The mission of the Department of Emergency Medicine is to be the preeminent Department of Emergency Medicine in the country by delivering excellent healthcare, with respect and dignity to all patients needing emergent or urgent care services; conducting ground-breaking research that enhances public health; and developing innovative educational programs for all levels of health care providers. This collection showcases journal articles and other publications written by faculty and researchers of the Department of Emergency Medicine.


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Recently Published

  • Interventions to Improve Mental Health, Well-Being, Physical Health, and Lifestyle Behaviors in Physicians and Nurses: A Systematic Review

    Melnyk, Bernadette Mazurek.; Kelly, Stephanie A.; Stephens, Janna; Dhakal, Kerry; McGovern, Colleen; Tucker, Sharon; Hoying, Jacqueline; McRae, Kenya; Ault, Samantha; Spurlock, Elizabeth; et al. (2020-04-27)
    OBJECTIVE: This systematic review focused on randomized controlled trials (RCTs) with physicians and nurses that tested interventions designed to improve their mental health, well-being, physical health, and lifestyle behaviors. DATA SOURCE: A systematic search of electronic databases from 2008 to May 2018 included PubMed, CINAHL, PsycINFO, SPORTDiscus, and the Cochrane Library. STUDY INCLUSION AND EXCLUSION CRITERIA: Inclusion criteria included an RCT design, samples of physicians and/or nurses, and publication year 2008 or later with outcomes targeting mental health, well-being/resiliency, healthy lifestyle behaviors, and/or physical health. Exclusion criteria included studies with a focus on burnout without measures of mood, resiliency, mindfulness, or stress; primary focus on an area other than health promotion; and non-English papers. DATA EXTRACTION: Quantitative and qualitative data were extracted from each study by 2 independent researchers using a standardized template created in Covidence. DATA SYNTHESIS: Although meta-analytic pooling across all studies was desired, a wide array of outcome measures made quantitative pooling unsuitable. Therefore, effect sizes were calculated and a mini meta-analysis was completed. RESULTS: Twenty-nine studies (N = 2708 participants) met the inclusion criteria. Results indicated that mindfulness and cognitive-behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression. Brief interventions that incorporate deep breathing and gratitude may be beneficial. Visual triggers, pedometers, and health coaching with texting increased physical activity. CONCLUSION: Healthcare systems must promote the health and well-being of physicians and nurses with evidence-based interventions to improve population health and enhance the quality and safety of the care that is delivered.
  • An Emergency Medicine-focused Summary of the HFSA/SAEM/ISHLT Clinical Consensus Document on the Emergency Management of Patients With Ventricular Assist Devices

    Darling, Chad E.; Martindale, Jennifer L.; Hiestand, Brian C.; Bonnell, Mark; Colvin, Monica; DeFilippis, Ersilia M.; Elliott, Tonya; Hamad, Eman; Pinney, Sean P.; Shah, Keyur B.; et al. (2020-03-16)
    Mechanical circulatory support is increasingly used as a long-term treatment option for patients with end-stage heart failure. Patients with implanted ventricular assist devices are at high risk for a range of diverse medical urgencies and emergencies. Given the increasing prevalence of mechanical circulatory support devices, this expert clinical consensus document seeks to help inform emergency medicine and prehospital providers regarding the approach to acute medical and surgical conditions encountered in these complex patients.
  • Federal Funding in Emergency Medicine: Demographics and Perspectives of Awardees

    Chai, Peter R.; Carreiro, Stephanie; Chapman, Brittany; Boyer, Edward W.; O'Laughlin, Kelli N. (2020-02-24)
    INTRODUCTION: Emergency physicians face multiple challenges to obtaining federal funding. The objective of this investigation was to describe the demographics of federally-funded emergency physicians and identify key challenges in obtaining funding. METHODS: We conducted a retrospective database search of the National Institutes of Health (NIH) Research Portfolio Online Reporting Tool (NIH RePORTER) to collect data regarding the distribution and characteristics of federally-funded grants awarded to emergency medicine (EM) principal investigators between 2010-2017. An electronic survey was then administered to the identified investigators to obtain additional demographic data, and information regarding their career paths, research environment, and perceived barriers to obtaining federal funding. RESULTS: We identified 219, corresponding to 51 unique, mentored career development awardees and 105 independent investigators. Sixty-two percent of investigators responded to the electronic survey. Awardees were predominantly White males, although a larger portion of the mentored awardee group was female. Greater than half of respondents reported their mentor to be outside of the field of EM. The most common awarding institution was the National Heart Lung and Blood Institute. Respondents identified barriers in finding adequate mentorship, time to gather preliminary data, and the quality of administrative support. CONCLUSION: The last five years have showed a trend toward increasing grants awarded to EM investigators; however, we identified several barriers to funding. Initiatives geared toward support and mentorship of junior faculty, particularly to females, minorities, and those in less heavily funded areas of the country are warranted.
  • Reduction of Inappropriate Antibiotic Use and Improved Outcomes by Implementation of an Algorithm-Based Clinical Guideline for Nonpurulent Skin and Soft Tissue Infections

    Haran, John P.; Goulding, Melissa; Campion, Maureen; Scully, Gail; Chandra, Arnav; Goldberg, Rebecca; Day, Allyson; McLendon, Emily; Clark, Melissa A. (2020-02-18)
    STUDY OBJECTIVE: Clinicians currently do not reliably adhere to antibiotic treatment guidelines, resulting in unnecessary patient exposure to broad-spectrum antimicrobials. Our objective is to determine whether a treatment intervention for the management of nonpurulent skin and soft tissue infections increases clinician adherence and improves patient outcomes. METHODS: Between January 1 and December 31, 2017, patients presenting to 2 emergency departments (EDs) and who had received a diagnosis of a nonpurulent skin and soft tissue infection were enrolled and assigned to a pre- or postintervention cohort with a treatment intervention implemented on June 1. Primary outcomes were percentage of ED providers following the guidelines and percentage of patients admitted to the hospital. Secondary outcomes were patient self-reported treatment failure and hospital readmission. RESULTS: There were 1,360 patients, 665 in the preintervention and 695 in the postintervention cohorts. After algorithm implementation, guideline adherence increased (43.0% versus 55.1%; P < .001) and number of patients admitted to the hospital declined (36.5% versus 12.0%; P < .001). In addition, patients reported fewer treatment failures (26.8% versus 16.5%; P=.02) and fewer readmissions (22.3% versus 12.7%; P=.013). After multivariate adjustment, guideline adherence increased by 22% (adjusted relative risk [RR] 1.22; 95% confidence interval [CI] 1.10 to 1.37), whereas hospital admissions were reduced by 26% (adjusted RR 0.74; 95% CI 0.64 to 0.87). In addition, the risks of treatment failure and readmission were reduced by 46% (adjusted RR 0.64; 95% CI 0.43 to 0.97) and 45% (adjusted RR 0.55; 95% CI 0.34 to 0.87), respectively. CONCLUSION: Among patients with a nonpurulent skin and soft tissue infection, implementing an easy-to-follow treatment algorithm can reduce unnecessary antibiotic exposure by increasing clinician guideline adherence while reducing patient treatment failure rates.
  • Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination

    O'Connor, Laurel; Porter, Liam; Dugas, Julianne; Robinson, Conor; Carrillo, Eli; Knowles, Kenneth; Nelson, Kerrie P.; Gigliotti, Ronald; Tennyson, Joseph; Weisberg, Stacy N.; et al. (2020-02-17)
    OBJECTIVES: If a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments. METHODS: This study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter-rater reliability was calculated utilizing Fleiss' and Model B kappa statistics. Fisher's exact tests were used to calculate p-values comparing the proportion in each cohort that responded "no capacity." Primary outcomes included inter-rater reliability in the physician and prehospital provider cohorts. RESULTS: The inter-rater agreement between the physicians was low (Fleiss' kappa = 0.31, standard error [SE] =0.06; model-based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss' kappa = 0.30, SE = 0.06; model-based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded "no capacity" was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1-Q3 = 1.00-3.00 for prehospital providers and Q1-Q3 =1.0-2.0 for physicians). CONCLUSIONS: There was poor inter-rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task.
  • Tools for Measuring Clinical Ultrasound Competency: Recommendations From the Ultrasound Competency Work Group

    Damewood, Sara C.; Leo, Megan; Bailitz, John; Gottlieb, Michael; Liu, Rachel; Hoffmann, Beatrice; Gaspari, Romolo J (2020-02-01)
    Competency in clinical ultrasound is essential to ensuring safe patient care. Competency in clinical ultrasound includes identifying when to perform a clinical ultrasound, performing the technical skills required for ultrasound image acquisition, accurately interpreting ultrasound images, and incorporating sonographic findings into clinical practice. In this concept paper, we discuss the advantages and limitations of existing tools to measure ultrasound competency. We propose strategies and future directions for assessing competency in clinical ultrasound.
  • 2017 AAAEM Benchmarking Survey: Comparing Pediatric and Adult Academic Emergency Departments

    Rathlev, Niels K.; Holt, Nate M.; Harbertson, Cathi A.; Hettler, Joeli; Reznek, Martin A.; Tsai, Shiu-Lin; Lopiano, Kenny K.; Bohrmann, Tommy; Scheulen, James J. (2020-01-21)
    OBJECTIVES: The Academy of Administrators in Academic Emergency Medicine Benchmark Survey of academic emergency departments (EDs) was conducted in 2017. We compared operational measures between pediatric and adult (defined as fewer than 5% pediatric visits) EDs based on survey data. Emergency departments in dedicated pediatric hospitals were not represented. METHODS: Measures included: (1) patient volumes, length of stay, and acuity; and 2) faculty staffing, productivity, and percent effort in academics. t Tests were used to compare continuous measures and inferences for categorical variables were made using Pearson chi test. RESULTS: The analysis included 17 pediatric and 52 adult EDs. We found a difference in the number of annual visits between adult (median, 66,275; interquartile range [IQR], 56,184-77,702) and pediatric EDs (median, 25,416; IQR, 19,840-29,349) (P < 0.0001). Mean "arrivals per faculty clinical hour" and "total arrivals per treatment space" showed no differences. The proportion of visits (1) arriving by emergency medical services and (2) for behavioral health were significantly higher in adult EDs (both P < 0.0001). The mean length of stay in hours for "all" patients was significantly longer in adult (5.4; IQR, 5.0-6.6) than in pediatric EDs (3.5; IQR, 2.9-4.3; P = 0.017). A similar difference was found for "discharged" patients (P = 0.004). Emergency severity indices, professional evaluation and management codes, and hospitalization rates all suggest higher acuity in adult EDs (all P < 0.0001). There were no differences in mean work relative value units per patient or in the distribution of full time equivalent effort dedicated to academics. CONCLUSIONS: In this cohort, significant differences in operational measures exist between academic adult and pediatric EDs. No differences were found when considering per unit measures, such as arrivals per faculty clinical hour or per treatment space.
  • What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care

    Isbell, Linda M.; Boudreaux, Edwin D.; Chimowitz, Hannah; Liu, Guanyu; Cyr, Emma; Kimball, Ezekiel (2020-01-15)
    BACKGROUND: Despite calls to study how healthcare providers' emotions may impact patient safety, little research has addressed this topic. The current study aimed to develop a comprehensive understanding of emergency department (ED) providers' emotional experiences, including what triggers their emotions, the perceived effects of emotions on clinical decision making and patient care, and strategies providers use to manage their emotions to reduce patient safety risks. METHODS: Employing grounded theory, we conducted 86 semi-structured qualitative interviews with experienced ED providers (45 physicians and 41 nurses) from four academic medical centres and four community hospitals in the Northeastern USA. Constant comparative analysis was used to develop a grounded model of provider emotions and patient safety in the ED. RESULTS: ED providers reported experiencing a wide range of emotions in response to patient, hospital, and system-level factors. Patients triggered both positive and negative emotions; hospital and system-level factors largely triggered negative emotions. Providers expressed awareness of possible adverse effects of negative emotions on clinical decision making, highlighting concerns about patient safety. Providers described strategies they employ to regulate their emotions, including emotional suppression, distraction, and cognitive reappraisal. Many providers believed that these strategies effectively guarded against the risk of emotions negatively influencing their clinical decision making. CONCLUSION: The role of emotions in patient safety is in its early stages and many opportunities exist for researchers, educators, and clinicians to further address this important issue. Our findings highlight the need for future work to (1) determine whether providers' emotion regulation strategies are effective at mitigating patient safety risk, (2) incorporate emotional intelligence training into healthcare education, and (3) shift the cultural norms in medicine to support meaningful discourse around emotions. permissions.
  • Circulating microRNA Profiles in Acetaminophen Toxicity

    Carreiro, Stephanie; Marvel-Coen, James; Lee, Rosalind; Chapman, Brittany; Ambros, Victor R. (2019-12-02)
    INTRODUCTION: Acetaminophen toxicity has been associated with elevation of microRNAs. The present study was to evaluate overall microRNA profiles and previously identified microRNAs to differentiate acetaminophen (APAP) toxicity from other causes of transaminase elevation. METHODS: This was an observational study of adults with presumed acetaminophen toxicity at presentation. Serum samples were collected every 12 hours during hospitalization. Total miRNAs were extracted from plasma and levels of 327 microRNAs were quantified using real-time polymerase chain reaction. A standard measure of miRNA expression (delta-delta cycle threshold) was calculated for each microRNAs. A two-level cluster analysis was performed using a random k-means algorithm. Demographic and clinical characteristics of each cluster were compared using ANOVA, Wilcoxon rank sum, Kruskal-Wallis, and chi-square tests. Performance of specific miRNAs of interest was also evaluated. RESULTS: Twenty-seven subjects were enrolled (21 with a final diagnosis of acetaminophen toxicity), and a total of 61 samples were analyzed. Five clusters were identified, two of which demonstrated clear clinical patterns and included specific elevated miRNAs previously reported to be elevated in APAP toxicity patients. Features associated with clusters 1 and 5 included confirmed acetaminophen toxicity, high peak alanine aminotransferase, and late presentation. Clusters 2-4 contained lower peak microRNAs, lower peak alanine aminotransferase, and heterogeneous clinical characteristics. CONCLUSIONS: Severe cases of acetaminophen toxicity showed two distinct patterns of microRNA elevation which were similar to previous work, while less severe cases were difficult to distinguish from non-acetaminophen-associated cases. Further work is needed to incorporate microRNA profiles into the diagnostic algorithm of acetaminophen toxicity.
  • Clinical operations of academic versus non-academic emergency departments: a descriptive comparison of two large emergency department operations surveys

    Reznek, Martin A.; Michael, Sean S.; Harbertson, Cathi A.; Scheulen, James J.; Augustine, James J. (2019-11-21)
    BACKGROUND: Academic and non-academic emergency departments (EDs) are regularly compared in clinical operations benchmarking despite suggestion that the two groups may differ in their clinical operations characteristics. and outcomes. We sought to describe and compare clinical operations characteristics of academic versus non-academic EDs. METHODS: We performed a descriptive, comparative analysis of academic and non-academic adult and general EDs with 40,000+ annual encounters, using the Academy of Academic Administrators of Emergency Medicine (AAAEM)/Association of Academic Chairs of Emergency Medicine (AACEM) and Emergency Department Benchmarking Alliance (EDBA) survey results. We defined academic EDs as primary teaching sites for emergency medicine (EM) residencies and non-academic EDs as sites with minimal resident involvement. We constructed the academic and non-academic cohorts from the AAAEM/AACEM and EDBA surveys, respectively, and analyzed metrics common to both surveys. RESULTS: Eighty and 454 EDs met inclusion criteria for academic and non-academic EDs, respectively. Academic EDs had more median annual patient encounters (73,001 vs 54,393), lower median proportion of pediatric patients (6.3% vs 14.5%), higher median proportion of EMS patients (27% vs 19%), and were more commonly designated as Level I or II Trauma Centers (94% vs 24%). Median patient arrival-to-provider times did not differ (26 vs 25 min). Median length-of-stay was longer (277 vs 190 min) for academic EDs, and left-before-treatment-complete was higher (5.7% vs 2.9%). MRI utilization was higher for academic EDs (2.2% patients with at least one MRI vs 1.0 MRIs performed per 100 patients). Patients-per-hour of provider coverage was lower for academic EDs with and without consideration for advanced practice providers and residents. CONCLUSIONS: Demographic and operational performance measures differ between academic and non-academic EDs, suggesting that the two groups may be inappropriate operational performance comparators. Causes for the differences remain unclear but the differences appear not to be attributed solely to the academic mission.
  • The AURORA Study: a longitudinal, multimodal library of brain biology and function after traumatic stress exposure

    McLean, Samuel A.; Haran, John P.; Kessler, Ronald (2019-11-19)
    Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.
  • Gender differences in funding among grant recipients in emergency medicine: A multicenter analysis

    Dubosh, Nicole M.; Boyle, Katherine L.; Carreiro, Stephanie; Yankama, Tuyen; Landry, Alden M. (2019-11-18)
    OBJECTIVE: To describe differences in funded grants between male and female faculty in two academic emergency departments. METHODS: This was a retrospective analysis of grant funding at two academic emergency departments from January 2012-September 2018. We queried the grants department databases at each institution and obtained records of all funded grants for emergency medicine (EM) faculty. We extracted the following information for each award: gender of the principal investigator (PI), PI academic rank, grant mechanism (government, institutional, industry, organizational), and percent effort. Differences by gender were compared using Chi-square or Fisher's exact test and Wilcoxon-rank sum. RESULTS: One-hundred and thirty grants were awarded to EM faculty at the two institutions during the study period. Of the funded grants, 35 (27%) of recipients were female. Among grant recipients, females held lower academic ranking than males (p-value < 0.001): Instructor (49% vs 51%), Assistant Professor (36% vs 64%), Associate Professor (9% vs 91%), and Professor (0% vs 100%), respectively. Organizational grants were dispersed equally between funded faculty, but females received a fewer government, industry, and institutional grants (p-value = 0.007). Female grant recipients were awarded a higher median percent of effort compared to males (14% [IQR: 3-51] vs 8% [IQR: 1-15], respectively, p-value = 0.023). CONCLUSION: In this multicenter analysis, gender discrepancies exist among funded grants of EM faculty. Male recipients had higher academic ranking than their female counterparts. Female recipients were less likely to have government, institutional, and industry grants but received a greater percent effort on funding that was awarded.
  • Impact of the mental health and dynamic referral for oncology (MHADRO) program on oncology patient outcomes, health care utilization, and health provider behaviors: A multi-site randomized control trial

    O'Hea, Erin L.; Kroll-Desrosiers, Aimee; Cutillo, Alexandra S.; Michalak, Hannah R.; Barton, Bruce A.; Harralson, Tina; Carmack, Cindy; McMahon, Cori; Boudreaux, Edwin D. (2019-11-05)
    OBJECTIVE: The MHADRO assesses psychosocial and medical needs, provides tailored feedback reports, and connects patients to mental health providers. This study examined the MHADRO's effect on patient outcomes, health care utilization, and oncology provider documentation and behaviors. METHODS: 836 patients were part of a multi-site RCT and assessments were conducted at baseline, 2, 6 and 12 months. RESULTS: The intervention group engaged in less emergency calls to providers. There were no differences in psychosocial outcomes at follow up assessments. Providers of patients in the intervention group were more likely to: document psychosocial symptoms and history; refer to psychosocial services; encourage support groups; seek psychological evaluations during visits. Patients who agreed to a mental health referral had decreased hospitalizations, increased mental health care interactions, and stronger ratings of counseling potential benefits. This group also reported increased psychosocial distress at all follow-up assessments. CONCLUSION: The MHADRO may increase access to mental health care, lessen utilization, and improve providers' management of psychosocial needs, but does not appear to impact overall functioning over time. PRACTICE IMPLICATIONS: Providers are encouraged to consider incorporating programs, like the MHADRO, into patient care as they may have the potential to impact screening and management of patients' psychosocial needs.
  • Sex differences in patients with suicidal intent that are managed by toxicologists: An analysis of the Toxicology Investigators' Consortium (ToxIC) Registry

    Beauchamp, Gillian A.; Fishbein, Jacob; Makar, Gregory A.; Pechulis, Rita M.; Cook, Matthew D.; Cannon, Robert D.; Katz, Kenneth D.; Kincaid, Hope; Carey, Jennifer L.; Greenberg, Marna Rayl; et al. (2019-10-08)
    INTRODUCTION: The Toxicology Investigator's Consortium (ToxIC) maintains a prospective case registry of all patients that have been managed at the bedside by medical toxicologists. We set out to characterize the differences in toxicological suicide attempts between men and women among adult patients with poisonings managed by medical toxicologists. METHODS: ToxIC database consults for adults aged 19-65 whose primary reasons for encounter were classified as suicide attempt were used for this study (1/2010-12/2016). Data used for analysis included primary agents of toxic exposure, routes of administration, and complications. The statistical analysis was limited to descriptive methods. RESULTS: Out of 51,440 registry cases, 33,259 cases remained for analysis after applying the ages 19-65 and removing those without complete data. Of these, there were 4827 suicide attempts (14.5% of toxicological exposures) which were sub classified by gender. There were more females (F) than males (M) whose toxicology consults were due to suicidal attempts (57.6% versus 42.4%). We also found that more males used alcohol as their primary agent (2.8%M v 1.5%F) or a nonpharmaceutical (%7.4M v %2.3 F). CONCLUSIONS: In our study, we found that there were more females than males who attempted suicide by self-poisoning; and more of them used pharmaceuticals than males. In contrast, a greater number of males used nonpharmaceuticals such as alcohol. We did not find large sex-differences in suicide completion rates, routes of administration, or subsequent symptomologies. In summary, sex-based differences were observed between adult patients with suicidal-intent exposures/ingestions managed at the bedside by medical toxicologists.
  • Higher Educational Attainment is Associated with Lower Risk of a Future Suicide Attempt Among Non-Hispanic Whites but not Non-Hispanic Blacks

    Assari, Shervin; Schatten, Heather T.; Arias, Sarah A.; Miller, Ivan W.; Camargo, Carlos A.; Boudreaux, Edwin D. (2019-10-01)
    PURPOSE: In a sample of patients presenting to the emergency department (ED), the current study was conducted with two aims: (1) to investigate the protective effects of educational attainment (i.e., completing college) on subsequent risk of suicide attempt/death among patients presenting to the ED and (2) to compare this effect between non-Hispanic Black and non-Hispanic White ED patients. METHODS: The current study analyzed data from the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) study, a quasi-experimental, eight-center study of universal suicide screening and follow-up of ED patients presenting for suicidal ideation and behavior. Our sample included 937 non-Hispanic White and 211 non-Hispanic Blacks. The dependent variable was suicide attempt/death during the 52-week follow-up. The independent variable was completing college. Age, gender, lesbian/gay/bisexual status, psychiatric history, and previous suicide attempts at baseline were covariates. Race/ethnicity was the focal effect modifier. Logistic regression models were used to test the protective effects of educational attainment on suicide risk in the overall sample and by race/ethnicity. RESULTS: In the overall sample, educational attainment was not associated with suicide risk over the follow-up period. A significant interaction was found between race/ethnicity and educational attainment on suicide risk, suggesting a larger protective effect for non-Hispanic Whites compared with non-Hispanic Blacks. In race/ethnicity-specific models, completing college was associated with decreased future suicide risk for non-Hispanic Whites but not Blacks. CONCLUSIONS: Consistent with the Minorities' Diminished Return theory, educational attainment better protected non-Hispanic White than non-Hispanic Blacks against future suicide attempt/death. While Whites who have not completed college may be at an increased risk of suicide, risk of suicide seems to be independent of educational attainment for non-Hispanic Blacks.
  • Global Emergency Medicine: A Review of the Literature from 2018

    Trehan, Indi; Osei-Ampofo, Maxwell; Balhara, Kamna S.; Hexom, Braden J.; Kivlehan, Sean M.; Modi, Payal; Pousson, Amelia Y.; Selvam, Anand; Quao, Nana Serwaa A.; Cho, Daniel K.; et al. (2019-10-01)
    OBJECTIVES: The Global Emergency Medicine Literature Review (GEMLR) conducts a systematic annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most rigorously conducted and widely relevant research in global EM. METHODS: An electronic search of PubMed, a comprehensive retrieval of articles from specific journals, and search of the gray literature were conducted. Title and abstracts retrieved by these searches were screened by a total of 22 reviewers based on their relevance to the field of global EM, across the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). All articles that were deemed relevant by at least one reviewer, their editor, and the managing editor underwent formal scoring of overall methodologic quality and importance to global EM. Two independent reviewers scored all articles; editors provided a third score in cases of widely discrepant scores. RESULTS: A total of 19,102 articles were identified by the searches and, after screening and removal of duplicates, a total of 517 articles underwent full review. Twenty-five percent were categorized as DHR, 61% as ECRLS, and 15% as EMD. Inter-rater reliability testing between the reviewers revealed a Cohen's kappa score of 0.213 when considering the complete score or 0.426 when excluding the more subjective half of the score. A total of 25 articles scored higher than 17.5 of 20; these were selected for a full summary and critique. CONCLUSIONS: In 2018, the total number of articles relevant to global EM that were identified by our search continued to increase. Studies and reviews focusing on pediatric infections, several new and traditionally underrepresented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top-scoring articles. A shortage of articles related to the development of EM as a specialty was identified.
  • Potential uses of naltrexone in emergency department patients with opioid use disorder

    Bradley, Evan S.; Liss, David; Carreiro, Stephanie P.; Brush, David Eric; Babu, Kavita M. (2019-09-01)
    Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.
  • Screening and Intervention for Suicide Prevention: A Cost-Effectiveness Analysis of the ED-SAFE Interventions

    Dunlap, Laura J.; Orme, Stephen; Zarkin, Gary A.; Arias, Sarah A.; Miller, Ivan W.; Camargo, Carlos A. Jr; Sullivan, Ashley F.; Allen, Michael H.; Goldstein, Amy B.; Manton, Anne P.; et al. (2019-08-27)
    OBJECTIVE: Suicide screening followed by an intervention may identify suicidal individuals and prevent recurring self-harm, but few cost-effectiveness studies have been conducted. This study sought to determine whether the increased costs of implementing screening and intervention in hospital emergency departments (EDs) are justified by improvements in patient outcomes (decreased attempts and deaths by suicide). METHODS: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study recruited participants in eight U.S. EDs between August 2010 and November 2013. The eight sites sequentially implemented two interventions: universal screening added to treatment as usual and universal screening plus a telephone-based intervention delivered over 12 months post-ED visit. This study calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves to evaluate screening and suicide outcome measures and costs for the two interventions relative to treatment as usual. Costs were calculated from the provider perspective (e.g., wage and salary data and rental costs for hospital space) per patient and per site. RESULTS: Average per-patient costs to a participating ED of universal screening plus intervention were $1,063 per month, approximately $500 more than universal screening added to treatment as usual. Universal screening plus intervention was more effective in preventing suicides compared with universal screening added to treatment as usual and treatment as usual alone. CONCLUSIONS: Although the choice of universal screening plus intervention depends on the value placed on the outcome by decision makers, results suggest that implementing such suicide prevention measures can lead to significant cost savings.
  • Interest in and barriers to participation in a Facebook-delivered weight loss program among female cancer survivors with overweight or obesity

    May, Christine N.; Jake-Schoffman, Danielle E.; Evans, Martinus M.; Silfee, Valerie J.; Zhang, Fang Fang; Blok, Amanda C.; Carey, Jennifer L.; Ding, Eric Y.; Pritschmann, Ricarda K. (2019-08-21)
    Background: Although excess body weight is linked to post-treatment complications for cancer survivors, obesity rates have increased rapidly among adult cancer survivors. Innovative approaches to weight loss programs, such as via social media, are needed to engage female cancer survivors. The purpose of this study is to explore important components of a Facebook-delivered weight loss program for female cancer survivors. Methods: Female cancer survivors who are overweight or obese and finished active treatment completed a web-based, mixed-methods survey. Results: Participants (N=96) were on average 54.3+/-9.6 years old, 89% white, 66% obese, and 87% tried to lose weight in the last year. Health concerns were the most important reason (88%) for wanting to lose weight. Barriers to weight loss included other health issues (52%) and perceived sacrifice/burden of weight loss process (35%). Qualitative themes for barriers included inability to make dietary changes (19%), lack of motivation (18%), and physical limitations (13%). Participants were most interested in a weight loss program delivered via Facebook (81%), led by a weight loss counselor (78%), provided healthy recipes (73%) and exercise videos (72%). Qualitative themes included information on cancer treatment effects (25%), calorie tracker (21%), and exercise modifications (17%). Qualitatively, concerns about weight loss included fear of cancer recurrence (20%) and lack of confidence in weight loss efforts (17%). Conclusions: While female cancer survivors are interested in a Facebook-delivered weight loss program, additional research needs to address customization and delivery to address specific barriers experienced by cancer survivors.
  • HFSA/SAEM/ISHLT Clinical Expert Consensus Document on the Emergency Management of Patients with Ventricular Assist Devices

    Givertz, Michael M.; DeFilippis, Ersilia M.; Colvin, Monica; Darling, Chad E.; Elliott, Tonya; Hamad, Eman; Hiestand, Brian C.; Martindale, Jennifer L.; Pinney, Sean P.; Shah, Keyur B.; et al. (2019-07-01)
    Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers.

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