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Bartlett E, Morse SC, Morse D, Goodson L, Adams KN, Nichol G. Randomized feasibility trial of remote ischemic conditioning to enhance resuscitation (RICE). Resuscitation 2024; 195:110003. [PMID: 37839518 DOI: 10.1016/j.resuscitation.2023.110003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
RATIONALE Restoration of blood flow after out-of-hospital cardiac arrest (OHCA) is associated with inflammation that causes cellular injury. The extent of this reperfusion injury (RI) is associated with the duration of ischemia and adequacy of resuscitation. Remote ischemic conditioning (RIC) consists of repeated application of non-lethal ischemia then reperfusion to a limb distal to the heart by inflating a blood pressure (BP) cuff. Trials in animal models in cardiac arrest and in humans with acute infarction show RIC reduces RI. OBJECTIVE We sought to demonstrate the feasibility and safety of RIC in patients resuscitated from OHCA and transported to hospital. METHODS This study was conducted under exception from informed consent (EFIC) for emergency research. Eligible subjects were randomized with masked allocation to control (standard care) versus intervention (standard care and RIC). Included were adults with non-traumatic OHCA. The primary outcome was attrition, the proportion of patients enrolled and not on allocated therapy for the study duration. Key secondary outcomes were survival to discharge, neurologic status at discharge, hospital-free survival, and adverse events. Results were summarized descriptively as recommended for pilot studies. RESULTS N = 30 patients were enrolled (n = 14 control, n = 16 intervention). Mean age of enrolled patients was 52.5 ± 16.2 years. Eight (27%) were female gender and 7 (23%) had a shockable first recorded rhythm. 100% of enrolled patients completed their allocated study intervention (i.e., 0% attrition). The RIC group had 7 (44%) survival to discharge and median Rankin score of 6 (IQR 1, 6) at discharge as compared to the standard care group which had 6 (43%) survival to discharge and median Rankin score of 6 (IQR 1.5, 6) at discharge. A single patient (6%) in the intervention group had transient occlusion of their upper extremity intravenous line, which immediately resolved on repositioning of the blood pressure cuff. CONCLUSION Application of RIC to patients resuscitated from CA and transported to an ED is feasible and safe. An adequately powered trial is required to assess whether RIC is effective at decreasing morbidity and mortality after CA.
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Affiliation(s)
- Emily Bartlett
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Sophie C Morse
- University of Washington School of Medicine, University of Washington, Seattle, WA, United States; University of Washington-Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Dana Morse
- University of Washington-Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Lucy Goodson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Karen N Adams
- University of Washington-Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, United States.
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Morse SC, Fockele C, Huynh LN, Zatzick A, Whiteside LK. A qualitative study of people who use methamphetamine during the early COVID-19 pandemic to inform future ED harm reduction strategies. Int J Emerg Med 2023; 16:30. [PMID: 37106338 PMCID: PMC10139825 DOI: 10.1186/s12245-023-00505-0] [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: 10/26/2022] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Morbidity and mortality rates related to methamphetamine are on the rise. Simultaneously, social-distancing guidelines were issued in March 2020 to decrease transmission of COVID-19. The aim of this study was to explore concerns regarding methamphetamine use during the COVID-19 pandemic and subsequent harm reduction strategies with patients who use methamphetamine to inform emergency department (ED)-based harm reduction approaches. METHODS A mixed-methods study of adults residing in Washington with high-risk methamphetamine use and a recent ED visit from April-September 2020 was performed. Participants completed a survey and a semi-structured interview on perceptions and experiences of COVID-19. Descriptive statistics were used for survey responses. Interview transcripts were analyzed and guided by modified grounded theory using an iterative approach to refine the guide and codebook. Interviews were independently coded by 2 investigators and discussed until consensus. RESULTS Twenty-five participants completed the survey; 20 participants were interviewed (45% recently used heroin, 40% unstably housed). Thirty-five percent was worried about COVID-19 infection. Three themes emerged from the interviews: (1) increase in meth use, (2) interplay of meth obtention and COVID-19, and (3) interactions with healthcare and social services. CONCLUSIONS People who use methamphetamine noted an increase in use along with the social distancing guidelines put in place for COVID-19 and employed a variety of harm reduction profiles when obtaining methamphetamine. Also, the pandemic brought difficulties in accessing care and amplified mistrust in healthcare instructions and public health messages. Based on these qualitative interviews, further work should consider aligning methamphetamine and COVID-19 harm reduction messages and working with trusted community resources to improve harm reduction strategies for methamphetamine use and COVID-19. IRB: Informed Consent by the University of Washington Human Subjects Division (approval number, STUDY00009277).
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Affiliation(s)
- Sophie C Morse
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | - Callan Fockele
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Ly Ngoc Huynh
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Alina Zatzick
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
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Fockele CE, Morse SC, van Draanen J, Leyde S, Banta-Green C, Huynh LN, Zatzick A, Whiteside LK. "That Line Just Kept Moving": Motivations and Experiences of People Who Use Methamphetamine. West J Emerg Med 2023; 24:218-227. [PMID: 36976607 PMCID: PMC10047723 DOI: 10.5811/westjem.2022.12.58396] [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: 08/14/2022] [Accepted: 12/16/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Methamphetamine use is on the rise with increasing emergency department (ED) visits, behavioral health crises, and deaths associated with use and overdose. Emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and violence against staff, but little is known about the patient's perspective. In this study our objective was to identify the motivations for initiation and continued methamphetamine use among people who use methamphetamine and their experiences in the ED to guide future ED-based approaches. METHODS This was a qualitative study of adults residing in the state of Washington in 2020, who used methamphetamine in the prior 30 days, met criteria for moderate- to high-risk use, reported recently receiving care in the ED, and had phone access. Twenty individuals were recruited to complete a brief survey and semi-structured interview, which was recorded and transcribed prior to being coded. Modified grounded theory guided the analysis, and the interview guide and codebook were iteratively refined. Three investigators coded the interviews until consensus was reached. Data was collected until thematic saturation. RESULTS Participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. Many initially used methamphetamine to enhance social interactions, combat boredom, and escape difficult circumstances by numbing the senses. However, continued use regularly led to isolation, ED visits for the medical and psychological sequelae of methamphetamine use, and engagement in increasingly risky behaviors. Because of their overwhelmingly frustrating experiences in the past, interviewees anticipated difficult interactions with healthcare clinicians, leading to combativeness in the ED, avoidance of the ED at all costs, and downstream medical complications. Participants desired a non-judgmental conversation and linkage to outpatient social resources and addiction treatment. CONCLUSION Methamphetamine use can lead patients to seek care in the ED, where they often feel stigmatized and are provided little assistance. Emergency clinicians should acknowledge addiction as a chronic condition, address acute medical and psychiatric symptoms adequately, and provide positive connections to addiction and medical resources. Future work should incorporate the perspectives of people who use methamphetamine into ED-based programs and interventions.
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Affiliation(s)
- Callan Elswick Fockele
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Sophie C Morse
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Jenna van Draanen
- University of Washington School of Public Health, Department of Health Systems and Population Health, Seattle, Washington
- University of Washington, Department of Child, Family, and Population Health Nursing, Seattle, Washington
| | - Sarah Leyde
- Harborview Medical Center, University of Washington, Department of Medicine, Seattle, Washington
| | - Caleb Banta-Green
- School of Public Health, University of Washington, Department of Health Services and Population Health, Seattle, Washington
- University of Washington School of Medicine, Addictions, Drug & Alcohol Institute, Department of Psychiatry and Behavioral Sciences, Seattle, Washington
| | - Ly Ngoc Huynh
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Alina Zatzick
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Lauren K Whiteside
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
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Rodriguez RM, Nichol G, Eucker SA, Chang AM, O'Laughlin KN, Pauley A, Rising KL, Eswaran V, Morse D, Li C, Patel A, Duber HC, Arreguin M, Shughart L, Glidden D, Butler J, Kemball R, Chan V, Lara-Chavez C, Guth A, Olarewaju I, Morse SC, Patel A, Schaeffer K, Grau D, Arab A, Tupetz A, Walker E, Watts P, Shughart H, Yan B, Finkelstein S, Chen H, Daniels N, White J, Sarafian J, Howard L, Alali L, Agun G, Chan EA, Covington A, Klasson C. Effect of COVID-19 Vaccine Messaging Platforms in Emergency Departments on Vaccine Acceptance and Uptake: A Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:115-123. [PMID: 36574256 PMCID: PMC9856883 DOI: 10.1001/jamainternmed.2022.5909] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Large segments of the US population's primary health care access occurs in emergency departments (EDs). These groups have disproportionately high COVID-19 vaccine hesitancy and lower vaccine uptake. OBJECTIVE To determine whether provision of COVID-19 vaccine messaging platforms in EDs increases COVID-19 vaccine acceptance and uptake in unvaccinated patients. DESIGN, SETTING, AND PARTICIPANTS This prospective cluster randomized clinical trial was conducted at 7 hospital EDs in 4 US cities from December 6, 2021, to July 28, 2022. Noncritically ill adult patients who had not previously received COVID-19 vaccines were enrolled. INTERVENTIONS A 3-pronged COVID-19 vaccine messaging platform (an English- or Spanish-language 4-minute video; a 1-page informational flyer; and a brief, scripted message from an ED physician or nurse) was delivered during patient waiting times. MAIN OUTCOMES AND MEASURES The 2 primary outcomes were (1) COVID-19 vaccine acceptance, assessed by survey responses in the ED, and (2) receipt of a COVID-19 vaccine within 30 days, ascertained by ED confirmation of vaccination, electronic health record review, and telephone follow-up. RESULTS Of the 496 participants enrolled (221 during intervention weeks and 275 during control weeks), the median (IQR) age was 39 (30-54) years, 205 (41.3%) were female, 193 (38.9%) were African American, 97 (19.6%) were Latinx, and 218 (44.0%) lacked primary care physicians. More intervention group participants, compared with control participants, stated that they would accept the vaccine in the ED (57 [25.8%] vs 33 [12.0%]; adjusted difference, 11.9 [95% CI, 4.5-19.3] percentage points; number needed to treat [NNT], 8 [95% CI, 5-22]). More intervention group participants than control participants received a COVID-19 vaccine within 30 days of their ED visit (44 [20.0%] vs 24 [8.7%]; adjusted difference, 7.9 [95% CI, 1.7-14.1] percentage points; NNT, 13 [95% CI, 7-60]). The intervention group had greater outcome effect sizes than the control group in participants who lacked a primary care physician (acceptance, 38 of 101 [37.6%] vs 16 of 117 [13.7%] [P for interaction = .004]; uptake, 31 of 101 [30.7%] vs 11 of 117 [9.4%] [P for interaction = .006]), as well as in Latinx persons (acceptance, 23 of 52 [44.2%] vs 5 of 48 [10.4%] [P for interaction = .004]; uptake, 22 of 52 [42.3%] vs 4 of 48 [8.3%] [P for interaction < .001]). CONCLUSIONS AND RELEVANCE Results of this cluster randomized clinical trial showed that with low NNT, implementation of COVID-19 vaccine messaging platforms in EDs leads to greater vaccine acceptance and uptake in unvaccinated ED patients. Broad implementation in EDs could lead to greater COVID-19 vaccine delivery to underserved populations whose primary health care access occurs in EDs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05142332.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco
| | - Graham Nichol
- Center for Prehospital Emergency Care, Division of General Internal Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Stephanie A Eucker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anna Marie Chang
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Alena Pauley
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vidya Eswaran
- Department of Emergency Medicine, University of California, San Francisco
| | - Dana Morse
- Department of Emergency Medicine, University of Washington, Seattle
| | - Cindy Li
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ashini Patel
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Herbie C Duber
- Department of Emergency Medicine, University of Washington, Seattle
| | - Mireya Arreguin
- Department of Emergency Medicine, University of California, San Francisco
| | - Lindsey Shughart
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dave Glidden
- Department of Epidemiology & Biostatistics, University of California, San Francisco
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Fockele CE, Duber HC, Finegood B, Morse SC, Whiteside LK. Improving transitions of care for patients initiated on buprenorphine for opioid use disorder from the emergency departments in King County, Washington. J Am Coll Emerg Physicians Open 2021; 2:e12408. [PMID: 33778807 PMCID: PMC7987236 DOI: 10.1002/emp2.12408] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/11/2021] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
STUDY OBJECTIVE Opioid use disorder (OUD) is on the rise nationwide with increasing emergency department (ED) visits and deaths secondary to overdose. Although previous research has shown that patients who are started on buprenorphine in the ED have increased engagement in addiction treatment, access to on-demand medications for OUD is still limited, in part because of the need for linkages to outpatient care. The objective of this study is to describe emergency and outpatient providers' perception of local barriers to transitions of care for ED-initiated buprenorphine patients. METHODS Purposive sampling was used to recruit key stakeholders, identified as physicians, addiction specialists, and hospital administrators, from 10 EDs and 11 outpatient clinics in King County, Washington. Twenty-one interviews were recorded and transcribed and then coded using an integrated deductive and inductive content analysis approach by 2 team members to verify accuracy of the analysis. Interview guides and coding were informed by the Consolidated Framework for Implementation Research (CFIR), which provides a structure of domains and constructs associated with effective implementation of evidence-based practice. RESULTS From the 21 interviews with emergency and outpatient providers, this study identified 4 barriers to transitions of care for ED-initiated buprenorphine patients: scope of practice, prescribing capacity, referral incoordination, and loss to follow-up. CONCLUSION Next steps for implementation of this intervention in a community setting include establishing a standard of care for treatment and referral for ED patients with OUD, increasing buprenorphine prescribing capacity, creating a central repository for streamlined referrals and follow-up, and supporting low-barrier scheduling and navigation services.
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Affiliation(s)
| | - Herbert C. Duber
- Department of Emergency MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Brad Finegood
- Department of Public HealthPublic Health‐Seattle and King CountySeattleWashingtonUSA
| | - Sophie C. Morse
- Department of Emergency MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Lauren K. Whiteside
- Department of Emergency MedicineUniversity of WashingtonSeattleWashingtonUSA
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