Background Residents from diverse specialties perform clinical rotations in the emergency department (ED). There is little research about the value of the ED rotation for them. Objectives We sought ...to determine the learning objectives of non-EM residents (NEMRs) in the ED, the effectiveness of the rotation, and the highest-yield components of their experience. Methods From 2017-2019, we surveyed NEMR on their pre-rotation learning objectives and their comfort level with 15 common ED presentations/procedures before and after the rotation. We assessed how well their objectives were met, the highest-yield components of their rotation, and opportunities for improvement. Results We collected responses from 56 (47%) pre-rotation and 61 (51%) post-rotation residents over a two-year period. The five most commonly cited learning goals were: management of acutely ill patients, triage skills, procedural competence, and ultrasound. Seventy-eight percent (78%) of residents reported their learning goals were moderately to very well met during their rotation. NEMRs' level of comfort improved in all the commonly encountered clinical experiences in the ED in a statistically significant manner. They cited on-shift teaching by attending physicians and senior EM residents as the most valuable learning resource. Conclusion NEMR from diverse medical and surgical specialties could identify specific learning objectives for their EM rotation with common themes, and the majority felt their educational goals were met. They gained comfort with the management and triage of all the assessed common ED conditions. By collecting and defining their specific needs and goals, we are better equipped to improve the quality and value of the rotation.
Cardiac rehabilitation (CR) can improve quality of life and reduce subsequent hospitalizations for individuals with cardiovascular disease. Nevertheless, CR is underutilized, and less is known about ...the current content, patient population, and workforce of CR programs in North Carolina.
To describe CR services, patient participation, and workforce in North Carolina in order to characterize CR infrastructure and identify opportunities to improve CR use.
We distributed an electronic survey to all certified outpatient CR programs in North Carolina in spring 2019. Descriptive statistics were used to summarize program characteristics, participant characteristics, and current workforce. Data were analyzed overall and by region.
Responding programs (89.5% response rate, n=68) had been in operation for a mean of 24 (SD: 10.4) years. Programs have similar availability across the state, operating 4 days a week with 5 sessions per day. A majority of programs offered nutrition counseling (98.5%), stress management (94.1%), aerobic exercise (86.8%), and weight training (86.8%). Patients were majority male (65%), aged 65 or older (75%), and White (75%). Nearly half of patients referred to CR attended at least 1 session, though 25% discontinued early. Most programs were staffed by a median of 2 full-time nurses (97%) and by a median of 1.5 full-time exercise physiologists (96%). Mental health and administrative professionals were less frequent in CR settings.
Since this survey was primarily completed by program directors, further research is needed to understand the challenges, experiences, and needs of the frontline CR workforce, as well as the direct experiences of patients who participate in CR.
CR programs in North Carolina offer a range of services. While half of patients referred to CR initiate services, interventions are needed to improve initiation and adherence to CR.
BACKGROUND:Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis ...method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method Kaplan-Meier (KM) vs. competing risk when assessing patterns of guideline adoption in elderly patients.
METHODS:Medicare beneficiaries aged 65–95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI.
RESULTS:At 1-year post-AMI, 14.2% 95% confidence interval (CI), 14.0%–14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%–15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%–52.7%) and 53.4% (95% CI, 53.1%–53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%–17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively.
CONCLUSIONS:In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.
Around one million United States emergency department (ED) visits annually are due to acute decompensated heart failure (ADHF) symptoms. Characterizing ED symptom presentation of ADHF patients may ...improve clinical care, yet sex and age differences in ED chief complaints have not been thoroughly investigated. This paper aims to describe differences in chief complaints and comorbid conditions for ED patients with a ADHF diagnosis, stratified by sex and age.
Retrospective analysis of adults presenting to North Carolina EDs in NC DETECT, a statewide syndromic surveillance system, between 2010 and 2016 with a diagnosis of ADHF. Frequencies of chief complaint categories for ED visits and comorbid conditions, stratified by sex and age, were evaluated and standardized differences computed.
Top chief complaints were dyspnea (19.1%), chest pain (13.5%), and other respiratory complaints (13.4%). In the 18-44 age group, females when compared to males reported more nausea/vomiting (6.7% versus 4.1%) and headache (4.2% versus 2.0%). In those 45-64 and 65+ years old, complaints were similar by sex. When stratified by age group alone, the 18-44 and 45-64 age groups had more complaints of chest pain, whereas balance issues, weakness, and confusion were more common in the 65+ age group.
Sex and age differences in atypical ADHF symptoms were seen in in ED patients with ADHF. Characterizing variation of ADHF symptoms in ED patients can inform the identification of ED patients with ADHF and the management of ADHF-related symptoms.
Unmet health‐related social needs are common amongst older US adults and impact both quality of life and health outcomes. One of the ways that unmet health‐related social needs impact health is ...through malnutrition, an imbalance in a person's intake of energy and/or nutrients. Lack of reliable access to a sufficient quantity of nutritious food is a specific health‐related social need that can be assessed rapidly and, when unmet, is a direct risk factor for malnutrition and may be indicative of a broader range of unmet health‐related social needs. We conducted a cross‐sectional study to characterise malnutrition and food insecurity amongst older adults receiving emergency department (ED) care using brief, validated measures and to assess the burden of a broader range of health‐related social needs amongst these patients. Patients were asked about their need for and willingness to receive a range of social services. The study was conducted in an academic ED serving a racially and socioeconomically diverse population in the Southeastern United States. A convenience sample of noncritically ill adults aged 60 years and older was approached between November 2018 and April 2019. Study patients (n = 127) were predominantly non‐Hispanic white (67%), community dwelling (91%) and urban residents (66%) with 28% screening positive for malnutrition risk, 16% for food insecurity and 5% for both. Of those at risk for malnutrition, 25 (69%) reported ≥2 unmet health‐related social needs and 14 (38%) were receptive to social services. Amongst food insecure patients, 18 (90%) reported additional unmet health‐related social needs and 13 (65%) were receptive to receiving social services. In conclusion, a brief set of questions can identify subgroups of older ED patients who are food insecure or at risk for malnutrition. Individuals who screen positive for food insecurity have a high burden of unmet health‐related social needs.
Objective: To describe the use of secondary prevention methods and to investigate the effect of cardiac rehabilitation (CR) initiation on hospitalization following myocardial infarction among older ...adults. Methods: Medicare beneficiaries having a myocardial infarction (MI) in 2008 and survived to discharge were eligible for this study. In aim 2, beneficiaries also had to survive 60 days post discharge and have a revascularization procedure during hospitalization. Competing risk analysis was used to estimate the cumulative incidence of adoption of secondary prevention recommendations such as initiating cardiac rehabilitation and the difference in the cumulative incidence of subsequent hospital admission between cardiac rehabilitation initiators and non-initiators. Results: At 30 days post-MI 6.7% (95% CI: 6.5%, 6.8%) of beneficiaries included in aim 1 initiated cardiac rehabilitation and 14.2% (95% CI: 14.0%, 14.5%) initiated by 1-year post-MI using competing risk analysis. From the Kaplan-Meier analysis, 6.9% (95% CI: 6.7%, 7.0%) and 15.1% (95% CI: 14.8%, 15.3%) of beneficiaries initiated cardiac at 30 days and 1-year post myocardial infarction respectively. Overall 4.5% (95%CI: 4.4%, 4.6%) of patients died by 30 days post myocardial infarction rising to 17.0% (95%CI: 16.8%, 17.3%) at 1 year post myocardial infarction. At 1-year post discharge, cardiac rehabilitation initiators in aim 2 had a lower risk of recurrent MI (4.2% 95%CI: 3.5%, 5.1%), cardiovascular (15.7% 95%CI: 14.3%, 17.2%), and all-cause (30.4% 95%CI: 28.8%, 32.1%) hospitalization than non-initiators (18.0% 95%CI: 17.6%, 18.4%; 33.2% 95%CI: 32.5%, 33.8%). Conclusions: Cardiac rehabilitation participation was low in Medicare beneficiaries. Outpatient cardiac rehabilitation was associated with a reduced risk of recurrent myocardial infarction, cardiovascular disease, and all-cause hospital admissions 1-year post discharge in older myocardial infarction survivors.
Background
Prehospital 12‐lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a ...prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency‐related factors associated with failure to perform a prehospital ECG across a statewide geography.
Methods and Results
We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008–2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification‐level of the EMS provider (paramedic vsbasic/intermediate) and system‐level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99).
Conclusions
Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural‐urban treatment differences.
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