highest-priority questions were related to determining or developing EM-applicable available tools and on-shift interventions for SDM and working to determine the proportion of the broader SDM curriculum that should be taught and assessed at each level of training. Educating patients and the community about SDM was also raised as an important concept for consideration. The remaining research priorities were divided into high-, moderate-, and lower-priority groups. Moreover, there was consensus that the overall approach to SDM should be consistent with the high-quality educational design utilized for other pertinent topics in EM.

BACKGROUND: The authors have previously demonstrated highly reliable automated classification of free-text computed tomography (CT) imaging reports using a hybrid system that pairs linguistic (natural language processing) and statistical (machine learning) techniques. Previously performed for identifying the outcome of orbital fracture in unprocessed radiology reports from a clinical data repository, the performance has not been replicated for more complex outcomes. OBJECTIVES: To validate automated outcome classification performance of a hybrid natural language processing (NLP) and machine learning system for brain CT imaging reports. The hypothesis was that our system has performance characteristics for identifying pediatric traumatic brain injury (TBI). METHODS: This was a secondary analysis of a subset of 2,121 CT reports from the Pediatric Emergency Care Applied Research Network (PECARN) TBI study. For that project, radiologists dictated CT reports as free text, which were then deidentified and scanned as PDF documents. Trained data abstractors manually coded each report for TBI outcome. Text was extracted from the PDF files using optical character recognition. The data set was randomly split evenly for training and testing. Training patient reports were used as input to the Medical Language Extraction and Encoding (MedLEE) NLP tool to create structured output containing standardized medical terms and modifiers for negation, certainty, and temporal status. A random subset stratified by site was analyzed using descriptive quantitative content analysis to confirm identification of TBI findings based on the National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements project. FINDINGS were coded for presence or absence, weighted by frequency of mentions, and past/future/indication modifiers were filtered. After combining with the manual reference standard, a decision tree classifier was created using data mining tools WEKA 3.7.5 and Salford Predictive Miner 7.0. Performance of the decision tree classifier was evaluated on the test patient reports. RESULTS: The prevalence of TBI in the sampled population was 159 of 2,217 (7.2%). The automated classification for pediatric TBI is comparable to our prior results, with the notable exception of lower positive predictive value. Manual review of misclassified reports, 95.5% of which were false-positives, revealed that a sizable number of false-positive errors were due to differing outcome definitions between NINDS TBI findings and PECARN clinical important TBI findings and report ambiguity not meeting definition criteria. CONCLUSIONS: A hybrid NLP and machine learning automated classification system continues to show promise in coding free-text electronic clinical data. For complex outcomes, it can reliably identify negative reports, but manual review of positive reports may be required. As such, it can still streamline data collection for clinical research and performance improvement. Language: en

Background Given that orbital fractures are found in only one of every eight patients receiving computed tomography for acute orbital trauma, we sought to prospectively identify clinical predictors of orbital fracture that may obviate the need for exposing low-risk patients to ionizing radiation. Methods Prospective cohort study conducted from July 2007 through October 2009 at two urban emergency departments. Consecutive patients undergoing computed tomography for acute blunt orbital trauma were evaluated on 15 clinical findings before imaging. The primary outcome of interest was presence of any acute orbital fracture. The secondary outcome was a fracture requiring emergent operative intervention. Multivariable logistic regression analysis with multiple imputation was used to derive a predictive risk score. Results A total of 2,262 patients with acute orbital trauma were enrolled. Median age was 38 years with male predominance (68.3%). Acute orbital fractures were found in 360 patients (15.9%). The derived risk score included orbital rim tenderness, periorbital emphysema, subconjunctival hemorrhage, pain with extraocular movement, impaired extraocular movement, and epistaxis. Across 10 multiply imputed data sets, a mean of 660 patients (29.2%) lacked all six equally weighted predictors, of which 6.3% (95% confidence interval, 4.3-8.2) experienced an acute orbital fracture and only 0.5% (95% confidence interval, 0.0-1.0) required emergent operative intervention. Conclusion Six clinical predictors identify patients with blunt orbital trauma at increased risk for acute orbital fracture. A risk score of 0 identifies patients at very low risk for emergent operative intervention. Multicenter studies are needed to validate these findings and derive a clinical decision instrument to reduce orbital imaging without compromising patient safety. Level of evidence Diagnostic study, level II.

Background The influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ED) has not been well studied. It has traditionally been taught that there is a “golden period” beyond which lacerations are at higher risk of infection and therefore should not be closed primarily. The proposed cutoff for this golden period has been highly variable (3–24 h in surgical textbooks). Our objective is to answer the following research question: are wounds closed via primary repair after the golden period at increased risk for infection? Methods We searched MEDLINE, EMBASE, and other databases as well as bibliographies of relevant articles. We included studies that enrolled ED patients with lacerations repaired by primary closure. Exclusion: (1) delayed primary repair or secondary closure, (2) wounds requiring intra-operative repair, skin graft, drains, or extensive debridement, and (3) grossly contaminated or infected at presentation. We compared the outcome of wound infection in two groups of early versus delayed presentations (based on the cut-offs selected by the original articles). We used “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) criteria to assess the quality of the included trials. Results 418 studies were identified. Four trials enrolling 3724 patients in aggregate met our inclusion/exclusion criteria. The overall quality of evidence was low. The infection rate in the wounds that presented with delay ranged from 1.4% to 32%. One study with the smallest sample size (only 19 delayed wounds), which only enrolled lacerations to hand and forearm, showed higher rate of infection in patients with delayed (older than 12 h) wounds (relative risk of infection: 4.8, 95% confidence interval, 1.9–12.0). The infection rate in delayed wound groups in the remaining three studies was not significantly different. Conclusion The existing evidence does not support the existence of a golden period nor does it support the role of wound age on infection rate in simple lacerations.

Background Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of purulent skin and soft-tissue infections (SSTIs) in the Unites States. Little is known regarding health care provider management strategies for abscesses in the emergency department (ED). Understanding variability in practice patterns could be an important step in implementing evidence-based guidelines. Objectives The objectives of this study are to describe practice patterns for purulent SSTI in a single, urban, academic ED, including antibiotic selection and incision and drainage (I & D) technique, and to compare these practices with current evidence. Methods Prospective data were collected on a convenience sample of adults presenting to our urban, academic ED (annual volume, 65 000 per year) between June 2009 and May 2010. Characteristics of patients and their providers were collected as well as specific management strategies including use of irrigation, packing, and antibiotics. Results One hundred forty-five patients were enrolled. Most SSTIs were single (80.4% abscesses), most commonly on the extremities (29.8%). Both I & D and antibiotics were used 79.9% of the time, with the largest predictor for the addition of antibiotics being erythema more than 2 cm (odds ratio, 4.52; 95% confidence interval, 1.39-14.7); I & D technique varied by provider-type and experience. Providers suspected MRSA in 75% of cases, despite only 48% demonstrating MRSA on culture. Many patients received antimicrobials after I & D, even in those with 2 cm or less abscesses (57.5%). Conclusions Practice patterns vary significantly, especially antibiotic overuse, at least in this urban academic ED. Further study should be undertaken to evaluate factors that influence management strategies for SSTI.

Background Despite familiarity with triggers for asthma, there is little recent study on the association of triggers with the emergency department (ED) presentation of adult asthma exacerbation. Methods Retrospective electronic chart review of adult patients treated in an urban teaching hospital ED with chief complaint and diagnostic coding related to asthma and upper respiratory tract infection (URI) was conducted. Monthly aeroallergen data and environmental conditions were obtained from a local allergen extract laboratory and local government sources. Data analysis was performed using Newey-West time series regression modeling with adjustment for autocorrelation or ordinary least squares linear regression modeling using outcome variables of asthma visits and admissions. Results There were 56 747 visits, with 554 asthma visits and 1 514 URI visits. Asthma visits (R2 = 0.631) were positively correlated with tree pollen counts (correlation coefficient = 0.458 [0.152-0.765]) and average humidity (correlation coefficient = 1.528 [0.296-2.760]). Asthma admissions (R2 = 0.480) were negatively correlated with average temperature (correlation coefficient = −0.557 [−1.052 to −0.061]) when adjusting for confounding by fine particulate matter. Conclusions The ED acute asthma exacerbation presentation is positively correlated with tree pollen and humidity, whereas need for admission is associated with dropping temperatures. These results reinforce the need for vigilance during periods of increased risk and perhaps focused preventative strategies.

ACADEMIC EMERGENCY MEDICINE 2011; 18:313–316 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection. Methods: National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI. Results: Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete. Conclusions: National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs. ACADEMIC EMERGENCY MEDICINE 2011; 18:1–4 © 2011 by the Society for Academic Emergency Medicine