Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with ...resident-presented lectures would increase residents' sense of cultural humility and ability to identify vulnerable populations.
At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data.
A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar trend.
This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making.
Background
Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related ...to implicit bias, emergency medicine (EM) leaders’ self‐awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace.
Methods
Investigators facilitated an hour‐long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts‐based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach.
Results
A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias.
Conclusions
This qualitative analysis of reflections from an arts‐based workshop highlights perceived fears and barriers that may impact EM physicians’ motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.
Highlights • Inflammation is known to be associated with heart failure. • Decompensated heart failure (ADHF) patients had elevated inflammatory markers. • ADHF patients had distinct monocyte subsets ...compared with healthy control subjects (HCs). • Treatment of heart failure made monocyte profiles more closely resemble those of HCs.
Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical ...Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED.
We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA.
This was a retrospective pre–post cohort of ED visits from 2012–2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed.
We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat NNT = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ.
Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.
An additional limitation of the matching is that beyond age and sex, there is no other demographic information of the patient including comorbidities and pre-existing cardiac disease. ...it is ...plausible that important differences in baseline medical conditions exist between the groups. IO placement is less likely to select against comorbid illness and allows a provider to quickly resume other critical tasks involved in cardiac arrest care. Because the current study was largely limited by the ability to obtain IV access for epinephrine administration, future studies should investigate the utility of IO line as rescue, or first line, access. ...another unreported variable is the use of vasopressin, amiodarone, lidocaine, atropine, or bicarbonate - all of which have been part of cardiac arrest care in recent years. ...an OHCA presents EMS with an austere environment and transportation further exacerbates this crisis by restricting a provider to driving.
Many of the ethnic and racial workforce inequities in the United States are present in health care systems. Low representation of African American/Black individuals in the health care system ...workforce can be traced to a history of exclusionary practices that leave such individuals less likely to pursue health careers. Past research found that low representation is driven by inequities in health, education, and employment that are a result of structural racism. Pathways programs have been identified as one of the methods to increase recruitment, retention, and promotion in health-related career fields for African American/Black individuals. As prior research has shown, these programs recruit and support the graduation of students from underrepresented communities at all educational stages to increase their representation in specific fields. This article describes the development of key factors in framework design for the Health System-Community Pathways Program (HCPP), which aims to increase representation of African American/Black communities in the health care system workforce and improve the quality of their experience in pursuing careers in these fields. The HCPP framework of key factors is informed by an environmental scan, interviews and focus groups, and an expert discussion panel session. The article's authors come from diverse backgrounds; the team included African American/Black physicians and members of other historically marginalized communities. The qualitative research drew insights from diverse African American/Black community stakeholders; the study was reviewed by many stakeholders to ensure that the design of the research and the end product maximally benefits the community on which it focuses.
Objectives
Our study aims to better understand and describe the current state of diversity, equity, and inclusion (DEI) leadership in emergency medicine (EM) by identifying the prevalence of ...department DEI leadership positions, their demographics, and their job duty characteristics.
Methods
We disseminated an electronic survey from April to July 2022 to Society for Academic Emergency Medicine (SAEM) Association of Academic Chairs of Emergency Medicine, Academy for Diversity and Inclusion in Emergency Medicine, and the Equity and Inclusion Committee to identify department DEI leads. From July to August 2022, a 45‐question survey was sent to all identified DEI leaders on individual characteristics, DEI experience, and DEI lead job description.
Results
We received a response from 79 out of 120 academic EM departments identified (65.8%). Of the responding institutions, 59 (74.7%) reported a DEI leader. A total of 74.6% of these DEI leaders responded at least partially to our survey and 57.6% responded in full. The most common titles were vice/associate chair of DEI (34.4%), director of DEI (28.1%), and DEI committee chair (18.8%). Most respondents (84.4%) were the inaugural DEI lead in their department and 84.4% of respondents did not have a formal DEI role in their department previously. On average, respondents have had their DEI title for 2 years (range 0–7 years) with an average of 7 years (range 0–30 years) of experience performing DEI work. Many (63.4%) do not receive any funded effort for their DEI roles. Most DEI leads were not tenure track (72.2%) and most commonly at the rank of assistant professor (47.2%) followed by associate professor (33.3%), full professor (16.7%), and instructor (2.8%).
Conclusions
This is the first known study to assess the characteristics of DEI department leaders in EM. EM DEI leadership positions are new, common, and led by diverse personal identities and are often not funded. Future directions could gain qualitative insight into this workforce to guide best practices in EM DEI leadership.
Rapid profiling of signaling pathways has been a long sought after goal in biological sciences and clinical medicine. To understand these signaling pathways, their protein components must be ...profiled. The protein components of signaling pathways are typically profiled with protein immunoblotting. Protein immunoblotting is a powerful technique but has several limitations including the large sample requirements, high amounts of antibody, and limitations in assay throughput. To overcome some of these limitations, we have designed a microfluidic protein immunoblotting device to profile multiple signaling pathways simultaneously. We show the utility of this approach by profiling inflammatory signaling pathways (NFκB, JAK-STAT, and MAPK) in cell models and human samples. The microfluidic immunoblotting device can profile proteins and protein modifications with 5380-fold less antibody compared to traditional protein immunoblotting. Additionally, this microfluidic device interfaces with commonly available immunoblotting equipment, has the ability to multiplex, and is compatible with several protein detection methodologies. We anticipate that this microfluidic device will complement existing techniques and is well suited for life science applications.
Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) ...is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known.
This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure.
A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%;
< 0.001) and non-ED-ICU cohort (65.8% vs 43.1%;
< 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.
Objectives
It is essential to engage learners in efforts aimed at dismantling racism and other contributors to health care disparities. Barriers to their involvement include limited access to data. ...The objective of our study was to create a data dashboard using an existing quality improvement (QI) infrastructure and provide resident access to data to facilitate exploratory analysis on disparities in emergency department (ED) patient care.
Methods
Focusing on patient populations that have previously been shown in the literature to suffer significant disparities in the ED, we extracted outcomes across a variety of metrics already collected as part of routine ED operations. Using data visualization software, we developed an interactive dashboard for visual exploratory analyses.
Results
We designed a dashboard for our resident learners with views that are flexible and allow user selected filters to view clinical outcomes by patient age, treatment area, and chief complaint. Learners were also allowed to select grouping and outcomes of interest to investigate questions and form new hypotheses of their choosing. Available dashboard views included summary counts view to assess ED visits over time by selectable group, a rooming and triage acuity view, time‐to‐event survival curve view, histogram and box plot views for continuous variables, a view to assess outcome variables by time of day of ED arrival, customizable contingency table views, and correspondence analysis.
Conclusions
Utilizing an existing QI infrastructure, we developed a dashboard that provides a new perspective into commonly collected ED operations data to allow for the exploration of disparities in ED care that is accessible to learners. Future directions include using these data to refine hypotheses on ED disparities, understand root causes, develop interventions, and measure their impact.
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