Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People With Lived Experience

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.

Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial

STUDY OBJECTIVE

Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores.

METHODS

In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison.

RESULTS

All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66).

CONCLUSION

Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.

Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems

BACKGROUND

Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

METHODS

This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

RESULTS

Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

CONCLUSIONS

Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

Methadone Induction for a Patient With Precipitated Withdrawal in the Emergency Department: A Case Report

In the era of illicit fentanyl, reports on difficulties with buprenorphine inductions for patients with opioid use disorder are emerging. Methadone is the only other approved medication treatment with efficacy similar to buprenorphine but without risks of precipitated withdrawal. Unfortunately, outpatient methadone inductions can take days to weeks to complete, due in part to regulations that limit administration to opioid treatment programs. We describe a patient with opioid use disorder who presented to the emergency department in precipitated withdrawal who completed a same-day methadone induction with next-day dosing at an opioid treatment program as part of an emergency department methadone protocol. As opioid-related deaths rise, emergency department-initiated methadone is feasible for patients with opioid use disorder.

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

OBJECTIVE

To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder.

DESIGN

Pragmatic cluster randomized controlled trial (EMBED).

SETTING

18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform.

PARTICIPANTS

599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder.

INTERVENTION

A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral.

MAIN OUTCOME MEASURES

Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.

RESULTS

1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01).

CONCLUSIONS

User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03658642.

"Just give them a choice": Patients' perspectives on starting medications for opioid use disorder in the ED

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.

The Impact of a Medical Education Research Faculty Development Program on Career Development, Through the Lens of Social Cognitive Career Theory

OBJECTIVES

The Medical Education Research Certificate at the Council of Residency Directors in Emergency Medicine (MERC at CORD), a specialized adaptation of the Association of American Medical Colleges MERC program, provides faculty development in education research in emergency medicine. However, its long-term influence on career development remains unknown. Our study explored the impact of MERC at CORD on career development through the lens of social cognitive career (SCC) theory.

METHODS

This was a prospective qualitative study using a constructivist/interpretivist paradigm to assess long-term career development outcomes. A purposeful randomized stratified sampling strategy of MERC at CORD graduates (2011-2014) ensured diversity of representation (sex, region, number of research publications, and project group leadership). Subjects were invited by e-mail to participate in semistructured phone interviews. Thematic analysis by two independent reviewers followed an iterative process until saturation was reached.

RESULTS

Twelve graduates were interviewed. All engaged with MERC at CORD early in their careers with minimal previous education research experience. Currently, all hold medical education leadership positions. Graduates had a mean of 19.3 publications (range = 9-43). Themes explaining reasons for participating in MERC at CORD include: desire for education research skills, recommendation of mentors/colleagues, and accessibility. Themes citing the program's value to career development include networking/collaboration, mentorship, informational framework to build upon, and the application of theoretical knowledge through experiential learning. MERC at CORD impacted career development aligning with the core domains of SCC theory including self-efficacy, outcome expectations, and goals.

CONCLUSION

MERC at CORD enhanced the long-term career development of participants by providing a core knowledge framework in a mentored, experiential learning environment. Participants identified themes aligned with SCC theory as influential in their long-term career advancement in medical education including the development of education research skills, successful completion of education research, career acceleration, promotion, niche development, and formulation of professional goals.

A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients

STUDY OBJECTIVE

The HEART score is a risk stratification aid that may safely reduce chest pain admissions for emergency department patients. However, differences in interpretation of subjective components potentially alters the performance of the score. We compared agreement between HEART scores determined during clinical practice with research-generated scores and estimated their accuracy in predicting 30-day major adverse cardiac events.

METHODS

We prospectively enrolled adult ED patients with symptoms concerning for acute coronary syndrome at a single tertiary center. ED clinicians submitted their clinical HEART scores during the patient encounter. Researchers then independently interviewed patients to generate a research HEART score. Patients were followed by phone and chart review for major adverse cardiac events. Weighted kappa; unweighted Cohen's kappa; prevalence-adjusted, bias-adjusted kappa (PABAK); and test probabilities were calculated.

RESULTS

From November 2016 to June 2019, 336 patients were enrolled, 261 (77.7%) were admitted, and 30 (8.9%) had major adverse cardiac events. Dichotomized HEART score agreement was 78% (kappa 0.48, 95% confidence interval [CI] 0.37 to 0.58; PABAK 0.57, 95% CI 0.48 to 0.65) with the lowest agreement in the history (72%; WK 0.14, 95% CI 0.06 to 0.22) and electrocardiogram (85%; WK 0.4, 95% CI 0.3 to 0.49) components. Compared with researchers, clinicians had 100% sensitivity (95% CI 88.4% to 100%) (versus 86.7%, 95% CI 69.3% to 96.2%) and 27.8% specificity (95% CI 22.8% to 33.2%) (versus 34.6%, 95% CI 29.3% to 40.3%) for major adverse cardiac events. Four participants with low research HEART scores had major adverse cardiac events.

CONCLUSION

ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

No evidence of increasing COVID-19 in health care workers after implementation of high flow nasal cannula: A safety evaluation

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.

Management of Postabortion Complications for the Emergency Medicine Clinician

Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.

Safety Assessment of a Noninvasive Respiratory Protocol for Adults With COVID-19

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.

No evidence of increasing COVID-19 in health care workers after implementation of high flow nasal cannula: A safety evaluation

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.

Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US

IMPORTANCE

As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known.

OBJECTIVE

To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts.

EXPOSURES

Time (day) as a continuous variable.

MAIN OUTCOMES AND MEASURES

Daily counts of ED visits, hospital admissions, and COVID-19 cases.

RESULTS

A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina.

CONCLUSIONS AND RELEVANCE

From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US

IMPORTANCE

As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known.

OBJECTIVE

To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts.

EXPOSURES

Time (day) as a continuous variable.

MAIN OUTCOMES AND MEASURES

Daily counts of ED visits, hospital admissions, and COVID-19 cases.

RESULTS

A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina.

CONCLUSIONS AND RELEVANCE

From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

Incidence of future arrests in adults involved in the criminal justice system with opioid use disorder receiving extended release naltrexone compared to treatment as usual

BACKGROUND

Criminal justice involved (CJS) populations with opioid use disorder (OUD) have high rates of relapse, future arrests, and death upon release. While medication for OUD (MOUD) reduces opioid relapse, concerns regarding diversion and stigma limit treatment in CJS populations. Extended release naltrexone (XR-NTX), as an opioid antagonist, may be more acceptable to CJS administrators. However, the impact of XR-NTX on criminal recidivism remains unknown.

METHODS

Arrest data from a published randomized trial comparing XR-NTX to treatment as usual (TAU) was captured by self-report and official state arrest records. Comparisons of future arrests, time to first arrest and total number of arrests were performed using chi square tests and multivariable generalized regression models. Secondary outcomes explored differences in arrests by type and severity of crime, use of opioid and other drugs, and study phase.

RESULTS

Of 308 participants randomized, 300 had arrest data. The incidence of arrests did not differ between XR-NTX (47.6%) and TAU (42.5%) participants. (ChiSq p = 0.37). Additionally, there was no significant difference in time to first arrest (adjusted HR 1.35, CI 0.96-1.89) and number of arrests per participant (adjusted IR 1.33, CI 0.78-2.27). Controlling for gender, age, previous criminal activity, and use of non-opioid drugs, logistic regression demonstrated no significant difference in incidence of arrests between groups (adjusted OR 1.38, 95% CI 0.85-2.22).

CONCLUSIONS

We detected no significant difference in arrests between CJS participants with OUD randomized to XR-NTX or TAU. Despite its efficacy in reducing opioid use, XR-NTX alone may be insufficient to reduce criminal recidivism.

Accuracy Screening for ST Elevation Myocardial Infarction in a Task-switching Simulation

INTRODUCTION

Interruptions in the emergency department (ED) are associated with clinical errors, yet are important when providing care to multiple patients. Screening triage electrocardiograms (ECG) for ST-segment elevation myocardial infarction (STEMI) represent a critical interrupting task that emergency physicians (EP) frequently encounter. To address interruptions such as ECG interpretation, many EPs engage in task switching, pausing their primary task to address an interrupting task. The impact of task switching on clinical errors in interpreting screening ECGs for STEMI remains unknown.

METHODS

Resident and attending EPs were invited to participate in a crossover simulation trial. Physicians first completed a task-switching simulation in which they viewed patient presentations interrupted by clinical tasks, including screening ECGs requiring immediate interpretation before resuming the patient presentation. Participants then completed an uninterrupted simulation in which patient presentations and clinical tasks were completed sequentially without interruption. The primary outcome was accuracy of ECG interpretation for STEMI during task switching and uninterrupted simulations.

RESULTS

Thirty-five participants completed the study. We found no significant difference in accuracy of ECG interpretation for STEMI (task switching 0.89, uninterrupted 0.91, paired t-test p=0.21). Attending physician status (odds ratio [OR] [2.56], confidence interval [CI] [1.66-3.94], p<0.01) and inferior STEMI (OR [0.08], CI [0.04-0.14], p<0.01) were associated with increased and decreased odds of correct interpretation, respectively. Low self-reported confidence in interpretation was associated with decreased odds of correct interpretation in the task-switching simulation, but not in the uninterrupted simulation (interaction p=0.02).

CONCLUSION

In our simulation, task switching was not associated with overall accuracy of ECG interpretation for STEMI. However, odds of correct interpretation decreased with inferior STEMI ECGs and when participants self-reported low confidence when interrupted. Our study highlights opportunities to improve through focused ECG training, as well as self-identification of "high-risk" screening ECGs prone to error during interrupted clinical workflow.

Healthcare utilization in adults with opioid dependence receiving extended release naltrexone compared to treatment as usual

BACKGROUND

Opioid use disorders have reached epidemic proportions, with overdose now the leading cause of accidental death in the United States. Extended release naltrexone (XR-NTX) has emerged as a medication treatment that reduces opioid use and craving. However, the effect of XR-NTX therapy on acute healthcare utilization, including emergency department visits and inpatient hospitalizations, remains uncertain. The objective of the current study is to evaluate hospital-based healthcare resource utilization in adults involved in the criminal justice system with a history of opioid use disorder randomized to XR-NTX therapy compared with treatment as usual (TAU) during a 6-month treatment phase and 12months post-treatment follow up.

METHODS

This retrospective exploratory analysis uses data collected in a published randomized trial. Comparisons of the number of emergency department visits and hospital admissions (for drug detox, psychiatric care and other medical reasons) were performed using chi square tests for any admission and negative binomial models for number of admissions.

RESULTS

Of the 308 participants randomized, 96% had utilization data (76% complete 6months, 67% complete follow up). No significant differences were seen in overall healthcare utilization (IRR=0.88, 95%CI 0.63-1.23, p=0.45), or substance use-related drug detox hospitalizations (IRR=0.83, 95%CI 0.32-2.16, p=0.71). Despite having more participants report chronic medical problems at baseline (43% vs. 32%, p=0.05), those receiving XR-NTX generally experienced equivalent or lower rates of healthcare utilization compared to TAU. The XR-NTX group had significantly lower medical/surgical related hospital admissions (IRR=0.55, 95%CI 0.30-1.00, p=0.05) during the course of the entire study.

CONCLUSIONS

XR-NTX did not significantly increase rates of healthcare utilization compared to TAU. Provider concerns regarding healthcare utilization should not preclude the consideration of XR-NTX as therapy for opioid use disorders.

Comparison of the multiple mini-interview with the traditional interview for U.S. emergency medicine residency applicants: a single-institution experience

PURPOSE

The multiple mini-interview (MMI) is a validated interview technique used primarily to evaluate medical school applicants. No study has compared MMIs with traditional interviews (TIs) in the evaluation of U.S. emergency medicine residency (EMR) applicants.

METHOD

During the 2011-2012 interview season, a four-station MMI was incorporated into the interview process for EMR applicants at Alameda Health System-Highland Hospital (AHS). A postinterview anonymous questionnaire was offered to all applicants after they submitted their rank lists but prior to release of National Residency Matching Program results. Respondents rated their perceptions of the MMI and TI on a five-point Likert scale. McNemar chi-square test was used to explore differences in respondents' perceptions of interview styles.

RESULTS

One hundred ten interviewees completed the survey (73%). Overall, applicants found the TI more enjoyable than the MMI process (98 [89%] compared with 48 [44%], McNemar chi-square=28.66, P<.01) and preferred the TI process to the MMI (66 [60%] compared with 9 [10%], McNemar chi-square=40.81, P<.01). Sixteen applicants (14%) indicated that the use of the MMI would negatively affect their ranking of the program.

CONCLUSIONS

In contrast to prior studies, U.S. EMR applicants to AHS preferred the TI to the MMI. Further investigation into the use of the MMI for selecting U.S. EMR applicants is warranted.

Comparative Effectiveness of Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest: Insight from a Large Data Registry

This study was done to determine the effectiveness of therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) among a large cohort of adults in the Cardiac Arrest Registry to Enhance Survival (CARES), with an emphasis on subgroups with a nonshockable first documented rhythm. This was an IRB approved retrospective cohort study. All adult index events at participating sites from November 2010 to December 2013 were study eligible. All patient data elements were provided. Summary statistics were calculated for all patients with and without TH. For multivariate adjustment, a multilevel (i.e., hierarchical), mixed-effects logistic regression (MLR) model was used with hospitals treated as random effects. Propensity score matching (PSM) on both shockable and nonshockable patients was done as a sensitivity analysis. After predefined exclusions, our final sample size was 6369 records for analysis: shockable=2992 (47.0%); asystole=1657 (26.0%); pulseless electrical activity=1249 (19.6%); other unspecified nonshockable=471 (7.4%). Unadjusted differences in neurological status at hospital discharge with and without TH were similar (p=0.295). After multivariate adjustment, TH had either no association with good neurological status at hospital discharge or that TH was actually associated with worse neurological outcome, particularly in patients with a nonshockable first documented rhythm (i.e., for NS patients, MLR odds ratio for TH=1.444; 95% CI [1.039, 2.006] p=0.029, and OR=1.017, p=0.927 via PSM). Highlighting our limitations, we conclude that when TH is indiscriminately provided to a large population of OHCA survivors with a nonshockable first documented rhythm, evidence for its effectiveness is diminished. We suggest more uniform and rigid guidelines for application.

Management strategies for acute headache in the emergency department

Approximately 2.1 million patients per year present to United States emergency departments with a primary headache disorder. For emergency clinicians, the responsibility is twofold: First, exclude causes of headaches that pose immediate threats to the life and welfare of patients. Second, provide safe, effective, and rapid treatment of symptoms, while facilitating discharge from the emergency department with appropriate follow-up. While emergency management focuses on identification and treatment of life-threatening causes of headache, such as subarachnoid hemorrhage or bacterial meningitis, there is a tendency to misdiagnose specific primary headache disorders and fail to provide consistent, effective treatments in accordance with published guidelines. These mistakes can be avoided by resisting the temptation to label patients with specific primary headache diagnoses and by adopting a consistent, reproducible strategy for treatment of primary headache disorders in the emergency department that is evidence-based and effective.