The impact of racism on emergency health care workers

INTRODUCTION

Discrimination based on race is a known source of stress in individuals and is a contributor to poor health outcomes in patients. However, less is known about how the experiences of racism impact the stress levels of emergency health care workers (EHCWs).

OBJECTIVES

The goal of this study was to assess the impact that racism has on the stress of EHCWs.

METHODS

An anonymous electronic cross-sectional survey of EHCWs including attending physicians, resident physicians, advanced practice providers, nurses, and staff at three large metropolitan hospitals was administered in the summer of 2020. The survey evaluated the stress related to systemic racism and the COVID-19 pandemic in addition to the wellness measures utilized to cope with these stressors. The focus of this article is the impact of systemic racism on EHCWs.

RESULTS

Of the 576 eligible participants, the total number of respondents utilized for analysis was 260. Overall, 64% of participants were very concerned about the state of racism in the United States, and 30% reported moderate-high or high stress resulting from racism. When stratified by race, 46% of Black participants reported moderate-high or high stress resulting from racism, compared to 31% of other participants of color and 23% of White participants (p = 0.002).

CONCLUSION

Systemic racism is a significant concern and source of stress for EHCWs. Additional research about systemic racism, its impact on medical providers, and more importantly, active strategies to reduce and ultimately eliminate it in health care is needed.

A Novel Simulation to Assess Residents' Utilization of a Medical Interpreter

INTRODUCTION

Physicians must be facile in working with a medical interpreter (MI) given the large population of patients with limited English proficiency.

METHODS

To facilitate residents' assessment of their ability to interact with non-English-speaking patients, we developed a simulation case involving one such patient. The case involved a 31-year-old Spanish-speaking postpartum female who presented with eclamptic seizures. The learner needed to request an MI to assist with obtaining the patient's medical history once her concerned family member (also Spanish speaking) arrived. The major critical actions included appropriate use of MI services, recognition of the risk for eclamptic seizures, proper evaluation and treatment, and appropriate disposition to an obstetrician. The case required a high-fidelity mannequin and simulation operator, nurse simulated participant, Spanish-speaking actor (to play the husband or family member), certified Spanish MI, and faculty evaluator.

RESULTS

We implemented this case with 60 emergency medicine residents, ranging from PGY 1 to 3. The learner was assessed by both the faculty observer and MI. Checklists for assessment and debriefing materials were provided. Two of 60 residents did not request an MI. When compared to a prior version of this case that did not include the language barrier, median scores dropped from 12 to 10 out of 24, suggesting that the language barrier created a more challenging case.

DISCUSSION

The use of MIs is an integral part of health care practice in the United States, and we present a simulation case that can assess learners' use of MIs.

Contributors to and impact of residual shunting after device closure of atrial septal defects

BACKGROUND

The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined.

METHODS

From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling.

RESULTS

Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death.

CONCLUSIONS

Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.

Impact of Frailty and Sociodemographic Factors on Hospital Admission From an Emergency Department Observation Unit

Understanding factors associated with an increased risk of hospital admission from emergency department (ED) observation units (OUs) could be valuable in disposition decisions. To evaluate the impact of frailty and sociodemographic factors (SDFs) on admission risk, patients in an ED OU were surveyed. Survey measures included SDFs, social habits, and frailty measured by the Katz Index of Independence in Activities of Daily Living. Of 306 surveyed, 18% were admitted and 82% were discharged. Demographics were similar between groups. More admitted patients responded positively to the Katz Index (28% vs 13%, P = .007; odds ratio = 2.73; 95% CI = 1.35-5.51). College graduation and current employment favored the discharge group, while admitted patients were more likely to receive Social Security disability insurance. Frailty remained associated with admission on multivariable analysis. Frailty, disability insurance, and lower education are predictors of admission from an OU and could serve as screening criteria in disposition decisions.

Comparison of long-term postoperative sequelae in patients with tetralogy of Fallot versus isolated pulmonic stenosis

Patients with tetralogy of Fallot (TOF) after complete repair and pulmonic stenosis (PS) after surgical valvotomy often develop significant pulmonic regurgitation (PR) that eventually requires valve replacement. Although criteria exist for the timing of pulmonary valve replacement in TOF, it remains less clear when to intervene in valvotomy patients and whether TOF recommendations can be applied. Our aim was to compare the structural and functional sequelae of valvotomy for PS with complete repair for TOF. We compared the clinical characteristics, electrocardiograms, echocardiograms, cardiac magnetic resonance imaging (MRI), and invasive hemodynamics of 109 adults (34 PS and 75 TOF) newly referred to a congenital heart disease center for evaluation of PR between 2005 and 2012. Both cohorts were similar in terms of baseline demographics and presenting New York Heart Association function class. Valvotomy patients had a slightly greater degree of PR by echocardiogram, although it was similar by cardiac MRI. Electrocardiography QRS width was greater in patients with TOF (114±27 vs 150±28 ms, p<0.001). MRI right ventricular ejection fraction (49±8 vs 41±11%, p=0.001) and left ventricular ejection fraction (59±7 vs 52±10%, p=0.002) were lower in patients with TOF. Pacemaker or defibrillator implantation was significantly greater in patients with TOF (3% vs 23%, p=0.011). In conclusion, patients postvalvotomy and complete repair present with similar degrees of PR and severity of symptoms. Biventricular systolic function and electrocardiography QRS width appear less affected, suggesting morphologic changes in TOF and its repair that extend beyond the effects of PR. These findings suggest the need for developing disease-specific guidelines for patients with PR postvalvotomy.