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Louras N, Reading Turchioe M, Shafran Topaz L, Demetres MR, Ellison M, Abudu-Solo J, Blutinger E, Munjal KG, Daniels B, Masterson Creber RM. Mobile Integrated Health Interventions for Older Adults: A Systematic Review. Innov Aging 2023; 7:igad017. [PMID: 37090165 PMCID: PMC10114527 DOI: 10.1093/geroni/igad017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Indexed: 03/04/2023] Open
Abstract
Background and Objectives Mobile integrated health (MIH) interventions have not been well described in older adult populations. The objective of this systematic review was to evaluate the characteristics and effectiveness of MIH programs on health-related outcomes among older adults. Research Design and Methods We searched Ovid MEDLINE, Ovid EMBASE, CINAHL, AgeLine, Social Work Abstracts, and The Cochrane Library through June 2021 for randomized controlled trials or cohort studies evaluating MIH among adults aged 65 and older in the general community. Studies were screened for eligibility against predefined inclusion/exclusion criteria. Using at least 2 independent reviewers, quality was appraised using the Downs and Black checklist and study characteristics and findings were synthesized and evaluated for potential bias. Results Screening of 2,160 records identified 15 studies. The mean age of participants was 67 years. The MIH interventions varied in their focus, community paramedic training, types of assessments and interventions delivered, physician oversight, use of telemedicine, and post-visit follow-up. Studies reported significant reductions in emergency call volume (5 studies) and immediate emergency department (ED) transports (3 studies). The 3 studies examining subsequent ED visits and 4 studies examining readmission rates reported mixed results. Studies reported low adverse event rates (5 studies), high patient and provider satisfaction (5 studies), and costs equivalent to or less than usual paramedic care (3 studies). Discussion and Implications There is wide variability in MIH provider training, program coordination, and quality-based metrics, creating heterogeneity that make definitive conclusions challenging. Nonetheless, studies suggest MIH reduces emergency call volume and ED transport rates while improving patient experience and reducing overall health care costs.
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Affiliation(s)
- Nathan Louras
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Leah Shafran Topaz
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Michelle R Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medical College, New York, New York, USA
| | - Melani Ellison
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Jamie Abudu-Solo
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Erik Blutinger
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Kevin G Munjal
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Brock Daniels
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
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Munjal KG, Yeturu SK, Chapin HH, Tan N, Gregoriou D, Garcia D, Grudzen C, Hwang U, Morano B, Neher H, Gorbenko K, Youngblood G, Misra A, Dietrich S, Gonzalez C, Appel G, Jacobs E, Siu A, Richardson LD. Feasibility of the Transport PLUS intervention to improve the transitions of care for patients transported home by ambulance: a non-randomized pilot study. Pilot Feasibility Stud 2022; 8:169. [PMID: 35932067 PMCID: PMC9354351 DOI: 10.1186/s40814-022-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background The growing population of patients over the age of 65 faces particular vulnerability following discharge after hospitalization or an emergency room visit. Specific areas of concern include a high risk for falls and poor comprehension of discharge instructions. Emergency medical technicians (EMTs), who frequently transport these patients home from the hospital, are uniquely positioned to aid in mitigating transition of care risks and are both trained and utilized to do so using the Transport PLUS intervention. Methods Existing literature and focus groups of various stakeholders were utilized to develop two checklists: the fall safety assessment (FSA) and the discharge comprehension assessment (DCA). EMTs were trained to administer the intervention to eligible patients in the geriatric population. Using data from the checklists, follow-up phone calls, and electronic health records, we measured the presence of hazards, removal of hazards, the presence of discharge comprehension issues, and correction or reinforcement of comprehension. These results were validated during home visits by community health workers (CHWs). Feasibility outcomes included patient acceptance of the Transport PLUS intervention and accuracy of the EMT assessment. Qualitative feedback via focus groups was also obtained. Clinical outcomes measured included 3-day and 30-day readmission or ED revisit. Results One-hundred three EMTs were trained to administer the intervention and participated in 439 patient encounters. The intervention was determined to be feasible, and patients were highly amenable to the intervention, as evidenced by a 92% and 74% acceptance rate of the DCA and FSA, respectively. The majority of patients also reported that they found the intervention helpful (90%) and self-reported removing 40% of fall hazards; 85% of such changes were validated by CHWs. Readmission/revisit rates are also reported. Conclusions The Transport PLUS intervention is a feasible, easily implemented tool in preventative community paramedicine with high levels of patient acceptance. Further study is merited to determine the effectiveness of the intervention in reducing rates of readmission or revisit. A randomized control trial has since begun utilizing the knowledge gained within this study.
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Affiliation(s)
- Kevin G Munjal
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Sai Kaushik Yeturu
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA.
| | - Hugh H Chapin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Nadir Tan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Diana Gregoriou
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Daniela Garcia
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Corita Grudzen
- Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Barbara Morano
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Hayley Neher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Ksenia Gorbenko
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA.,Institute for Health Equity Research and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Glen Youngblood
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Anjali Misra
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Staley Dietrich
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Cyndi Gonzalez
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA
| | - Giselle Appel
- Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Erica Jacobs
- George Washington University School of Medicine, Washington D.C., USA
| | - Albert Siu
- Department of Geriatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY, 10029, USA.,Institute for Health Equity Research and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Isakov A, Carr M, Munjal KG, Kumar L, Gausche-Hill M. EMS Agenda 2050 Meets the COVID-19 Pandemic. Health Secur 2022; 20:S97-S106. [PMID: 35475661 DOI: 10.1089/hs.2021.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alexander Isakov
- Alexander Isakov, MD, MPH, FACEP, FAEMS, is a Professor of Emergency Medicine, Section of Prehospital and Disaster Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Michael Carr
- Michael Carr, MD, FACEP, is an Assistant Professor of Emergency Medicine, Section of Prehospital and Disaster Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin G Munjal
- Kevin G. Munjal, MD, MPH, MSCR, is an Associate Professor of Emergency Medicine and Population Health Science and Policy, Departments of Emergency Medicine, Population Health Science and Policy, and Prehospital Care, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lekshmi Kumar
- Lekshmi Kumar, MD, MPH, FACEP, FAEMS, is an Associate Professor of Emergency Medicine, Section of Prehospital and Disaster Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Marianne Gausche-Hill
- Marianne Gausche-Hill MD, FACEP, FAAP, FAEMS, is a Professor of Clinical Emergency Medicine and Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Monti K, Bachi K, Gray M, Mahajan V, Sweeney G, Oprescu A, Munjal KG, Hurd YL, Lim S. Data mining-based clinical profiles of substance use-related emergency department utilizers. Am J Emerg Med 2022; 53:104-111. [PMID: 35007871 PMCID: PMC8844240 DOI: 10.1016/j.ajem.2021.12.059] [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: 08/30/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Substance-use is a prevalent presentation to the emergency department (ED); however, the clinical characterization of patients who are treated and discharged without admission for further treatment is under-investigated. The study aims to define and characterize the clinical profiles of this patient population. METHODS Patients' presentations were examined by clinical data mining (chart review) of ED records of substance use-related events of individuals discharged without admission for further treatment. Records (N = 199) from three major hospitals in New York City from March and June 2017 were randomly sampled with primary diagnosis of alcohol, opioid-related and other psychoactive substance-use presentations. Qualitative thematic coding of clinical presentation with inter-rater reliability was performed. Quantitative distinctive validity tested independence through Pearson's chi-squared and analysis of variance using Fisher's F-test. RESULTS Six distinct clinical profiles were identified, including, High Utilizers (chronically intoxicated with comorbid health conditions) (36.7%), Single Episode (20.1%), Service Request (14.1%), Altered Mental Status (13.6%), Overdose (9.0%), and Withdrawal (7.5%). The profiles differed (p < 0.05) in age, housing status, payor, mode of arrival, referral source, index visit time, prescribed treatment, triage acuity level, psychiatric history, and medical history. Differences (p < 0.05) between groups across clinical profiles in age and pain level at triage were observed. CONCLUSIONS The identified clinical profiles represent the broad spectrum and complex nature of substance use-related ED utilization, highlighting critical factors of psychosocial and mental-health comorbidities. These findings provide a preliminary foundation to support person-centered interventions to decrease substance use-related ED utilization and to increase engagement/linkage of patients to addiction treatment.
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Affiliation(s)
- Kristina Monti
- Addiction Institute of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keren Bachi
- Addiction Institute of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Madeline Gray
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vibhor Mahajan
- Addiction Institute of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Gabrielle Sweeney
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anna Oprescu
- Addiction Institute of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kevin G. Munjal
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yasmin L. Hurd
- Addiction Institute of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY,Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY,Corresponding author at: Hess Center for Science and Medicine Building, 10th Floor Room 105 Office, 1470 Madison Avenue, Box 1639, New York, NY 10029-6574
| | - Sabina Lim
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Munjal KG, Shastry S, Chapin H, Tan N, Misra A, Greenberg E, Traisman B, Kleiman R, Loo G, Grudzen C, Chason K, Richardson LD. Retrospective Cohort Study of Rates of Return Emergency Department Visits Among Patients Transported Home by Ambulance. J Emerg Med 2020; 59:147-152. [PMID: 32561107 DOI: 10.1016/j.jemermed.2020.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Emergency Medical Services (EMS) is an important resource that interacts with our most vulnerable patients during transport home after hospital discharge. EMS providers may be appropriately situated to support the transition of care to the home environment. OBJECTIVES This study aimed to determine whether patients transported home by ambulance experience higher rates of return emergency department (ED) visits and readmission compared with similar patients transported home by other means. METHODS This was a retrospective cohort study conducted at a U.S. tertiary care academic hospital. Patients aged 65 years and over transported home via ambulance after hospital discharge between January and March 2012 were included. Rates of 72-h and 30-day ED revisits and 30-day hospital readmissions were calculated. Odds ratios were calculated and revisit rates between groups were compared. RESULTS There were 207 patients aged 65 and over transported home by ambulance. Matched controls were found for 162 patients. Compared with the matched controls, the exposed group experienced a statistically significant higher rate of 30-day ED returns (18.519% vs. 10.494%; odds ratio [OR] 1.939; p = 0.043). The exposed group also experienced a higher rate of 72-h ED returns (2.469% vs. 0.617%; OR 4.076) and 30-day readmissions (12.346% vs. 6.173%; OR 2.141), though results did not reach statistical significance. CONCLUSION The study findings suggest that transport home via ambulance after hospital discharge could be predictive of a high risk of recidivism independent of established readmission risk factors. Programs that expand the role of EMS to include post-transport interventions may warrant further exploration.
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Affiliation(s)
- Kevin G Munjal
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Siri Shastry
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Hugh Chapin
- Care Transitions and Population Health, Mount Sinai St. Luke's, New York, New York
| | - Nadir Tan
- Accenture Scientific Informatics Services, New York, New York
| | | | - Eric Greenberg
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | | | - Rose Kleiman
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Corita Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York
| | - Kevin Chason
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
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Affiliation(s)
- Kevin G Munjal
- Departments of Emergency Medicine, Population Health Science & Policy, and Prehospital Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregg S Margolis
- Health Policy Fellowships and Leadership Programs, National Academy of Medicine, Washington, DC
| | - Arthur L Kellermann
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Chellappa DK, DeCherrie LV, Escobar C, Gregoriou D, Munjal KG. Supporting the on-call primary care physician with community paramedicine. Intern Med J 2018; 48:1261-1264. [PMID: 30288895 DOI: 10.1111/imj.14049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/08/2018] [Accepted: 07/07/2018] [Indexed: 11/29/2022]
Abstract
Prior to being referred to the emergency department (ED), patients such as the frail elderly often call their primary care physician. However, the on-call primary care physician or covering provider does not always have the tools to make an accurate and safe assessment over the phone or to treat patients remotely. This often results in preventable transport to an ED, avoidable admissions and iatrogenic events. An opportunity exists to reduce unnecessary ED referrals by enhancing the capabilities of the on-call primary care physician. In this communication, we describe the development of a community paramedicine programme that supports on-call primary care providers managing a high-risk patient population with the goal of reducing avoidable ED referrals.
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Affiliation(s)
- Deepa K Chellappa
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Escobar
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diana Gregoriou
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin G Munjal
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Goldberg SA, Porat A, Strother CG, Lim NQ, Wijeratne HRS, Sanchez G, Munjal KG. Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department. PREHOSP EMERG CARE 2016; 21:14-17. [PMID: 27420753 DOI: 10.1080/10903127.2016.1194930] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Patient handoff occurs when responsibility for patient diagnosis, treatment, or ongoing care is transferred from one healthcare professional to another. Patient handoff is an integral component of quality patient care and is increasingly identified as a potential source of medical error. However, evaluation of handoff from field providers to ED personnel is limited. We here present a quantitative analysis of the information transferred from EMS providers to ED physicians during handoff of critically ill and injured patients. METHODS This study was conducted at an urban academic medical center with an emergency department census of greater than 100,000 visits annually. All patients arriving to our institution by EMS and meeting predefined triage criteria are brought immediately to the ED resuscitation area upon EMS arrival. Handoff from EMS to ED providers occurring in the resuscitation area was observed and audio recorded by trained research assistants and subsequently coded for content. The emergency department team as well as EMS were blinded to study design. RESULTS Ninety patient handoffs were evaluated. In 78% (95%CI = 70.0-86.7) of all handoffs, EMS provided a chief concern. In 58% (95%CI = 47.7-67.7) of handoffs EMS provided a description of the scene and in 57% (95%CI = 46.7-66.7) they provided a complete set of vital signs. In 47% (95%CI = 31.3-57.5) of handoffs pertinent physical exam findings were described. The EMS provider gave an overall assessment of the patient's clinical status in 31% (95%CI = 21.6-40.3) of cases. Significantly more paramedic handoffs included vital signs (70% vs. 37%, χ2 = 9.69, p = 0.002) and physical exam findings (63% vs. 23%, χ2 = 14.11, p < 0.001). Paramedics were more likely to provide an overall assessment (39% vs. 17%, χ2 = 4.71, p < 0.05). CONCLUSIONS While patient handoff is a critical component of safe and effective patient care, our study confirms previous literature demonstrating poor quality handoff from EMS to ED providers in critically ill and injured patients. Our analysis demonstrates the need for further training in the provision of patient handoff.
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Munjal KG, Shastry S, Loo GT, Reid D, Grudzen C, Shah MN, Chapin HH, First B, Sirirungruang S, Alpert E, Chason K, Richardson LD. Patient Perspectives on EMS Alternate Destination Models. PREHOSP EMERG CARE 2016; 20:705-711. [DOI: 10.1080/10903127.2016.1182604] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Wall SP, Kaufman BJ, Williams N, Norman EM, Gilbert AJ, Munjal KG, Maikhor S, Goldstein MJ, Rivera JE, Lerner H, Meyers C, Machado M, Montella S, Pressman M, Teperman LW, Dubler NN, Goldfrank LR, Goldfrank LR, Maikhor S, Montella S, Meyers C, Tuttle V, Wall SP, Williams N, Machado M, Pressman M, Munjal K, Simon RJ, Bazel J, Freese J, Handelsman A, Kaufman BJ, Levin A, Matallana L, Munjal K, Prezant D, Simmons G, Gilbert AJ, Goldstein M, Dubler NN, Gonder CJ, Hedrington Z, Lerner H, O'Hara D, Rivera JE, Sabeta ME, Smith CL, Torres M, Yushkov Y, Teperman LW. Lesson From the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program. Ann Emerg Med 2016; 67:531-537.e39. [DOI: 10.1016/j.annemergmed.2015.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 09/09/2015] [Accepted: 09/16/2015] [Indexed: 11/16/2022]
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Munjal KG. The Role of the Medical Director A more collaborative, multidisciplinary oversight is called for in the future. EMS World 2016; Suppl:10-11. [PMID: 29847038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Because of the expanded role EMS providers may paly in the community, medical direction in EMS 3.o should appropriately be a collaborative effort led by EMS subspecialty-certified physicians specially trained in emergency medicine, but also physicians who specialize in disciplines such as internal/family medicine, critical care, cardiology, nephrology, endocrinology and pulmonary medicine. The EMS 3.0 medical director should be able to build patient-centered coalitions of physicians to help meet the care coordination goals of the patient, their physicians and the EMS system.
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Chang AK, Bijur PE, Munjal KG, John Gallagher E. Randomized clinical trial of hydrocodone/acetaminophen versus codeine/acetaminophen in the treatment of acute extremity pain after emergency department discharge. Acad Emerg Med 2014; 21:227-35. [PMID: 24628747 DOI: 10.1111/acem.12331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 09/03/2013] [Accepted: 09/16/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to test the hypothesis that hydrocodone/acetaminophen (Vicodin [5/500]) provides more efficacious analgesia than codeine/acetaminophen (Tylenol #3 [30/300]) in patients discharged from the emergency department (ED). Both are currently Drug Enforcement Administration (DEA) Schedule III narcotics. METHODS This was a prospective, randomized, double-blind, clinical trial of patients with acute extremity pain who were discharged home from the ED, comparing a 3-day supply of oral hydrocodone/acetaminophen (5 mg/500 mg) to oral codeine/acetaminophen (30 mg/300 mg). Pain was measured on a valid and reproducible verbal numeric rating scale (NRS) ranging from 0 to 10, and patients were contacted by telephone approximately 24 hours after being discharged. The primary outcome was the between-group difference in improvement in pain at 2 hours following the most recent ingestion of the study drug, relative to the time of phone contact after ED discharge. Secondary outcomes compared side-effect profiles and patient satisfaction. RESULTS The median time from ED discharge to follow-up was 26 hours (interquartile range [IQR] = 24 to 39 hours). The mean NRS pain score before the most recent dose of pain medication after ED discharge was 7.6 NRS units for both groups. The mean decrease in pain scores 2 hours after pain medications were taken were 3.9 NRS units in the hydrocodone/acetaminophen group versus 3.5 NRS units in the codeine/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval [CI] = -0.3 to 1.2 NRS units). No differences were found in side effects or patient satisfaction. CONCLUSIONS Both medications decreased NRS pain scores by approximately 50%. However, the oral hydrocodone/acetaminophen failed to provide clinically or statistically superior pain relief compared to oral codeine/acetaminophen when prescribed to patients discharged from the ED with acute extremity pain. Similarly, there were no clinically or statistically important differences in side-effect profiles or patient satisfaction. If the DEA reclassifies hydrocodone as a Schedule II narcotic, as recently recommended by its advisory board, our data suggest that the codeine/acetaminophen may be a clinically reasonable Schedule III substitute for hydrocodone/acetaminophen at ED discharge. These findings should be regarded as tentative and require independent validation in similar and other acute pain models.
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Affiliation(s)
- Andrew K. Chang
- The Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
| | - Polly E. Bijur
- The Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
| | - Kevin G. Munjal
- The Department of Emergency Medicine; Mount Sinai Medical Center; New York NY
| | - E. John Gallagher
- The Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
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Munjal KG, Wall SP, Goldfrank LR, Gilbert A, Kaufman BJ, Dubler NN. A Rationale in Support of Uncontrolled Donation after Circulatory Determination of Death. Hastings Cent Rep 2012; 43:19-26. [PMID: 23254821 DOI: 10.1002/hast.113] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Wall SP, Kaufman BJ, Gilbert AJ, Yushkov Y, Goldstein M, Rivera JE, O'Hara D, Lerner H, Sabeta M, Torres M, Smith CL, Hedrington Z, Selck F, Munjal KG, Machado M, Montella S, Pressman M, Teperman LW, Dubler NN, Goldfrank LR. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city. Am J Transplant 2011; 11:1417-26. [PMID: 21711448 DOI: 10.1111/j.1600-6143.2011.03582.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.
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Affiliation(s)
- S P Wall
- Bellevue Hospital Center, New York, NY, USA
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Munjal KG, Silverman RA, Freese J, Braun JD, Kaufman BJ, Isaacs D, Werner A, Webber M, Hall CB, Prezant DJ. Utilization of emergency medical services in a large urban area: description of call types and temporal trends. PREHOSP EMERG CARE 2011; 15:371-80. [PMID: 21521036 DOI: 10.3109/10903127.2011.561403] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Emergency medical services (EMS) systems are used by the public for a range of medically related problems. OBJECTIVE To understand and analyze the patterns of EMS utilization and trends over time in a large urban EMS system so that we may better direct efforts toward improving those services. METHODS The 63 call type designations from all New York City (NYC) 9-1-1 EMS calls between 1999 and 2007 were obtained and grouped into 10 broad and 30 specific medical categories. Aggregated numbers of total EMS calls and individual categories were divided by NYC resident population estimates to determine utilization rates. Temporal trends were evaluated for statistical significance with Spearman's rho (ρ). RESULTS There were 9,916,904 EMS calls between 1999 and 2007, with an average of 1,101,878 calls/year. Utilization rates increased from 129.5 to 141.9 calls/1,000 residents/year over the study period (average annual rise of 1.16%). Among all medical/surgical call types (excluding trauma), there was an average annual increase of 1.8%/year. The most substantial increases were among "psychiatric/drug related" (+5.6%/year), "generalized illness" (+3.2%/year), and "environmental related" calls (+2.9%/year). The largest decrease was among "respiratory" calls (-1.2%/year), specifically for "asthma" (-5.0%/year). For trauma call types, there was an annual average decrease of 0.4%/year, with the category of "violence related" calls having the greatest decline (-3.3%/year). CONCLUSION There was an increase in overall EMS utilization rates, though not all call types rose uniformly. Rather, a number of significant trends were identified reflecting either changing medical needs or changing patterns of EMS utilization in NYC's population.
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Affiliation(s)
- Kevin G Munjal
- Office of Medical Affairs, The New York City Fire Department, Brooklyn, New York 11201, USA
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