T32 programs in emergency medicine: A report from the ACEP-SAEM Federal Research Funding Workgroup

Advancing care in Emergency Medicine (EM) requires the development of well-trained researchers, but our specialty has lower amounts of research funding compared to similar medical fields. Increasing the number of pathways available for research training supports the growth of new investigators. To address the need for more EM researchers, the Society of Academic Emergency Medicine and the American College of Emergency Physicians convened a Federal Research Funding Workgroup. Here, we report the workgroup recommendations regarding the creation of Research Training Fellowships using the T32 grant structure sponsored by the National Institutes of Health. After reviewing the history of NIH-grant supported research fellowships in EM, we outline the rationale and describe the core components of T32-supported research fellowships, including program design, fellow evaluation, and recruitment considerations.

National needs assessment of emergency medicine faculty regarding scholarly activity practices and support

Objectives

We aimed to assess the attitudes and perceptions of scholarly activity (SA) practices among emergency medicine (EM) physicians who are engaged in training residents. This study examined the belief and need for modern-day SA, potential barriers, and department resources provided.

Methods

We conducted a descriptive cross-sectional survey study of EM physicians across the United States identified from the American College of Emergency Physicians and American College of Osteopathic Physicians directories. The survey consisted of 18 items regarding demographics, attitude toward SA, department support, and questions regarding residency programs.

Results

A total of 660 survey recipients completed the survey out of a possible pool of 4296 individuals (15% response rate), of which 530 (80%) indicated they were core faculty. Of core faculty, 428 (80.8%) were part of an allopathic program, whereas 102 (19.2%) were part of an osteopathic program. Department support was provided for protected time (385; 58.3%), research staff (346; 52.4%), Institutional Review Board preparation (240; 36.4%), and biostatistics (314; 47.6%). Of all the institutional roles, the largest percentage (82/125, 65.6%) of chair/vice chair/associate chairs strongly agreed or agreed (score of 5 or 4 of 5) with the statement, "Overall, I am satisfied with the scholarly support provided by my department." There was no difference in agreement with this statement between respondents in an allopathic versus osteopathic program (210/428, 49.1% allopathic; 45/102, 44.1% osteopathic).

Conclusion

There is a need for increased departmental support for SA. To optimally implement the Accreditation Council for Graduate Medical Education (ACGME) SA requirements into strategy and action, the ACGME should consider providing EM residency programs with an outline of best SA practices to foster a uniform consensus across academic institutions.

A Tale of Three Pandemics – SARS-CoV-2, HCV, and HIV in an Urban Emergency Department in Baltimore, Maryland

Background

We sought to determine the prevalence and sociodemographic and clinical correlates of acute and convalescent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections among emergency department (ED) patients in Baltimore.

Methods

Remnant blood samples from 7450 unique patients were collected over 4 months in 2020 for SARS-CoV-2 antibody (Ab), HCV Ab, and HIV-1/2 antigen and Ab. Among them, 5012 patients were tested by polymerase chain reaction for SARS-CoV-2 based on clinical suspicion. Sociodemographics, ED clinical presentations, and outcomes associated with coinfections were assessed.

Results

Overall, 729 (9.8%) patients had SARS-CoV-2 (acute or convalescent), 934 (12.5%) HCV, 372 (5.0%) HIV infection, and 211 patients (2.8%) had evidence of any coinfection (HCV/HIV, 1.5%; SARS-CoV-2/HCV, 0.7%; SARS-CoV-2/HIV, 0.3%; SARS-CoV-2/HCV/HIV, 0.3%). The prevalence of SARS-CoV-2 (acute or convalescent) was significantly higher in those with HCV or HIV vs those without (13.6% vs 9.1%, P < .001). Key sociodemographic disparities (race, ethnicity, and poverty) and specific ED clinical characteristics were significantly correlated with having any coinfections vs no infection or individual monoinfection. Among those with HCV or HIV, aged 18–34 years, Black race, Hispanic ethnicity, and a cardiovascular-related chief complaint had a significantly higher odds of having SARS-CoV-2 (prevalence ratios: 2.02, 2.37, 5.81, and 2.07, respectively).

Conclusions

The burden of SARS-CoV-2, HCV, and HIV co-pandemics and their associations with specific sociodemographic disparities, clinical presentations, and outcomes suggest that urban EDs should consider implementing integrated screening and linkage-to-care programs for these 3 infections.

Estimating HIV, HCV and HSV2 incidence from emergency department serosurvey

Background: Our understanding of pathogens and disease transmission has improved dramatically over the past 100 years, but coinfection, how different pathogens interact with each other, remains a challenge. Cross-sectional serological studies including multiple pathogens offer a crucial insight into this problem.  Methods: We use data from three cross-sectional serological surveys (in 2003, 2007 and 2013) in a Baltimore emergency department to predict the prevalence for HIV, hepatitis C virus (HCV) and herpes simplex virus, type 2 (HSV2), in a fourth survey (in 2016). We develop a mathematical model to make this prediction and to estimate the incidence of infection and coinfection in each age and ethnic group in each year. Results: Overall we find a much stronger age cohort effect than a time effect, so that, while incidence at a given age may decrease over time, individuals born at similar times experience a more constant force of infection over time. Conclusions: These results emphasise the importance of age-cohort counselling and early intervention while people are young. Our approach adds value to data such as these by providing age- and time-specific incidence estimates which could not be obtained any other way, and allows forecasting to enable future public health planning.

Demographic and clinical correlates of acute and convalescent SARS-CoV-2 infection among patients of a U.S. emergency department

Background

Emergency Departments (EDs) have served as critical surveillance sites for infectious diseases. We sought to determine the prevalence and temporal trends of acute (by PCR) and convalescent (by antibody [Ab]) SARS-CoV-2 infection during the earliest phase of the pandemic among patients in an urban ED in Baltimore City.

Methods

We tested remnant blood samples from 3255 unique ED patients, collected between March 16th and May 31st 2020 for SARS-CoV-2 Ab. PCR for acute SARS-CoV-2 infection from nasopharyngeal swabs was obtained on any patients based on clinical suspicion. Hospital records were abstracted and factors associated with SARS-CoV-2 infection were assessed.

Results

Of 3255 ED patients, 8.2% (95%CI: 7.3%, 9.2%) individuals had evidence of SARS-CoV-2 infection; 155 PCR+, 78 Ab+, and 35 who were both PCR+ and Ab+. Prevalence of disease increased throughout the study period, ranging from 3.2% (95%CI: 1.8%, 5.2%) PCR+ and 0.6% (95%CI: 0.1%, 1.8%) Ab+ in March, to 6.2% (95%CI: 5.1%, 7.4%) PCR+ and 4.2% (95%CI: 3.3%, 5.3%) Ab+ in May. The highest SARS-CoV-2 prevalence was found in Hispanic individuals who made up 8.4% (95%CI: 7.4%, 9.4%) of individuals screened, but 35% (95%CI: 29%, 41%) of infections (PCR and/or Ab+). Demographic and clinical factors independently associated with acute infection included Hispanic ethnicity, loss of smell or taste, subjective fever, cough, muscle ache and fever. Factors independently associated with convalescent infection were Hispanic ethnicity and low oxygen saturation.

Conclusions

The burden of COVID-19 in Baltimore City increased dramatically over the 11-week study period and was disproportionately higher among Hispanic individuals. ED-based surveillance methods are important for identifying both acute and convalescent SARS-CoV-2 infections and provides important information regarding demographic and clinical correlates of disease in the local community.

Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial

IMPORTANCE

Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis.

OBJECTIVE

To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020.

INTERVENTIONS

Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality.

RESULTS

Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group.

CONCLUSIONS AND RELEVANCE

Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03509350.

Characterization and impact of COVID-19-tested and infected patients: Experience of The Johns Hopkins Health System Regional Emergency Departments

BACKGROUND

There is limited understanding of the characteristics and operational burden of persons under investigation (PUIs) and those testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presenting to emergency departments (EDs).

METHODS

We reviewed all adult ED visits to 5 Johns Hopkins Health System hospitals in the Maryland/District of Columbia (DC) region during the initial coronavirus disease 2019 (COVID-19) surge, analyzing SARS-CoV-2 polymerase chain reaction test eligibility, results, demographics, acuity, clinical conditions, and dispositions.

RESULTS

Of 27,335 visits, 11,402 (41.7%) were tested and 2484 (21.8%) were SARS-CoV-2 positive. Test-positive rates among Hispanics, Asians, African Americans/Blacks, and Whites were 51.6%, 23.7%, 19.8%, and 12.7% respectively. African American/Blacks infection rates (25.5%-33.8%) were approximately double those of Whites (11.1%-21.1%) in the 3 southern Maryland/DC EDs. Conditions with high test-positive rates were fever (41.9%), constitutional (36.4%), upper respiratory (36.9%), and lower respiratory (31.2%) symptoms. Test-positive rates were similar in all age groups (19.9% to 25.8%), although rates of hospitalization increased successively with age. Almost half, 1103 (44.4%), of test-positive patients required admission, of which 206 (18.7%) were to an ICU.

CONCLUSION

The initial surge of SARS-CoV-2 test-positive patients experienced in a regional hospital system had ≈ 42% of patients meeting testing criteria and nearly one-fifth of those testing positive. The operational burden on ED practice, including intense adherence to infection control precautions, cannot be understated. Disproportionately high rates of infection among underrepresented minorities underscores the vulnerability in this population. The high rate of infection among self-identified Asians was unexpected.

Emergency Medicine Career Outcomes and Scholarly Pursuits: The Impact of Transitioning From a Three-year to a Four-year Niche-based Residency Curriculum

OBJECTIVES

In 2008, our emergency medicine (EM) residency program transitioned from a 3-year to a 4-year format. We analyzed the effect that this change had on the scholarly productivity and career choice of graduates, hypothesizing that it would lead residents to be more scholarly productive and graduates to more frequently obtain academic appointments and leadership roles in their first postresidency positions.

METHODS

This was a retrospective analysis of graduates (N = 95) from a single residency program that underwent a curriculum change from a 3-year to a 4-year format. Three cohorts prior to (n = 36) and five cohorts after (n = 59) this transition were included. The primary outcome of interest was the setting of graduates' first postresidency position. Secondary outcomes included completion of scholarly activity during training and attaining a leadership role in the first postresidency position.

RESULTS

Of the 4-year program graduates, 44% obtained an academic position compared to 28% of 3-year program graduates. After confounders were controlled for, this difference was statistically discernible only if fellowships were excluded (including fellowship, odds ratio [OR] = 2.25, 95% CI = 0.87 to 5.78; excluding fellowship, OR = 3.53, 95% CI = 1.13 to 11.05). Four-year graduates were more likely to obtain a leadership position immediately after graduation (OR = 13.72, 95% CI = 2.45 to 76.99). Compared to residents in the 3-year program, residents in the 4-year format had a similar likelihood of producing any scholarly work by graduation (OR = 1.69, 95% CI = 0.49 to 5.80) but were more likely to publish peer-reviewed manuscripts (OR = 3.92, 95% CI = 2.25 to 6.83).

CONCLUSIONS

Compared to 3-year residency graduates, graduates of our 4-year curriculum were more likely to obtain nonfellowship academic appointments and leadership positions immediately after graduation and to publish their scholarly work during residency. This study suggests that residency applicants seeking to be academically productive during residency and leaders in the field of EM should consider training in a 4-year program with similar goals.

Pandemic influenza and major disease outbreak preparedness in US emergency departments: A survey of medical directors and department chairs

STUDY OBJECTIVES

To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, χ², and ANOVA.

PARTICIPANTS

ED medical directors and department chairs.

RESULTS

One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak.

CONCLUSIONS

Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

In response: Letter on update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03509350. Registered on 26 April 2018.

Comparison of Ultrasound-Guided Vs Traditional Arterial Cannulation by Emergency Medicine Residents

Introduction

We sought to determine whether ultrasound-guided arterial cannulation (USGAC) is more successful than traditional radial artery cannulation (AC) as performed by emergency medicine (EM) residents with standard ultrasound training.

Methods

We identified 60 patients age 18 years or older at a tertiary care, urban academic emergency department who required radial AC for either continuous blood pressure monitoring or frequent blood draws. Patients were randomized to receive radial AC via either USGAC or traditional AC. If there were three unsuccessful attempts, patients were crossed over to the alternative technique. All EM residents underwent standardized, general ultrasound training.

Results

The USGAC group required fewer attempts as compared to the traditional AC group (mean 1.3 and 2.0, respectively; p<0.001); 29 out of 30 (96%) successful radial arterial lines were placed using USGAC, whereas 14 out of 30 (47%) successful lines were placed using traditional AC (p<0.001). There was no significant difference in length of procedure or complication rate between the two groups. There was no difference in provider experience with respect to USGAC vs traditional AC.

Conclusion

EM residents were more successful and had fewer cannulation attempts with USGAC when compared to traditional AC after standard, intern-level ultrasound training.

Update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol: statistical analysis plan for a prospective, multicenter, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial

BACKGROUND

Observational research suggests that combined therapy with Vitamin C, thiamine and hydrocortisone may reduce mortality in patients with septic shock.

METHODS AND DESIGN

The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a multicenter, double-blind, adaptive sample size, randomized, placebo-controlled trial designed to test the efficacy of combination therapy with vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) given every 6 h for up to 16 doses in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. The primary outcome is ventilator- and vasopressor-free days with mortality as the key secondary outcome. Recruitment began in August 2018 and is ongoing; 501 participants have been enrolled to date, with a planned maximum sample size of 2000. The Data and Safety Monitoring Board reviewed interim results at N = 200, 300, 400 and 500, and has recommended continuing recruitment. The next interim analysis will occur when N = 1000. This update presents the statistical analysis plan. Specifically, we provide definitions for key treatment and outcome variables, and for intent-to-treat, per-protocol, and safety analysis datasets. We describe the planned descriptive analyses, the main analysis of the primary end point, our approach to secondary and exploratory analyses, and handling of missing data. Our goal is to provide enough detail that our approach could be replicated by an independent study group, thereby enhancing the transparency of the study.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03509350. Registered on 26 April 2018.

The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol: a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial

BACKGROUND

Sepsis accounts for 30% to 50% of all in-hospital deaths in the United States. Other than antibiotics and source control, management strategies are largely supportive with fluid resuscitation and respiratory, renal, and circulatory support. Intravenous vitamin C in conjunction with thiamine and hydrocortisone has recently been suggested to improve outcomes in patients with sepsis in a single-center before-and-after study. However, before this therapeutic strategy is adopted, a rigorous assessment of its efficacy is needed.

METHODS

The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial. It will enroll patients with sepsis causing respiratory or circulatory compromise or both. Patients will be randomly assigned (1:1) to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 h or matching placebos until a total of 16 administrations have been completed or intensive care unit discharge occurs (whichever is first). Patients randomly assigned to the comparator group are permitted to receive open-label stress-dose steroids at the discretion of the treating clinical team. The primary outcome is consecutive days free of ventilator and vasopressor support (VVFDs) in the 30 days following randomization. The key secondary outcome is mortality at 30 days. Sample size will be determined adaptively by using interim analyses with pre-stated stopping rules to allow the early recognition of a large mortality benefit if one exists and to refocus on the more sensitive outcome of VVFDs if an early large mortality benefit is not observed.

DISCUSSION

VICTAS is a large, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial that will test the efficacy of vitamin C, thiamine, and hydrocortisone as a combined therapy in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. Because the components of this therapy are inexpensive and readily available and have very favorable risk profiles, demonstrated efficacy would have immediate implications for the management of sepsis worldwide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03509350 . First registered on April 26, 2018, and last verified on December 20, 2018. Protocol version: 1.4, January 9, 2019.

Trends and Characterization of Academic Emergency Department Patient Visits: A Five-year Review

OBJECTIVES

To meet the unique comparative data needs of academic emergency departments (EDs), we describe the recent 5-year national and regional trends for adult emergency patients' characteristics and operational parameters at academic emergency medical centers.

METHODS

Data collected from the recent 5-year period academic year (AY) 2012 through AY 2016 of the Academy of Administrators in Academic Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) Academic Emergency Medicine Benchmarking Survey were analyzed for trends in 1) ED volumes and modes of arrival, 2) triage acuity level, 3) trends in ED professional fee billing, and 4) disposition patterns of ED patients including admission rates and walkouts. The AY spanned the 12-month period of July 1 through June 30. Only primary academic or academic affiliate hospitals data were included. Community and freestanding affiliated EDs were excluded. Institutional-specific data were stratified into four cohorts based on the following annual ED visit volumes: under 40,000, 40,000 to 60,000, 60,000 to 80,000, and over 80,000. Triage acuity levels were based on the Emergency Severity Index (ESI). Professional fee billing was analyzed specifically for CPT codes 99284, 99285, and 99291 (critical care). Left without being seen (LWBS), defined as leaving before a screening examine by a licensed medical provider, and screened and left (SAL), i.e., patients who were screened by a provider, but left before definitive evaluation and management, were similarly evaluated. Total walkouts were defined as the sum of LWBS and SAL.

RESULTS

Forty-four primary academic and academic affiliate sites completed the survey for all 5 years. The mean annual patient census increased 13.4% over the study period, with the majority (80%) of sites experiencing volume growth. Acuity/illness severity, measured as ESI 1 and 2, and CPT codes 99284, 99295, and 99291 increased an aggregate 18.2 and 8.4%, respectively. Large-volume hospitals (>60,000-80,000, >80,000) admissions increased by 15 and 21.6%, respectively, primarily due to surge in 2016. Overall emergency medical services (EMS) arrivals increased 7.3% although admissions from EMS remained relatively stable. LWBS rates decreased 19.5%, but total walkouts did not appear to change.

CONCLUSION

With a focus on larger academic institutions, differences were noted in the overall increases in volume and acuity. In this survey, participating institutions experienced increased volumes of patients with seemingly higher illness severity. While inroads have been made in LWBS rates, there has not been an overall decrease in total walkouts. The data reported here differed in many aspects compared to other benchmark surveys.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments

STUDY OBJECTIVES

The shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in specific disease states. However, there is scarcity of data about the utility of the SI in the general emergency department (ED)population. Our goal was to use a large national database of EDs in the United States (US) to determine whether the likelihood of inpatient mortality and hospital admission was associated with initial SI at presentation.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey were retrospectively reviewed to obtain a weighted sample of all US ED visits between 2005 and 2010. All adults >18 years old who survived the ED visit were included, regardless of their chief complaint. Likelihood ratios (LR) were calculated for a range of SI values, in order to determine SI thresholds most predictive of hospital admission and inpatient mortality. +LRs >5 were considered to be clinically significant.

RESULTS

A total of 526 455 251 adult patient encounters were included in the analysis. 56.9% were women, 73.9% were white and 53.2% were between the ages of 18 and 44 years. 88 326 638 (15.7%) unique ED visits resulted in hospital admission and 1 927 235 (2.6%) visits resulted in inpatient mortality. SI>1.3 was associated with a clinically significant increase in both the likelihood of hospital admission (+LR=6.64) and inpatient mortality (+LR=5.67). SI>0.7 and >0.9, the traditional cited cut-offs, were only associated with marginal increases (+LR= 1.13; 1.54 for SI>0.7 and +LR=1.95; 2.59 for SI>0.9 for hospital admission and inpatient mortality, respectively).

CONCLUSIONS

In this largest retrospective study to date on SI in the general ED population, we demonstrated that initial SI at presentation to the ED could potentially be useful in predicting the likelihood of hospital admission and inpatient mortality, which could help guide rapid and accurate acuity designation, resource allocation and disposition.

Contributions of Academic Emergency Medicine Programs to U.S. Health Care: Summary of the AAAEM-AACEM Benchmarking Data

OBJECTIVES

The societal contribution of emergency care in the United States has been described. The role and impact of academic emergency departments (EDs) has been less clear. Our report summarizes the results of a benchmarking effort specifically focused on academic emergency medicine (EM) practices.

METHODS

From October through December 2016, the Academy of Academic Administrators of Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly administered a benchmarking survey to allopathic, academic departments and divisions of emergency medicine. Participation was voluntary and nonanonymous. The survey queried various aspects of the three components of the tripartite academic mission: clinical care, education and research, and faculty effort and compensation. Responses reflected a calendar year from July 1, 2015, to June 30, 2016.

RESULTS

Of 107 eligible U.S. allopathic, academic departments and divisions of emergency medicine, 79 (74%) responded to the survey overall, although individual questions were not always answered by all responding programs. The 79 responding programs reported 6,876,189 patient visits at 97 primary and affiliated academic clinical sites. A number of clinical operations metrics related to the care of these patients at these sites are reported in this study. All responding programs had active educational programs for EM residents, with a median of 37 residents per program. Nearly half of the overall respondents reported responsibility for teaching medical students in mandatory EM clerkships. Fifty-two programs reported research and publication activity, with a total of $129,494,676 of grant funding and 3,059 publications. Median faculty effort distribution was clinical effort, 66.9%; education effort, 12.7%; administrative effort, 12.0%; and research effort, 6.9%. Median faculty salary was $277,045.

CONCLUSIONS

Academic EM programs are characterized by significant productivity in clinical operations, education, and research. The survey results reported in this investigation provide appropriate benchmarking for academic EM programs because they allow for comparison of academic programs to each other, rather than nonacademic programs that do not necessarily share the additional missions of research and education and may have dissimilar working environments.

Differentiating among Attempted, Completed, and Multiple Nonfatal Strangulation in Women Experiencing Intimate Partner Violence

PURPOSE

Because identification of intimate partner violence (IPV) in health care settings is low and strangulation increases lethality risk among women experiencing IPV, we examined the prevalence and correlates of nonfatal strangulation among 1,008 women survivors of IPV.

METHODS

Trained researchers conducted semistructured interviews with women survivors of IPV referred by police. Multinomial logistic regression examined differential correlates of attempted, completed, and multiple strangulation.

RESULTS

Interviews were conducted with 71.14% of eligible women contacted by researchers. A high proportion (79.66%) of the women interviewed experienced attempted (11.70%), completed (30.16%), or multiple (37.80%) strangulation. Each form of strangulation was independently significantly associated with sexual violence when compared with no strangulation. African American women were at increased risk of attempted (adjusted relative risk ratio [ARR], 2.02; p < .05), completed (ARR, 1.79; p < .05), and multiple strangulation (ARR, 2.62; p < .001). Compared with no strangulation, multiple strangulation was associated with more IPV injury and risk factors for homicide, including loss of consciousness (ARR, 2.95; p < .05) and miscarriage (ARR, 5.08; p < .05). Women who had lost consciousness owing to strangulation were more likely to seek medical care than those who had been strangled but had not lost consciousness (p < .01).

CONCLUSIONS

Strangulation is a prevalent form of IPV that presents significant health risks to women. Women's health practitioners are optimally positioned to identify subtle signs and symptoms of strangulation, help women to understand the delayed sequelae and potential future fatality associated with strangulation, and connect them with appropriate resources to reduce the risk of morbidity and mortality.

A systematic review of emergency department based HIV testing and linkage to care initiatives in low resource settings

INTRODUCTION

Only 45% of people currently living with HIV infection in sub-Saharan Africa are aware of their HIV status. Unmet testing needs may be addressed by utilizing the Emergency Department (ED) as an innovative testing venue in low and middle-income countries (LMICs). The purpose of this review is to examine the burden of HIV infection described in EDs in LMICs, with a focus on summarizing the implementation of various ED-based HIV testing strategies.

METHODOLOGY AND RESULTS

We performed a systematic review of Pubmed, Embase, Scopus, Web of Science and the Cochrane Library on June 12, 2016. A three-concept search was employed with emergency medicine (e.g., Emergency department, emergency medical services), HIV/AIDS (e.g., human immunodeficiency virus, acquired immunodeficiency syndrome), and LMIC terms (e.g., developing country, under developed countries, specific country names). The search returned 2026 unique articles. Of these, thirteen met inclusion criteria and were included in the final review. There was a large variation in the reported prevalence of HIV infection in the ED population ranging from to 2.14% in India to 43.3% in Uganda. The proportion HIV positive patients with previously undiagnosed infection ranged from 90% to 65.22%.

CONCLUSION

In the United States ED-based HIV testing strategies have been front and center at curbing the HIV epidemic. The limited number of ED-based studies we observed in this study may represent the paucity of HIV testing in this venue in LMICs. All of the studies in this review demonstrated a high prevalence of HIV infection in the ED and an extraordinarily high percentage of previously undiagnosed HIV infection. Although the numbers of published reports are few, these diverse studies imply that in HIV endemic low resource settings EDs carry a large burden of undiagnosed HIV infections and may offer a unique testing venue.

SCREEN: A simple layperson administered screening algorithm in low resource international settings significantly reduces waiting time for critically ill children in primary healthcare clinics

BACKGROUND

In low resource settings, an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centers (PHC) result in prolonged waiting times and significant delays in identifying and evaluating critically ill children. The Sick Children Require Emergency Evaluation Now (SCREEN) program, a simple six-question screening algorithm administered by lay healthcare workers, was developed in 2014 to rapidly identify critically ill children and to expedite their care at the point of entry into a clinic. We sought to determine the impact of SCREEN on waiting times for critically ill children post real world implementation in Cape Town, South Africa.

METHODS AND FINDINGS

This is a prospective, observational implementation-effectiveness hybrid study that sought to determine: (1) the impact of SCREEN implementation on waiting times as a primary outcome measure, and (2) the effectiveness of the SCREEN tool in accurately identifying critically ill children when utilised by the QM and adherence by the QM to the SCREEN algorithm as secondary outcome measures. The study was conducted in two phases, Phase I control (pre-SCREEN implementation- three months in 2014) and Phase II (post-SCREEN implementation-two distinct three month periods in 2016). In Phase I, 1600 (92.38%) of 1732 children presenting to 4 clinics, had sufficient data for analysis and comprised the control sample. In Phase II, all 3383 of the children presenting to the 26 clinics during the sampling time frame had sufficient data for analysis. The proportion of critically ill children who saw a professional nurse within 10 minutes increased tenfold from 6.4% to 64% (Phase I to Phase II) with the median time to seeing a professional nurse reduced from 100.3 minutes to 4.9 minutes, (p < .001, respectively). Overall layperson screening compared to Integrated Management of Childhood Illnesses (IMCI) designation by a nurse had a sensitivity of 94.2% and a specificity of 88.1%, despite large variance in adherence to the SCREEN algorithm across clinics.

CONCLUSIONS

The SCREEN program when implemented in a real-world setting can significantly reduce waiting times for critically ill children in PHCs, however further work is required to improve the implementation of this innovative program.

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments

STUDY OBJECTIVE

A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland.

METHODS

We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015).

RESULTS

The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured.

CONCLUSION

There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland.

Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital

IMPORTANCE

The capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients.

OBJECTIVE

To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016.

MAIN OUTCOMES AND MEASURES

Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate.

RESULTS

Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%.

CONCLUSIONS AND RELEVANCE

Our estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.

Educational Value Units: A Mission-Based Approach to Assigning and Monitoring Faculty Teaching Activities in an Academic Medical Department

PROBLEM

Increasing emphasis on revenue generation could jeopardize the fundamental notion of what it means to be faculty. Despite being a core mission, education is often marginalized in academic medical departments, and expectations of faculty effort in this area are often vague. A potential solution is mission-based budgeting (MBB), which refers to the allocation of resources based on core-mission-related priorities.

APPROACH

From December 2012 to March 2013, the authors developed an educational value unit (EVU) system (using an MBB approach) to assign and monitor teaching activities related to the core departmental educational mission at the Department of Emergency Medicine, Johns Hopkins Medicine. EVUs were based on learner contact time, with one EVU equal to roughly one hour of in-person time with medical students or residents. Core education faculty vetted the proposed system; educational leaders determined the total EVUs needed and assessed the impact of their equitable distribution among faculty; and faculty members selected preferences and were assigned EVU obligations.

OUTCOMES

For academic year 2013-2014, 5,896 EVUs were distributed among 54 faculty. At the end of the year, complete EVU data were available for 47 faculty. Of these, only 6 failed to complete their assigned EVU obligations. All core teaching activities were covered, and educational efforts were distributed more equitably across faculty.

NEXT STEPS

The system is being refined, with an emphasis on incorporating learner outcome metrics, refining the teaching grid, incorporating failure to meet EVU obligations into yearly faculty evaluations, and disseminating the system to other departments and institutions.