Elder Mistreatment: Emergency Department Recognition and Management.

Gottesman E, Elman A, Rosen T; Department of Emergency Medicine, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York; Clin Geriatr Med; 2023 Nov;39(4):553-573.

Elder mistreatment is experienced by 5% to 15% of community-dwelling older adults each year. An emergency department (ED) encounter offers an important opportunity to identify elder mistreatment and initiate intervention. Strategies to improve detection of elder mistreatment include identifying high-risk patients; recognizing suggestive findings from the history, physical examination, imaging, and laboratory tests; and/or using screening tools. ED management of elder mistreatment includes addressing acute issues, maximizing the patient’s safety, and reporting to the authorities when appropriate.

Expanding Diabetes Screening to Identify Undiagnosed Cases Among Emergency Department Patients.

Lee DC, Reddy H, Koziatek CA, Klein N, Chitnis A, Creary K, Francois G, Akindutire O, Femia R, Caldwell R; Ronald O. Perelman Department of Emergency Medicine, New York; West J Emerg Med; 2023 Sep;24(5):962-966.

INTRODUCTION: Diabetes screening traditionally occurs in primary care settings, but many who are at high risk face barriers to accessing care and therefore delays in diagnosis and treatment. These same high-risk patients do frequently visit emergency departments (ED) and, therefore, might benefit from screening at that time. Our objective in this study was to analyze one year of results from a multisite, ED-based diabetes screening program.

METHODS: We assessed the demographics of patients screened, identified differences in rates of newly diagnosed diabetes by clinical site, and the geographic distribution of high and low hemoglobin A1c (HbA1c) results.

RESULTS: We performed diabetes screening (HbA1c) among 4,211 ED patients 40-70 years old, with a body mass index ≥25, and no prior history of diabetes. Of these patients screened for diabetes, 9% had a HbA1c result consistent with undiagnosed diabetes, and nearly half of these patients had a HbA1c ≥9.0%. Rates of newly diagnosed diabetes were notably higher at EDs located in neighborhoods of lower socioeconomic status.

CONCLUSION: Emergency department-based diabetes screening may be a practical and scalable solution to screen high-risk patients and reduce health disparities experienced in specific neighborhoods and demographic groups.

Treatment of Factor-Xa Inhibitor-Associated Bleeding With Andexanet Alfa or 4 Factor PCC: A Multicenter Feasibility Retrospective Study.

Singer AJ, Concha M, Williams J, Brown CS, Fernandes R, Thode HC Jr, Kirchman M, Rabinstein AA; Department of Emergency Medicine, Stony Brook; J Emerg Med; 2023 Sep;24(5):939-949.

BACKGROUND: There are no randomized trials comparing andexanet alfa and 4 factor prothrombin complex concentrate (4F-PCC) for the treatment of factor Xa inhibitor (FXa-I)-associated bleeds, and observational studies lack important patient characteristics. We pursued this study to demonstrate the feasibility of acquiring relevant patient characteristics from electronic health records. Secondarily, we explored outcomes in patients with life-threatening FXa-I associated bleeds after adjusting for these variables.

METHODS: We conducted a multicenter, chart review of 100 consecutive adult patients with FXa-I associated intracerebral hemorrhage (50) or gastrointestinal bleeding (50) treated with andexanet alfa or 4F-PCC. We collected demographic, clinical, laboratory, and imaging data including time from last factor FXa-I dose and bleed onset.

RESULTS: Mean (SD) age was 75 (12) years; 34% were female. Estimated time from last FXa-I dose to bleed onset was present in most cases (76%), and patients treated with andexanet alfa and 4F-PCC were similar in baseline characteristics. Hemostatic efficacy was excellent/good in 88% and 76% of patients treated with andexanet alfa and 4F-PCC, respectively (P=0.29). Rates of thrombotic events within 90 days were 14% and 16% in andexanet alfa and 4F-PCC patients, respectively (P=0.80). Survival to hospital discharge was 92% and 76% in andexanet alfa and 4F-PCC patients, respectively (P=0.25). Inclusion of an exploratory propensity score and treatment in a logistic regression model resulted in an odds ratio in favor of andexanet alfa of 2.01 (95% confidence interval 0.67-6.06) for excellent/good hemostatic efficacy, although the difference was not statistically significant.

CONCLUSIONS: Important patient characteristics are often documented supporting the feasibility of a large observational study comparing real-life outcomes in patients with FXa-I-associated bleeds treated with andexanet alfa or 4F-PCC. The small sample size in the current study precluded definitive conclusions regarding the safety and efficacy of andexanet alfa or 4F-PCC in FXa-I-associated bleeds.

Social Determinants of Health in EMS Records: A Mixed-Methods Analysis Using Natural Language Processing and Qualitative Content Analysis

Burnett SJ, Stemerman R, Innes JC, Kaisler MC, Crowe RP, Clemency BM; The State University of New York, Department of Emergency Medicine, Buffalo; West J Emerg Med; 2023 Sep;24(5):878- 887.

INTRODUCTION: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients’ environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients’ insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel.

METHODS: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory.

RESULTS: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients’ employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures.

CONCLUSION: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients’ SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

Application of a Low-cost, High-Fidelity Proximal Phalangeal Dislocation Reduction Model for Clinician Training.

Lord S, Geary S, Lord G; Albany Medical Center, Department of Emergency Medicine, Albany; West J Emerg Med; 2023 Sep;24(5):839-846.

INTRODUCTION: Patients present to the emergency department (ED) relatively commonly with traumatic closed proximal interphalangeal joint (PIPJ) dislocations, an orthopedic emergency. There is a paucity of teaching models and training simulations for clinicians to learn either the closed dislocated dorsal or volar interphalangeal joint reduction technique. We implemented a teaching model to demonstrate the utility of a novel reduction model designed from three-dimensional (3D) printable components that are easy to connect and do not require further machining or resin models to complete.

METHODS: Students watched a two-minute video and a model demonstration by the authors. Learners including emergency medicine (EM) residents and physician assistant fellows assessed model fidelity, convenience, perceived competency, and observed competency.

RESULTS: Seventeen of 21 (81%) participants agreed the model mimicked dorsal and volar PIPJ dislocations. Nineteen of 21 (90%) agreed the model was easy to use, 21/21 (100%) agreed the dorsal PIPJ model and 20/21 (95%) agreed the volar PIPJ model improved their competency.

CONCLUSION: Our 3D-printed, dorsal and volar dislocation reduction model is easy to use and affordable, and it improved perceived competency among EM learners at an academic ED.

Association of Racial Residential Segregation With Long-Term Outcomes and Readmissions After Out-of-Hospital Cardiac Arrest Among Medicare Beneficiaries.

Abbott EE, Buckler DG, Hsu JY, Abella BS, Richardson LD, Carr BG, Zebrowski AM; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai New York; J Am Heart Assoc; 2023 Oct 3;12(19):e030138.

BACKGROUND: The national impact of racial residential segregation on out-of-hospital cardiac arrest outcomes after initial resuscitation remains poorly understood. We sought to characterize the association between measures of racial and economic residential segregation at the ZIP code level and long-term survival and readmissions after out-of-hospital cardiac arrest among Medicare beneficiaries.

METHODS AND RESULTS: In this retrospective cohort study, using Medicare claims data, our primary predictor was the index of concentration at the extremes, a measure of racial and economic segregation. The primary outcomes were death up to 3years and readmissions. We estimated hazard ratios (HRs) across all 3 types of index of concentration at the extremes measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. In fully adjusted models for long-term survival, we found a decreased hazard of death and risk of readmission for beneficiaries residing in the more segregated White communities and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes across all 3 indices of concentration at the extremes measures (race: HR, 0.87 [95% CI, 0.81-0.93]; income: HR, 0.75 [95% CI, 0.69-0.78]; and race+income: HR, 0.77 [95% CI, 0.72-0.82]).

CONCLUSION: We found a decreased hazard of death and risk for readmission for those residing in the more segregated White communities and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes when using validated measures of racial and economic segregation. Although causal pathways and mechanisms remain unclear, disparities in outcomes after out-of-hospital cardiac arrest are associated with the structural components of race and wealth and persist up to 3 years after discharge.

Blueprint for the Development of Resuscitation and Emergency Critical Care Fellowships.

Bracey A, Tichauer MB, Wu GP, Barnicle RN, Lu CJ, Tanzi MV, Pellet AC, Pauzé DR, Weingart SD, Duncan LJ, Wright BJ; Department of Emergency Medicine Albany Medical Center Hospital, Albany; AEM Educ Train; 2023 Sep 15;7(5):e10905.

The volume of critically ill patients presenting to the emergency department (ED) is increasing rapidly. Continued growth will likely further stress an already strained U.S. health care system. Numerous studies have demonstrated an association with worsened outcomes for critically ill patients boarding in the ED. To address the increasing volume and complexity of critically ill patients presenting to EDs nationwide, resuscitation and emergency critical care (RECC) fellowships were developed. RECC programs teach a general approach to the management of the undifferentiated critically ill patient, advanced management of critically ill patients by disease presentation, and ongoing supportive care of the critically ill patient boarding in the ED. The result is critical care training beyond that of a typical emergency medicine (EM) residency with a focus on the unique features and challenges of caring for critically ill patients in the ED not normally found in critical care fellowships. Graduates from RECC fellowships are well suited to practicing in any ED practice model and may be especially well prepared for EDs that distinguish acuity between zones (e.g., re-suscitative care units, ED-based intensive care units). In addition to further developing clinical acumen, RECC fellowships provide graduates with a niche in EM education, research, and administration. In this article, we describe the philosophical principles and practical components necessary for the creation of future RECC fellowships.

Urine Toxicology Profiles of Emergency Department Patients With Untreated Opioid Use Disorder: A Multi-Site View.

Cowan E, Perrone J, Dziura J, Edelman EJ, Hawk K, Herring A, McCormack R, Murphy A, Phadke M, Fiellin DA, D’Onofrio G; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York; J Emerg Med; 2023 Oct;65(4):e357-e365.

BACKGROUND: Opioid overdose deaths in 2021 were the highest ever, driven by fentanyl and polysubstance use.

OBJECTIVE: The aim of the study was to characterize drug use, assessed by urine drug screens (UDSs), in patients with untreated opioid use disorder (OUD) presenting to 28 emergency departments (EDs) nationally and by region.

METHODS: We analyzed UDSs from patients enrolled in the CTN-0099 ED-INNOVATION (Emergency Department-Initiated Buprenorphine Validation) trial between July 12, 2020 and March 9, 2022. Participants were adult ED patients with OUD not engaged in addiction treatment with a UDS positive for an opioid, but negative for methadone. Sites were divided into “East” and “West” regions.

RESULTS: A UDS was available for all 925 enrolled participants, 543 from East and 382 from West. Fentanyl was in 702 specimens (76%) (n = 485 [89%] East vs. n = 217 [57%] West; p < 0.01) and was the only opioid in 269 (29%). After fentanyl, the most common opioids were morphine (presumably heroin; n = 411 [44%]; n = 192 [35%] East vs. n = 219 [57%] West; p < 0.01) and buprenorphine (n = 329 [36%]; n = 186 [35%] East vs. n = 143 [37%] West; p = 0.32). The most common drugs found with opioids were stimulants (n = 545 [59%]), tetrahydrocannabinol (n = 417 [45%]), and benzodiazepines (n = 151 [16%]). Amphetamine-type stimulants were more common in West (n = 209 [55%] vs. East (n = 125 [23%]). Cocaine was more common in East (n = 223 [41%]) vs. West (n = 82 [21%]). The presence of multiple drugs was common (n= 759 [82%]).

CONCLUSIONS: Most participants had UDS specimens containing multiple substances; a high proportion had fentanyl, stimulants, and buprenorphine. Regional differences were noted. Given the increased risk of death with fentanyl and polysubstance use, ED providers should be providing risk reduction counseling, treatment, and referral.

The Critical Role of the Specialized Social Worker as Part of ED/Hospital-Based Elder Mistreatment Response Teams.

Elman A, Cox S, Gottesman E, Herman S, Kirshner A, Tietz S, Shaw A, Hancock D, Chang ES, Baek D, Bloemen E, Clark S, Rosen T; Department of Emergency Medicine, Weill Cornell Medical College/ NewYork-Presbyterian Hospital, New York; J Elder Abuse Negl; 2023 Sep 10:1-11

The emergency department and hospital provide a unique and important opportunity to identify elder mistreatment and offer intervention. To help manage these complex cases, multi-disciplinary response teams have been launched. In developing these teams, it quickly became clear that social workers play a critical role in responding to elder mistreatment. Their unique skillset allows them to establish close connections with community resources, collaborate with various hospital stakeholders, support patients/families/caregivers through challenging situations, navigate the legal and protective systems, and balance patient safety and quality of life in disposition decision-making. The role of the social worker on these multi-faceted teams includes conducting a comprehensive biopsychosocial assessment, helping to develop a safe discharge plan, and making appropriate referrals, among other responsibilities. Any institution considering developing a multi-disciplinary program should recognize the critical importance of social work.

Reducing Low-Value ED Coags Across 11 Hospitals in a Safety Net Setting.

Walker TR, Bochner RE, Alaiev D, Talledo J, Tsega S, Krouss M, Cho HJ; NYC Health + Hospitals/Lincoln, Department of Emergency Medicine, Bronx; Am J Emerg Med; 2023 Aug 9;73:88-94.

BACKGROUND: Prothrombin/international normalized ratio and activated partial thromboplastin time (PT/INR and aPTT) are frequently ordered in emergency departments (EDs), but rarely affect management. They offer limited utility outside of select indications. Several quality improvement initiatives have shown reduction in ED use of PT/INR and aPTT using multifaceted interventions in well-resourced settings. Successful reduction of these low-value tests has not yet been shown using a single intervention across a large hospital system in a safety net setting. This study aims to determine if an intervention of two BPAs is associated with a reduction in PT/INR and aPTT usage across a large safety net system.

METHODS: This initiative was set at a large safety net system in the United States with 11 acute care hospitals. Two Best Practice Advisories (BPAs) discouraging inappropriate PT/INR and aPTT use were implemented from March 16, 2022-August 30, 2022. Order rate per 100 ED patients during the pre-intervention period was compared to the post-intervention period on both the system and individual hospital level. Complete blood count (CBC) testing served as a control, and packed red blood cell transfusions served as a balancing measure. An interrupted time series regression analysis was performed to capture immediate and temporal changes in ordering for all tests in the pre and post-intervention periods.

RESULTS: PT/INR tests exhibited an absolute decline of 4.11 tests per 100 ED encounters (95% confidence interval -5.17 to -3.05; relative reduction of 18.9%). aPTT tests exhibited absolute decline of 4.03 tests per 100 ED encounters (95% CI -5.10 to -2.97; relative reduction of 19.8%). The control measure, CBC, did not significantly change (-0.43, 95% CI -2.83 to 1.96). Individual hospitals showed variable response, with absolute reductions from 2.02 to 9.6 tests per 100 ED encounters for PT/INR (relative reduction 12.1%-30.5%) and 2.07 to 10.04 for aPTT (relative reduction 12.1%-31.4%). Regression analysis showed that the intervention caused an immediate 25.7% decline in PT/INR and 24.7% decline in aPTT tests compared to the control measure. The slope differences (rate of order increase pre vs post intervention) did not significantly decline compared to the control.

CONCLUSION: This BPA intervention reduced PT/INR and aPTT use across 11 EDs in a large, urban, safety net system. Further study is needed in implementation to other non-safety net settings.