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Introduction: Opioid use disorder (OUD) is a significant health issue impacting millions in the United States (US). Medications used for OUD (MOUD) (e.g., buprenorphine, methadone, naltrexone) and medications for overdose and symptom management (e.g., naloxone, clonidine) have been shown to be safe and effective tools in clinical management. MOUD therapy in Emergency Departments (EDs) improves patient outcomes and enhances engagement with formal addiction treatment; however, provider factors and institutional barriers have created hurdles to ED-based MOUD treatment and heterogeneity in ED based OUD care. We used a nationally representative dataset, the National Hospital Ambulatory Medical Care Survey (NHAMCS) to characterize MOUD prescribing practices across patient demographics, geographic regions, payers, providers, and comorbidities in EDs., Methods: NHAMCS is a survey conducted by the US Census Bureau assessing utilization of ambulatory healthcare services nationally. Survey staff compile encounter records from a nationally representative sample of EDs. We conducted a cross-sectional study using this data to assess visits in 2020 among patients aged 18-64 presenting with an opioid overdose or OUD. We estimated the proportion of patients who had any MOUD, clonidine, or naloxone treatment and 95% confidence intervals (CI). We modeled the association between patient demographic, location, comorbidities, and provider characteristics with receipt of MOUD treatment as unadjusted odds ratios (OR) and 95% CI., Results: There was a weighted frequency of 469,434 patients who were discharged from EDs after being seen for OUD or overdose. Naloxone, clonidine, and buprenorphine were the most frequent treatments administered and/or prescribed for OUDs or overdose. Overall, 54,123 (11.5%, 95%CI 0-128,977) patients who were discharged from the ED for OUDs or overdose received at least one type of MOUD. Hispanic race, (OR 17.9, 95%CI 1.33-241.90) and Western region (OR43.77, 95%CI 2.97-645.27) were associated with increased odds of receiving MOUDs, while arrival by ambulance was associated with decreased odds of receiving MOUDs (OR0.01, 95%CI 0.001-0.19). Being seen by an APP or physician assistant was associated with MOUD treatment (OR 16.68, 95%CI: 1.41-152.33; OR: 13.84, 95%CI: 3.58-53.51, respectively)., Conclusion: Our study findings suggest that MOUD and other medications for opioid overdose are infrequently used in the ED setting. This finding was especially notable in race, geographic region, mode of arrival, and those seen by APP, underscoring the need for further study into the root causes of these disparities. Our study provides a foundational understanding of MOUD patterns, guiding future research as the landscape of OUD treatment continues to shift., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Legislative bodies across the country have increasingly allowed off-road vehicles (ORVs) including all-terrain vehicles (ATVs) and utility task vehicles (UTVs) on public roads, an environment for which they are not designed. In 2004, Iowa gave individual counties the discretion to pass ordinances allowing ORVs on public roadways. The objective of this study was to evaluate the relationship between the passage of ORV ordinances and ORV crash rates, especially on public roads., Methods: An Iowa ORV roadway ordinance database and an Iowa ORV crash database (2002-2018) for all 99 counties were compiled. Crashes for which county location could not be determined were excluded. Utilizing a zero-inflated Poisson model, correcting for background crash frequency trends and population, investigators compared the relative rates of crashes after ordinance passage to time points before ordinance implementation and to counties without such ordinances. Sub-analyses, including that focused on more recent years (2008-2018), were also performed., Results: Forty-five county ORV roadway ordinances went into effect between 2011 and 2018 and 2,347 crashes (69%) met inclusion criteria. Adjusted for year, there was a 58% greater ORV crash rate in counties after passing an ORV roadway ordinance (incidence rate ratio (IRR) 1.58, 95% CI 1.32-1.90). Roadway crashes (n = 834) increased 48% after ordinance passage (IRR 1.48, 95% CI 1.14-1.94). This roadway crash association remained statistically significant when analysis was limited to the years 2008-2018 (IRR 1.39, CI 1.06-1.83, n = 544); to ATV crashes only (IRR 1.70, CI 1.20-2.40, n = 683); and to ATV crashes excluding counties with UTV-only ordinances (IRR 1.74, CI 1.40-2.15, n = 2,011)., Conclusions: ORV roadway and total crashes increased significantly after implementation of county ordinances allowing ORVs on public roadways and when compared to counties without such ordinances. It is likely that these increased crashes have resulted in more injuries and possibly deaths. Results from this study may help inform policymakers as they consider legislation regarding ORV usage on public roads., (© 2024. The Author(s).)

Purpose: Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated., Methods: We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use., Findings: Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38)., Conclusions: Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities., (© 2024 The Author(s). The Journal of Rural Health published by Wiley Periodicals LLC on behalf of National Rural Health Association.)

Objectives: This study sought to evaluate performance indicators to assist a static-based 9-1-1 agency in defining its response efficiency., Methods: Initial assessment of three metrics-unit hour utilization (UHU), fractile response intervals, and level 0 frequency (occurrence when no ambulances are available to respond)-suggested the agency's response over its four coverage zones was inefficient, so an operational change was implemented: an ambulance was relocated from one service area to another to improve the overall response productivity. A 2-year retrospective analysis was performed to determine the impact ambulance relocation had on the three targeted measurements., Results: The operational change resulted in a statistically significant change in unit hour utilization, a non-significant increase in fractile response intervals, and a statistically significant reduction in level 0 frequency from pre- to post-operational change times., Conclusions: These findings suggest a way to evaluate the efficiency of static-based ambulance deployment and potentially identify strategies for redeployment.

Background: As a result of the COVID-19 public health emergency (PHE), telehealth utilization accelerated to facilitate health care management and minimize risk. However, those with mental health conditions and substance use disorders (SUD)-who represent a vulnerable population, and members of underrepresented minorities (e.g., rural, racial/ethnic minorities, the elderly)-may not benefit from telehealth equally. Objective: To evaluate health equality in clinical effectiveness and utilization measures associated with telehealth for clinical management of mental health disorders and SUD to identify emerging patterns for underrepresented groups stratified by race/ethnicity, gender, age, rural status, insurance, sexual minorities, and social vulnerability. Methods: We performed a systematic review in PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL through November 2022. Studies included those with telehealth, COVID-19, health equity, and mental health or SUD treatment/care concepts. Our outcomes included general clinical measures, mental health or SUD clinical measures, and operational measures. Results: Of the 2,740 studies screened, 25 met eligibility criteria. The majority of studies ( n  = 20) evaluated telehealth for mental health conditions, while the remaining five studies evaluated telehealth for opioid use disorder/dependence. The most common study outcomes were utilization measures ( n  = 19) or demographic predictors of telehealth utilization ( n  = 3). Groups that consistently demonstrated less telehealth utilization during the PHE included rural residents, older populations, and Black/African American minorities. Conclusions: We observed evidence of inequities in telehealth utilization among several underrepresented groups. Future efforts should focus on measuring the contribution of utilization disparities on outcomes and strategies to mitigate disparities in implementation.

Background: Chronic health diseases such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM) affect 6 in 10 Americans and contribute to 90% of the $4.1 trillion health care expenditures. The objective of this study was to measure the effect of clinical video telehealth (CVT) on health care utilization and mortality. A retrospective cohort study of Veterans ≥65 years with CHF, COPD, or DM was conducted. Measures: Veterans using CVT were matched 1:3 on demographic characteristics to Veterans who did not use CVT. Outcomes included 1-year incidence of ED visits, inpatient admissions, and mortality, reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Final analytical cohorts included 22,280 Veterans with CHF, 51,872 Veterans with COPD, and 170,605 Veterans with DM. CVT utilization was associated with increased ED visits for CHF (aOR: 1.24; 95% CI: 1.15-1.34), COPD (aOR: 1.20; 95% CI: 1.14-1.26), and DM (aOR: 1.07; 95% CI: 1.00-1.10). For CHF, there was no difference between CVT utilization and inpatient admissions (aOR: 0.98; 95% CI 0.91-1.05) or mortality (aOR: 1.03; 95% CI: 0.93-1.15). For COPD, CVT was associated with increased inpatient admissions (aOR: 1.08; 95% CI: 1.02-1.13) and mortality (aOR: 1.36; 95% CI: 1.25-1.48). For DM, CVT utilization was associated with lower risk of inpatient admissions (aOR: 0.83; 95% CI: 0.80-0.86) and mortality (aOR: 0.89; 95% CI: 0.84-0.95). Conclusions: CVT use as an alternative care site might serve as an early warning system, such that this mechanism may indicate when an in-person assessment is needed for potential exacerbation of conditions. Although inpatient and mortality varied, ED utilization was higher with CVT. Exploring pathways accessing clinical care through CVT, and how CVT is directly or indirectly associated with immediate and long-term clinical outcomes would be valuable.

Introduction: The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities., Methods: We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group., Results: Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas., Discussion: We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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.)

Importance: Access to COVID-19 testing is critical to reducing transmission and supporting early treatment decisions; when made accessible, the timeliness of testing may also be an important metric in mitigating community spread of the infection. While disparities in transmission and outcomes of COVID-19 have been well documented, the extent of timeliness of testing and the association with demographic factors is unclear., Objectives: To evaluate demographic factors associated with delayed COVID-19 testing among health care personnel (HCP) during the COVID-19 pandemic., Design, Setting, and Participants: This cross-sectional study used data from the Preventing Emerging Infections Through Vaccine Effectiveness Testing study, a multicenter, test-negative, case-control vaccine effectiveness study that enrolled HCP who had COVID-19 symptoms and testing between December 2020 and April 2022. Data analysis was conducted from March 2022 to Junne 2023., Exposure: Displaying COVID-19-like symptoms and polymerase chain reaction testing occurring from the first day symptoms occurred up to 14 days after symptoms occurred., Main Outcomes and Measures: Variables of interest included patient demographics (sex, age, and clinical comorbidities) and COVID-19 characteristics (vaccination status and COVID-19 wave). The primary outcome was time from symptom onset to COVID-19 testing, which was defined as early testing (≤2 days) or delayed testing (≥3 days). Associations of demographic characteristics with delayed testing were measured while adjusting for clinical comorbidities, COVID-19 characteristics, and test site using multivariable modeling to estimate relative risks and 95% CIs., Results: A total of 5551 HCP (4859 female [82.9%]; 1954 aged 25-34 years [35.2%]; 4233 non-Hispanic White [76.3%], 370 non-Hispanic Black [6.7%], and 324 non-Hispanic Asian [5.8%]) were included in the final analysis. Overall, 2060 participants (37.1%) reported delayed testing and 3491 (62.9%) reported early testing. Compared with non-Hispanic White HCP, delayed testing was higher among non-Hispanic Black HCP (adjusted risk ratio, 1.18; 95%CI, 1.10-1.27) and for non-Hispanic HCP of other races (adjusted risk ratio, 1.17; 95% CI, 1.03-1.33). Sex and age were not associated with delayed testing. Compared with clinical HCP with graduate degrees, all other professional and educational groups had significantly delayed testing., Conclusions and Relevance: In this cross-sectional study of HCP, compared with non-Hispanic White HCP and clinical HCP with graduate degrees, non-Hispanic Black HCP, non-Hispanic HCP of other races, and HCP all other professional and education backgrounds were more likely to have delayed COVID-19 testing. These findings suggest that time to testing may serve as a valuable metric in evaluating sociodemographic disparities in the response to COVID-19 and future health mitigation strategies.

Background: Combined clinical and research training is common in residency programs outside emergency medicine (EM), and these pathways are particularly valuable for combined MD/PhD graduates planning to pursue a career as a physician-scientist. However, EM departments may not know what resources to provide these trainees during residency to create research-focused, productive, future faculty, and trainees may not know which programs support their goal of becoming a physician-scientist in EM. The objective of this study was to describe research training and resources available to MD/PhD graduates in EM residency training with a focus on dedicated research pathways., Methods: This study was a cross-sectional inventory conducted through an electronic survey of EM residency program directors. We sought to identify dedicated MD/PhD research training pathways, with a focus on both resources and training priorities. Descriptive statistics were used to summarize survey responses., Results: We collected 192 survey responses (69.6% response rate). Among respondents, 41 programs (21.4%) offered a research pathway/track, 52 (27.4%) offered a research fellowship, 22 (11.5%) offered both a residency research pathway/track and a research fellowship, and two (1.0%) offered a dedicated EM physician-scientist training pathway. Most programs considered research a priority and were enthusiastic about interviewing applicants planning a research career, but recruitment of physician-scientist applicants was not generally prioritized., Conclusions: Some EM residency programs offer combined clinical and mentored research training for prospective physician-scientists, and nearly all residency programs considered research important. Future work will focus on improving the EM physician-scientist pipeline by optimizing pathways available to trainees during residency and fellowship., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Authors. AEM Education and Training published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes., Objective: To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM., Design: Comparative effectiveness matched cohort study., Patients: Veterans aged 65 years and older treated for CHF, COPD, or DM., Main Measures: We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality., Key Results: A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16)., Conclusions: The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Riding lawn mower injuries are the most common cause of major limb loss in young U.S. children. Our study objective was to investigate the circumstances surrounding pediatric riding lawn mower injuries and to identify potential contributing risk factors and behaviors leading to these events., Methods: Followers/members of both a public and a private lawn mower injury support and prevention Facebook page who had or were aware of children who had suffered a lawn mower-related injury were invited to complete an electronic survey on Qualtrics. Duplicate cases and those involving push mowers were removed. Frequencies and chi-square analyses were performed., Results: 140 injured children were identified with 71% of surveys completed by parents and 19% by an adult survivor of a childhood incident. The majority of injured children were Caucasian (94%), male (64%), and ≤ 5 years of age at the time of the incident (63%). Bystanders were 69% of those injured, 24% were lawn mower riders, and mower operators and others accounted for 7%. The lawn mower operator was usually male (77%), being the father/stepfather in almost half. Overall, 59% of injuries occurred while traveling in reverse, 29% while moving forward. Nearly all (92%) had an amputation and/or permanent disability. Subgroup analysis (n = 130) found injured bystanders were younger than injured passengers with 71% versus 45% being < 5 years of age, respectively (p = 0.01). Over three-quarters of bystander incidents occurred while moving in reverse as compared to 17% of passenger incidents (p < 0.01). Amputations and/or permanent disabilities were greater among bystanders (97%) as compared to passengers (79%, p = 0.01). Only 3% of bystanders had an upper extremity injury as compared to 21% of passengers (p = 0.01). Seventy-three percent of bystander victims had received at least one ride on a lawn mower prior to their injury incident., Conclusions: Child bystanders seriously injured by riding lawn mowers were frequently given prior rides likely desensitizing them to their inherent dangers and leading them to seek rides when mowers were being used. Engineering changes preventing blade rotation when traveling in reverse and not giving children rides (both when and when not mowing) may be critical in preventing mower-related injuries., (© 2023. The Author(s).)

Introduction: Telepsychiatry consultation for rural providers may help address local staffing needs while ensuring timely and appropriate care from behavioral health experts. The purpose of this study was to assess the implementation of a telepsychiatry consultation service within medical and psychiatry inpatient units of hospitals serving predominantly rural areas. Methods: A mixed-methods study with qualitative interviews of site personnel and quantitative assessment of electronic health record data was conducted across 6 facilities in 3 U.S. states between June 2019 and May 2021. We interviewed 15 health care professionals 6 months after telepsychiatry was implemented, and we identified emerging themes related to the inpatient telepsychiatry service implementation and utilization through an inductive qualitative analysis approach. We then applied the themes emerging from this study to existing implementation science theoretical frameworks. Results: Telepsychiatry consultation was utilized for 437 medical inpatient cases and 531 psychiatric inpatient units. Average encounters by site ranged from 1 to 20 per month. The three main domains from the qualitative assessment included the impact on the care process (the partnership between inpatient units and the telehealth hub, and logistical dynamics), the care provider (resource availability in inpatient units and changes in inpatient units' capability), and the patient (impact on patient safety and care). Discussion: Implementation of a telepsychiatry service in the inpatient setting holds the promise of being beneficial to the patient, local hospital, and the rural community. In this study, we found that implementing this telepsychiatry service improved the clinical care processes, while addressing both the providers' and patients' needs.

Objective: Conceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management., Methods: This was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated., Results: Of the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%)., Conclusions: We found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding., Competing Interests: Declaration of Competing Interest This manuscript is not being considered for publication elsewhere. Each of the authors meets criteria for authorship, claim responsibility for the case report, and none have conflicts of interest to report. All authors participated in the concept and design, analysis, and interpretation, drafting and revising the manuscript, and approve the submitted manuscript. PVH, PV, RP and AN report no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: A mental health crisis can create challenges for individuals, families, and communities. This multifaceted issue often involves different professionals from law enforcement and health care systems, which may lead to siloed and suboptimal care. The virtual crisis care (VCC) program was developed to provide rural law enforcement with access to behavioral health professionals and facilitated collaborative care via telehealth technology., Objective: This study was designed to evaluate the implementation and use of a VCC program from a telehealth hub for law enforcement in rural areas., Methods: This study used a mixed methods approach. The quantitative data came from the telehealth hub's electronic record system. The qualitative data came from in-depth interviews with law enforcement in the 18 counties that adopted the VCC program., Results: Across the 181 VCC encounters, the telehealth hub's recommended disposition and the actual disposition were similar for remaining in place (n=141, 77.9%, and n=137, 75.7%, respectively), voluntary admission (n=9, 5.0%, and n=10, 5.5%, respectively), and involuntary committal (IVC; n=27, 14.9%, and n=19, 10.5%, respectively). Qualitative insights related to the VCC program's implementation, use, benefits, and challenges were identified, providing a comprehensive view of the virtual partnership between rural law enforcement and behavioral health professionals., Conclusions: Use of a VCC program likely averts unnecessary IVCs. Law enforcement interviews affirmed the positive impact of VCC due to its ease of use and the benefits it provides to the individuals in need, the first responders involved, law enforcement resources, and the community., (©M Muska Nataliansyah, Kimberly A S Merchant, J Priyanka Vakkalanka, Luke Mack, Seth Parsons, Marcia M Ward. Originally published in JMIR Mental Health (https://mental.jmir.org), 20.03.2023.)

Background: The American Board of Emergency Medicine (ABEM) In Training Exam (ITE) gauges residents' medical knowledge and has been shown to correlate with subsequent performance on the ABEM board qualifying examination. It is common for emergency medicine (EM) residencies to employ subspecialty-trained faculty members with the expectation of improved resident education and subspecialty knowledge. We hypothesized that the presence of subspecialty faculty in toxicology would increase residents' scores on the toxicology portion of the ITE., Methods: We assessed ABEM ITE scores at our institution from 2013-2022 and compared these to national data. The exposure of interest was the absence or presence of fellowship-trained toxicology faculty. The primary outcome was performance on the toxicology portion of the ITE, and secondary outcome was overall performance on the exam., Results: Residents who had ≥1 toxicology faculty were 37% (95% CI: 1.01-1.87) more likely to surpass the national average for toxicology scores, and those who had ≥2 toxicology faculty were 77% (95% CI: 1.28-2.44) more likely to surpass the national average for toxicology scores on the ABEM ITE. With the presence of ≥2 toxicology faculty, there was also an increase in toxicology score by years in training, with residents being 63% (95% CI: 1.01-2.64), 68% (95% CI: 1.08-2.61), and 92% (95% CI: 1.01-3.63) more likely to surpass the national average for toxicology score in first, second, and third years of residency, respectively. There was no significant relationship between the presence of toxicology faculty and the overall ABEM ITE scores., Conclusions: The presence of fellowship-trained toxicology faculty positively impacted residents' performance on the toxicology portion of the ABEM ITE but did not significantly impact the overall score. With the presence of ≥2 toxicology faculty we noted an improvement in toxicology scores throughout the 3 years of training, indicating that an individual rotation or educational block is probably less important than spaced repetition through a longitudinal curriculum., Competing Interests: All authors (CAT, JPV, BJO, NH, DJM) report no conflict of interest., (© 2023 The Authors. AEM Education and Training published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: Due to limited community resources for mental health and long travel distances, emergency departments (EDs) serve as the safety net for many rural residents facing crisis mental health care. In 2019, The Leona M. and Harry B. Helmsley Charitable Trust funded a project to establish and implement an ED-based telepsychiatry service for patients with mental health issues in underserved areas. The purpose of this study was to evaluate the implementation of this novel ED-based telepsychiatry service., Methods: This was a mixed-methods study evaluating the new ED-based telepsychiatry consult service implemented in five EDs across three rural states that participated within a mature hub-and-spoke telemedicine network between June 2019 and December 2020. Quantitative evaluation in this study included characteristics of the telehealth encounters and the patient population for whom this service was used. For qualitative assessments, we identified key themes from interviews with key informants at the ED spokes to assess overall facilitators, barriers, and impact. Integrating the quantitative and qualitative findings, we explored emergent phenomena and identified insights to provide a comprehensive perspective of the implementation process., Results: There were 4130 encounters for 3932 patients from the EDs during the evaluation period. Approximately 54% of encounters involved female patients. The majority of patients seen were white (51%) or Native American (44%) reflecting the population of the communities where the EDs were located. Among the indications for the telepsychiatry consult, the most frequently identified were depression (28%), suicide/self-harm (17%), and schizophrenia (12%). Across sites, 99% of clinician-to-clinician consults were by phone, and 99% of clinical assessments/evaluations were by video. The distribution of encounters varied by the day of the week and the time of day. Facilitators for the service included increasing need, a supportive infrastructure, a straightforward process, familiarity with telemedicine, and a collaborative relationship. Barriers identified by respondents at the sites included the lack of clarity of process and technical limitations. The themes emerging from the impact of the telepsychiatry consultation in the ED included workforce improvement, care improvement, patient satisfaction, cost-benefit, facilitating COVID care, and access improvement., Conclusions: Implementation of a telepsychiatry service in ED settings may be beneficial to the patient, local ED, and the underserved community. In this study, we found that implementing this service alleviated the burden of care during the COVID-19 pandemic, enhanced local site capability, and improved local ability to provide quality and effective care., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Negative bias against people who use illicit drugs adversely affects the care that they receive throughout the hospital. We hypothesized that emergency providers would display stronger negative bias toward these patients due to life-threatening contexts in which they treat this population. We also hypothesized that negative implicit bias would be associated with negative explicit bias., Methods: Faculty, nurses, and trainees at a midwestern tertiary care academic hospital were invited (June 26, 2019-September 5, 2019) to complete an online implicit association test and explicit bias survey., Results: Mean implicit association test results did not vary across demographics (n = 79). There were significant differences in explicit bias scores between departments regarding whether patients who use drugs deserve quality healthcare access (P = 0.017). We saw no significant associations between implicit and explicit bias scores., Conclusion: Though limited by sample size, the results indicate that emergency and obstetrics/gynecology providers display more negative explicit bias toward this patient population than other providers., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 American Society of Addiction Medicine.)

Objective: Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment., Methods: A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year., Results: Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65)., Conclusions: As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems., (© 2021. Society of General Internal Medicine.)

Objective: To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention., Data Sources: National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017., Study Design: Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year., Data Collection/extraction Methods: Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality., Principal Findings: A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07)., Conclusions: Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention., (© 2021 Health Research and Educational Trust.)

Objectives: The objective was to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit in the emergency department (ED) on hospital admissions, ED length of stay, and 30-day follow-up for patients presenting with suicidal ideation or attempt., Methods: This study was a before-and-after analysis of introducing the EmPATH unit within a Midwestern academic medical center on outcomes of adult patients (≥18 years) presenting with suicidal ideation or suicidal attempt. The primary outcome in this study was the change in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED before and after implementation of the EmPATH unit. Secondary outcomes compared were changes in proportion of any admission, incomplete admission defined as discharge from the ED after admission request placed, outpatient follow-up, return ED visits within 30 days of admission, and ED boarding time. Association between the EmPATH unit implementation and categorical outcomes were determined using log-binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). Continuous outcomes were log-transformed and generalized estimating equations were used to examine as the mean difference by time period., Results: There were 962 patients presenting with suicidal ideation (n = 435 before EmPATH unit, n = 527 after EmPATH unit). Compared to the pre-EmPATH-unit period, there was a reduction in psychiatric admission (RR = 0.48, 95% CI = 0.40 to 0.56), any admission (RR = 0.65, 95% CI = 0.58 to 0.73), incomplete admission (RR = 0.22, 95% CI = 0.11 to 0.43), and 30-day return to the ED (RR = 0.74, 95% CI = 0.56 to 0.98). ED boarding time among admitted patients was reduced by approximately two-thirds both in admitted patients (RR = 0.34, 95% CI = 0.30 to 0.39) and among those with incomplete admissions (RR = 0.37, 95% CI = 0.23 to 0.61). There was a 60% increase in a 30-day follow-up care established at the time of discharge (RR = 1.60, 95% CI = 1.40 to 1.82)., Conclusions: The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care., (© 2021 by the Society for Academic Emergency Medicine.)

Introduction: In the current national opioid crisis, where 10% of the US population has or has had a substance use disorder (SUD), emergency department (ED) clinicians are challenged when treating pain in the ED and when prescribing pain medications to these patients on discharge as there is concern for contributing to the cycle of addiction. The objective of this study was to examine whether acute pain is treated differently in patients with and without current or past SUD by quantifying the amount of opioid analgesia given in the ED and prescribed on discharge., Methods: Retrospective cohort study of patients presenting to a 60,000-visit tertiary referral ED with acute fracture between January 1, 2016 and June 30, 2019. The primary exposure was indication of SUD (SUD+) versus those without SUD (SUD-). The primary outcome was receipt of opioids in the ED, and the secondary outcome was opioids prescribed at discharge., Results: 117 matched pairs (n = 234) were included in the sample. Overall, 53.4% and 62.4% of patients received opioids in the ED or a prescription for opioids, respectively. Opioid receipt in the ED was lower among SUD+ patients compared to SUD- patients (48.7% and 58.1%, respectively; aOR: 0.33; 95%CI: 0.14, 0.77). Similarly, receipt of a prescription for opioids was lower among SUD+ patients compared to SUD- patients (56.4% and 68.4%, respectively; aOR: 0.50; 95%CI: 0.26, 0.95)., Conclusions: Overall, ED clinicians gave opioids less frequently to SUD+ patients in the ED and on discharge from the ED compared to SUD- patients with acute pain secondary to acute fracture., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Mental health and substance use disorder (MHSUD) patients in the emergency department (ED) have been facing increasing lengths of stay due to a shortage of inpatient beds. Previous research indicates mobile crisis outreach (MCO) reduces long ED stays for MHSUD patients. Our objective was to assess the impact of MCO contact on future ED utilization., Methods: We conducted a retrospective chart review of patients presenting to a large Midwest university ED with an MHSUD chief complaint from 2015-2018. We defined the exposure as those who had MCO contact and any MHSUD-related ED visit within 30 days of MCO contact. The MCO patients were 2:1 propensity score-matched by demographic data and comorbidities matched to patients with no MCO contact. Outcomes were all-cause and psychiatric-specific reasons for return to the ED within one year of the index ED visit. We report descriptive statistics and odds ratios (OR) to describe the difference between the two groups, and hazard ratios (HR) to estimate the risk of return ED visit., Results: The final sample included 106 MCO and 196 non-MCO patients. The MCO patients were more likely to be homeless (OR 14.8; 95% confidence interval [CI],1.87, 117), less likely to have adequate family or social support (OR 0.51; 95% CI, 0.31, 0.84), and less likely to have a hospital bed requested for them in the index visit by ED providers (OR 0.50; 95% CI, 0.29, 0.88). For those who returned to the ED, the median time for all-cause return to the ED was 28 days (interquartile range [IQR]: 6-93 days) for the MCO patients and 88 days (IQR: 20-164 days) for non-MCO patients. The risk of all-cause return to the ED was greater among MCO patients (67%) compared to non-MCO patients (49%) (adjusted HR: 1.66; 95% CI, 1.22, 2.27)., Conclusion: The MCO patients had less family and social support; however, they were less likely to require hospitalization for each visit, likely due to MCO involvement. Patients with MCO contact presented to the ED more frequently than non-MCO patients, which implies a strong linkage between the ED and MCO in our community. An effective referral to community service from the ED and MCO and collaboration could be the next step to improve healthcare utilization.

Objective: Facilities that process and package meat for consumer sale and consumption (meatpacking plants) were early sites of coronavirus disease 2019 (COVID-19) outbreaks. The aim of this study was to characterize the association between meatpacking plant exposure and clinical outcomes among emergency department (ED) patients with COVID-19 symptoms., Methods: This was a retrospective cohort study of patients presenting to a single ED, from March 1 to May 31, 2020, who had: 1) symptoms consistent with COVID-19 and 2) a COVID-19 test performed. The primary outcome was COVID-19 positivity, and secondary outcomes included hospital admission from the ED, ventilator use, intensive care unit (ICU) admission, hospital length of stay (LOS; <48 or ≥48 h), and mortality., Results: Patients from meatpacking plants were more likely to be Black or Hispanic than the ED patients without this occupational exposure. Patients with a meatpacking plant exposure were more likely to test positive for COVID-19 (adjusted relative risk [aRR] = 2.37, 95% confidence interval [CI] = 1.59 to 3.53) but had similar rates of hospital admission (aRR = 0.94, 95% CI = 0.82 to 1.07) and hospital LOS (aRR = 0.76, 95% CI = 0.45 to 1.23). There was no significant difference in ventilator use among patients with meatpacking and nonmeatpacking plant exposure (8.2% vs. 11.1%, p = 0.531), ICU admissions (4.1% vs. 12.0%, p = 0.094), and mortality (2.0% vs. 4.1%, p = 0.473)., Conclusions: Workers in meatpacking plants in Iowa had a higher rate of testing positive for COVID-19 but were not more likely to be hospitalized for their illness. These patients were disproportionately Black and Hispanic., (© 2021 by the Society for Academic Emergency Medicine.)

Introduction: Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine's prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved., Methods: We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017-March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED., Results: A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5-18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1)., Conclusion: Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.

Background: Historically, it has been assumed that the Emergency Department (ED) is a place for maximally aggressive care and that Emergency Medicine Providers (EMPs) are biased towards life-prolonging care. However, emphasis on early recognition of code status preferences is increasingly making the ED a venue for code status discussions (CSDs). In 2018, our hospital implemented a policy requiring EMPs to place a code status order (CSO) for all patients admitted through the ED. We hypothesized that if EMPs enter CSDs with a bias toward life-prolonging care, or if the venue of the ED biases CSDs towards life-prolonging care, then we would observe a decrease in the percentage of patients selecting DNR status following our institution's aforementioned CSO mandate., Methods: We present a retrospective analysis of rates of DNR orders placed for patients admitted through our ED comparing six-month periods before and after the implementation of the above policy., Results: Using quality improvement data, we identified patients admitted through the ED during pre (n=7,858) and post (n=8,069) study periods. We observed the following: after implementation DNR preference identified prior to hospital admission from the ED increased from 0.4% to 5.3% (relative risk (RR) 12.5; 95% CI: 5.2-29.9), defining CS in the ED setting at the time of admission increased from 2.4% to 98.6% (p <0.001), and DNR orders placed during inpatient admission was unchanged (RR=0.97 (95% CI = 0.88-1.07))., Discussion: Our results suggest that the ED can be an appropriate venue for CSDs.

Background : Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods : A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results : Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions : Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

Background: Approximately 10% of teens report experiencing sexual dating violence (SDV) or physical dating violence (PDV), collectively represented as teen dating violence (TDV). This study examines the association between laws incorporating TDV education in schools on TDV prevalence., Methods: TDV prevalence was estimated using data contributed by 36 states that participated in the 2015 Youth Risk Behavioral Surveillance Survey (YRBS). Presence of TDV laws was determined using Westlaw, a legal search engine. The adjusted odds of TDV victimisation was estimated by the presence or absence of a state law and length of time the law was in effect using hierarchical regression modelling, clustering on state, controlling for individual-level and state-level covariates and incorporating the YRBS-weighted survey design., Results: After controlling for individual-level and state-level covariates, the presence of a law was not associated with TDV (adjusted OR (aOR) 0.97; 95% CI 0.88 to 1.06), PDV (aOR 1.12; 95% CI 0.95 to 1.33) or SDV (aOR 0.99; 95% CI 0.91 to 1.08). These odds did not differ across the length of time the policies were in effect., Conclusions: This study suggest that just the presence of a law incorporating TDV education in schools is not associated with reduced TDV victimisation but further research is needed to understand the association of the content of these laws and their implementation on TDV victimisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency departments (EDs) with suicidal ideation or attempt., Methods: Retrospective propensity-matched cohort study of patients treated for suicidal attempt and ideation in 13 rural critical access hospital EDs participating in a telemedicine network. Patients for whom telemedicine was used were matched 1:1 to those who did not have telemedicine as an exposure (n=139 TM+, n=139 TM-) using optimal matching of propensity scores based on administrative data. Our primary outcome was ED length-of-stay (LOS), and secondary outcomes included admission proportion, use of chemical or physical restraint, 30 day ED return, involuntary detention orders, treatment/follow-up plan and 6-month mortality. Analyses for multivariable models were conducted using conditional linear and logistic regression clustered on matched pairs with purposeful selection of covariates., Results: Mean ED LOS was not associated with telemedicine consultation among all patients, but was associated with a 29.3% decrease in transferred patients (95% CI 11.1 to 47.5). The adjusted odds of hospital admission (either local or through transfer) was 2.35 (95% CI 1.10 to 5.00) times greater among TM+ patients compared with TM- patients. Involuntary hold placement was lower in those exposed to telemedicine (adjusted odds ratio (aOR): 0.48; 95% CI 0.23 to 0.97). We did not observe significant differences in other outcomes., Conclusion: The role of telemedicine in influencing access, quality and efficiency of care in underserved rural hospitals is critically important as these networks become more prevalent in rural healthcare environments., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer., Design: Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims., Setting and Subjects: Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013., Interventions: None., Measurements and Main Results: Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39)., Conclusions: The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.

Introduction: Procedural sedation and analgesia (PSA) provides safe and effective relief for pain, anxiety and discomfort during procedures performed in the emergency department (ED). Our objective was to identify hospital-level factors associated with routine PSA capnography use in the ED., Methods: This study was a cross-sectional telephone survey of ED nurse managers and designees in a Midwestern state. Respondents identified information about hospital infrastructure, physician staffing, family practice (FP) physicians only, board-certified emergency physicians (EPs) only (or both), and critical intervention capabilities. Additional characteristics including ED volume and hospital designation (i.e., rural-urban classification) were obtained from the Centers for Medicare and Medicaid Services and the state hospital association database, respectively. The primary outcome was reported use of PSA capnography. We conducted univariate analyses (relative risks, 95% confidence interval [CI]) to identify associations between hospital-level characteristics and PSA capnography use., Results: We had an overall response rate of 98% (n=118 participating hospitals). The majority of EDs were in rural settings (78%), with a median of 5,057 visits per year (interquartile range 2,823-14,322). Nearly half of the EDs were staffed by FP physicians only, while 16% had board-certified EPs only. Nearly all hospitals (n=114, 97%), reported using continuous capnography for ventilated patients, and 74% reported use of capnography during PSA. Urban hospitals were more likely to use PSA capnography than critical access hospitals (relative risk 1.45; 95% CI, 1.22-1.73), and PSA capnography use increased with each ED volume quartile. Facilities with only EPs were 1.46 (95% CI, 1.15-1.87) times more likely to use PSA capnography than facilities with FP physicians only., Conclusion: Continuous capnography was available in nearly all EDs, independent of size, location or patient volume. The implementation of capnography during PSA was less penetrant. Smaller, rural departments were less likely than their larger, urban counterparts to implement these national guidelines. Rurality and hospital size may be potential institutional barriers to capnography implementation., 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.

Background: Telemedicine allows patients to connect with healthcare providers remotely. It has recently expanded to evaluate low-acuity illnesses such as pharyngitis by using patients' personal communication devices. The purpose of our study was to compare the telemedicine-facilitated physical examination with an in-person examination in emergency department (ED) patients with sore throat., Materials and Methods: This was a prospective, observational, blinded diagnostic concordance study of patients being seen for sore throat in a 60,000-visit Midwestern academic ED. A telemedicine and a face-to-face examination were performed independently by two advanced practice providers (APP), blinded to the results of the other evaluator. The primary outcome was agreement on pharyngeal redness between the evaluators, with secondary outcomes of agreement and inter-rater reliability on 14 other aspects of the pharyngeal physical examination. We also conducted a survey of patients and providers to evaluate perceptions and preferences for sore throat evaluation using telemedicine., Results: Sixty-two patients were enrolled, with a median tonsil size of 1.0. Inter-rater agreement (kappa) for tonsil size was 0.394, which was worse than our predetermined concordance threshold. Other kappa values ranged from 0 to 0.434, and telemedicine was best for detecting abnormal coloration of the palate and tender superficial cervical lymph nodes (anterior structures), but poor for detecting abnormal submandibular lymph nodes or asymmetry of the posterior pharynx (posterior structures). In survey responses, telemedicine was judged easier to use and more comfortable for providers than patients; however, neither patients nor providers preferred in-person to telemedicine evaluation., Conclusion: Telemedicine exhibited poor agreement with the in-person physical examination on the primary outcome of tonsil size, but exhibited moderate agreement on coloration of the palate and cervical lymphadenopathy. Future work should better characterize the importance of the physical examination in treatment decisions for patients with sore throat and the use of telemedicine in avoiding in-person healthcare visits.

Background: To assess clinical and epidemiological trends of severe sepsis., Methods: Ecological study of patients presenting to the emergency department with severe sepsis or septic shock between 2005 and 2013. Patients were identified using the state-wide hospital administrative database. Key outcomes included incidence rates (IRs) and mortality rates (per 1000 population) by age and medically underserved areas (MUAs), sepsis case fatality rate (deaths per 100 sepsis cases), and proportions of transfer and comorbidities., Results: There were 154 019 sepsis cases identified. In 2005, 85+ yo in non-MUAs had a 44% increase in IR compared with those in MUAs, and this difference rose to 74% by 2013. Mortality rates were 1.6 (95% CI 1.3 to 1.8) times greater among 85+ yo in non-MUAs. Mortality rates increased by 1.8% annually, while the sepsis case fatality rate decreased by 7.7%. The proportion of transfer among sepsis cases decreased by 2.1% per year (3.8% in non-MUAs, 0.7% in MUAs)., Conclusions: Sepsis incidence varies geographically, and access to healthcare is one proposed mechanism that may explain heterogeneity. Over time, we may be capturing higher acuity sepsis cases with better recognition and management, as well as observing differential diagnostic coding documentation by location., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: The aim of this systematic review was to identify isolated acute cyanide poison cases and to identify reported signs, symptoms, and laboratory findings., Methods: We searched MEDLINE, Cochrane Reviews, and Web of Science case reports and series using a number of MeSH descriptors pertaining to cyanide, toxicity, and poisonings. We excluded studies on plants, laboratory analyses, smoke inhalation poisonings, animals as well as non-English language articles and those in which data were not available. Data extracted included demographics, exposure characteristics, acute signs/symptoms, and medical management and outcome., Results: From the initial 2976 articles retrieved, 65 articles (52 case reports, 13 case series) met inclusion criteria and described 102 patients. Most patients were unresponsive (78%), hypotensive (54%), or had respiratory failure (73%); other signs and symptoms included cardiac arrest (20%), seizures (20%), cyanosis (15%), cherry red skin (11%), and had an odor present (15%). Medical management included cyanide antidote kit (20%), sodium thiosulfate (40%), and hydroxocobalamin (29%). The majority of cases (66%) required intubation with mechanical ventilation and a substantial number (39%) developed refractory hypotension requiring vasopressor support., Conclusions: Contrary to general reviews published on cyanide toxicity, reports of cherry red skin and bitter almond odor were rare among published cyanide cases. Consistent with other studies, metabolic acidosis with significant lactic acidosis were the laboratory values consistently associated with cyanide toxicity. Healthcare providers may overlook cyanide toxicity in the differential diagnosis, if certain expected characteristics, such as the odor of almonds or a cherry red color of the skin are absent on physical examination.

Purpose: (1) To test whether serum bicarbonate or anion gap can be used to predict elevated lactate or mortality in emergency department (ED) patients with sepsis, and (2) to define thresholds that may predict elevated lactate and mortality., Methods: Retrospective diagnostic-validation study of adults with sepsis treated in a 60,000-visit Midwestern university ED (2010-2015). In the derivation sample, 8 experts selected thresholds based on objective measures to optimize clinical utility. Test performance was reported using likelihood ratios (LR +/-) in the validation cohort., Results: We included 4159 patients. Anion gap predicted lactate>2 better than bicarbonate [ROC AUC 0.680 vs. 0.609], and anion gap predicted lactate>4 better than lactate>2 [ROC AUC 0.816 vs. 0.680]. In the validation cohort, anion gap ≥20mEq/L had LR+ for lactate>2 of 3.670 (2.630-5.122), lactate>4 of 7.019 (5.310-9.278), and mortality of 2.768 (1.922-3.986). Anion gap predicted mortality similar to lactate>2 [LR+ 2.768 vs. LR+ 2.09; LR- 0.823 vs. 0.447]., Conclusions: Anion gap and serum bicarbonate poorly predict changes in lactate and mortality. In resource-limited settings where lactate is unavailable, anion gap ≥20mEq/L may be used to further risk-stratify patients for ongoing sepsis care, but lactate remains a preferred biomarker., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes., Objectives: This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota., Methods: Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality., Results: Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9)., Conclusions: ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.

Study Objective: Loperamide abuse has been increasing in the United States as a potential alternative to manage opioid withdrawal symptoms or to achieve euphoric effects of opioid use. In June 2016, the Food and Drug Administration warned health care providers and the general public about potential serious adverse outcomes, including cardiac dysrhythmias and death. The purpose of this study is to determine recent trends in intentional loperamide abuse and misuse, reported clinical effects and management, and medical outcomes as reported to poison centers across the United States., Methods: Loperamide exposures reported to the National Poison Data System indicating intentional misuse, abuse, and suspected suicide between January 1, 2010, and December 31, 2015, were assessed. Demographic and temporal trends, as well as reported clinical effects, medical management, and health outcomes, were analyzed., Results: There was a 91% increase in reported exposures from 2010 to 2015, of which half were single-agent loperamide use only. Loperamide exposures reported to the National Poison Data System increased at approximately 38 cases per year (95% confidence interval [CI] 32.5 to 42.9; P<0.0001). Fifteen deaths were reported during this time frame, of which 8 involved single-agent loperamide abuse., Conclusion: Loperamide abuse and misuse are projected to increase in the absence of any methods to reduce exposure or curb abuse. Health care providers should consider the potential for loperamide toxicity when managing patients with opioidlike toxicity., (Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Context: While low toxicity is reported, there are sparse data on the safety of acute picaridin (icaridin) exposures in humans., Objective: The purpose of this study was to review National Poison Data System (NPDS) data regarding ingestion of insect repellents containing picaridin and compare those to insect repellents containing DEET and other insect repellents not containing DEET., Methods: NPDS was queried for single agent human insect repellent ingestions reported between 1 January 2000 and 31 May 2015 using the American Association of Poison Control Center generic categories 201048 (Insect Repellents with DEET) and 201049 (Insect Repellents without DEET). Picaridin-containing product exposures were assessed using Poisindex(®) product ID 6744589. Insect repellents of unknown type were not included., Results: 68,429 exposures occurred; 24% were non-DEET-containing products, of which 2% were picaridin-containing products. Among picaridin exposures, 92.9% were managed outside of a health-care facility; there were no reported cases of major effect or death, and only one case of moderate effect. Primary symptoms across all insect repellent exposures included ocular irritation/pain, vomiting, red eye/conjunctivitis, and oral irritation. Treatment primarily included dilution/irrigation/wash., Conclusion: Unintentional ingestion of picaridin-containing and other insect repellents was associated only with minor toxicity and was generally managed outside of a health-care facility.

Lyme disease is a multisystem tickborne illness caused by the spirochete Borrelia burgdorferi and is the most common vectorborne disease in the United States. Prognosis after initiation of appropriate antibiotic therapy is typically good if treated early. Wilderness providers caring for patients who live in or travel to high-incidence Lyme disease areas should be aware of the basic biology, epidemiology, clinical manifestations, and treatment of Lyme disease., (Published by Elsevier Inc.)

Objective: The purpose of this study was to characterize the epidemiological trends associated with substances used in intentional exposures among children while on school property reported to the U.S. National Poison Data System (NPDS)., Materials and Methods: NPDS was queried for intentional (abuse, misuse, suspected suicide, and unknown intentional) exposures reported to occur on school property between calendar years 2004 and 2013. Records were restricted to children 6-18 years of age. Demographic, exposure, and clinical characteristics were assessed., Results: A total of 56,882 substances were intentionally used on school property by 50,379 children, of which 39.8% were females (n = 20,070), 57.7% were males (n = 29,084), and 2.4% were unknown gender (n = 1,225). The most frequent pharmaceutical exposures reported included sedatives (n = 4,096; 8.1%), analgesics (n = 4,022; 8.0%), and cough and cold preparations (n = 3,529; 7.0%). The majority of exposures were managed on site (n = 21,464; 42.6%), followed by care at a healthcare facility (n = 20,048; 39.7%). Serious outcomes (moderate or major effects and death) accounted for nine percent of all reported exposures. Compared to reference groups, female gender, teenagers 17-18 years, and pharmaceutical substances (Prevalence Ratios = 4.6, 9.4, and 9.9, respectively) were associated with suspected suicides when compared with other intentional exposures., Conclusions: Along with other national data about behaviors in the adolescent and teenage population, additional trends in risky behavior may be gleaned by surveillance through poison centers. With over 5,000 annual reports to the poison centers about intentional exposures on school property, school personnel and parents/guardians must be vigilant about the range of pharmaceutical and non-pharmaceutical substances that are used for abuse, misuse, or suicide.

Objective: Numerous reputable sources for healthcare providers advocate routine imaging to rule out an embedded tooth or fang after a snake bite. The objective of this study was to determine whether these foreign bodies can be reliably excluded by bedside ultrasonography., Methods: All emergency medicine (EM) residents and faculty at a single institution were invited to participate. Two sets of 5 ultrasound gel phantoms were prepared using a method previously validated to have the same density as human tissue. In the first set of 5 phantoms, 1 snake fang was embedded to simulate a retained foreign body. Similarly, in the second set of 5 phantoms, 1 snake tooth was also embedded. Participants were asked to identify the presence or absence of a foreign body in each phantom using bedside ultrasonography. Year of training and confidence in excluding a snake foreign body were also recorded., Results: Each participant (n=27) performed ultrasound imaging on 10 phantoms for a total of 270 samples. Range of experience included postgraduate year 1 (25.9%), postgraduate year 2 (29.6%), postgraduate year 3 (33.3%), and graduates of EM residency (11.1%). The sensitivity and negative predictive value for ruling out an embedded fang was 92.6% and 98.1%, respectively. The sensitivity and negative predictive value for ruling out an embedded tooth was 77.8% and 93.7%, respectively. Among all the phantoms, there was a sensitivity of 85.2% and a negative predictive value of 96%., Conclusion: Bedside ultrasonography performed by an EM physician is a feasible option to rule out embedded foreign bodies after a snake bite if imaging is warranted., (Copyright © 2015 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Although clinical use of dexmedetomidine (DEX), an alpha2-adrenergic receptor agonist, has increased, its role in patients admitted to intensive care units secondary to toxicological sequelae has not been well established., Objectives: The primary objective of this study was to describe clinical and adverse effects observed in poisoned patients receiving DEX for sedation., Methods: This was an observational case series with retrospective chart review of poisoned patients who received DEX for sedation at an academic medical center. The primary endpoint was incidence of adverse effects of DEX therapy including bradycardia, hypotension, seizures, and arrhythmias. For comparison, vital signs were collected hourly for the 5 h preceding the DEX therapy and every hour during DEX therapy until the therapy ended. Additional endpoints included therapy duration; time within target Richmond Agitation Sedation Score (RASS); and concomitant sedation, analgesia, and vasopressor requirements., Results: Twenty-two patients were included. Median initial and median DEX infusion rates were similar to the commonly used rates for sedation. Median heart rate was lower during the therapy (82 vs. 93 beats/minute, p < 0.05). Median systolic blood pressure before and during therapy was similar (111 vs. 109 mmHg, p = 0.745). Five patients experienced an adverse effect per study definitions during therapy. No additional adverse effects were noted. Median time within target RASS and duration of therapy was 6.5 and 44.5 h, respectively. Seventeen patients (77%) had concomitant use of other sedation and/or analgesia with four (23%) of these patients requiring additional agents after DEX initiation. Seven patients (32%) had concomitant vasopressor support with four (57%) of these patients requiring vasopressor support after DEX initiation., Conclusion: Common adverse effects of DEX were noted in this study. The requirement for vasopressor support during therapy warrants further investigation into the safety of DEX in poisoned patients. Larger, comparative studies need to be performed before the use of DEX can be routinely recommended in poisoned patients.

Context: The Centers for Disease Control and Prevention (CDC) has reported an increase in electronic cigarette (e-cigarette) use in both adults and adolescents. Poison Center calls provide data on exposures pertaining to e-cigarette devices and components (including nicotine-refill cartridges), potentially identifying epidemiological trends in reported exposures over time., Objective: To characterize the trends in e-cigarette exposures reported to United States (U.S.) Poison Centers between 01 June 2010 and 30 September 2013., Methods: We obtained data from the American Association of Poison Control Centers (AAPCC) for all exposures involving e-cigarettes reported to the National Poison Data System (NPDS) by U.S. Poison Centers and described trends in exposures over time, demographics, geographical characteristics, clinical effects and outcomes, management site, and exposure route., Results: A total of 1,700 exposures were reported to Poison Centers during this time. The most frequent age groups were children 5 years or below with 717 (42.2%) exposures and adults ages 20-39 years with 466 (27.4%) exposures. Temporal trends showed an increase of 1.36 exposures per month [95% CI: 1.16-1.56] from June 2010 through December 2012, after which exposures increased by 9.60 per month [95% CI: 8.64-10.55] from January through September 2013. The majority of patients who were followed reported that they had only minor effects., Conclusions: The majority of exposures to e-cigarette devices and components occurred in children of 5 years or below due to accidental exposure. Based on the available data, the reported exposures have resulted in minimal toxicity. Calls to Poison Centers regarding these products have rapidly increased since 2010, and continued surveillance may show changes in the epidemiological trends surrounding e-cigarette exposures.