1
|
O'Neal HR, Sheybani R, Kraus CK, Self WH, Shah AM, Thomas CB, Tse HTK, Scoggins R. Cellular host response sepsis test for risk stratification of patients in the emergency department: A pooled analysis. Acad Emerg Med 2024. [PMID: 38643433 DOI: 10.1111/acem.14923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/06/2024] [Accepted: 03/31/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES Sepsis is one of the most common, costly, and misdiagnosed conditions in U.S. emergency departments (EDs). ED providers often treat on nonspecific signs, subjective suspicion, or presumption of infection, resulting in over- and undertreatment. An increased understanding of host response has opened a new direction for sepsis diagnostics. The IntelliSep test is a U.S. Food and Drug Administration-cleared cellular host response diagnostic that could help distinguish sepsis in ED settings. Our objective was to evaluate the potential of the cellular host response test to expedite appropriate care for patients who present with signs of infection. METHODS We performed a pooled analysis of five adult (≥18 years) cohorts enrolled at seven geographically diverse U.S. sites in separate studies. Structured blinded adjudication was used to classify presence or absence of sepsis, and only patients with high confidence in the adjudicated label were included (n = 1002), defined as patients for whom there was consensus in the determination of sepsis per the Sepsis-3 and severe sepsis per the Sepsis-2 definitions between both the independent adjudication panel and the site-level physician. RESULTS Among patients with signs or suspicion of infection, the test achieved similar or better performance compared to other indicators in identifying patients at high risk for sepsis (specificity > 83%) and significantly superior performance in identifying those at low risk (sensitivity > 92%; 0% sepsis-associated mortality). The test also stratified severity of illness, as shown by 30-day in-hospital mortality (p < 0.001), hospital length of stay (p < 0.01), and use of hospital resources (p < 0.001). CONCLUSIONS Our data suggest that the cellular host response test provides clinically actionable results for patients at both high and low risk for sepsis and provides a rapid, objective means for risk stratification of patients with signs of infection. If integrated into standard of care, the test may help improve outcomes and reduce unnecessary antibiotic use.
Collapse
Affiliation(s)
- Hollis R O'Neal
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana, USA
| | | | - Chadd K Kraus
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt Institute for Clinical and Translational Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ajay M Shah
- Cytovale, Inc., San Francisco, California, USA
| | - Christopher B Thomas
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, Louisiana, USA
| | | | - Robert Scoggins
- Cytovale, Inc., San Francisco, California, USA
- Pulmonary & Critical Care, Kootenai Health, Coeur d'Alene, Idaho, USA
| |
Collapse
|
2
|
Wang HE, Tomaszewski C, March J, Crowe R, Goldstein LN, Gausche‐Hill M, Kraus CK. JACEP Open annual report 2023. J Am Coll Emerg Physicians Open 2024; 5:e13111. [PMID: 38322380 PMCID: PMC10844755 DOI: 10.1002/emp2.13111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | | | - Juan March
- Division of EMS, Department of Emergency MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | | | - Lara N. Goldstein
- Department of Emergency MedicineMemorial Healthcare SystemHollywoodFloridaUSA
| | - Marianne Gausche‐Hill
- Departments of Emergency Medicine and PediatricsHarbor‐University of California Los Angeles Medical CenterLos AngelesCaliforniaUSA
| | - Chadd K. Kraus
- Department of Emergency and Hospital MedicineLehigh Valley Health NetworkAllentownPennsylvaniaUSA
| |
Collapse
|
3
|
Reisdorff EJ, Johnston MM, Kraus CK, Keim SM, Santen SA. Association between the American Board of Emergency Medicine Oral Certifying Examination and Future State Medical Board Disciplinary Actions. J Am Coll Emerg Physicians Open 2024; 5:e13119. [PMID: 38322376 PMCID: PMC10844754 DOI: 10.1002/emp2.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives The American Board of Emergency Medicine (ABEM) requires a written examination (the Qualifying Examination) followed by the Oral Certifying Examination (OCE) to obtain ABEM certification. Maintaining ABEM certification is associated with fewer state medical board (SMB) disciplinary actions. We sought to determine the association between poor initial performance on the OCE and subsequent severe SMB disciplinary action. Methods We included physicians who completed US categorical emergency medicine residencies in 2016 and earlier. We classified OCE performance as good (passed on first attempt) and poor (never passed or required > 1 attempt to pass). We obtained data on physician SMB disciplinary actions from the National Practitioner Data Bank that were limited to actions that denied licensure or altered the status of a medical license (eg, suspension). We determined the association between poor OCE performance and subsequent severe SMB disciplinary action. Results Of 34,871, 93.5% passed the OCE on the first attempt, 6.1% required multiple attempts, and 0.3% never passed. Of the physicians (93.5%) with good OCE performance, 1.0% received a severe SMB action. Among physicians with poor OCE performance, 2.3% received a severe action; and of those who never passed, 1.7% received a severe action (Table 1). Poor OCE performance was associated with an increased odds of severe SMB disciplinary action (OR 2.21, 95% CI: 1.57-3.12). Conclusion Physicians with poor OCE performance exhibited higher odds of experiencing a subsequent severe SMB disciplinary action. The OCE may have utility as a predictor of future professionalism or clinical performance.
Collapse
Affiliation(s)
| | | | - Chadd K. Kraus
- American Board of Emergency Medicine, East LansingMichiganUSA
| | - Samuel M. Keim
- Department of Emergency MedicineArizona College of Medicine, TucsonArizonaUSA
| | - Sally A. Santen
- Department of Emergency MedicineUniversity of Cincinnati, College of Medicine, CincinnatiOhioUSA
| |
Collapse
|
4
|
Kraus CK, Ferry J. Emergency Department Care of the Patient with Suicidal or Homicidal Symptoms. Emerg Med Clin North Am 2024; 42:31-40. [PMID: 37977751 DOI: 10.1016/j.emc.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Patients frequently present to the emergency department (ED) with acute suicidal and homicidal thoughts. These patients require timely evaluation, with determination of disposition by either voluntary or involuntary hospitalization or discharge with appropriate outpatient follow-up. Safety concerns should be prioritized for patients as well as ED staff. Patient dignity and autonomy should be respected throughout the process.
Collapse
Affiliation(s)
- Chadd K Kraus
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Allentown, PA, USA; University of South Florida Morsani College of Medicine.
| | - James Ferry
- Department of Emergency Medicine, Geisinger, Danville, Pennsylvania, USA
| |
Collapse
|
5
|
Gorgas DL, Calderon Y, Carter WA, White SR, Feldhaus KM, Reisdorff EJ, Joldersma KB, Kraus CK. The correlation between performance on the American Board of Emergency Medicine (ABEM) qualifying and oral certifying examinations. Acad Emerg Med 2024; 31:91-93. [PMID: 37515431 DOI: 10.1111/acem.14780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/09/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Diane L Gorgas
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Yvette Calderon
- Department of Emergency Medicine, Icahn School of Medicine, Mount Sinai Health System, Bronx, New York, USA
| | - Wallace A Carter
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Suzanne R White
- Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Kim M Feldhaus
- Department of Emergency Medicine, Foothills Hospital, Boulder, Colorado, USA
| | - Earl J Reisdorff
- American Board of Emergency Medicine, East Lansing, Michigan, USA
| | | | - Chadd K Kraus
- American Board of Emergency Medicine, East Lansing, Michigan, USA
| |
Collapse
|
6
|
Kraus CK, O’Neal HR, Ledeboer NA, Rice TW, Self WH, Rothman RE. Variability in Provider Assessment of Sepsis and Potential of Host Response Technology to Address this Dilemma-Results of an Online Delphi Study. J Pers Med 2023; 13:1685. [PMID: 38138912 PMCID: PMC10744443 DOI: 10.3390/jpm13121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/27/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023] Open
Abstract
Potentially septic patients have a huge clinical and economic impact on hospitals and often present to the emergency department (ED) with undifferentiated symptoms. The triage of these patients is complex and has historically relied heavily upon provider judgment. This study aims to evaluate the consistency of provider judgment and the potential of a new host response sepsis test to aid in the triage process. A modified Delphi study involving 26 participants from multiple specialties was conducted to evaluate provider agreement about sepsis risk and to test proposed actions based on the results of a sepsis test. The participants considered case vignettes of potentially septic patients designed to represent diagnostic dilemmas. Provider assessment of sepsis risk in these cases ranged from 10% to 90% and agreement was poor. Agreement about clinical actions to take in response to testing improved when participants considered their own hypothetical borderline cases. New host response testing for sepsis may have the potential to improve sepsis diagnosis and care and should be applied in a protocolized fashion to ensure consistency of results.
Collapse
Affiliation(s)
- Chadd K. Kraus
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network (LVHN), University of South Florida (USF) Morsani College of Medicine, Tampa, FL 33602, USA
| | - Hollis R. O’Neal
- Department of Critical Care Medicine, Louisiana State University, Baton Rouge, LA 70803, USA;
| | - Nathan A. Ledeboer
- Department of Pathology & Laboratory Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| |
Collapse
|
7
|
Gettel CJ, Courtney DM, Agrawal P, Madsen TE, Rothenberg C, Mills AM, Lall MD, Keim SM, Kraus CK, Ranney ML, Venkatesh AK. Emergency medicine physician workforce attrition differences by age and gender. Acad Emerg Med 2023; 30:1092-1100. [PMID: 37313983 DOI: 10.1111/acem.14764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/06/2023] [Accepted: 06/11/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Emergency care workforce concerns have gained national prominence given recent data suggesting higher than previously estimated attrition. With little known regarding characteristics of physicians leaving the workforce, we sought to investigate the age and number of years since residency graduation at which male and female emergency physicians (EPs) exhibited workforce attrition. METHODS We performed a repeated cross-sectional analysis of EPs reimbursed by Medicare linked to date of birth and residency graduation date data from the American Board of Emergency Medicine for the years 2013-2020. Stratified by gender, our primary outcomes were the median age and number of years since residency graduation at the time of attrition, defined as the last year during the study time frame that an EP provided clinical services. We constructed a multivariate logistic regression model to examine the association between gender and EP workforce attrition. RESULTS A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5-65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0-53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82-2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post-residency graduation times in the workforce of 17.5 (9.5-25.5) years and 10.5 (5.5-18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation. CONCLUSIONS Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.
Collapse
Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Pooja Agrawal
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School at Brown University, Providence, Rhode Island, USA
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Michelle D Lall
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA
| | - Samuel M Keim
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Chadd K Kraus
- American Board of Emergency Medicine (ABEM), East Lansing, Michigan, USA
| | - Megan L Ranney
- Department of Emergency Medicine, Alpert Medical School at Brown University, Providence, Rhode Island, USA
- Brown-Lifespan Center for Digital Health, Providence, Rhode Island, USA
- Department of Behavioral and Social Science, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
8
|
Brandler ES, Isenberg DL, Herres J, Zhao H, Kraus CK, Ackerman D, Sigal A, Kuc A, Nomura JT, Wojcik S, Mullen MT, Gentile NT. Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi. J Am Coll Emerg Physicians Open 2023; 4:e13048. [PMID: 37840864 PMCID: PMC10568043 DOI: 10.1002/emp2.13048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. Methods This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT. Results Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). Conclusion Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.
Collapse
Affiliation(s)
- Ethan S. Brandler
- Department of Emergency MedicineState University of New York‐Stony BrookStony BrookNew YorkUSA
| | - Derek L. Isenberg
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Joseph Herres
- Department of Emergency MedicineJefferson Einstein – Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Huaqing Zhao
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| | - Daniel Ackerman
- Department of NeurologySt. Luke's University HealthBethlehemPennsylvaniaUSA
| | - Adam Sigal
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | - Alexander Kuc
- Department of Emergency MedicineCooper University HealthCamdenNew JerseyUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Susan Wojcik
- Department of Emergency MedicineState University of New York‐UpstateSyracuseNew YorkUSA
| | - Michael T. Mullen
- Department of NeurologyLewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA
| | - Nina T. Gentile
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| |
Collapse
|
9
|
Sigal A, Isenberg DL, Kraus CK, Ackerman D, Herres J, Brandler ES, Kuc A, Nomura JT, Cooney DR, Mullen MT, Zhao H, Gentile NT. A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke. West J Emerg Med 2023; 24:931-938. [PMID: 37788034 PMCID: PMC10527839 DOI: 10.5811/westjem.58946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/21/2023] [Accepted: 04/18/2023] [Indexed: 10/04/2023] Open
Abstract
Introduction: Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT. Methods: We conducted an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry of 2,400 LVOS patients treated at nine ESCs in the United States. We examined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale. Results: A total of 435 patients were included in the final analysis. The mean DIDO time for patients with good outcomes was 17 minute shorter than patients with poor outcomes (122 minutes [min] vs 139 min, P = 0.04). Absolute DIDO cutoff times of ≤60 min, ≤90 min, or ≤120 min were not associated with improved functional outcomes (46.4 vs 32.3%, P = 0.12; 38.6 vs 30.6%, P = 0.10; and 36.4 vs 28.9%, P = 0.10, respectively). This held true for patients with hyperacute strokes of less than four-hour onset. Lower baseline National Institutes of Health Stroke Scale (NIHSS) score (11.9 vs 18.2, P = <.001) and younger age (62.5 vs 74.9 years (P < .001) were associated with improved outcomes. On multiple regression analysis, age (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.45-2.02) and baseline NIHSS score (OR 1.67, 95% CI 1.42-1.98) were associated with improved outcomes while DIDO time was not associated with better outcome (OR 1.13, 95% CI 0.99-1.30). Conclusion: Although the DIDO time was shorter for patients with a good outcome, this was non-significant in multiple regression analysis. Receipt of intravenous thrombolysis and time to EVT were not associated with better outcomes, while male gender, lower age, arrival by private vehicle, and lower NIHSS score portended better outcomes. No absolute DIDO-time cutoff or modifiable factor was associated with improved outcomes for LVOS. This study underscores the need to streamline DIDO times but not to set an artificial DIDO time benchmark to meet.
Collapse
Affiliation(s)
- Adam Sigal
- Reading Hospital, Department of Emergency Medicine, West Reading, Pennsylvania
| | - Derek L Isenberg
- Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania,
| | - Chadd K Kraus
- Geisinger Health, Department of Emergency Medicine, Danville, Pennsylvania
| | - Daniel Ackerman
- St. Luke's Health System, Department of Neurology, Bethlehem, Pennsylvania
| | - Joseph Herres
- Einstein Health System, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Ethan S Brandler
- State University of New York-Stony Brook, Department of Emergency Medicine, Stony Brook, New York
| | - Alexander Kuc
- Cooper University Healthcare, Department of Emergency Medicine, Camden, New Jersey
| | - Jason T Nomura
- Christiana Care, Department of Emergency, Newark, Delaware
| | - Derek R Cooney
- State University of New York-Upstate, Department of Emergency Medicine, Syracuse, New York
| | - Michael T Mullen
- Lewis Katz School of Medicine at Temple University, Department of Neurology, Philadelphia, Pennsylvania
| | - Huaqing Zhao
- Lewis Katz School of Medicine at Temple University, Center for Biostatistics and Epidemiology, Philadelphia, Pennsylvania
| | - Nina T Gentile
- Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Koshy GV, Fitzpatrick MH, Kraus CK. Not all roses are sweet-Pediatric ependymoma. J Am Coll Emerg Physicians Open 2023; 4:e12993. [PMID: 37304856 PMCID: PMC10250962 DOI: 10.1002/emp2.12993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/14/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023] Open
Abstract
Ependymomas are rare malignant neoplasms that originate from radial glial cells within the central nervous system. Within pediatric central nervous tumors, ependymomas constitute the third most common entity with the majority occurring within the posterior fossa. Over the past decade, there have been monumental strides in classifying and grading central nervous tumors, specifically ependymomas. Revised classifications now identify ependymomas by anatomic location, histopathological and genetic subgroups with varying levels of symptom presentation and disease progression. Standard care of therapy remains surgical resection with post- operative radiotherapy.
Collapse
Affiliation(s)
- George V. Koshy
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| | | | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| |
Collapse
|
11
|
Ulmer TP, Kraus CK. A pain in the neck. J Am Coll Emerg Physicians Open 2023; 4:e12973. [PMID: 37223214 PMCID: PMC10202195 DOI: 10.1002/emp2.12973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 04/27/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- Todd P. Ulmer
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| |
Collapse
|
12
|
Kraus CK, Nguyen HB, Jacobsen RC, Ledeboer NA, May LS, O'Neal HR, Puskarich MA, Rice TW, Self WH, Rothman RE. Rapid identification of sepsis in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e12984. [PMID: 37284425 PMCID: PMC10239543 DOI: 10.1002/emp2.12984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
Objectives Recent research has helped define the complex pathways in sepsis, affording new opportunities for advancing diagnostics tests. Given significant advances in the field, a group of academic investigators from emergency medicine, intensive care, pathology, and pharmacology assembled to develop consensus around key gaps and potential future use for emerging rapid host response diagnostics assays in the emergency department (ED) setting. Methods A modified Delphi study was conducted that included 26 panelists (expert consensus panel) from multiple specialties. A smaller steering committee first defined a list of Delphi statements related to the need for and future potential use of a hypothetical sepsis diagnostic test in the ED. Likert scoring was used to assess panelists agreement or disagreement with statements. Two successive rounds of surveys were conducted and consensus for statements was operationally defined as achieving agreement or disagreement of 75% or greater. Results Significant gaps were identified related to current tools for assessing risk of sepsis in the ED. Strong consensus indicated the need for a test providing an indication of the severity of dysregulated host immune response, which would be helpful even if it did not identify the specific pathogen. Although there was a relatively high degree of uncertainty regarding which patients would most benefit from the test, the panel agreed that an ideal host response sepsis test should aim to be integrated into ED triage and thus should produce results in less than 30 minutes. The panel also agreed that such a test would be most valuable for improving sepsis outcomes and reducing rates of unnecessary antibiotic use. Conclusion The expert consensus panel expressed strong consensus regarding gaps in sepsis diagnostics in the ED and the potential for new rapid host response tests to help fill these gaps. These finding provide a baseline framework for assessing key attributes of evolving host response diagnostic tests for sepsis in the ED.
Collapse
Affiliation(s)
- Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| | - H. Bryant Nguyen
- Department of MedicinePulmonary and Critical Care DivisionLoma Linda UniversityLoma LindaCaliforniaUSA
| | - Ryan C. Jacobsen
- Department of Emergency MedicineUniversity of Kansas HospitalKansas CityKansasUSA
| | - Nathan A. Ledeboer
- Department of Pathology & Laboratory MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Larissa S. May
- Department of Emergency MedicineUC Davis HealthDavisCaliforniaUSA
| | - Hollis R. O'Neal
- Department of Critical Care MedicineLouisiana State UniversityBaton RougeLouisianaUSA
| | - Michael A. Puskarich
- Department of Emergency MedicineHennepin County Medical CenterUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Sciences and Division of AllergyPulmonary and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Sciences and Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Richard E. Rothman
- Department of Emergency MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| |
Collapse
|
13
|
Stains EL, Kennalley AL, Bachir AS, Kraus CK, Piper BJ. Is Medical Cannabis Evidence-Based Medicine? Concerns Based on Qualifying Conditions and the National Academy of Sciences Report. medRxiv 2023:2023.05.01.23289286. [PMID: 37214833 PMCID: PMC10197720 DOI: 10.1101/2023.05.01.23289286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This study aims to examine the coherence of state-level qualifying conditions (QCs) for medical cannabis (MC) with the evidence-based conclusions of the 2017 National Academies of Sciences (NAS) report. Data was collected for the QCs from 38 states where MC was legal in 2023 and compared to the QC data from 31 states where MC was legal in 2017. Each condition was divided into a NAS-established category based on the level of evidence supporting their effectiveness. The findings revealed wide variation in the number of QCs between states, with only an average of 8.4% of QCs in each state generally satisfying the substantial evidence category. Over three fourths of states included QCs with limited evidence of ineffectiveness (78.9%) or no/insufficient evidence (76.3%). Additionally, four fifths (81.6%) of states included QCs not covered in the NAS report. Only a few states appeared to have updated their QCs after the NAS report was released. This investigation highlights a large discrepancy between the state-level recommendations for MC and the supporting data.
Collapse
|
14
|
Czaja MP, Kraus CK, Phyo S, Olivieri P, Mederos DR, Puente I, Mohammed S, Berkeley RP, Slattery D, Gildea TH, Hardman C, Palmer B, Whitmill ML, Aluyen U, Pinnow JM, Young A, Eastin CD, Kester NM, Works KR, Pfeffer AN, Keller AW, Tobias A, Li B, Yorkgitis B, Saadat S, Langdorf MI. Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations. West J Emerg Med 2023; 24:552-565. [PMID: 37278791 DOI: 10.5811/westjem.58395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/25/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described. METHODS We gathered clinical and logistic information from 31 hospitals in the US about 403 survivors of 13 mass shootings, each event involving greater than 10 injuries, from 2012-19. Local champions in emergency medicine and trauma surgery provided clinical data from electronic health records within 24 hours of a mass shooting. We organized descriptive statistics of individual-level diagnoses recorded in medical records using International Classification of Diseases codes, according to the Barell Injury Diagnosis Matrix (BIDM), a standardized tool that classifies 12 types of injuries within 36 body regions. RESULTS Of the 403 patients who were evaluated at a hospital, 364 sustained physical injuries-252 by gunshot wound (GSW) and 112 by non-ballistic trauma-and 39 were uninjured. Fifty patients had 75 psychiatric diagnoses. Nearly 10% of victims came to the hospital for symptoms triggered by, but not directly related to, the shooting, or for exacerbations of underlying conditions. There were 362 gunshot wounds recorded in the Barell Matrix (1.44 per patient). The Emergency Severity Index (ESI) distribution was skewed toward higher acuity than typical for an emergency department (ED), with 15.1% ESI 1 and 17.6% ESI 2 patients. Semi-automatic firearms were used in 100% of these civilian public mass shootings, with 50 total weapons for 13 shootings (Route 91 Harvest Festival, Las Vegas. 24). Assailant motivations were reported to be associated with hate crimes in 23.1%. CONCLUSION Survivors of mass shootings have substantial morbidity and characteristic injury distribution, but 37% of victims had no GSW. Law enforcement, emergency medical systems, and hospital and ED disaster planners can use this information for injury mitigation and public policy planning. The BIDM is useful to organize data regarding gun violence injuries. We call for additional research funding to prevent and mitigate interpersonal firearm injuries, and for the National Violent Death Reporting System to expand tracking of injuries, their sequelae, complications, and societal costs.
Collapse
Affiliation(s)
- Matthew P Czaja
- Ponce Health Sciences University School of Medicine, Ponce, Puerto Rico
| | - Chadd K Kraus
- Geisinger Emergency Medicine, Danville, Pennsylvania
| | - Su Phyo
- Touro University Nevada College of Osteopathic Medicine, Henderson, Nevada
| | | | - Dalier R Mederos
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida
| | - Ivan Puente
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida
| | - Salman Mohammed
- Kirk Kerkorian School of Medicine at UNLV, Department of Emergency Medicine, Las Vegas, Nevada
| | - Ross P Berkeley
- Kirk Kerkorian School of Medicine at UNLV, Department of Emergency Medicine, Las Vegas, Nevada
| | - David Slattery
- Kirk Kerkorian School of Medicine at UNLV, Department of Emergency Medicine, Las Vegas, Nevada
| | - Thomas H Gildea
- St. Louise Regional Hospital, Department of Emergency Medicine, Gilroy, California
- Santa Clara Valley Medical Center, Department of Emergency Medicine, San Jose, California
| | - Claire Hardman
- Wright State University Boonshoft School of Medicine, Department of Surgery, Dayton, Ohio
| | - Brandi Palmer
- Kettering Health Main Campus, Trauma Research Program, Kettering, Ohio
| | - Melissa L Whitmill
- Kettering Health Main Campus, Division of Acute Care Surgery, Critical Care, and Trauma, Department of Surgery, Kettering, Ohio
| | - Una Aluyen
- Texas Tech University Health Sciences Center School of Medicine, Department of Emergency Medicine, Odessa, Texas
| | - Jeffery M Pinnow
- Medical Center Hospital, Department of Emergency Medicine, Odessa, Texas
| | - Amanda Young
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Carly D Eastin
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Nurani M Kester
- University of Texas Health Science Center at San Antonio, Department of Emergency Medicine, San Antonio, Texas
| | - Kaitlyn R Works
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Andrew N Pfeffer
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Aleksander W Keller
- University of Pittsburgh Medical Center, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Adam Tobias
- University of Pittsburgh Medical Center, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Benjamin Li
- Denver Health, Department of Emergency Medicine, Denver, Colorado
| | - Brian Yorkgitis
- University of Florida College of Medicine, Division of Acute Care Surgery, Department of Surgery, Jacksonville, Florida
| | - Soheil Saadat
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Mark I Langdorf
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
15
|
Kuc A, Isenberg DL, Kraus CK, Ackerman D, Sigal A, Herres J, Brandler ES, Cooney DR, Nomura JT, Mullen MT, Zhao H, Gentile NT. Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy. Am J Emerg Med 2023; 69:87-91. [PMID: 37084482 DOI: 10.1016/j.ajem.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION In the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT. METHODS The Optimizing Prehospital Use of Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry is comprised of all LVOS patients who underwent EVT at one of nine endovascular centers in the Northeast United States between 2015 and 2020. We queried the registry for all patients who were transferred from a non-ESC to one of the nine ESCs for EVT. Univariate analysis was performed using t-tests to obtain a p value. A priori, we defined a p value of <0.05 as significant. Multiple logistic regression was conducted to determine the association of variables to estimate an odds ratio. RESULTS 511 patients were included in the final analysis. The mean DIDO times for all patients was 137.8 min. Vascular imaging and treatment at a non-certified stroke center were associated with longer DIDO times by 23 and 14 min, respectively. On multivariate analyses, the acquisition of vascular imaging was associated with 16 additional minutes spent at the non-ESC while presentation to a non-stroke certified hospital was associated with 20 additional minutes spent at the transferring hospital. The administration of intravenous thrombolysis (IVT) was associated with 15 min less spent at the non-ESC. DISCUSSION Vascular imaging and non-stroke certified stroke centers were associated with longer DIDO times. Non-ESCs should integrate vascular imaging into their workflow as feasible to reduce DIDO times. Further work examining other details regarding the transfer process such as transfer via ground or air, could help further identify opportunities to improve DIDO times.
Collapse
Affiliation(s)
- Alexander Kuc
- Department of Emergency Medicine, Cooper University Hospital, United States of America
| | - Derek L Isenberg
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, United States of America.
| | - Chadd K Kraus
- Department of Emergency Medicine, Geisinger, United States of America
| | - Daniel Ackerman
- Department of Neurology, St. Lukes Health System, United States of America
| | - Adam Sigal
- Department of Emergency Medicine, Tower Health, United States of America
| | - Joseph Herres
- Department of Emergency Medicine, Einstein Health System, United States of America
| | - Ethan S Brandler
- Department of Emergency Medicine, State University of New York-Stony Brook, United States of America
| | - Derek R Cooney
- Department of Emergency Medicine, State University of New York-Upstate, United States of America
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care, United States of America
| | - Michael T Mullen
- Department of Neurolology, Lewis Katz School of Medicine at Temple University, United States of America
| | - Huaqing Zhao
- Center for Biostatistics and Epidemiology, Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, United States of America
| | - Nina T Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, United States of America
| |
Collapse
|
16
|
Kraus CK, Langdorf MI, Czaja MP. Non-fatal injuries from Mass Shootings in the United States, 2012-2019: Epidemiology, Outcomes and Medical Resource Use. J Emerg Med 2023. [DOI: 10.1016/j.jemermed.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
|
17
|
Wang HE, Tomaszewski C, Marco CA, March J, Kraus CK. JACEP open annual report 2022. J Am Coll Emerg Physicians Open 2023; 4:e12899. [PMID: 36776212 PMCID: PMC9902675 DOI: 10.1002/emp2.12899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | | | - Catherine A. Marco
- Penn State Health Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Juan March
- Department of Emergency MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| |
Collapse
|
18
|
Isenberg D, Sigal A, Kraus CK, Ackerman D, Brandler ES, Mullen MT, Kuc A, Herres J, Nomura J, Cooney DR, Zhao H, Gentile NT. Abstract TP37: Door-in-door-out Time Is Not Related To Outcomes In Large Vessel Occlusion Stroke. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Endovascular thrombectomy (EVT) a significantly improves outcomes in large vessel occlusion (LVO) stroke. Time to thrombectomy is a major determinant of neurologic outcomes. When patients with LVO arrive at a stroke center that does not perform thrombectomy they require urgent transfer to an endovascular-capable stroke center (ESC) for EVT. The goal of this study was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in a large multi-center registry.
Methods:
We conducted a retrospective review of patients from the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry initially evaluated at non-ESC and then transferred to ESC for EVT. We determined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale (mRS).
Results:
The mean DIDO time for patients with good outcomes was 17 minutes shorter than patients with poor outcomes (122 minutes v. 139 minutes). DIDO cutoff times of cohorts of ≤ 60 minutes, ≤ 90 minutes, or ≤ 120 were not associated with improved functional outcomes for those undergoing EVT (46.4% vs 32.3% p=0.12; 38.6% vs 30.6%, p=0.10; and 36.4% vs 28.9%, p=0.10, respectively). This trend for time cohorts held even for those with hyperacute strokes of <4-hour onset. Lower baseline NIHSS (11.9 vs 18.2, p=<0.001) was associated with improved outcomes.
Conclusion:
Although the DIDO time was shorter for patients with a good outcome, no clear time cutoff was associated with improved outcomes for LVOS. Factors associated with improved outcomes were a lower stroke severity score at presentation. This study underscores the need to streamline DIDO times but not to set an artificial benchmark not supported by evidence.
Collapse
Affiliation(s)
- Derek Isenberg
- Lewis Katz Sch of Medicine at Temple Univ, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | - Huaquing Zhao
- Lewis Katz Sch of Medicine at Temple Univ, Philadelphia, PA
| | | | | |
Collapse
|
19
|
Stickles SP, Kane DS, Kraus CK, Strony RJ, Ablordeppey EA, Doering MM, Theodoro D, Lee JS, Carpenter CR. Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol. PLoS One 2022; 17:e0269697. [PMID: 35749370 PMCID: PMC9231708 DOI: 10.1371/journal.pone.0269697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
The use of ultrasound-guided regional anesthesia for pain management has become increasingly prevalent in Emergency Medicine, with studies noting excellent pain control while sparing opioid use. However, the use of ultrasound-guided regional anesthesia may be hampered by concern about risks for patient harm. This systematic review protocol describes our approach to evaluate the incidence of adverse events from the use of ultrasound-guided regional anesthesia by Emergency Physicians as described in the literature. This project will also seek to document the scope of ultrasound-guided regional anesthesia applications being performed in Emergency Medicine literature, and potentially serve as a framework for future systematic reviews evaluating adverse events in Emergency Medicine.
Collapse
Affiliation(s)
- Sean P. Stickles
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
- * E-mail:
| | - Deborah Shipley Kane
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Chadd K. Kraus
- Department of Emergency Medicine, Geisinger Health Systems, Danville, Pennsylvania, United States of America
| | - Robert J. Strony
- Department of Emergency Medicine, Geisinger Health Systems, Danville, Pennsylvania, United States of America
| | - Enyo A. Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Michelle M. Doering
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Daniel Theodoro
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Jacques Simon Lee
- Department of Family and Community Medicine, Mount Sinai Hospital, Schwartz/Reisman Emergency Centre, Toronto, Ontario, Canada
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| |
Collapse
|
20
|
Katsilometes J, Galuska M, Kraus CK, Levitin HW, Leuchten S, Daugherty-Luck J, Lata J, Brannan G, Santarelli A, Ashurst J. Multisite assessment of emergency medicine resident knowledge of evidence-based medicine as measured by the Fresno Test of Evidence-Based Medicine. J Osteopath Med 2022; 122:509-515. [PMID: 35704661 DOI: 10.1515/jom-2022-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/16/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Evidence-based medicine (EBM) is the application of scientific evidence while treating a patient. To date, however, there is very little evidence describing how residents in emergency medicine understand and incorporate EBM into practice. OBJECTIVES The aim of this study was to determine EBM theoretical and quantitative knowledge in emergency medicine residents in community hospital-based training programs. METHODS A sample of emergency medicine residents from nine hospitals was enrolled to complete a cross-sectional assessment of EBM skills from April 2021 through June 2021. Performance on the Fresno Test of Evidence-Based Medicine (FTEBM) was assessed utilizing descriptive statistics, t tests, and one-way analysis of variance. RESULTS A total of 50.8% (124/244) of current emergency medicine residents completed the FTEBM during the study period. No significant difference on FTEBM scores was noted between the different types of medical degrees (DO vs. MD) (p=0.511), holding an advanced research degree (p=0.117), or between each postgraduate year of training (p=0.356). The mean score of those residents who rated their knowledge of EBM as average or higher was 36.0% (32.8-39.1%). The mean score of those residents who rated their programs as having an "average" or higher institutional focus on EBM was 34.9% (32.2-37.6%). CONCLUSIONS Participating emergency medicine residents show an incomplete understanding of EBM both in theory and applied computations despite rating themselves as having an average understanding. Emergency medicine residencies would be well suited to implement a standardized EBM curriculum that focuses on longitudinal reinforcement of key concepts needed for the practicing physician.
Collapse
Affiliation(s)
- James Katsilometes
- Pacific Northwest University College of Osteopathic Medicine, Yakima, WA, USA
| | - Michael Galuska
- Conemaugh Health System, Department of Emergency Medicine, Johnstown, PA, USA
| | - Chadd K Kraus
- Geisinger Medical Center, Department of Emergency Medicine, Danville, PA, USA
| | - Howard W Levitin
- OhioHealth Doctors Hospital, Emergency Medicine Residency Program, Columbus, OH, USA
| | - Scott Leuchten
- St. Barnabas Hospital, Department of Emergency Medicine, Bronx, NY, USA
| | - Jane Daugherty-Luck
- Trinity Health System, Department of Emergency Medicine, Steubenville, OH, USA
| | - Julie Lata
- McLaren Macomb Hospital, Department of Emergency Medicine, Mt. Clemens, MI, USA
| | - Grace Brannan
- Department of Clinical Research and Medical Education, Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Anthony Santarelli
- Kingman Regional Medical Center, Department of Graduate Medical Education, Kingman, AZ, USA
| | - John Ashurst
- Kingman Regional Medical Center, Department of Graduate Medical Education, Kingman, AZ, USA
| | | |
Collapse
|
21
|
Isenberg DL, Henry KA, Sigal A, Deaner T, Nomura JT, Murphy KA, Cooney D, Wojcik S, Brandler ES, Kuc A, Carroll G, Kraus CK, Shahan JB, Herres J, Ackerman D, Gentile NT. Correction: Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care. BMC Neurol 2022; 22:171. [PMID: 35525937 PMCID: PMC9077974 DOI: 10.1186/s12883-022-02695-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Derek L Isenberg
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
| | - Kevin A Henry
- Department Geography and Urban Studies, Temple University, Philadelphia, PA, USA
| | - Adam Sigal
- Department of Emergency Medicine, Tower Health, Reading, PA, USA
| | - Traci Deaner
- Department of Emergency Medicine, Tower Health, Reading, PA, USA
| | - Jason T Nomura
- Department of Emergency Medicine, ChristianaCare, Newark, DE, USA
| | | | - Derek Cooney
- Department of Emergency Medicine, State University of New York-Upstate Campus, Syracuse, NY, USA
| | - Susan Wojcik
- Department of Emergency Medicine, State University of New York-Upstate Campus, Syracuse, NY, USA
| | - Ethan S Brandler
- Deparement of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - Alexander Kuc
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Gerard Carroll
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Chadd K Kraus
- Department of Emergency Medicine, Geisinger, Danville, PA, USA
| | - Judy B Shahan
- Department of Emergency Medicine, Geisinger, Danville, PA, USA
| | - Joseph Herres
- Department of Emergency Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Daniel Ackerman
- Department of Neurology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nina T Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| |
Collapse
|
22
|
Czaja MP, Kraus CK, Phyo S, Olivieri P, Mederos DR, Puente I, Mohammed S, Berkeley RP, Slattery D, Gildea TH, Hardman C, Palmer B, Whitmill ML, Aluyen U, Pinnow JM, Young A, Eastin CD, Kester NM, Works KR, Pfeffer AN, Keller AW, Tobias A, Li B, Yorkgitis B, Saadat S, Langdorf MI. Injury Characteristics, Outcomes, and Health Care Services Use Associated With Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019. JAMA Netw Open 2022; 5:e2213737. [PMID: 35622366 PMCID: PMC9142871 DOI: 10.1001/jamanetworkopen.2022.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Civilian public mass shootings (CPMSs) in the US result in substantial injuries. However, the types and consequences of these injuries have not been systematically described. OBJECTIVE To describe the injury characteristics, outcomes, and health care burden associated with nonfatal injuries sustained during CPMSs and to better understand the consequences to patients, hospitals, and society at large. DESIGN, SETTING, AND PARTICIPANTS This retrospective case series of nonfatal injuries from 13 consecutive CPMSs (defined as ≥10 injured individuals) from 31 hospitals in the US from July 20, 2012, to August 31, 2019, used data from trauma logs and medical records to capture injuries, procedures, lengths of stay, functional impairment, disposition, and charges. A total of 403 individuals treated in hospitals within 24 hours of the CPMSs were included in the analysis. Data were analyzed from October 27 to December 5, 2021. EXPOSURES Nonfatal injuries sustained during CPMSs. MAIN OUTCOMES AND MEASURES Injuries and diagnoses, treating services, procedures, hospital care, and monetary charges. RESULTS Among the 403 individuals included in the study, the median age was 33.0 (IQR, 24.5-48.0 [range, 1 to >89]) years, and 209 (51.9%) were women. Among the 386 patients with race and ethnicity data available, 13 (3.4%) were Asian; 44 (11.4%), Black or African American; 59 (15.3), Hispanic/Latinx; and 270 (69.9%), White. Injuries included 252 gunshot wounds (62.5%) and 112 other injuries (27.8%), and 39 patients (9.7%) had no physical injuries. One hundred seventy-eight individuals (53.1%) arrived by ambulance. Of 494 body regions injured (mean [SD], 1.35 [0.68] per patient), most common included an extremity (282 [57.1%]), abdomen and/or pelvis (66 [13.4%]), head and/or neck (65 [13.2%]), and chest (50 [10.1%]). Overall, 147 individuals (36.5%) were admitted to a hospital, 95 (23.6%) underwent 1 surgical procedure, and 42 (10.4%) underwent multiple procedures (1.82 per patient). Among the 252 patients with gunshot wounds, the most common initial procedures were general and trauma surgery (41 [16.3%]) and orthopedic surgery (36 [14.3%]). In the emergency department, 148 of 364 injured individuals (40.7%) had 199 procedures (1.34 per patient). Median hospital length of stay was 4.0 (IQR, 2.0-7.5) days; for 50 patients in the intensive care unit, 3.0 (IQR, 2.0-8.0) days (13.7% of injuries and 34.0% of admissions). Among 364 injured patients, 160 (44.0%) had functional disability at discharge, with 19 (13.3%) sent to long-term care. The mean (SD) charges per patient were $64 976 ($160 083). CONCLUSIONS AND RELEVANCE Civilian public mass shootings cause substantial morbidity. For every death, 5.8 individuals are injured. These results suggest that including nonfatal injuries in the overall burden of CPMSs may help inform public policy to prevent and mitigate the harm caused by such events.
Collapse
Affiliation(s)
- Matthew P. Czaja
- Ponce Health Sciences University School of Medicine, Ponce, Puerto Rico
| | | | - Su Phyo
- Touro University Nevada College of Osteopathic Medicine, Henderson
| | | | - Dalier R. Mederos
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Salman Mohammed
- Department of Emergency Medicine, University of Nevada, Las Vegas Kirk Kerkorian School of Medicine, Las Vegas
| | - Ross P. Berkeley
- Department of Emergency Medicine, University of Nevada, Las Vegas Kirk Kerkorian School of Medicine, Las Vegas
| | - David Slattery
- Department of Emergency Medicine, University of Nevada, Las Vegas Kirk Kerkorian School of Medicine, Las Vegas
| | - Thomas H. Gildea
- Department of Emergency Medicine, St Louise Regional Hospital, Gilroy, California
- Department of Emergency Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Claire Hardman
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Brandi Palmer
- Trauma Research Program, Kettering Medical Center, Kettering, Ohio
| | - Melissa L. Whitmill
- Division of Acute Care Surgery, Critical Care, and Trauma, Department of Surgery, Kettering Medical Center, Kettering, Ohio
| | - Una Aluyen
- Department of Emergency Medicine, Texas Tech University Health Sciences Center School of Medicine, Odessa
| | - Jeffery M. Pinnow
- Department of Emergency Medicine, Medical Center Hospital, Odessa, Texas
| | - Amanda Young
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Carly D. Eastin
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Nurani M. Kester
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio
| | - Kaitlyn R. Works
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew N. Pfeffer
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aleksander W. Keller
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam Tobias
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Benjamin Li
- Department of Emergency Medicine, Denver Health, Denver, Colorado
| | - Brian Yorkgitis
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Jacksonville
| | - Soheil Saadat
- Department of Emergency Medicine, School of Medicine, University of California, Irvine
| | - Mark I. Langdorf
- Department of Emergency Medicine, School of Medicine, University of California, Irvine
| |
Collapse
|
23
|
Stoltzfus GT, Kraus CK. The forgotten disease. J Am Coll Emerg Physicians Open 2022; 3:e12715. [PMID: 35387324 PMCID: PMC8976195 DOI: 10.1002/emp2.12715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Garrett T. Stoltzfus
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| | - Chadd K. Kraus
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| |
Collapse
|
24
|
Melnychuk E, Sallade TD, Kraus CK. Hospitals as disaster victims: Lessons not learned? J Am Coll Emerg Physicians Open 2022; 3:e12632. [PMID: 35036993 PMCID: PMC8749465 DOI: 10.1002/emp2.12632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 11/07/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Hospitals are a key component to disaster response but are susceptible to the effects of disasters as well, including infrastructure damage that disrupts patient care. These events offer an opportunity for evaluation and improvement of preparedness and response efforts when hospitals are affected directly by a disaster. The objective of this structured review was to evaluate the existing literature on hospitals as disaster victims. METHODS A structured and scoping review of peer-reviewed literature, gray literature, and news reports related to hospitals as disaster victims was completed to identify and analyze themes and lessons observed from disasters in which hospitals are victims, to aid in future emergency operations planning and disaster response. RESULTS The literature search and secondary search of referenes identified 366 records in English. A variety of common barriers to successful disaster response include loss of power, water, heating and ventilation, communications, health information technology, staffing, supplies, safety and security, and structural and non-structural damage. CONCLUSIONS There are common weaknesses in disaster preparedness that we can learn from and account for in future planning with the aim of improving resilience in the face of future disasters.
Collapse
Affiliation(s)
- Eric Melnychuk
- Department of Emergency MedicineGeisinger Medical CenterDanvillePAUSA
- Department of Critical Care MedicineGeisinger Medical CenterDanvillePAUSA
| | - Thomas D. Sallade
- Department of Emergency MedicineGeisinger Medical CenterDanvillePAUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePAUSA
| |
Collapse
|
25
|
Kraus CK. Mask effectiveness against viral illnesses in health care professionals. J Am Coll Emerg Physicians Open 2021; 2:e12583. [PMID: 34746924 PMCID: PMC8549016 DOI: 10.1002/emp2.12583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| |
Collapse
|
26
|
Olaf MF, Kraus CK. Igniting Inquiry: Development and Implementation of a Novel Journal Club Curriculum in an Emergency Medicine Residency. J Emerg Med 2021; 61:596-601. [PMID: 34481687 DOI: 10.1016/j.jemermed.2021.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/02/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The journal club is a long-standing pillar of medical education and medical practice, although its components and format are quite variable. In addition, selecting literature for discussion must strike a delicate balance between reviewing seminal and durable articles with that of emerging evidence, all while complementing a residency curriculum. Although the critical appraisal of literature is a fundamental skill of the practicing physician, a universal curriculum has not yet been optimized to facilitate journal club. OBJECTIVE We sought to design and implement a comprehensive, complementary, and evidence-based journal club curriculum that was modular in design, reproducible, and effective at generating participation. METHODS Our novel curricular design incorporates many evidence-based components, including optimizing the learning environment, providing ease of access to resources, and using educational methodology that immerses learners in the experience in a structured manner. In addition, the curriculum complements, but does not duplicate, the core residency curriculum. In 2020, we analyzed our data, using descriptive and comparative statistical methods. RESULTS We demonstrated significant improvement in common metrics used to analyze the efficacy of the journal club, including attendance and participation. Significant improvements were seen in both resident and attending participation. CONCLUSIONS Our design methods used resources easily available to our residency program and commonly available to others, with minimal time and resource cost. Further study is required to measure long-term educational outcomes.
Collapse
Affiliation(s)
- Mark F Olaf
- Geisinger Commonwealth School of Medicine, Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania.
| | - Chadd K Kraus
- Geisinger Commonwealth School of Medicine, Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania
| |
Collapse
|
27
|
Kraus CK, Langdorf MI. Firearms Injury Prevention, Emergency Medicine, and the Public's Health: A Call for Unity of Purpose. West J Emerg Med 2021; 22:457-458. [PMID: 34125013 PMCID: PMC8202984 DOI: 10.5811/westjem.2021.4.52861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Chadd K Kraus
- Geisinger, Department of Emergency Medicine, Danville, Pennsylvania
| | - Mark I Langdorf
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
28
|
Laam LA, Wary AA, Strony RS, Fitzpatrick MH, Kraus CK. Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. J Am Coll Emerg Physicians Open 2021; 2:e12401. [PMID: 33718931 PMCID: PMC7926013 DOI: 10.1002/emp2.12401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/22/2021] [Accepted: 02/12/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patients boarding in the emergency department (ED) as a result of delays in bed placement are associated with increased morbidity and mortality. Prior literature on ED boarding does not explore the impact of boarding on patients admitted to the hospital from the ED. The objective of this study was to evaluate the impact of patient boarding on ED length of stay for all patients admitted to the hospital. METHODS This was an institutional review board-approved, retrospective review of all patients from January 1, 2015, through June 30, 2019, presenting to 2 large EDs in a single health system in Pennsylvania. Quantile regression models were created to estimate the impact of patients boarding in the ED on length of stay for all ED patients admitted to the hospital. RESULTS A total number of 466,449 ED encounters were analyzed across two EDs. At one ED, for every patient boarded, the median ED length of stay for all admitted patients increased by 14.0 minutes (P < 0.001). At the second ED, for every patient boarded in the ED, the median ED length of stay increased by 12.4 minutes (P < 0.001). CONCLUSION ED boarding impacts length of stay for all patients admitted through the ED and not just those admitted patients who are boarded. This study provides an estimate for the increased ED length of stay experienced by all patients admitted to the hospital as a function of patient boarding.
Collapse
Affiliation(s)
- Leslie A. Laam
- Steele Institute for Health InnovationGeisinger HealthDanvillePennsylvaniaUSA
| | - Andrea A. Wary
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| | - Ronald S. Strony
- Geisinger Wyoming Valley Medical CenterGeisinger HealthWilkes‐BarrePennsylvaniaUSA
| | | | - Chadd K. Kraus
- Geisinger Medical CenterGeisinger HealthDanvillePennsylvaniaUSA
| |
Collapse
|
29
|
Cassone MA, Kraus CK, Senter N. Man with persistent low back pain radiating down leg. J Am Coll Emerg Physicians Open 2021; 2:e12414. [PMID: 33842923 PMCID: PMC8018197 DOI: 10.1002/emp2.12414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Marc A. Cassone
- Department of Emergency MedicineNorthern Navajo Medical CenterShiprockNew MexicoUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| | - Natalie Senter
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| |
Collapse
|
30
|
Kraus CK. The emergency department waiting room: A barometer of hospital throughput and capacity? J Am Coll Emerg Physicians Open 2020; 1:1060-1061. [PMID: 33145558 PMCID: PMC7593417 DOI: 10.1002/emp2.12217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/20/2022] Open
|
31
|
Kraus CK. Invited Editorial: Dedicated homeless clinics and emergency department utilization: a new horizon? J Am Coll Emerg Physicians Open 2020; 1:837-838. [PMID: 33145528 PMCID: PMC7593460 DOI: 10.1002/emp2.12135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| |
Collapse
|
32
|
Baker EF, Geiderman JM, Kraus CK, Goett R. The role of hospital ethics committees in emergency medicine practice. J Am Coll Emerg Physicians Open 2020; 1:403-407. [PMID: 33000063 PMCID: PMC7493501 DOI: 10.1002/emp2.12136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/08/2022] Open
Abstract
Emergency physicians face real-time ethical dilemmas that may occur at any hour of the day or night. Hospital ethics committees and ethics consultation services are not always able to provide immediate responses to emergency physicians' consultation requests. When faced with an emergent dilemma, emergency physicians sometimes rely on risk management or hospital counsel to answer legal questions, but may be better served by real-time ethics consultation. When other resources are not immediately available, emergency physicians should feel confident in making timely decisions, guided by basic principles of medical ethics. We make the following recommendations: (1) availability of a member of the hospital ethics committee to provide in-person or telephonic consultation concurrent with patient care; (2) appointment to the hospital ethics committee of an emergency physician who is familiar with bioethical principles and is available for consultation when other ethics consultants are not; and (3) development of educational tools by professional societies or similar organizations to assist emergency physicians in making reasoned and defensible clinical ethics decisions.
Collapse
Affiliation(s)
- Eileen F Baker
- University of Toledo College of Medicine and Life Sciences Toledo Ohio USA
- Inc, Riverwood Emergency Services Perrysburg Ohio USA
| | - Joel M Geiderman
- Emergency Medicine Department of Emergency Medicine Ruth and Harry Roman Emergency Department Cedars-Sinai Medical Center Los Angeles California USA
| | - Chadd K Kraus
- Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| | - Rebecca Goett
- Emergency and Palliative Medicine Rutgers New Jersey Medical School Newark New Jersey USA
| |
Collapse
|
33
|
Kraus CK, Moskop JC, Marshall KD, Bookman K. Ethical issues in access to and delivery of emergency department care in an era of changing reimbursement and novel payment models. J Am Coll Emerg Physicians Open 2020; 1:276-280. [PMID: 33000043 PMCID: PMC7493566 DOI: 10.1002/emp2.12067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/09/2020] [Accepted: 03/25/2020] [Indexed: 11/23/2022] Open
Abstract
Hospital emergency departments (EDs) and the emergency physicians, nurses, and other health professionals who provide emergency care in them, are a critical component of the United States (US) health care system in the 21st century. Although access to emergency care has become a de facto right in the United States, funding for emergency care is fragmented and complex, which causes confusion and conflict about who should bear the cost of care. This article examines the tension between universal access to emergency care in the United States and the fragmentary, tenuous, and contentious financial arrangements that make it possible, viewing the issue in context of the historical development, legal and moral foundations, current situation, and future challenges of ED care in the United States. It begins with a review of the origins and evolution of emergency care and of hospital EDs in the United States. It then examines arguments for a right to emergency medical care and for shared obligations of patients to seek and of professionals and society to provide that care. Finally, it reviews current strategies and future prospects for protecting access to emergency care for patients who require it.
Collapse
Affiliation(s)
- Chadd K. Kraus
- Department of Emergency MedicineGeisinger Health SystemDanvillePennsylvania
| | - John C. Moskop
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth Carolina
| | | | - Kelly Bookman
- Department of Emergency MedicineUniversity of ColoradoDenverColorado
| | | |
Collapse
|
34
|
Halupa AJ, Strony RJ, Bulbin DH, Kraus CK. Pseudogout Diagnosed By Point-of-care Ultrasound. Clin Pract Cases Emerg Med 2019; 3:425-427. [PMID: 31763605 PMCID: PMC6861017 DOI: 10.5811/cpcem.2019.7.43244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/23/2019] [Accepted: 07/29/2019] [Indexed: 12/02/2022] Open
Abstract
A 71-year-old male presented to the emergency department (ED) for worsening right knee pain for the prior 3–4 weeks. Point-of-care ultrasound (POCUS) of the right knee showed a pseudo-double contour sign. Subsequent ultrasound-guided arthrocentesis of the knee joint was performed, and fluid studies showed the presence of calcium pyrophosphate crystals, which was consistent with pseudogout. Ultrasound for detection of calcium pyrophosphate crystals in pseudogout and chondrocalcinosis has sensitivity of 86.7% and specificity of 96.4% making POCUS a valuable tool for diagnosing crystalline-induced arthropathy in the ED.
Collapse
Affiliation(s)
- Anthony J Halupa
- Geisinger Medical Center, Department of Emergency Medicine, Danville, Pennsylvania
| | - Robert J Strony
- Geisinger Medical Center, Department of Emergency Medicine, Danville, Pennsylvania
| | - David H Bulbin
- Geisinger Medical Center, Department of Rheumatology, Danville, Pennsylvania
| | - Chadd K Kraus
- Geisinger Medical Center, Department of Emergency Medicine, Danville, Pennsylvania
| |
Collapse
|
35
|
Sallade TD, Kraus CK, Hoffman L. Symptomatic Pericardial Cyst: An Atypical Case of Pleuritic Chest Pain. Clin Pract Cases Emerg Med 2019; 3:199-201. [PMID: 31403092 PMCID: PMC6682250 DOI: 10.5811/cpcem.2019.5.42601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/19/2019] [Accepted: 05/16/2019] [Indexed: 11/12/2022] Open
Abstract
Pericardial cysts were first described in 1837 as diverticula extending from the pericardium. They are rare and frequently asymptomatic. Symptomatic presentations may be similar to more common causes of chest pain or dyspnea such as acute coronary syndrome or pulmonary embolism. Emergency physicians should consider mediastinal mass, and in this case pericardial cyst, in the differential diagnosis of chest pain because of the risk for tamponade, sudden cardiac death, or other life-threatening complications. Here, we describe a novel presentation of a pericardial cyst presenting as atypical chest pain.
Collapse
Affiliation(s)
- T Douglas Sallade
- Geisinger Medical Center, Department of Emergency Medicine, Danville, Pennsylvania
| | - Chadd K Kraus
- Geisinger Medical Center, Department of Emergency Medicine, Danville, Pennsylvania
| | - Lisa Hoffman
- Geisinger Medical Center, Department of Emergency Medicine, Danville, Pennsylvania
| |
Collapse
|
36
|
Abstract
The number of both print and electronic open access (OA) journals has increased dramatically. Although electronic availability of information on the Internet may offer greater potential for information sharing, it also gives rise to "predatory" journals and deceptive publishers. In this Invited Commentary, the authors describe both the opportunities and potential perils that come with OA publications.Definitions for four models of legitimate OA are provided: the gold model, the green model, the platinum model, and the hybrid model. Benefits and risks of each model are discussed. The authors also distinguish between legitimate OA journals and predatory journals, highlighting several existing tools and resources for distinguishing between the two.Finally, the authors provide a checklist to help authors evaluate the policies and processes of journals and thereby avoid predatory publications.
Collapse
Affiliation(s)
- Eileen F Baker
- E.F. Baker is emergency physician, Riverwood Emergency Services, Inc., Perrysburg, Ohio, and assistant professor, Department of Emergency Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; ORCID: http://orcid.org/0000-0003-0501-5220. K.V. Iserson is professor emeritus, Department of Emergency Medicine, University of Arizona, Tucson, Arizona; ORCID: http://orcid.org/0000-0002-6823-8950. A.L. Aswegan is emergency physician, Union Hospital, Elkton, Maryland. G.L. Larkin is professor, Summa Health System and Northeast Ohio Medical University, Akron, Ohio. A.R. Derse is Julia and David Uihlein Chair in Medical Humanities, professor of bioethics and emergency medicine, and director, Center for Bioethics and Medical Humanities, Institute for Health and Equity and Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. C.K. Kraus is system director of emergency medicine research, Department of Emergency Medicine, Geisinger Health System, Danville, Pennsylvania
| | | | | | | | | | | |
Collapse
|
37
|
Kane BG, Totten VY, Kraus CK, Allswede M, Diercks DB, Garg N, Ling L, McDonald EN, Rosenau AM, Wilk M, Holmes AD, Hemminger A, Greenberg MR. Creating Consensus: Revisiting the Emergency Medicine Resident Scholarly Activity Requirement. West J Emerg Med 2018; 20:369-375. [PMID: 30881559 PMCID: PMC6404691 DOI: 10.5811/westjem.2018.10.39293] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/27/2018] [Accepted: 10/17/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction In the context of the upcoming single accreditation system for graduate medical education resulting from an agreement between the Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association and American Association of Colleges of Osteopathic Medicine, we saw the opportunity for charting a new course for emergency medicine (EM) scholarly activity (SA). Our goal was to engage relevant stakeholders to produce a consensus document. Methods Consensus building focused on the goals, definition, and endpoints of SA. Representatives from stakeholder organizations were asked to help develop a survey regarding the SA requirement. The survey was then distributed to those with vested interests. We used the preliminary data to find areas of concordance and discordance and presented them at a consensus-building session. Outcomes were then re-ranked. Results By consensus, the primary role(s) of SA should be the following: 1) instruct residents in the process of scientific inquiry; 2) expose them to the mechanics of research; 3) teach them lifelong skills, including search strategies and critical appraisal; and 4) teach them how to formulate a question, search for the answer, and evaluate its strength. To meet these goals, the activity should have the general elements of hypothesis generation, data collection and analytical thinking, and interpretation of results. We also determined consensus on the endpoints, and acceptable documentation of the outcome. Conclusion This consensus document may serve as a best-practices guideline for EM residency programs by delineating the goals, definitions, and endpoints for EM residents’ SA. However, each residency program must evaluate its available scholarly activity resources and individually implement requirements by balancing the ACGME Review Committee for Emergency Medicine requirements with their own circumstances.
Collapse
Affiliation(s)
- Bryan G Kane
- Lehigh Valley Hospital, Department of Emergency Medicine and Hospital Medicine, Allentown, Pennsylvania.,University of South Florida, Morsani College of Medicine, Lehigh Valley Campus, Allentown, Pennsylvania
| | - Vicken Y Totten
- Kaweah Delta Medical Center, Department of Emergency Medicine, Visalia, California
| | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Michael Allswede
- Mountainview Hospital, Department of Emergency Medicine, Las Vegas, Nevada
| | - Deborah B Diercks
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Nidhi Garg
- Long Island Jewish Medical Center, Northwell Health, Department of Emergency Medicine, New Hyde Park, New York
| | - Louis Ling
- Accreditation Council for Graduate Medical Education, Chicago, Illinois.,University of Minnesota, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Eric N McDonald
- University of Mississippi, Department of Emergency Medicine, Oxford, Mississippi
| | - Alex M Rosenau
- Lehigh Valley Hospital, Department of Emergency Medicine and Hospital Medicine, Allentown, Pennsylvania.,University of South Florida, Morsani College of Medicine, Lehigh Valley Campus, Allentown, Pennsylvania
| | - Mike Wilk
- Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Alexandria D Holmes
- Lehigh Valley Hospital, Department of Emergency Medicine and Hospital Medicine, Allentown, Pennsylvania.,University of South Florida, Morsani College of Medicine, Lehigh Valley Campus, Allentown, Pennsylvania
| | - Adam Hemminger
- Lehigh Valley Hospital, Department of Emergency Medicine and Hospital Medicine, Allentown, Pennsylvania.,University of South Florida, Morsani College of Medicine, Lehigh Valley Campus, Allentown, Pennsylvania
| | - Marna Rayl Greenberg
- Lehigh Valley Hospital, Department of Emergency Medicine and Hospital Medicine, Allentown, Pennsylvania.,University of South Florida, Morsani College of Medicine, Lehigh Valley Campus, Allentown, Pennsylvania
| |
Collapse
|
38
|
Gottlieb M, Lotfipour S, Murphy L, Kraus CK, Langabeer JR, Langdorf MI. Scholarship in Emergency Medicine: A Primer for Junior Academics Part I: Writing and Publishing. West J Emerg Med 2018; 19:996-1002. [PMID: 30429932 PMCID: PMC6225948 DOI: 10.5811/westjem.2018.39283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/26/2018] [Accepted: 08/15/2018] [Indexed: 11/22/2022] Open
Abstract
The landscape of scholarly writing, publishing, and university promotion can be complex and challenging. Mentorship may be limited. To be successful it is important to understand the key components of writing and publishing. In this article, we provide expert consensus recommendations on four key challenges faced by junior faculty: writing the paper; selecting contributors and the importance of authorship order; journal selection and indexing; and responding to critiques. After reviewing this paper, the reader should have an enhanced understanding of these challenges and strategies to successfully address them.
Collapse
Affiliation(s)
- Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Shahram Lotfipour
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Linda Murphy
- University of California Irvine, UCI Science Library Reference Department, Irvine, California
| | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | | | - Mark I Langdorf
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
39
|
Murphy LS, Kraus CK, Lotfipour S, Gottlieb M, Langabeer JR, Langdorf MI. Measuring Scholarly Productivity: A Primer for Junior Faculty. Part III: Understanding Publication Metrics. West J Emerg Med 2018; 19:1003-1011. [PMID: 30429933 PMCID: PMC6225941 DOI: 10.5811/westjem.2018.9.38213] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 09/24/2018] [Indexed: 11/11/2022] Open
Abstract
There are approximately 78 indexed journals in the specialty of emergency medicine (EM), making it challenging to determine which is the best option for junior faculty. This paper is the final component of a three-part series focused on guiding junior faculty to enhance their scholarly productivity. As an EM junior faculty's research career advances, the bibliometric tools and resources detailed in this paper should be considered when developing a publication submission strategy. The tenure and promotion decision process in many universities relies at least in part on these types of bibliometrics. This paper provides an understanding of new, alternative metrics that can be used to promote scientific progress in a transparent and timely manner.
Collapse
Affiliation(s)
- Linda S Murphy
- University of California-Irvine Libraries, Reference Department, Irvine, California
| | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Shahram Lotfipour
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | | | - Mark I Langdorf
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
40
|
Kraus CK, Carlisle TE, Carney DM. Emergency Medicine Physician Assistant (EMPA) Postgraduate Training Programs: Program Characteristics and Training Curricula. West J Emerg Med 2018; 19:803-807. [PMID: 30202490 PMCID: PMC6123089 DOI: 10.5811/westjem.2018.6.37892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction A growing number of formal postgraduate training programs have been established to provide emergency medicine physician assistants (EMPA) with the unique skills and knowledge to work in the emergency department (ED). The objective of this study was to provide an overview of the current state of EMPA postgraduate training and to describe program characteristics and curriculum components. Methods We conducted a cross-sectional study of EMPA postgraduate training programs using data from websites and contacting individual programs to provide program characteristics and curriculum components. Variables collected included length of program, curriculum (e.g., clinical rotations, didactic experience, and research opportunities), size of program/number of trainees, affiliation with emergency medicine (EM) residency, geographic location, and salary. Results We identified 29 EMPA postgraduate training programs in 17 states, with at least one additional program in development. The mean length of EMPA training programs is 15 months (range 12-24 months). The most common non-ED/elective rotations are orthopedics, ultrasound, anesthesiology, and trauma. The mean number of trainees per class is 3.46 (median 3, range 1-16 trainees); 27 of 29 (93%) programs were in institutions that also had an EM residency program. The mean annual salary is $58,566 (range $43,000-90,000). Conclusion EMPA postgraduate training programs have common characteristics and curriculum components despite a lack of a specialty-specific accrediting organization or certifying examination. The overall growth and current number of these programs merits further research focusing on whether standardized curricula, formal recognition, and accreditation should be developed.
Collapse
Affiliation(s)
- Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Terry E Carlisle
- University of Missouri-Columbia, Department of Emergency Medicine, Columbia, Missouri
| | | |
Collapse
|
41
|
Ritter JT, Kraus CK. Blunt Traumatic Cervical Vascular Injury Without any Modified Denver Criteria. Clin Pract Cases Emerg Med 2018; 2:200-202. [PMID: 30083632 PMCID: PMC6075485 DOI: 10.5811/cpcem.2018.4.37719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/05/2018] [Accepted: 04/19/2018] [Indexed: 11/11/2022] Open
Abstract
Blunt traumatic cervical vascular injury (BCVI) is challenging to recognize, but it is a potentially devastating entity that warrants attention from emergency physicians. Injury to the vertebral or carotid artery can result in a delayed manifestation of neurologic injury that may be preventable if promptly recognized and treated. The modified Denver Criteria are frequently used to guide imaging decisions for BCVI; however, injuries can still be missed. We present a case of BCVI in a trauma patient whose initial presentation evaded standard screening criteria, illustrating the need for a high index of suspicion for BCVI in blunt trauma.
Collapse
Affiliation(s)
- Jed T Ritter
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| |
Collapse
|
42
|
Jesus JE, Marshall KD, Kraus CK, Derse AR, Baker EF, McGreevy J. Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU? J Emerg Med 2018; 55:435-440. [PMID: 30054156 DOI: 10.1016/j.jemermed.2018.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 05/17/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. OBJECTIVES In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU. DISCUSSION Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition. CONCLUSIONS End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.
Collapse
Affiliation(s)
| | | | | | | | - Eileen F Baker
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | | |
Collapse
|
43
|
Langabeer J, Gottlieb M, Kraus CK, Lotfipour S, Murphy LS, Langdorf MI. Scholarship in Emergency Medicine: A Primer for Junior Academics: Part II: Promoting Your Career and Achieving Your Goals. West J Emerg Med 2018; 19:741-745. [PMID: 30013714 PMCID: PMC6040906 DOI: 10.5811/westjem.2018.5.37539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/19/2018] [Accepted: 05/15/2018] [Indexed: 12/03/2022] Open
Abstract
Scholarship is an important component of success for academic emergency physicians. Scholarship can take many forms, but all require careful planning. In this article, we provide expert consensus recommendations for improving junior faculty’s scholarship in emergency medicine (EM). Specific focus is given to promoting your research career, obtaining additional training opportunities, networking in EM, and other strategies for strategically directing a long-term career in academic medicine.
Collapse
Affiliation(s)
| | | | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Shahram Lotfipour
- University of California Irvine Health School of Medicine, Department of Emergency, Irvine, California
| | - Linda S Murphy
- University of California Irvine, UCI Science Library Reference Department, Irvine, California
| | - Mark I Langdorf
- University of California Irvine Health School of Medicine, Department of Emergency, Irvine, California
| |
Collapse
|
44
|
Lam H, Katyal N, Parker C, Natteru P, Nattanamai P, Newey CR, Kraus CK. Thromboelastography With Platelet Mapping is Not an Effective Measure of Platelet Inhibition in Patients With Spontaneous Intracerebral Hemorrhage on Antiplatelet Therapy. Cureus 2018; 10:e2515. [PMID: 29942718 PMCID: PMC6015994 DOI: 10.7759/cureus.2515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thromboelastography with platelet mapping (TEG-PM) is a modality to measure platelet function, especially in patients taking antiplatelet medications. It consists of two components: arachidonic acid (AA), which is sensitive to aspirin, and adenosine diphosphate (ADP), which is sensitive to clopidogrel. In patients with spontaneous intracerebral hemorrhages (sICH), the clinical interpretation of platelet mapping is unclear. The objective of this study was to evaluate TEG-PM in patients with sICH on aspirin and/or clopidogrel who receive platelet transfusions. This study was an IRB-approved, retrospective case-control study over three years at an academic medical center. Adult patients with sICH were included if they had an admission computed tomography head (CTH) and platelet mapping followed by a repeat platelet mapping and CTH post platelet transfusion. A threshold of 50% inhibition was used as the benchmark for both ADP and AA inhibition. Around 248 subjects with sICH were identified, and 107 were excluded for incomplete documentation, leaving 141 for analysis. Of these, nine met our inclusion criteria. No statistical significance was found on the antithrombotic effects of aspirin or clopidogrel on TEG-PM (p=1.00 for both). Sensitivity and specificity of TEG-PM for clopidogrel was 100% and 42.9%, respectively, and 80% and 0%, respectively, for aspirin. Platelet transfusion did not significantly change AA or ADP inhibition (p=1.00). Hemorrhagic expansion on CTH was not associated with a decrease AA or ADP inhibition (p=1.00). TEG-PM is not an effective measure of platelet inhibition in sICH patients who were on antiplatelet medications and is not a reliable measurement following platelet transfusion.
Collapse
Affiliation(s)
- Helena Lam
- University of Missouri School of Medicine, Columbia, USA
| | - Nakul Katyal
- Department of Neurology, University of Missouri, Columbia, USA
| | | | - Prashant Natteru
- Department of Neurology, University of Mississippi Medical Center, Jackson, USA
| | | | | | - Chadd K Kraus
- Emergency Medicine, Geisinger Health System, Danville, USA
| |
Collapse
|
45
|
Applegren ND, Kraus CK. Lyme Disease: Emergency Department Considerations. J Emerg Med 2017; 52:815-824. [DOI: 10.1016/j.jemermed.2017.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 12/21/2016] [Accepted: 01/22/2017] [Indexed: 11/28/2022]
|
46
|
Kraus CK, Marco CA. Shared decision making in the ED: ethical considerations. Am J Emerg Med 2016; 34:1668-72. [DOI: 10.1016/j.ajem.2016.05.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022] Open
|
47
|
Kraus CK, Greenberg MR, Ray DE, Dy SM. Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors. J Pain Symptom Manage 2016; 51:898-906. [PMID: 26988848 DOI: 10.1016/j.jpainsymman.2015.12.334] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 11/25/2022]
Abstract
CONTEXT Emergency medicine (EM) residents perceive palliative care (PC) skills as important and want training, yet there is a general lack of formal PC training in EM residency programs. A clearer definition of the PC educational needs of EM trainees is a research priority. OBJECTIVES To assess PC competency education in EM residency programs. METHODS This was a mixed-mode survey of residency program directors, associate program directors, and assistant program directors at accredited EM residency programs, evaluating four educational domains: 1) importance of specific competencies for senior EM residents, 2) senior resident skills in PC competencies, 3) effectiveness of educational methods, and 4) barriers to training. RESULTS Response rate was 50% from more than 100 residency programs. Most respondents (64%) identified PC competencies as important for residents to learn, and 59% reported that they teach7 PC skills in their residency program. In Domains 1 and 2, crucial conversations, management of pain, and management of the imminently dying had the highest scores for importance and residents' skill. In Domain 3, bedside teaching, mentoring from hospice and palliative medicine faculty, and case-based simulation were the most effective educational methods. In Domain 4, lack of PC expertise among faculty and lack of interest by faculty and residents were the greatest barriers. There were differences between competency importance and senior resident skill level for management of the dying child, withdrawal/withholding of nonbeneficial interventions, and ethical/legal issues. CONCLUSION There are specific barriers and opportunities for PC competency training and gaps in resident skill level. Specifically, there are discrepancies in competency importance and residency skill in the management of the dying child, nonbeneficial interventions, and ethical and legal issues that could be a focus for educational interventions in PC competency training in EM residencies.
Collapse
Affiliation(s)
- Chadd K Kraus
- Department of Emergency Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
| | - Marna R Greenberg
- Department of Emergency Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Daniel E Ray
- Section of Palliative Medicine and Hospice, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Sydney Morss Dy
- Duffey Pain/Palliative Care Program, Johns Hopkins Kimmel Cancer Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
48
|
Kraus CK. Transformative Leadership: Emergency Physicians Lead AOA and AMA. West J Emerg Med 2016; 16:1086-7. [PMID: 26759660 PMCID: PMC4703191 DOI: 10.5811/westjem.2015.10.28816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/23/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chadd K Kraus
- University of Missouri-Columbia, Department of Emergency Medicine, Columbia, Missouri
| |
Collapse
|
49
|
Hsieh YH, Kelen GD, Beck KJ, Kraus CK, Shahan JB, Laeyendecker OB, Quinn TC, Rothman RE. Evaluation of hidden HIV infections in an urban ED with a rapid HIV screening program. Am J Emerg Med 2015; 34:180-4. [PMID: 26589466 DOI: 10.1016/j.ajem.2015.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND To investigate the prevalence of undiagnosed HIV infections in an emergency department (ED) with an established screening program. METHODS Evaluation of the prevalence and risk factors for HIV from an 8-week (June 24, 2007-August 18, 2007) identity-unlinked HIV serosurvey, conducted at the same time as an ongoing opt-in rapid oral-fluid HIV screening program. Testing facilitators offering 24/7 bedside rapid testing to patients aged 18 to 64 years, with concordant collection of excess sera collected as part of routine clinical procedures. Known HIV positivity was determined by (1) medical record review or self-report from the screening program and/or (2) presence of antiretrovirals in serum specimens. RESULTS Among 3207 patients, 1165 (36.3%) patients were offered an HIV test. Among those offered, 567 (48.7%) consented to testing. Concordance identity-unlinked study revealed that the prevalence of undiagnosed infections was as follows: 2.3% in all patients, 1.0% in those offered testing vs 3.0% in those not offered testing (P < .001); and 1.3% in those who declined testing compared with 0.4% in those who were tested (P = .077). Higher median viral loads were observed in those not offered testing (14255 copies/mL; interquartile range, 1147-64354) vs those offered testing (1865 copies/mL; interquartile range, undetectable-21786), but the difference was not statistically significant. CONCLUSIONS High undiagnosed HIV prevalence was observed in ED patients who were not offered HIV testing and those who declined testing, compared with those who were tested. This indicates that even with an intensive facilitator-based rapid HIV screening model, significant missed opportunities remain with regard to identifying undiagnosed infections in the ED.
Collapse
Affiliation(s)
- Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kaylin J Beck
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Judy B Shahan
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oliver B Laeyendecker
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Thomas C Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
50
|
Hsieh YH, Kelen GD, Laeyendecker O, Kraus CK, Quinn TC, Rothman RE. HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department. Ann Emerg Med 2015; 66:69-78. [PMID: 25720801 PMCID: PMC4478148 DOI: 10.1016/j.annemergmed.2015.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 12/16/2014] [Accepted: 12/31/2014] [Indexed: 01/11/2023]
Abstract
STUDY OBJECTIVE The recently released HIV Care Continuum Initiative is a cornerstone of the National AIDS Strategy and a model for improving care for those living with HIV. To our knowledge, there are no studies exploring the entirety of the HIV Care Continuum for patients in the emergency department (ED). We determine gaps in the HIV Care Continuum to identify potential opportunities for improved care for HIV-infected ED patients. METHODS A mixed-methods approach was used in 1 inner-city ED in 2007. Data elements were derived from an identity-unlinked HIV seroprevalence study, an ongoing nontargeted HIV screening program, and a structured survey of known HIV-positive ED patients. RESULTS Identity-unlinked testing of 3,417 unique ED patients found that 265 (7.8%) were HIV positive. Of patients testing HIV positive, 73% had received a previous diagnosis (based on self-report, chart review, or presence of antiretrovirals in serum), but only 61% were recognized by the clinician as being HIV infected (based on self-report or chart review). Of patients testing positive, 43% were linked to care, 39% were retained in care, 27% were receiving antiretrovirals, 26% were aware of their receiving antiretroviral treatment, 22% were virally suppressed, and only 9% were self-aware of their viral suppression. CONCLUSION To our knowledge, this study is the first to quantify gaps in HIV care for an ED patient population, with the HIV Care Continuum as a framework. Our findings identified distinct phases (ie, testing, provider awareness of HIV diagnosis, and linkage to care) in which the greatest opportunities for intervention exist, if appropriate resources were allocated. This schema could serve as a model for other indolent treatable diseases frequently observed in EDs, where continuity of care is critical.
Collapse
Affiliation(s)
- Yu-Hsiang Hsieh
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Gabor D Kelen
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oliver Laeyendecker
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | | | - Thomas C Quinn
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Richard E Rothman
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|