1
|
Westafer LM, Beck SA, Simon C, Potee B, Soares WE, Schoenfeld EM. Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People With Lived Experience. Ann Emerg Med 2024; 83:340-350. [PMID: 38180403 PMCID: PMC10960719 DOI: 10.1016/j.annemergmed.2023.11.020] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024]
Abstract
STUDY OBJECTIVE Although an increasing number of emergency departments (ED) offer opioid agonist treatment, naloxone, and other harm reduction measures, little is known about patient perspectives on harm reduction practices delivered in the ED. The objective of this study was to identify patient-focused barriers and facilitators to harm reduction strategies in the ED. METHODS We conducted semistructured interviews with a convenience sample of individuals in Massachusetts diagnosed with opioid use disorder. We developed an interview guide, and interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. After initial interviews and coding, we triangulated the results among a focus group of 4 individuals with lived experience. RESULTS We interviewed 25 participants with opioid use disorder, 6 recruited from 1 ED and 19 recruited from opioid agonist treatment clinics. Key themes included accessibility of harm reduction supplies, lack of self-care resulting from withdrawal and hopelessness, the impact of stigma on the likelihood of using harm reduction practices, habit and knowledge, as well as the need for user-centered harm reduction interventions. CONCLUSION In this study, people with lived experience discussed the characteristics and need for user-centered harm reduction strategies in the ED that centered on reducing stigma, treatment of withdrawal, and availability of harm reduction materials.
Collapse
Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | | | - Caty Simon
- National Survivors Union, Greensboro, NC; Whose Corner Is It Anyway, Holyoke, MA
| | | | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| |
Collapse
|
2
|
Barron RJ, Faynshtayn NG, Jessen E, Girardin AL, Kamine TH, Schoenfeld EM, Hardy EJ, Baird J, Siero AA, McGregor AJ. Characteristics of acute sexual assault care in New England emergency departments. J Am Coll Emerg Physicians Open 2023; 4:e12955. [PMID: 37193060 PMCID: PMC10182368 DOI: 10.1002/emp2.12955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 05/18/2023] Open
Abstract
Objective Interventions such as written protocols and sexual assault nurse examiner programs improve outcomes for patients who have experienced acute sexual assault. How widely and in what ways such interventions have been implemented is largely unknown. We sought to characterize the current state of acute sexual assault care in New England. Methods We conducted a cross-sectional survey of individuals acute with knowledge of emergency department (ED) operations in relation to sexual assault care at New England adult EDs. Our primary outcomes included the availability and coverage of dedicated and non-dedicated sexual assault forensic examiners in EDs. Secondary outcomes included frequency of and reasons for patient transfer; treatment before transfer; availability of written sexual assault protocols; characteristics and scope of practice of dedicated and non-dedicated sexual assault forensic examiners (SAFEs), provision of care in SAFEs' absence; availability, coverage, and characteristics of victim advocacy and follow-up resources; and barriers to and facilitators of care. Results We approached all 186 distinct adult EDs in New England to recruit participants; 92 (49.5%) individuals participated, most commonly physician medical directors (n = 34, 44.1%). Two thirds of participants reported they at times have access to a dedicated (n = 52, 65%, 95% confidence interval [CI], 54.5%-75.5%) or non-dedicated (n = 50, 64.1%; 95% CI, 53.5%-74.7%) SAFE, but fewer reported always having this access (n = 9, 17.3%; 95% CI, 7%-27.6%; n = 13, 26%; 95% CI, 13.8%-38.2%). We describe in detail findings related to our secondary outcomes. Conclusions Although SAFEs are recognized as a strategy to provide high-quality acute sexual assault care, their availability and coverage is limited.
Collapse
Affiliation(s)
- Rebecca J. Barron
- Department of Emergency MedicineUMass Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | | | - Erica Jessen
- Baystate Medical CenterSpringfieldMassachusettsUSA
| | - Abigail L. Girardin
- Department of Emergency MedicineUMass Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Tovy Haber Kamine
- Department of SurgeryUMass Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Health Care Delivery and Population ScienceUMass Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Elizabeth M. Schoenfeld
- Department of Emergency MedicineUMass Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Health Care Delivery and Population ScienceUMass Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Erica J. Hardy
- Departments of Medicine and Obstetrics and GynecologyAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Janette Baird
- Department of Emergency MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Alan A. Siero
- University of California at RiversideRiversideCaliforniaUSA
| | - Alyson J. McGregor
- Department of Emergency MedicineUniversity of South Carolina School of Medicine GreenvilleGreenvilleSouth CarolinaUSA
| |
Collapse
|
3
|
Schoenfeld EM, Westafer LM, Beck SA, Potee BG, Vysetty S, Simon C, Tozloski JM, Girardin AL, Soares WE. "Just give them a choice": Patients' perspectives on starting medications for opioid use disorder in the ED. Acad Emerg Med 2022; 29:928-943. [PMID: 35426962 PMCID: PMC9378535 DOI: 10.1111/acem.14507] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Medications for opioid use disorder (MOUD) prescribed in the emergency department (ED) have the potential to save lives and help people start and maintain recovery. We sought to explore patient perspectives regarding the initiation of buprenorphine and methadone in the ED with the goal of improving interactions and fostering shared decision making (SDM) around these important treatment options. METHODS We conducted semistructured interviews with a purposeful sample of people with opioid use disorder (OUD) regarding ED visits and their experiences with MOUD. The interview guide was based on the Ottawa Decision Support Framework, a framework for examining decisional needs and tailoring decisional support, and the research team's experience with MOUD and SDM. Interviews were recorded, transcribed, and analyzed in an iterative process using both the Ottawa Framework and a social-ecological framework. Themes were identified and organized and implications for clinical care were noted and discussed. RESULTS Twenty-six participants were interviewed, seven in person in the ED and 19 via video conferencing software. The majority had tried both buprenorphine and methadone, and almost all had been in an ED for an issue related to opioid use. Participants reported social, pharmacological, and emotional factors that played into their decision making. Regarding buprenorphine, they noted advantages such as its efficacy and logistical ease and disadvantages such as the need to wait to start it (risk of precipitated withdrawal) and that one could not use other opioids while taking it. Additionally, participants felt that: (1) both buprenorphine and methadone should be offered; (2) because "one person's pro is another person's con," clinicians will need to understand the facets of the options; (3) clinicians will need to have these conversations without appearing judgmental; and (4) many patients may not be "ready" for MOUD, but it should still be offered. CONCLUSIONS Although participants were supportive of offering buprenorphine in the ED, many felt that methadone should also be offered. They felt that treatment should be tailored to an individual's needs and circumstances and clarified what factors might be important considerations for people with OUD.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
- Department for Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - Lauren M. Westafer
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
- Department for Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | | | | | - Sravanthi Vysetty
- Lincoln Memorial University DeBusk College of Osteopathic Medicine Harrogate Tennessee USA
| | - Caty Simon
- Urban Survivors Union Greensboro North Carolina USA
- Whose Corner Is It Anyway Holyoke Massachusetts USA
| | - Jillian M. Tozloski
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - Abigail L. Girardin
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - William E. Soares
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
- Department for Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| |
Collapse
|
4
|
Schoenfeld EM, Lin MP, Samuels‐Kalow ME. Executive summary of the 2021 SAEM consensus conference: From bedside to policy: Advancing social emergency medicine and population health through research, collaboration, and education. Acad Emerg Med 2022; 29:354-363. [PMID: 35064982 DOI: 10.1111/acem.14451] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Social emergency medicine (social EM) examines the intersection of emergency care and the social factors that influence health outcomes. In 2021, the SAEM consensus conference focused on social EM and population health, with the goal of prioritizing research topics, creating collaborations, and advancing the field of social EM. METHODS Organization of the conference began in 2019 within SAEM. Cochairs were identified and a planning committee created the framework for the conference. Leaders for subgroups were identified, and subgroups performed literature reviews and identified additional stakeholders within EM and community organizations. As a result of the COVID-19 pandemic, the conference format was modified. RESULTS A total of 246 participants registered for the conference and participated in some capacity at three distinct online sessions. Research prioritization subgroups were as follows-group 1: ED screening and referral for social and access needs; group 2: structural competency; and group 3: race, racism, and antiracism. Thirty-two "projects in progress" were presented within five domains-identity and health: people and places; health care systems; training and education; material needs; and individual and structural violence. CONCLUSIONS Despite ongoing challenges posed by the COVID-19 pandemic, the 2021 SAEM consensus conference brought together hundreds of stakeholders to define research priorities and create collaborations to push the field forward.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine & Department of Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - Michelle P. Lin
- Department of Emergency Medicine, Department of Population Health Science & Policy, Institute for Health Equity Research Icahn School of Medicine at Mount Sinai New York New York USA
| | - Margaret E. Samuels‐Kalow
- Department of Emergency Medicine, Harvard Medical School Massachusetts General Hospital Boston Massachusetts USA
| |
Collapse
|
5
|
Billah T, Gordon L, Schoenfeld EM, Chang BP, Hess EP, Probst MA. Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study. J Am Coll Emerg Physicians Open 2022; 3:e12629. [PMID: 35079731 PMCID: PMC8769071 DOI: 10.1002/emp2.12629] [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: 08/26/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Decision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED). METHODS We conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low-risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis. RESULTS We approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow-up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs. CONCLUSIONS ECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.
Collapse
Affiliation(s)
- Tausif Billah
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Lauren Gordon
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Elizabeth M. Schoenfeld
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Bernard P. Chang
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
| | - Erik P. Hess
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Marc A. Probst
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
| |
Collapse
|
6
|
Schoenfeld EM, Soares W, Schaeffer EM, Gitlin J, Burke K, Westafer L. "This is part of emergency medicine now": A qualitative assessment of emergency clinicians' facilitators of and barriers to initiating buprenorphine. Acad Emerg Med 2022; 29:28-40. [PMID: 34374466 PMCID: PMC8842516 DOI: 10.1111/acem.14369] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Despite evidence demonstrating the safety and efficacy of buprenorphine for the treatment of emergency department (ED) patients with opioid use disorder (OUD), incorporation into clinical practice has been highly variable. We explored barriers and facilitators to the prescription of buprenorphine, as perceived by practicing ED clinicians. METHODS We conducted semistructured interviews with a purposeful sample of ED clinicians. An interview guide was developed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework implementation science frameworks. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. RESULTS We interviewed 25 ED clinicians from 11 states in the United States. Participants were diverse with regard to years in practice and practice setting. While outer setting barriers such as the logistic costs of getting a DEA-X waiver and lack of clear follow-up for patients were noted by many participants, individual-level determinants driven by emotion (stigma), beliefs about consequences and roles, and knowledge predominated. Participants' responses suggested that implementation strategies should address stigma, local culture, knowledge gaps, and logistic challenges, but that a particular order to addressing barriers may be necessary. CONCLUSIONS While some participants were hesitant to adopt a "new" role in treating patients with medications for OUD, many already had and gave concrete strategies regarding how to encourage others to embrace their attitude of "this is part of emergency medicine now."
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA
| | - William Soares
- Department of Emergency Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA
| | - Emily M. Schaeffer
- Department of Emergency Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
| | - Jacob Gitlin
- University of Massachusetts Medical School, Worcester, MA
| | - Kimberly Burke
- University of Massachusetts Medical School, Worcester, MA
| | - Lauren Westafer
- Department of Emergency Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA
| |
Collapse
|
7
|
Shah R, Della Porta A, Leung S, Samuels-Kalow M, Schoenfeld EM, Richardson LD, Lin MP. A Scoping Review of Current Social Emergency Medicine Research. West J Emerg Med 2021; 22:1360-1368. [PMID: 34787563 PMCID: PMC8597693 DOI: 10.5811/westjem.2021.4.51518] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Social emergency medicine (EM) is an emerging field that examines the intersection of emergency care and social factors that influence health outcomes. We conducted a scoping review to explore the breadth and content of existing research pertaining to social EM to identify potential areas where future social EM research efforts should be directed. Methods We conducted a comprehensive PubMed search using Medical Subject Heading terms and phrases pertaining to social EM topic areas (e.g., “homelessness,” “housing instability”) based on previously published expert consensus. For searches that yielded fewer than 100 total publications, we used the PubMed “similar publications” tool to expand the search and ensure no relevant publications were missed. Studies were independently abstracted by two investigators and classified as relevant if they were conducted in US or Canadian emergency departments (ED). We classified relevant publications by study design type (observational or interventional research, systematic review, or commentary), publication site, and year. Discrepancies in relevant publications or classification were reviewed by a third investigator. Results Our search strategy yielded 1,571 publications, of which 590 (38%) were relevant to social EM; among relevant publications, 58 (10%) were interventional studies, 410 (69%) were observational studies, 26 (4%) were systematic reviews, and 96 (16%) were commentaries. The majority (68%) of studies were published between 2010–2020. Firearm research and lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research in particular grew rapidly over the last five years. The human trafficking topic area had the highest percentage (21%) of interventional studies. A significant portion of publications -- as high as 42% in the firearm violence topic area – included observational data or interventions related to children or the pediatric ED. Areas with more search results often included many publications describing disparities known to predispose ED patients to adverse outcomes (e.g., socioeconomic or racial disparities), or the influence of social determinants on ED utilization. Conclusion Social emergency medicine research has been growing over the past 10 years, although areas such as firearm violence and LGBTQ health have had more research activity than other topics. The field would benefit from a consensus-driven research agenda.
Collapse
Affiliation(s)
- Ruhee Shah
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Sherman Leung
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Margaret Samuels-Kalow
- Massachusetts General Hospital/Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Elizabeth M Schoenfeld
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Lynne D Richardson
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, New York.,Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, New York, New York.,Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, New York, New York
| | - Michelle P Lin
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, New York.,Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, New York, New York.,Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, New York, New York
| |
Collapse
|
8
|
Chartash D, Sharifi M, Emerson B, Frank R, Schoenfeld EM, Tanner J, Brandt C, Taylor RA. Documentation of Shared Decisionmaking in the Emergency Department. Ann Emerg Med 2021; 78:637-649. [PMID: 34340873 DOI: 10.1016/j.annemergmed.2021.04.038] [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: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE While patient-centered communication and shared decisionmaking are increasingly recognized as vital aspects of clinical practice, little is known about their characteristics in real-world emergency department (ED) settings. We constructed a natural language processing tool to identify patient-centered communication as documented in ED notes and to describe visit-level, site-level, and temporal patterns within a large health system. METHODS This was a 2-part study involving (1) the development and validation of an natural language processing tool using regular expressions to identify shared decisionmaking and (2) a retrospective analysis using mixed effects logistic regression and trend analysis of shared decisionmaking and general patient discussion using the natural language processing tool to assess ED physician and advanced practice provider notes from 2013 to 2020. RESULTS Compared to chart review of 600 ED notes, the accuracy rates of the natural language processing tool for identification of shared decisionmaking and general patient discussion were 96.7% (95% CI 94.9% to 97.9%) and 88.9% (95% confidence interval [CI] 86.1% to 91.3%), respectively. The natural language processing tool identified shared decisionmaking in 58,246 (2.2%) and general patient discussion in 590,933 (22%) notes. From 2013 to 2020, natural language processing-detected shared decisionmaking increased 300% and general patient discussion increased 50%. We observed higher odds of shared decisionmaking documentation among physicians versus advanced practice providers (odds ratio [OR] 1.14, 95% CI 1.07 to 1.23) and among female versus male patients (OR 1.13, 95% CI 1.11 to 1.15). Black patients had lower odds of shared decisionmaking (OR 0.8, 95% CI 0.84 to 0.88) compared with White patients. Shared decisionmaking and general patient discussion were also associated with higher levels of triage and commercial insurance status. CONCLUSION In this study, we developed and validated an natural language processing tool using regular expressions to extract shared decisionmaking from ED notes and found multiple potential factors contributing to variation, including social, demographic, temporal, and presentation characteristics.
Collapse
Affiliation(s)
- David Chartash
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT
| | - Mona Sharifi
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT; Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Beth Emerson
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Robert Frank
- Department of Linguistics, Yale University, New Haven, CT
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate Institute for Healthcare Delivery and Population Science, Springfield, MS
| | - Jason Tanner
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Cynthia Brandt
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Richard A Taylor
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
| |
Collapse
|
9
|
Daniel NJ, Patel SB, St Marie P, Schoenfeld EM. Rethinking hiker preparedness: Association of carrying "10 essentials" with adverse events and satisfaction among day-hikers. Am J Emerg Med 2021; 49:253-256. [PMID: 34167048 DOI: 10.1016/j.ajem.2021.06.017] [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: 02/13/2021] [Revised: 05/21/2021] [Accepted: 06/05/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Many trusted organizations recommend a particular set of gear for hikers. Termed the "10 essentials," the importance of these items to wilderness preparedness has not been critically evaluated. We sought to better understand the value of these items in day hiker preparedness by assessing the association between carried items, the occurrence of adverse events, and satisfaction. METHODS A cross-sectional survey study was conducted at Mount Monadnock (NH) over 4 non-consecutive days. Adults finishing a day hike were invited to participate. The survey assessed items carried, adverse events, satisfaction, and whether hikers felt prepared for the adverse events that occurred. The primary outcome was the occurrence of an adverse event. RESULTS A total sample of 961 hikers reported 1686 adverse events. Hikers felt prepared for 89% of the events experienced. The most common adverse events reported were thirst (62%), hunger (50%), feeling cold (18%), and needing rain gear (11%). Medical events such as sprains and lacerations made up 18% of all adverse events. Carrying more items was associated with an increased likelihood of reporting an adverse event and a decreased likelihood of adverse events that the hiker was not prepared for, without a change in satisfaction rates. CONCLUSIONS Carrying more items did not translate into improved satisfaction for day hikers, but was associated with fewer events for which the hiker was unprepared. Other than adverse events related to hunger, thirst, weather, and minor medical events, adverse events were unlikely during this day hike. Nutrition, hydration, and insulation were the items reported as most often needed, followed by a kit to treat minor medical events, while the remaining 6 items were infrequently used.
Collapse
Affiliation(s)
- Nicholas J Daniel
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
| | - Samir B Patel
- Department of Emergency Medicine, Wake Forest Baptist Health, Winston-Salem, NC, United States of America
| | - Peter St Marie
- Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America
| | - Elizabeth M Schoenfeld
- Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America
| |
Collapse
|
10
|
Walter LA, Schoenfeld EM, Smith CH, Shufflebarger E, Khoury C, Baldwin K, Hess J, Heimann M, Crosby C, Sontheimer SY, Gragg S, Hand D, McIlwain J, Greene C, Skains RM, Hess EP. Emergency department-based interventions affecting social determinants of health in the United States: A scoping review. Acad Emerg Med 2021; 28:666-674. [PMID: 33368833 PMCID: PMC11019818 DOI: 10.1111/acem.14201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Social determinants of health (SDoH) have significant implications for health outcomes in the United States. Emergency departments (EDs) function as the safety nets of the American health care system, caring for many vulnerable populations. ED-based interventions to assess social risk and mitigate social needs have been reported in the literature. However, the breadth and scope of these interventions have not been evaluated. As the field of social emergency medicine (SEM) expands, a mapping and categorization of previous interventions may help shape future research. We sought to identify, summarize, and characterize ED-based interventions aimed at mitigating negative SDoH. METHODS We conducted a scoping review to identify and characterize peer-reviewed research articles that report ED-based interventions to address or impact SDoH in the United States. We designed and conducted a search in Medline, CINAHL, and Cochrane CENTRAL databases. Abstracts and, subsequently, full articles were reviewed independently by two reviewers to identify potentially relevant articles. Included articles were categorized by type of intervention and primary SDoH domain. Reported outcomes were also categorized by type and efficacy. RESULTS A total of 10,856 abstracts were identified and reviewed, and 596 potentially relevant studies were identified. Full article review identified 135 articles for inclusion. These articles were further subdivided into three intervention types: a) provider educational intervention (18%), b) disease modification with SDoH focus (26%), and c) direct SDoH intervention (60%), with 4% including two "types." Articles were subsequently further grouped into seven SDoH domains: 1) access to care (33%), 2) discrimination/group disparities (7%), 3) exposure to violence/crime (34%), 4) food insecurity (2%), 5) housing issues/homelessness (3%), 6) language/literacy/health literacy (12%), 7) socioeconomic disparities/poverty (10%). The majority of articles reported that the intervention studied was effective for the primary outcome identified (78%). CONCLUSION Emergency department-based interventions that address seven different SDoH domains have been reported in the peer-reviewed literature over the past 30 years, utilizing a variety of approaches including provider education and direct and indirect focus on social risk and need. Characterization and understanding of previous interventions may help identify opportunities for future interventions as well as guide a SEM research agenda.
Collapse
Affiliation(s)
- Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate Medical Cente, Springfield, Massachusetts, USA
| | - Catherine H Smith
- Lister Hill Library, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erin Shufflebarger
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Khoury
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katherine Baldwin
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Jennifer Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew Heimann
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cameron Crosby
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sylvia Y Sontheimer
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Stephen Gragg
- ChristianaCare EM/IM Residency Program, Newark, Delaware, USA
| | - Delissa Hand
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph McIlwain
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Christopher Greene
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
11
|
Schoenfeld EM, Poronsky KE, Westafer LM, DiFronzo BM, Visintainer P, Scales CD, Hess EP, Lindenauer PK. Feasibility and efficacy of a decision aid for emergency department patients with suspected ureterolithiasis: protocol for an adaptive randomized controlled trial. Trials 2021; 22:201. [PMID: 33691760 PMCID: PMC7944622 DOI: 10.1186/s13063-021-05140-9] [Citation(s) in RCA: 2] [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] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 12/23/2022] Open
Abstract
Background Approximately 2 million patients present to emergency departments in the USA annually with signs and symptoms of ureterolithiasis (or renal colic, the pain from an obstructing kidney stone). Both ultrasound and CT scan can be used for diagnosis, but the vast majority of patients receive a CT scan. Diagnostic pathways utilizing ultrasound have been shown to decrease radiation exposure to patients but are potentially less accurate. Because of these and other trade-offs, this decision has been proposed as appropriate for Shared Decision-Making (SDM), where clinicians and patients discuss clinical options and their consequences and arrive at a decision together. We developed a decision aid to facilitate SDM in this scenario. The objective of this study is to determine the effects of this decision aid, as compared to usual care, on patient knowledge, radiation exposure, engagement, safety, and healthcare utilization. Methods This is the protocol for an adaptive randomized controlled trial to determine the effects of the intervention—a decision aid (“Kidney Stone Choice”)—on patient-centered outcomes, compared with usual care. Patients age 18–55 presenting to the emergency department with signs and symptoms consistent with acute uncomplicated ureterolithiasis will be consecutively enrolled and randomized. Participants will be blinded to group allocation. We will collect outcomes related to patient knowledge, radiation exposure, trust in physician, safety, and downstream healthcare utilization. Discussion We hypothesize that this study will demonstrate that “Kidney Stone Choice,” the decision aid created for this scenario, improves patient knowledge and decreases exposure to ionizing radiation. The adaptive design of this study will allow us to identify issues with fidelity and feasibility and subsequently evaluate the intervention for efficacy. Trial registration ClinicalTrials.gov NCT04234035. Registered on 21 January 2020 – Retrospectively Registered Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05140-9.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
| | - Kye E Poronsky
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Lauren M Westafer
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Brianna M DiFronzo
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Paul Visintainer
- Department of Medicine, and Institute for Healthcare Delivery and Population Science Epidemiology and Biostatistics Research Core, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Charles D Scales
- Duke Clinical Research Institute and Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, TN, Memphis, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
12
|
Westafer LM, Soares WE, Salvador D, Medarametla V, Schoenfeld EM. No evidence of increasing COVID-19 in health care workers after implementation of high flow nasal cannula: A safety evaluation. Am J Emerg Med 2021. [PMID: 33059983 DOI: 10.1016/j.ajem.2020.09.086,pubmed:33059983] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Initial recommendations discouraged high flow nasal cannula (HFNC) in COVID-19 patients, driven by concern for healthcare worker (HCW) exposure. Noting high morbidity and mortality from early invasive mechanical ventilation, we implemented a COVID-19 respiratory protocol employing HFNC in severe COVID-19 and HCW exposed to COVID-19 patients on HFNC wore N95/KN95 masks. Utilization of HFNC increased significantly but questions remained regarding HCW infection rate. METHODS We performed a retrospective evaluation of employee infections in our healthcare system using the Employee Health Services database and unit records of employees tested between March 15, 2020 and May 23, 2020. We assessed the incidence of infections before and after the implementation of the protocol, stratifying by clinical or non-clinical role as well as inpatient COVID-19 unit. RESULTS During the study period, 13.9% (228/1635) of employees tested for COVID-19 were positive. Forty-six percent of infections were in non-clinical staff. After implementation of the respiratory protocol, the proportion of positive tests in clinical staff (41.5%) was not higher than that in non-clinical staff (43.8%). Of the clinicians working in the high-risk COVID-19 unit, there was no increase in infections after protocol implementation compared with clinicians working in COVID-19 units that did not use HFNC. CONCLUSION We found no evidence of increased COVID-19 infections in HCW after the implementation of a respiratory protocol that increased use of HFNC in patients with COVID-19; however, these results are hypothesis generating.
Collapse
Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Doug Salvador
- University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Venkatrao Medarametla
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| |
Collapse
|
13
|
Soares WE, Schoenfeld EM, Visintainer P, Elia T, Medarametla V, Schoenfeld DA, Deutsch A, Salvador D, Dietzen D, Tidswell MA, DePergola PA, Marie PS, Westafer LM. Safety Assessment of a Noninvasive Respiratory Protocol for Adults With COVID-19. J Hosp Med 2020; 15:734-738. [PMID: 33231547 PMCID: PMC8034674 DOI: 10.12788/jhm.3548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/13/2020] [Indexed: 12/21/2022]
Abstract
As evidence emerged supporting noninvasive strategies for coronavirus disease 2019 (COVID-19)-related respiratory distress, we implemented a noninvasive COVID-19 respiratory protocol (NCRP) that encouraged high-flow nasal cannula (HFNC) and self-proning across our healthcare system. To assess safety, we conducted a retrospective chart review evaluating mortality and other patient safety outcomes after implementation of the NCRP protocol (April 3, 2020, to April 15, 2020) for adult patients hospitalized with COVID-19, compared with preimplementation outcomes (March 15, 2020, to April 2, 2020). During the study, there were 469 COVID-19 admissions. Fewer patients underwent intubation after implementation (10.7% [23 of 215]), compared with before implementation (25.2% [64 of 254]) (P < .01). Overall, 26.2% of patients died (24% before implementation vs 28.8% after implementation; P = .14). In patients without a do not resuscitate/do not intubate order prior to admission, mortality was 21.8% before implementation vs 21.9% after implementation. Overall, we found no significant increase in mortality following implementation of a noninvasive respiratory protocol that decreased intubations in patients with COVID-19.
Collapse
Affiliation(s)
- William E Soares
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
- Corresponding Author: William E Soares III, MD, MS; ; Telephone: 413-794-6244; Twitter: @BillSoaresIII
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Paul Visintainer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Tala Elia
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
| | | | - David A Schoenfeld
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashley Deutsch
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Doug Salvador
- Department of Healthcare Quality, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Diane Dietzen
- Department of Healthcare Quality, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Mark A Tidswell
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Peter A DePergola
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Peter St. Marie
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Lauren M Westafer
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| |
Collapse
|
14
|
Westafer LM, Soares WE, Salvador D, Medarametla V, Schoenfeld EM. No evidence of increasing COVID-19 in health care workers after implementation of high flow nasal cannula: A safety evaluation. Am J Emerg Med 2020; 39:158-161. [PMID: 33059983 PMCID: PMC7539832 DOI: 10.1016/j.ajem.2020.09.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 11/17/2022] Open
Abstract
Background Initial recommendations discouraged high flow nasal cannula (HFNC) in COVID-19 patients, driven by concern for healthcare worker (HCW) exposure. Noting high morbidity and mortality from early invasive mechanical ventilation, we implemented a COVID-19 respiratory protocol employing HFNC in severe COVID-19 and HCW exposed to COVID-19 patients on HFNC wore N95/KN95 masks. Utilization of HFNC increased significantly but questions remained regarding HCW infection rate. Methods We performed a retrospective evaluation of employee infections in our healthcare system using the Employee Health Services database and unit records of employees tested between March 15, 2020 and May 23, 2020. We assessed the incidence of infections before and after the implementation of the protocol, stratifying by clinical or non-clinical role as well as inpatient COVID-19 unit. Results During the study period, 13.9% (228/1635) of employees tested for COVID-19 were positive. Forty-six percent of infections were in non-clinical staff. After implementation of the respiratory protocol, the proportion of positive tests in clinical staff (41.5%) was not higher than that in non-clinical staff (43.8%). Of the clinicians working in the high-risk COVID-19 unit, there was no increase in infections after protocol implementation compared with clinicians working in COVID-19 units that did not use HFNC. Conclusion We found no evidence of increased COVID-19 infections in HCW after the implementation of a respiratory protocol that increased use of HFNC in patients with COVID-19; however, these results are hypothesis generating.
Collapse
Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Doug Salvador
- University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Venkatrao Medarametla
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| |
Collapse
|
15
|
Samuels‐Kalow ME, Ciccolo GE, Lin MP, Schoenfeld EM, Camargo CA. The terminology of social emergency medicine: Measuring social determinants of health, social risk, and social need. J Am Coll Emerg Physicians Open 2020; 1:852-856. [PMID: 33145531 PMCID: PMC7593464 DOI: 10.1002/emp2.12191] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 05/15/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023] Open
Abstract
Emergency medicine has increasingly focused on addressing social determinants of health (SDoH) in emergency medicine. However, efforts to standardize and evaluate measurement tools and compare results across studies have been limited by the plethora of terms (eg, SDoH, health-related social needs, social risk) and a lack of consensus regarding definitions. Specifically, the social risks of an individual may not align with the social needs of an individual, and this has ramifications for policy, research, risk stratification, and payment and for the measurement of health care quality. With the rise of social emergency medicine (SEM) as a field, there is a need for a simplified and consistent set of definitions. These definitions are important for clinicians screening in the emergency department, for health systems to understand service needs, for epidemiological tracking, and for research data sharing and harmonization. In this article, we propose a conceptual model for considering SDoH measurement and provide clear, actionable, definitions of key terms to increase consistency among clinicians, researchers, and policy makers.
Collapse
Affiliation(s)
- Margaret E. Samuels‐Kalow
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolMassachusettsUSA
| | - Gia E. Ciccolo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolMassachusettsUSA
| | - Michelle P. Lin
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population ScienceUniversity of Massachusetts Medical School – BaystateSpringfieldMassachusettsUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolMassachusettsUSA
| |
Collapse
|
16
|
Schoenfeld EM, Houghton C, Patel PM, Merwin LW, Poronsky KP, Caroll AL, Sánchez Santana C, Breslin M, Scales CD, Lindenauer PK, Mazor KM, Hess EP. Shared Decision Making in Patients With Suspected Uncomplicated Ureterolithiasis: A Decision Aid Development Study. Acad Emerg Med 2020; 27:554-565. [PMID: 32064724 DOI: 10.1111/acem.13917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients presenting to the emergency department (ED) with suspected uncomplicated ureterolithiasis. METHODS We used evidence-based DA development methods, including qualitative methods and iterative stakeholder engagement, to develop and refine a DA. Guided by the Ottawa Decision Support Framework, International Patient Decision Aid Standards (IPDAS), and a steering committee made up of stakeholders, we conducted interviews and focus groups with a purposive sample of patients, community members, emergency clinicians, and other stakeholders. We used an iterative process to code the transcripts and identify themes. We beta-tested the DA with patient-clinician dyads facing the decision in real time. RESULTS From August 2018 to August 2019, we engaged 102 participants in the design and iterative refinement of a DA focused on diagnostic options for patients with suspected ureterolithiasis. Forty-six were ED patients, community members, or patients with ureterolithiasis, and the remaining were emergency clinicians (doctors, residents, advanced practitioners), researchers, urologists, nurses, or other physicians. Patients and clinicians identified several key decisional needs including an understanding of accuracy, uncertainty, radiation exposure/cancer risk, and clear return precautions. Patients and community members identified facilitators to SDM, such as a checklist of signs and symptoms. Many stakeholders, including both patients and ED clinicians, expressed a strong pro-CT bias. A six-page DA was developed, iteratively refined, and beta-tested. CONCLUSIONS Using stakeholder engagement and qualitative inquiry, we developed an evidence-based DA to facilitate SDM around the question of CT scan utilization in patients with suspected uncomplicated ureterolithiasis. Future research will test the efficacy of the DA in facilitating SDM.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Connor Houghton
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Pooja M. Patel
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Leanora W. Merwin
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Kye P. Poronsky
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | | | | | - Maggie Breslin
- Design for Social Innovation Program School of Visual Arts (SVA) New York NY
| | - Charles D. Scales
- Duke Clinical Research Institute and Division of Urologic Surgery Duke University School of Medicine Durham NC
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Kathleen M. Mazor
- Department of Medicine University of Massachusetts Medical Schooland the Meyers Primary Care Institute Worcester MA
| | - Erik P. Hess
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham AL
| |
Collapse
|
17
|
Westafer LM, Kunz A, Bugajska P, Hughes A, Mazor KM, Schoenfeld EM, Stefan MS, Lindenauer PK. Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study. Acad Emerg Med 2020; 27:447-456. [PMID: 32220127 PMCID: PMC7418048 DOI: 10.1111/acem.13908] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 09/10/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE. METHODS We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. RESULTS We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. CONCLUSIONS This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.
Collapse
Affiliation(s)
- Lauren M Westafer
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Ashley Kunz
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | | | - Amber Hughes
- University of Massachusetts Amherst, Amherst, MA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA
- and the, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Elizabeth M Schoenfeld
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Mihaela S Stefan
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
- and the, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Peter K Lindenauer
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
- and the, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| |
Collapse
|
18
|
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate Medical Center, Springfield
| | - Lauren M Westafer
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate Medical Center, Springfield
| | - William E Soares
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate Medical Center, Springfield
| |
Collapse
|
19
|
Daniel NJ, Patel SB, St. Marie P, Schoenfeld EM. Assessment of “10 essential” preparedness among day-hikers on Mount Monadnock. Am J Emerg Med 2020; 38:401-403. [DOI: 10.1016/j.ajem.2019.158382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 10/26/2022] Open
|
20
|
Schoenfeld EM, Shieh MS, Pekow PS, Scales CD, Munger JM, Lindenauer PK. Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic. JAMA Netw Open 2019; 2:e1916454. [PMID: 31790565 PMCID: PMC6902745 DOI: 10.1001/jamanetworkopen.2019.16454] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients' likelihood of a subsequent urologic intervention could inform decision-making in this population. OBJECTIVES To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. MAIN OUTCOMES AND MEASURES The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. RESULTS A total of 66 218 unique index visits by 55 314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60 367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P < .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P < .001) compared with patients with all other insurance types. CONCLUSIONS AND RELEVANCE In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School–Baystate, Springfield
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
| | - Meng-Shiou Shieh
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
| | - Penelope S. Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
- School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Charles D. Scales
- Duke Clinical Research Institute, Division of Urologic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - James M. Munger
- Department of Emergency Medicine, University of Massachusetts Medical School–Baystate, Springfield
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
- Department of Medicine, University of Massachusetts Medical School–Baystate, Springfield
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| |
Collapse
|
21
|
Schoenfeld EM, Probst MA, Quigley DD, St Marie P, Nayyar N, Sabbagh SH, Beckford T, Kanzaria HK. Does Shared Decision Making Actually Occur in the Emergency Department? Looking at It from the Patients' Perspective. Acad Emerg Med 2019; 26:1369-1378. [PMID: 31465130 PMCID: PMC8099042 DOI: 10.1111/acem.13850] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We sought to assess the frequency, content, and quality of shared decision making (SDM) in the emergency department (ED), from patients' perspectives. METHODS Utilizing a cross-sectional, multisite approach, we administered an instrument, consisting of two validated SDM assessment tools-the CollaboRATE and the SDM-Q-9-and one newly developed tool to a sample of ED patients. Our primary outcome was the occurrence of SDM in the clinical encounter, as defined by participants giving "top-box" scores on the CollaboRATE measure, and the ability of patients to identify the topic of their SDM conversation. Secondary outcomes included the content of the SDM conversations, as judged by patients, and whether patients were able to complete each of the two validated scales included in the instrument. RESULTS After exclusions, 285 participants from two sites completed the composite instrument. Just under half identified as female (47%) or as white (47%). Roughly half gave top-box scores (i.e., indicating optimal SDM) on the CollaboRATE scale (49%). Less than half of the participants were able to indicate a decision they were involved in (44%), although those who did gave high scores for such conversations (73/100 via the SDM-Q-9 tool). The most frequently identified decisions discussed were admission versus discharge (19%), medication options (17%), and options for follow-up care (15%). CONCLUSIONS Fewer than half of ED patients surveyed reported they were involved in SDM. The most common decision for which SDM was used was around ED disposition (admission vs. discharge). When SDM was employed, patients generally rated the discussion highly.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Peter St Marie
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Nikita Nayyar
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Sarah H Sabbagh
- Department of Emergency Medicine, University of California at San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California at San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| |
Collapse
|
22
|
Schoenfeld EM, Mader S, Houghton C, Wenger R, Probst MA, Schoenfeld DA, Lindenauer PK, Mazor KM. The Effect of Shared Decisionmaking on Patients' Likelihood of Filing a Complaint or Lawsuit: A Simulation Study. Ann Emerg Med 2019; 74:126-136. [PMID: 30611638 PMCID: PMC6599569 DOI: 10.1016/j.annemergmed.2018.11.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 07/17/2018] [Revised: 11/06/2018] [Accepted: 11/12/2018] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Shared decisionmaking has been promoted as a method to increase the patient-centeredness of medical decisionmaking and decrease low-yield testing, but little is known about its medicolegal ramifications in the setting of an adverse outcome. We seek to determine whether the use of shared decisionmaking changes perceptions of fault and liability in the case of an adverse outcome. METHODS This was a randomized controlled simulation experiment conducted by survey, using clinical vignettes featuring no shared decisionmaking, brief shared decisionmaking, or thorough shared decisionmaking. Participants were adult US citizens recruited through an online crowd-sourcing platform. Participants were randomized to vignettes portraying 1 of 3 levels of shared decisionmaking. All other information given was identical, including the final clinical decision and the adverse outcome. The primary outcome was reported likelihood of pursuing legal action. Secondary outcomes included perceptions of fault, quality of care, and trust in physician. RESULTS We recruited 804 participants. Participants exposed to shared decisionmaking (brief and thorough) were 80% less likely to report a plan to contact a lawyer than those not exposed to shared decisionmaking (12% and 11% versus 41%; odds ratio 0.2; 95% confidence interval 0.12 to 0.31). Participants exposed to either level of shared decisionmaking reported higher trust, rated their physicians more highly, and were less likely to fault their physicians for the adverse outcome compared with those exposed to the no shared decisionmaking vignette. CONCLUSION In the setting of an adverse outcome from a missed diagnosis, use of shared decisionmaking may affect patients' perceptions of fault and liability.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA.
| | - Shelby Mader
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Connor Houghton
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Robert Wenger
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Schoenfeld
- Department of Biostatistics, Harvard School of Public Health, and Harvard Medical School, Boston, MA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Kathleen M Mazor
- Department of Medicine, University of Massachusetts Medical School, and Meyers Primary Care Institute, Worcester, MA
| |
Collapse
|
23
|
Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, Lindenauer PK, Mazor KM. Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis. Emerg Med J 2019; 36:346-354. [PMID: 31097464 DOI: 10.1136/emermed-2018-208242] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 11/13/2018] [Revised: 03/13/2019] [Accepted: 04/02/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED. METHODS We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory. RESULTS Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives. CONCLUSIONS EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA.,Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
| | - Sarah L Goff
- Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA.,School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Tala R Elia
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
| | - Errel R Khordipour
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - Kye E Poronsky
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
| | - Kelly A Nault
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
| | - Peter K Lindenauer
- Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Kathleen M Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Meyers Primary Care Institute, Worcester, Massachusetts, USA
| |
Collapse
|
24
|
Schoenfeld EM, Kanzaria HK, Quigley DD, Marie PS, Nayyar N, Sabbagh SH, Gress KL, Probst MA. Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey. Acad Emerg Med 2018; 25:1118-1128. [PMID: 29897639 PMCID: PMC6185792 DOI: 10.1111/acem.13499] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 04/12/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED. METHODS We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person. RESULTS Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved. CONCLUSION We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, Springfield, MA
- Institute for Healthcare Delivery and Population Science, Springfield, MA
| | - Hemal K Kanzaria
- University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Peter St Marie
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Nikita Nayyar
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Sarah H Sabbagh
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Kyle L Gress
- Georgetown University School of Medicine, Washington, DC
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
25
|
Schoenfeld EM, Goff SL, Downs G, Wenger RJ, Lindenauer PK, Mazor KM. A Qualitative Analysis of Patients' Perceptions of Shared Decision Making in the Emergency Department: "Let Me Know I Have a Choice". Acad Emerg Med 2018; 25:716-727. [PMID: 29577490 DOI: 10.1111/acem.13416] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients' perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients' desired level of involvement and what barriers and facilitators patients find most relevant to their experience. METHODS We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three-person coding team. Emergent themes were identified, discussed, and organized. RESULTS Twenty-nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self-efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians' good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care. CONCLUSIONS This exploration of ED patients' perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science Baystate Medical Center Springfield MA
| | - Sarah L. Goff
- Division of General Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science Baystate Medical Center Springfield MA
| | - Gwendolyn Downs
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Robert J. Wenger
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science Baystate Medical Center Springfield MA
| | - Kathleen M. Mazor
- Department of Medicine University of Massachusetts Medical School, and Meyers Primary Care Institute WorcesterMA
| |
Collapse
|
26
|
Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, Lindenauer PK, Mazor KM. A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education. J Grad Med Educ 2018; 10:43-50. [PMID: 29467972 PMCID: PMC5821016 DOI: 10.4300/jgme-d-17-00318.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/10/2017] [Accepted: 09/24/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Physicians need to rapidly and effectively facilitate patient-centered, shared decision-making (SDM) conversations, but little is known about how residents or attending physicians acquire this skill. OBJECTIVE We explored emergency medicine (EM) attending physicians' use of SDM in the context of their experience as former residents and current educators and assessed the implications of these findings on learning opportunities for residents. METHODS We used semistructured interviews with a purposeful sample of EM physicians. Interviews were transcribed verbatim, and 3 research team members performed iterative, open coding of transcripts, building a provisional codebook as work progressed. We analyzed the data with a focus on participants' acquisition and use of skills required for SDM and their use of SDM in the context of resident education. RESULTS Fifteen EM physicians from academic and community practices were interviewed. All reported using SDM techniques to some degree. Multiple themes noted had negative implications for resident acquisition of this skill: (1) the complex relationships among patients, residents, and attending physicians; (2) residents' skill levels; (3) the setting of busy emergency departments; and (4) individual attending factors. One theme was noted to facilitate resident education: the changing culture-with a cultural shift toward patient-centered care. CONCLUSIONS A constellation of factors may diminish opportunities for residents to acquire and practice SDM skills. Further research should explore residents' perspectives, address the modifiable obstacles identified, and examine whether these issues generalize to other specialties.
Collapse
|
27
|
Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, Melnick ER, Hess EP. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Ann Emerg Med 2017; 70:688-695. [PMID: 28559034 PMCID: PMC5834305 DOI: 10.1016/j.annemergmed.2017.03.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [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: 02/06/2017] [Revised: 03/22/2017] [Accepted: 03/27/2017] [Indexed: 01/27/2023]
Abstract
Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient's capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.
Collapse
Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, Baystate Medical Center/Tufts School of Medicine, Springfield, MA
| | - Michael D Menchine
- Department of Emergency Medicine, University of Southern California/Keck School of Medicine, Los Angeles, CA
| | | | | | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Erik P Hess
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
28
|
Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med 2017; 71:44-53.e4. [PMID: 28811122 DOI: 10.1016/j.annemergmed.2017.06.041] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [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: 05/20/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta-analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast-enhanced CT versus noncontrast CT. METHODS We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast. RESULTS The database search returned 14,691 articles, inclusive of duplicates. Twenty-six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta-analysis demonstrated that, compared with noncontrast CT, contrast-enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all-cause mortality (OR 1.0; 95% CI 0.73 to 1.36). CONCLUSION We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.
Collapse
Affiliation(s)
- Ryan D Aycock
- Emergency Services, Eglin Air Force Base Hospital, Eglin Air Force Base, FL.
| | - Lauren M Westafer
- Department of Emergency Medicine, Baystate Medical Center/UMMS, Springfield, MA
| | - Jennifer L Boxen
- Health Sciences Library, Hofstra Northwell School of Medicine, Hempstead, NY
| | - Nima Majlesi
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY
| | | | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis, Tufts Medical Center, Boston, MA
| |
Collapse
|
29
|
Villa-Uribe JL, Schoenfeld EM. Quality Initiatives May Affect Diagnostic Accuracy: STEMI Mimics in an Age of Decreasing Door to Balloon Time. Clin Pract Cases Emerg Med 2017; 1:118-121. [PMID: 29849369 PMCID: PMC5965411 DOI: 10.5811/cpcem.2016.12.33009] [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: 10/28/2016] [Revised: 12/13/2016] [Accepted: 12/19/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jose L Villa-Uribe
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Elizabeth M Schoenfeld
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Center for Quality of Care Research, Springfield, Massachusetts
| |
Collapse
|
30
|
Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, Lindenauer PK, Mazor KM. The Physician-as-Stakeholder: An Exploratory Qualitative Analysis of Physicians' Motivations for Using Shared Decision Making in the Emergency Department. Acad Emerg Med 2016; 23:1417-1427. [PMID: 27385557 DOI: 10.1111/acem.13043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/16/2016] [Accepted: 06/28/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Shared decision making (SDM) is increasingly recognized as an important facet of patient-centered care. Despite growing interest in SDM in the emergency department (ED), little is known about emergency physicians' (EPs') motivations for using SDM. Understanding current patterns of SDM use and EP's rationale for using SDM is essential for the development of interventions to increase use. OBJECTIVES Recognizing the EP as an important stakeholder in SDM research, we sought to identify and explore factors that may motivate EPs' engagement in SDM. METHODS In this qualitative study, informed by the Theory of Planned Behavior and Social Cognitive Theory, we conducted semistructured interviews with a purposeful sample of EPs. Interviews were recorded and transcribed verbatim. Using a directed qualitative content analysis approach, three members of the research team performed open coding of the transcripts in an iterative process, building a provisional code book as coding progressed. Respondent validation was employed to ensure methodologic rigor. RESULTS Fifteen EPs, ages 31-65, from both academic and community practice settings, were interviewed. Several had not heard of the specific phrase "shared decision making," but all understood the concept and felt that they used SDM techniques to some degree. Most noted they had often had an agenda when they used SDM, which often motivated them to have the conversation. Agendas described included counteracting an algorithmic or defensive approach to diagnosis and treatment, avoiding harmful tests, or sharing uncertainty. All participants believed that patients benefited from SDM in terms of satisfaction, engagement, or education. Nearly all participants identified research outcomes that they felt would encourage their use of SDM (e.g., improvements in patient engagement, mitigation of risk) and many prioritized patient-centered outcomes over systems outcomes such as improved resource utilization. Little consensus was seen, however, regarding the importance of individual outcomes: of eight potential research outcomes participants endorsed, no single outcome was endorsed by even half of the physicians interviewed. CONCLUSION Emergency physicians identified many factors that motivated them to use SDM. This study informs current research on SDM in the ED, particularly regarding the motivations of the physician-as-stakeholder.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Springfield MA
- Center for Quality of Care Research; Baystate Medical Center; Springfield MA
- Tufts University School of Medicine; Boston MA
| | - Sarah L. Goff
- Center for Quality of Care Research; Baystate Medical Center; Springfield MA
- Division of General Medicine; Baystate Medical Center; Springfield MA
| | - Tala R. Elia
- Department of Emergency Medicine; Baystate Medical Center; Springfield MA
- Tufts University School of Medicine; Boston MA
| | - Errel R. Khordipour
- Department of Emergency Medicine; Baystate Medical Center; Springfield MA
- Tufts University School of Medicine; Boston MA
| | - Kye E. Poronsky
- Department of Emergency Medicine; Baystate Medical Center; Springfield MA
| | - Kelly A. Nault
- Department of Emergency Medicine; Baystate Medical Center; Springfield MA
| | - Peter K. Lindenauer
- Center for Quality of Care Research; Baystate Medical Center; Springfield MA
- Division of General Medicine; Baystate Medical Center; Springfield MA
- Tufts University School of Medicine; Boston MA
| | - Kathleen M. Mazor
- Department of Medicine; University of Massachusetts Medical School; Worcester MA
| |
Collapse
|
31
|
Finnerty NM, Rodriguez RM, Carpenter CR, Sun BC, Theyyunni N, Ohle R, Dodd KW, Schoenfeld EM, Elm KD, Kline JA, Holmes JF, Kuppermann N. Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda. Acad Emerg Med 2015; 22:1406-16. [PMID: 26567885 DOI: 10.1111/acem.12828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.
Collapse
Affiliation(s)
- Nathan M. Finnerty
- Department of Emergency Medicine; The Ohio State University College of Medicine; Columbus OH
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California San Francisco School of Medicine; San Francisco CA
| | - Christopher R. Carpenter
- Department of Emergency Medicine; Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
| | - Nik Theyyunni
- Department of Emergency Medicine; University of Michigan Medical School; Ann Arbor MI
| | - Robert Ohle
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
- Department of Internal Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Kendra D. Elm
- Department of Emergency Medicine; University of Minnesota Medical School; Minneapolis MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| |
Collapse
|
32
|
Schoenfeld EM, Poronsky KE, Elia TR, Budhram GR, Garb JL, Mader TJ. Young patients with suspected uncomplicated renal colic are unlikely to have dangerous alternative diagnoses or need emergent intervention. West J Emerg Med 2015; 16:269-75. [PMID: 25834669 PMCID: PMC4380378 DOI: 10.5811/westjem.2015.1.23272] [Citation(s) in RCA: 15] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 01/13/2015] [Accepted: 01/21/2015] [Indexed: 01/27/2023] Open
Abstract
Introduction In the United States there is debate regarding the appropriate first test for new-onset renal colic, with non-contrast helical computed tomography (CT) receiving the highest ratings from both Agency for Healthcare Research and Quality and the American Urological Association. This is based not only on its accuracy for the diagnosis of renal colic, but also its ability to diagnose other surgical emergencies, which have been thought to occur in 10–15% of patients with suspected renal colic, based on previous studies. In younger patients, it may be reasonable to attempt to avoid immediate CT if concern for dangerous alternative diagnosis is low, based on the risks of radiation from CTs, and particularly in light of evidence that patients with renal colic have a very high likelihood of having multiple CTs in their lifetimes. The objective is to determine the proportion of patients with a dangerous alternative diagnosis in adult patients age 50 and under presenting with uncomplicated (non-infected) suspected renal colic, and also to determine what proportion of these patients undergo emergent urologic intervention. Methods Retrospective chart review of 12 months of patients age 18–50 presenting with “flank pain,” excluding patients with end stage renal disease, urinary tract infection, pregnancy and trauma. Dangerous alternative diagnosis was determined by CT. Results Two hundred and ninety-one patients met inclusion criteria. One hundred and fifteen patients had renal protocol CTs, and zero alternative emergent or urgent diagnoses were identified (one-sided 95% CI [0–2.7%]). Of the 291 encounters, there were 7 urologic procedures performed upon first admission (2.4%, 95% CI [1.0–4.9%]). The prevalence of kidney stone by final diagnosis was 58.8%. Conclusion This small sample suggests that in younger patients with uncomplicated renal colic, the benefit of immediate CT for suspected renal colic should be questioned. Further studies are needed to determine which patients benefit from immediate CT for suspected renal colic, and which patients could undergo alternate imaging such as ultrasound.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Baystate Medical Center/Tufts School of Medicine, Department of Emergency Medicine, Boston, Massachusetts
| | - Kye E Poronsky
- Baystate Medical Center/Tufts School of Medicine, Department of Emergency Medicine, Boston, Massachusetts
| | - Tala R Elia
- Baystate Medical Center/Tufts School of Medicine, Department of Emergency Medicine, Boston, Massachusetts
| | - Gavin R Budhram
- Baystate Medical Center/Tufts School of Medicine, Department of Emergency Medicine, Boston, Massachusetts
| | - Jane L Garb
- Baystate Medical Center/Tufts School of Medicine, Epidemiology/Biostatistics, Department of Academic Affairs, Boston, Massachusetts
| | - Timothy J Mader
- Baystate Medical Center/Tufts School of Medicine, Department of Emergency Medicine, Boston, Massachusetts
| |
Collapse
|
33
|
Schoenfeld EM, Capraro GA, Blank FSJ, Coute RA, Visintainer PF. Near-infrared spectroscopy assessment of tissue saturation of oxygen in torsed and healthy testes. Acad Emerg Med 2013; 20:1080-3. [PMID: 24127717 DOI: 10.1111/acem.12233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 04/26/2013] [Accepted: 04/28/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to assess whether testicular torsion is associated with low testicular tissue saturation of oxygen (StO2 ) as measured by transscrotal near-infrared spectroscopy (NIRS) and to compare the differences in NIRS values between testicles of the same patient, both in patients with testicular torsion and in healthy controls. METHODS This was an observational study of healthy controls and patients with surgically confirmed testicular torsion who were recruited from males under 30 years of age presenting to the emergency department (ED). The hypothesis was that the difference in NIRS values for the control's two testicles would be zero, and that the difference between the torsed and healthy testicles on an individual patient would not be zero. Based on animal data, the study was powered to detect an absolute difference of StO2 of 47%. RESULTS The mean StO2 for the left control patients' testicles was 73.6% (95% confidence interval [CI] = 68.0% to 79.1%) and the mean StO2 for the right controls' testicles for controls was 73.6% (95% CI = 66.9% to 80.4%; n = 17). The absolute difference in NIRS StO2 for left minus right for each individual was 3.5% (95% CI = 1.8% to 5.4%), which was significantly different (p = 0.0007), and refuted the hypothesis that there was no significant difference in StO2 between left and right testes in healthy patients. In the testicular torsion group, the torsed side had a mean StO2 of 82.8% (95% CI = 68.7% to 96.9%), and the contralateral nontorsed testes had a mean of 85.8% (95% CI = 72.3% to 99.3%). The mean StO2 difference, nontorsed minus torsed was 3.0% (range = -1% to 9%, 95% CI = -2% to 8%; p = 0.174), refuting the hypothesis that torsed testes would demonstrate significantly lower values for StO2 . CONCLUSIONS While pilot animal investigations support a potential role for transscrotal NIRS for the detection of testicular torsion, this first clinical translation of animal findings reveals that the investigated, transcutaneous, reflectance geometry NIRS device failed to demonstrate symmetric oxygenation of left and right testes in healthy controls and also failed to demonstrate depressed tissue saturation of oxygen values in patients with confirmed testicular torsion. While limited by a small sample size, other problems such as inability to calibrate depth of measurement of StO2 may have led to falsely elevated readings in patients with torsion.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency MedicineBaystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Geoffrey A. Capraro
- Department of Emergency Medicine; Rhode Island Hospital, Alpert School of Medicine; Brown University; Providence RI
| | - Fidela S. J. Blank
- Department of Emergency MedicineBaystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Ryan A. Coute
- Department of Emergency MedicineBaystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Paul F. Visintainer
- Department of Medicine, Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| |
Collapse
|
34
|
Schoenfeld EM, Lemkin DL. Massive hemothorax from a type-B aortic dissection. J Emerg Med 2012; 43:e267-e268. [PMID: 21524883 DOI: 10.1016/j.jemermed.2011.03.020] [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: 07/02/2010] [Revised: 08/31/2010] [Accepted: 03/20/2011] [Indexed: 05/30/2023]
|
35
|
Schoenfeld EM, McKay MP. Weekend emergency department visits in Nebraska: higher utilization, lower acuity. J Emerg Med 2009; 38:542-5. [PMID: 19232869 DOI: 10.1016/j.jemermed.2008.09.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [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: 06/26/2008] [Revised: 08/29/2008] [Accepted: 09/18/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND We know very little about differences in Emergency Department (ED) utilization and acuity on weekends compared with weekdays. Understanding such differences may help elucidate the role of the ED in the health care delivery system. STUDY OBJECTIVE To compare patterns of ED use on weekends with weekdays and analyze the differences between these two groups. METHODS The Health Care Utilization Project (HCUP) is a national state-by-state billing database from acute-care, non-federal hospitals. Data from Nebraska in 2004 was used to compare ED-only patient visits (patients discharged home or transferred to another health care facility) and ED-admitted visits (patients admitted to the same hospital after an ED visit) for weekend vs. weekday frequency, billed charges, sex, age, and primary payer. RESULTS Of all non-admitted patients who visited the ED, 34.5% came in on weekends. This yielded ED utilization rates of 25 visits/1,000 people on weekdays and 33 visits/1,000 people on weekends, an increase of 32% on weekends. Weekend-only ED patients of all ages and payer categories were charged lower hospital facility fees than weekday-only ED patients; USD 777 vs. USD 921, respectively (p < 0.001). Weekend ED patients were less likely to be admitted and less likely to die while in the ED (2 deaths/1000 ED visits for weekend-only patients vs. 3 deaths/1000 ED visits for weekday-only [p < 0.001]). CONCLUSIONS In Nebraska, EDs care for a greater number of low-acuity patients on weekends than on weekdays. This highlights the important role EDs play within the ambulatory care delivery system.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, George Washington University, Washington, DC 20037, USA
| | | |
Collapse
|
36
|
Schoenfeld EM, McKay MP. Mastitis and methicillin-resistant Staphylococcus aureus (MRSA): the calm before the storm? J Emerg Med 2009; 38:e31-4. [PMID: 19232875 DOI: 10.1016/j.jemermed.2008.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 10/20/2008] [Accepted: 11/26/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post-partum mastitis is a common infection in breastfeeding women, with an incidence of 9.5-16% in recent literature. Over the past decade, community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a significant pathogen in soft-tissue infections presenting to the emergency department. The incidence of mastitis caused by MRSA is unknown at this time, but likely increasing. OBJECTIVES We review the data on prevention and treatment of mastitis and address recent literature demonstrating increases in MRSA infections in the post-partum population and how we should change our practices in light of this emerging pathogen. CASE REPORT We present a case of simple mastitis in a health care worker who failed to improve until treated with antibiotics appropriate for a MRSA infection. CONCLUSION Recent evidence suggests that just as MRSA has become the prominent pathogen in other soft-tissue infections, mastitis is now increasingly caused by this pathogen. Physicians caring for patients with mastitis need to be aware of this bacteriologic shift to treat appropriately.
Collapse
|