RESUMEN

BACKGROUND: Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers. METHODS: We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants. RESULTS: Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle." CONCLUSIONS: Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

RESUMEN

Ninety-five adults enrolled in the Etiology of Pneumonia in the Community study with negative admission influenza polymerase chain reaction (PCR) tests received influenza vaccination during hospitalization. Acute and convalescent influenza serology was performed. After vaccination, seropositive (≥1:40) hemagglutination antibody titers (HAI) were achieved in 55% to influenza A(H1N1)pdm09, 58% to influenza A(H3N2), 77% to influenza B (Victoria), and 74% to influenza B (Yamagata) viruses. Sixty-six (69%) patients seroconverted (≥4-fold HAI rise) to ≥1 strain. Failure to seroconvert was associated with diabetes, bacterial detection, baseline seropositive titers for influenza B (Yamagata), and influenza vaccination in the previous season.

Asunto(s)

RESUMEN

OBJECTIVE: Benzodiazepines and opioids are prescribed simultaneously (i.e., "coprescribed") in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid coprescribing occurs and providers' reasons for coprescribing. METHODS: We conducted focus groups with emergency department (ED) providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semistructured interviews to elicit perspectives on benzodiazepine-opioid coprescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid coprescribing. RESULTS: Participants acknowledged coprescribing rarely and reluctantly and often provided specific discharge instructions when coprescribing. The decision to coprescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g., low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to coprescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of coprescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial. CONCLUSIONS: In this qualitative study of ED providers, we found that benzodiazepine-opioid coprescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to coprescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.

Asunto(s)

RESUMEN

OBJECTIVE: Burnout is prevalent among emergency medicine (EM) physicians, with physicians experiencing burnout more likely to report committing medical errors or delivering suboptimal care. The relationship between physician burnout and identifiable differences in clinical care, however, remains unclear. We examined if EM trainee burnout was associated with differences in clinical performance using high-fidelity simulation as a proxy for patient care. METHODS: In this cross-sectional study across six institutions, we measured trainee performance over four simulation scenarios based on recognized EM milestones. For each scenario a faculty rater assessed whether the trainee performed predefined critical actions specific to each case. A summation of performed actions across all cases resulted in a cumulative task (CT) score (range = 0-85). Raters also assigned an impression score on a 10-point scale (0 = poor; 10 = outstanding) assessing the trainee's overall performance after each scenario, with the mean of the scores resulting in an overall impression (OI) score. After the simulation assessment, we measured trainees' burnout via the Maslach Burnout Inventory through a confidential, electronic survey. Trainee depression, quality of life (QOL) and daytime sleepiness were also evaluated. Survey results were compared to simulation scores using analysis of variance and covariance. RESULTS: Fifty-eight of 89 (65.2%) eligible participants completed the survey and simulation assessment. Thirty-one of 58 (53.4%, 95% CI = 40.2% to 66.7%) trainees reported burnout. In trainees with burnout compared to those without, mean CT scores (73.4 vs. 75.2, 95% CI of difference = 0.06 to 3.51) and OI scores (6.4 vs 6.8, 95% CI of difference = 0.03 to 0.79) were negatively associated with burnout after controlling for training program. In contrast, QOL were positively associated with CT [F(1,48) = 4.796, p = 0.033] and OI [F(1,48) = 4.561, p = 0.038] scores. There were no significant associations between simulation performance and depression or daytime sleepiness. CONCLUSION: Emergency medicine trainees with burnout received lower cumulative performance scores over four high-fidelity simulation scenarios than trainees without burnout.

RESUMEN

BACKGROUND: Benzodiazepine-opioid combination therapy is potentially harmful due to the risk of synergistic respiratory depression, and the rate of death due to benzodiazepine-opioid overdose is increasing. Little is known about the prevalence and characteristics of benzodiazepine-opioid co-prescribing from the ED setting. METHODS: Secondary analysis of data from the National Hospital Ambulatory Medical Care Survey, using sample weights to generate population estimates. The primary objective was to describe the annual prevalence of benzodiazepine-opioid co-prescribing from 2006 to 2012, using 95% confidence intervals (95% CI) to compare adjacent years. The secondary objective was to compare characteristics of ED encounters receiving a benzodiazepine-opioid co-prescription versus those receiving an opioid prescription alone, using a multivariable logistic regression. RESULTS: The prevalence of benzodiazepine-opioid co-prescribing did not significantly change from 2006 to 2012. During this period, 2.7% (95% CI: 2.5-2.8%) of ED encounters prescribed an opioid were also prescribed a benzodiazepine. Relative to encounters receiving an opioid prescription alone, encounters receiving a co-prescription were more likely to represent a follow-up rather than initial visit (Odds Ratio [OR] 1.52), receive more medications (OR 1.41) and fewer procedures (OR 0.48) while in the ED, and more likely to have a diagnosis related to mental disorder (OR 20.60) or musculoskeletal problem (OR 3.71). CONCLUSIONS: From 2006 to 2012, almost 3% of all ED encounters receiving an opioid prescription also received a benzodiazepine co-prescription. The odds of benzodiazepine-opioid co-prescribing were significantly higher in ED encounters representing a follow-up visit and in diagnoses relating to a mental disorder or musculoskeletal problem.

Asunto(s)

Asunto(s)

RESUMEN

OBJECTIVES: The mortality benefit for pulmonary embolism (PE) is the difference in mortality between treated and untreated patients. The mortality benefit threshold is the mortality benefit above which testing for a condition should be initiated and below which it should not. To illustrate this concept, the authors developed a decision model to estimate the mortality benefit threshold at several pretest probabilities for low-risk emergency department (ED) patients with possible PE and compare those thresholds with contemporary management of PE in the United States and what is known and not known about treatment benefits with anticoagulation. METHODS: The authors built a decision model of a 25-year-old female with suspected PE. Model inputs were obtained from the literature or clinical judgment when data were unavailable. One-way sensitivity analysis was used to derive the mortality benefit threshold at several fixed pretest probabilities, and two-way sensitivity analysis was used to determine drivers of the mortality benefit threshold. RESULTS: At a 15% pretest probability, the mortality benefit threshold was 3.7%; at 10% it was 5.2%; at 5% it was 9.8%; at 2% it was 23.5%; at 1% it was 46.3%; and at 0.5% it was 92.1%. In two-way sensitivity analyses, D-dimer specificity, CT angiography (CTA)/CT venography (CTV) sensitivity, annual cancer risk, probability of death from renal failure, and probability of major bleeding were major model drivers. CONCLUSIONS: The mortality benefit threshold for initiating PE testing is very high at low pretest probabilities of PE, which should be considered by clinicians in their diagnostic approach to PE in the ED. The mortality benefit threshold is a novel way of exploring the benefits and risks of ED-based testing, particularly in situations like PE where testing (i.e., CT use) carries real risks and the benefits of treatment are uncertain.

Asunto(s)

RESUMEN

OBJECTIVES: Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality. METHODS: This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance. RESULTS: Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05). CONCLUSIONS: In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.

Asunto(s)

RESUMEN

OBJECTIVES: Available D-dimer assays have low specificity and may increase radiographic testing for pulmonary embolism (PE). To help clinicians better target testing, this study sought to quantify the effect of risk factors for a positive quantitative D-dimer in patients evaluated for PE. METHODS: This was a prospective, multicenter, observational study. Emergency department (ED) patients evaluated for PE with a quantitative D-dimer were eligible for inclusion. The main outcome of interest was a positive D-dimer. Odds ratio (ORs) and 95% confidence intervals (CIs) were determined by multivariable logistic regression. Adjusted estimates of relative risk were also calculated. RESULTS: A total of 4,346 patients had D-dimer testing, of whom 2,930 (67%) were women. A total of 2,500 (57%) were white, 1,474 (34%) were black or African American, 238 (6%) were Hispanic, and 144 (3%) were of other race or ethnicity. The mean (+/-SD) age was 48 (+/-17) years. Overall, 1,903 (44%) D-dimers were positive. Model fit was adequate (c-statistic = 0.739, Hosmer and Lemeshow p-value = 0.13). Significant positive predictors of D-dimer positive included female sex; increasing age; black (vs. white) race; cocaine use; general, limb, or neurologic immobility; hemoptysis; hemodialysis; active malignancy; rheumatoid arthritis; lupus; sickle cell disease; prior venous thromboembolism (VTE; not under treatment); pregnancy and postpartum state; and abdominal, chest, orthopedic, or other surgery. Warfarin use was protective. In contrast, several variables known to be associated with PE were not associated with positive D-dimer results: body mass index (BMI), estrogen use, family history of PE, (inactive) malignancy, thrombophilia, trauma within 4 weeks, travel, and prior VTE (under treatment). CONCLUSIONS: Many factors are associated with a positive D-dimer test. The effect of these factors on the usefulness of the test should be considered prior to ordering a D-dimer.

Asunto(s)

RESUMEN

OBJECTIVES: The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. METHODS: A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. RESULTS: A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). CONCLUSIONS: While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

Asunto(s)

RESUMEN

OBJECTIVES: Rotating (non-emergency medicine [EM]) residents perform clinical rotations in many academic emergency departments (EDs). The primary objective of this work was to quantify characteristics of rotating residents and the didactic curricula offered to them during their EM rotations. Secondary objectives were to identify barriers to instituting such didactics and to establish ideal curricular contents. METHODS: A Web-based survey was administered by e-mail to residency directors of all U.S. allopathic EM residency programs. Consent was obtained in the first part of the survey, and the study was deemed exempt from full review by the institutional review board. Questions solicited information regarding type and quantity of rotating residents in their main EDs, the "didactic educational format" available to rotating residents, and ideal and actual didactic curricular contents. Statistics were reported as proportions and means with 95% confidence intervals (CIs) and medians with interquartile ranges (IQRs). RESULTS: Surveys were sent to 143 programs, and the response rate was 71%. Ninety-nine percent of respondents had rotating residents in their EDs, and the median number per month was 4 (IQR = 3-6). Five percent of respondents had established didactic curricula specifically for rotating residents, and 64% sent them to either EM resident or medical student lectures. Thirty-one percent of programs reported no didactics, and 65% of these felt there was no need for such education. Resuscitation, trauma, and toxicology were cited as the most important subjects for actual and ideal curricula. CONCLUSIONS: Most academic EDs have rotating residents, but very few provide didactic education specific to their learning needs and almost a third provide no didactics.

Asunto(s)

RESUMEN

OBJECTIVES: The utility of D-dimer testing for suspected pulmonary embolism (PE) can be limited by test specificity. The authors tested if the threshold of the quantitative D-dimer can be varied according to pretest probability (PTP) of PE to increase specificity while maintaining a negative predictive value (NPV) of >99%. METHODS: This was a prospective, observational multicenter study of emergency department (ED) patients in the United States. Eligible patients had a diagnostic study ordered to evaluate possible PE. PTP was determined by the clinician's unstructured estimate and the Wells score. Five different D-dimer assays were used. D-dimer test performance was measured using 1) standard thresholds and 2) variable threshold values: twice (for low PTP patients), equal (intermediate PTP patients), or half (high PTP patients) of standard threshold. Venous thromboembolism (VTE) within 45 days required positive imaging plus decision to treat. RESULTS: The authors enrolled 7,940 patients tested for PE, and clinicians ordered a quantitative D-dimer for 4,357 (55%) patients who had PTPs distributed as follows: low (74%), moderate (21%), or high (4%). At standard cutoffs, across all PTP strata, quantitative D-dimer testing had a test sensitivity of 94% (95% confidence interval [CI] = 91% to 97%), specificity of 58% (95% CI = 56% to 60%), and NPV of 99.5% (95% CI = 99.1% to 99.7%). If variable cutoffs had been used the overall sensitivity would have been 88% (95% CI = 83% to 92%), specificity 75% (95% CI = 74% to 76%), and NPV 99.1% (95% CI = 98.7% to 99.4%). CONCLUSIONS: This large multicenter observational sample demonstrates that emergency medicine clinicians currently order a D-dimer in the majority of patients tested for PE, including a large proportion with intermediate PTP and high PTP. Varying the D-dimer's cutoff according to PTP can increase specificity with no measurable decrease in NPV.

Asunto(s)