Recent reports suggest rising intensity of emergency department (ED) billing practices, sparking concerns that this may represent up-coding. However, it may reflect increasing severity and complexity ...of care in the ED population. We hypothesize that this in part may be reflected in more severe manifestations of illness as indicated by vital sign abnormalities.
Using 18 years of data from the National Hospital Ambulatory Medical Care Survey, we conducted a retrospective secondary analysis of adults (>18 years). We assessed standard vital signs using weighted descriptive statistics (heart rate, oxygen saturation, temperature, and systolic blood pressure SBP), as well as hypotension and tachycardia. Finally, we evaluated for differing effects stratifying by subpopulations of interest, including age (<65 vs ≥65), payer type, arrival by ambulance, and high-risk diagnoses.
In total there were 418,849 observations representing 1,745,368,303 ED visits. We found only minimal variations in vital signs over the study period: heart rate (median 85, interquartile range IQR 74-97); oxygen saturation (median 98, IQR 97-99); temperature (median 98.1, IQR 97.6-98.6); and SBP (median 134, IQR 120-149). Similar results were found among the subpopulations tested. The proportion of visits with hypotension decreased (first/last year difference 0.5% 95% CI 0.2%-0.7%) while there was no difference in the proportion of patients with tachycardia.
Arrival vital signs in the ED have largely remained unchanged or improved over the most recent 18 years of nationally representative data, even for key subpopulations. Greater intensity in ED billing practices is not explained by changes in arrival vital signs.
Study objective Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the ...association between mode of out-of-hospital transport (police department versus emergency medical services EMS) and mortality among patients with penetrating trauma in Philadelphia. Methods This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Results Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval CI 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio OR 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. Conclusion We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.
Objectives
Studies examining the relationship between obesity and acute coronary syndrome (ACS) have been limited to patients with confirmed diagnoses. The authors sought to determine the ...relationship between body mass index (BMI) and 30‐day cardiovascular events in emergency department (ED) patients with potential ACS.
Methods
This was a secondary analysis of a prospective cohort study of patients who presented to the ED with potential ACS. Patients were stratified according to their BMI: underweight (BMI < 18.49 kg/m2), normal weight (BMI = 18.5 to 24.99 kg/m2), overweight (BMI = 25 to 29.99 kg/m2), obese (BMI = 30 to 34.99 kg/m2), and very obese (BMI > 35 kg/m2). The primary outcome was acute myocardial infarction (AMI), death, or revascularization within 30 days of presentation. A logistic regression analysis was used to adjust for confounding variables and adjusted odds ratios (aOR) with 95% confidence intervals (CIs) are presented for cardiac events and readmission outcomes.
Results
Of the 3,946 patients included in this study, 73 (1.9%) were underweight, 911 (23%) were normal weight, 1,199 (30.4%) were overweight, 872 (22.1%) were obese, and 891 (22.6%) were very obese. Although increased levels of obesity were associated with a greater number of cardiac risk factors, there was no difference in 30‐day cardiovascular events between those of normal weight and underweight (aOR = 1.1; 95% CI = 0.4 to 2.7), overweight (aOR = 1.0; 95% CI = 0.7 to 1.4), obese (aOR = 1.2; 95% CI = 0.8 to1.7), or very obese (aOR = 0.8; 95% CI = 0.5 to 1.3). Those who were underweight were more likely to be readmitted within 30 days (aOR = 1.9; 95% CI = 1.0 to 3.7), and those who were very obese were less likely to be readmitted within 30 days (aOR = 0.7; 95% CI = 0.5 to 0.9).
Conclusions
Among patients who present to the ED with potential ACS, BMI is not associated with higher risk of cardiovascular outcomes at 30 days.
Resumen
Relación entre el Índice de Masa Corporal y el Pronóstico de los Pacientes que Consultan por un Potencial Síndrome Coronario Agudo
Objetivos
Los estudios que examinan la relación entre la obesidad y el síndrome coronario agudo (SCA) se han limitado a pacientes con el diagnóstico confirmado. Los autores investigan la relación entre el índice de masa corporal (IMC) y los eventos cardiovasculares durante los 30 días siguientes en los pacientes con un potencial SCA que consultan en el servicio de urgencias (SU).
Metodología
Análisis secundario de un estudio de cohorte prospectivo de pacientes que acudieron al SU con un potencial SCA. Los pacientes fueron clasificados acorde a su IMC: peso bajo (IMC < 18,49 kg/m2), peso normal (IMC 18,5 a 24,99 kg/m2), sobrepeso (IMC 25 a 29,99 kg/m2), obeso (IMC 30 a 34.99 kg/m2) y muy obeso (BMI > 35 kg/m2). El resultado principal fue el infarto agudo de miocardio (IAM), la muerte o la revascularización en los primeros 30 días tras la visita. Se utilizó un análisis de regresión logística para ajustar las variables de confusión y se presentaron las razones de ventajas ajustadas (ORa) con los intervalos de confianza (IC) del 95% para los eventos cardiacos y los resultados de reingreso.
Resultados
De los 3.946 pacientes incluidos en este estudio, 73 (1,9%) fueron de bajo peso, 911 (23%) de peso normal, 1.199 (30,4%) con sobrepeso, 872 (22,1%) obesos y 891 (22.6%) muy obesos. Aunque los niveles elevados de obesidad se asociaron con un mayor número de factores de riesgo cardiovasculares, no hubo diferencias en los eventos cardiovasculares a los 30 días entre aquéllos con peso normal y bajo peso (ORa 1,1; IC 95% = 0,4 a 2,7), sobrepeso (ORa 1,0; IC 95% = 0,7 a 1,4), obesos (ORa 1,2; IC 95% = 0,8 a 1,7), o muy obesos (ORa 0,8; IC 95% = 0,5 a 1,3). Aquéllos que tenían bajo peso tuvieron mayor probabilidad de ser reingresados en los 30 días siguientes (ORa 1,9; IC 95% = 1,0 a 3,7), y aquéllos que fueron muy obesos tuvieron menor probabilidad (ORa 0,7; IC 95% = 0,5 a 0,9).
Conclusiones
En los pacientes que acuden al SU con un potencial SCA, el IMC no está asociado con un mayor riesgo de resultados cardiovasculares adversos a los 30 días.
Urine drug screens (UDS) have unproven clinical utility in emergency department (ED) chest pain presentations. A test with such limited clinical utility may exponentiate biases in care, but little is ...known about the epidemiology of UDS use for this indication. We hypothesized that UDS utilization varies nationally across race and gender.
This was a retrospective observational analysis of adult ED visits for chest pain in the 2011-2019 National Hospital Ambulatory Medical Care Survey. We calculated the utilization of UDS across race/ethnicity and gender and then characterized predictors of use via adjusted logistic regression models.
We analyzed 13,567 adult chest pain visits, representative of 85.8 million visits nationally. Use of UDS occurred for 4.6% of visits (95% CI 3.9%-5.4%). White females underwent UDS at 3.3% of visits (95% CI 2.5%-4.2%), and Black females at 4.1% (95% CI 2.9%-5.2%). White males were tested at 5.8% of visits (95% CI 4.4%-7.2%), while Black males were tested at 9.3% of visits (95% CI 6.4%-12.2%). A multivariate logistic regression model including race, gender, and time period shows significantly increased odds of ordering UDS for Black patients (odds ratio OR 1.45 (95% CI 1.11-1.90, p = 0.007)) and male patients (OR 2.0 (95% CI 1.55-2.58, p < 0.001) as compared to White patients and female patients.
We identified wide disparities in the utilization of UDS for the evaluation of chest pain. If UDS were used at the rate observed for White women, Black men would undergo nearly 50,000 fewer tests annually. Future research should weigh the potential of the UDS to magnify biases in care against the unproven clinical utility of the test.
Fire and police first responders are often the first to arrive in medical emergencies and provide basic life support services until specialized personnel arrive. This study aims to evaluate rates of ...fire or police first responder-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, as well as their associated impact on out-of-hospital cardiac arrest (OHCA) outcomes.
We completed a secondary data analysis of the MI-CARES registry from 2014 to 2019. We reported rates of CPR initiation and AED use by fire or police first responders. Multilevel modeling was utilized to evaluate the relationship between fire/police first responder-initiated interventions and outcomes of interest: ROSC upon emergency department arrival, survival to hospital discharge, and good neurologic outcome.
Our cohort included 25,067 OHCA incidents. We found fire or police first responders initiated CPR in 31.8% of OHCA events and AED use in 6.1% of OHCA events. Likelihood of sustained ROSC on ED arrival after CPR initiated by a fire/police first responder was not statistically different as compared to EMS initiated CPR (aOR 1.01, CI 0.93–1.11). However, fire/police first responder interventions were associated with significantly higher odds of survival to hospital discharge and survival with good neurologic outcome (aOR 1.25, 95% CI 1.08–1.45 and aOR 1.40, 95% CI 1.18–1.65, respectively). Similar associations were see when examining fire or police initiated AED use.
Fire or police first responders may be an underutilized, potentially powerful mechanism for improving OHCA survival. Future studies should investigate barriers and opportunities for increasing first responder interventions by these groups in OHCA.
Objective
In the United States, police are often important co‐responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive ...understanding of the mechanisms by which police response modifies time to in‐hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement.
Methods
PubMed, SCOPUS, and Criminal Justice s databases were utilized to identify articles. English‐language, US‐based, peer‐reviewed articles published on or prior to March 30, 2022 were eligible for inclusion.
Results
Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level.
Conclusions
Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well‐being, there remains a paucity of data examining and driving current practices.
Medical students often express their plans to care for medically underserved populations, but little is known about how this interest remains during medical school (MS). This study examined how ...self-reported interest in working with medically underserved communities may change during MS training based on several student characteristics.
A secondary data analysis of all student records in the Electronic Residency Application Service (ERAS) from 2005 to 2010 is presented. Predictors included gender, under-represented in medicine (URiM) status, age, academic metrics, career interest, and medical specialty choice. Outcomes included interest in caring for medically underserved populations when entering MS, graduating MS, and graduating MS controlling for entering interest.
The total population included 6890 student records (49.5% women and 18.2% URiM). Women had a higher likelihood of being interested in practicing in underserved communities when entering and graduating MS (odds ratio OR 1.55, 95% confidence interval CI 1.37-1.77; OR 1.24, 95% CI 1.09-1.40). For all outcomes, URiM students had a higher likelihood of planning on a career with underserved populations compared with their non-URiM peers. Compared with Emergency Medicine, Internal Medicine/Pediatrics and Family Medicine had a higher likelihood of plans to work with underserved populations upon entering, graduating, and at graduation controlling for entering interest.
Gender, race, and specialty choice all had meaningful associations with a student's plans on practice in an underserved community. This study's findings can help support efforts to improve MS diversity nationally and drive study on cultural effects embedded within medical specialty identity.
Precision medicine is data-driven health care tailored to individual patients based on their unique attributes, including biologic profiles, disease expressions, local environments, and socioeconomic ...conditions. Emergency medicine (EM) has been peripheral to the precision medicine discourse, lacking both a unified definition of precision medicine and a clear research agenda. We convened a national consensus conference to build a shared mental model and develop a research agenda for precision EM.
We held a conference to (1) define precision EM, (2) develop an evidence-based research agenda, and (3) identify educational gaps for current and future EM clinicians. Nine preconference workgroups (biomedical ethics, data science, health professions education, health care delivery and access, informatics, omics, population health, sex and gender, and technology and digital tools), comprising 84 individuals, garnered expert opinion, reviewed relevant literature, engaged with patients, and developed key research questions. During the conference, each workgroup shared how they defined precision EM within their domain, presented relevant conceptual frameworks, and engaged a broad set of stakeholders to refine precision EM research questions using a multistage consensus-building process.
A total of 217 individuals participated in this initiative, of whom 115 were conference-day attendees. Consensus-building activities yielded a definition of precision EM and key research questions that comprised a new 10-year precision EM research agenda. The consensus process revealed three themes: (1) preeminence of data, (2) interconnectedness of research questions across domains, and (3) promises and pitfalls of advances in health technology and data science/artificial intelligence. The Health Professions Education Workgroup identified educational gaps in precision EM and discussed a training roadmap for the specialty.
A research agenda for precision EM, developed with extensive stakeholder input, recognizes the potential and challenges of precision EM. Comprehensive clinician training in this field is essential to advance EM in this domain.
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