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James d'Etienne, MD

The influence of patient perception of physician empathy on patient satisfaction among attending physicians working with residents in an emergent care setting

Wed, 08/25/2021 - 05:00

Health Sci Rep. 2021 Aug 17;4(3):e337. doi: 10.1002/hsr2.337. eCollection 2021 Sep.

ABSTRACT

BACKGROUND: It is unclear whether the patient's perception of attending physician empathy and the patient's satisfaction can be affected when attending physicians work alongside residents. We aim to determine the influence residents may have on (1) patient perception of attending physician empathy and (2) patient satisfaction as it relates to their respective attending physicians.

METHODS: This is a prospective single-center observational study. Patient perception of physician empathy was measured using Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE) in both attendings and residents in the Emergency Department. Patient satisfaction with attending physicians and residents was measured by real-time patient satisfaction survey. Multivariate logistic regressions were performed to determine the association between patient satisfaction and JSPPPE after patient demographics, attending physician different experience, and residents with different years of training were adjusted.

RESULTS: A total of 351 patients were enrolled. Mean JSPPPE scores were 30.1 among attending working alone, 30.1 in attending working with PGY-1 EM residents, 29.6 in attending working with PGY-2, and 27.8 in attending working with PGY-3 (p < 0.05). Strong correlation occurred between attending JSPPPE score and patient satisfaction to attending physicians (ρ > 0.5). The adjusted odds ratio was 1.32 (95% CI 1.23-1.41, p < 0.001) on attending's JSPPPE score predicting patient satisfaction to the attending physicians. However, there were no significant differences on patient satisfaction among four different groups.

CONCLUSION: Empathy has strong correlation with patient satisfaction. Decreased patient perception of attending physician empathy was found when working with senior residents in comparison to working alone or with junior residents.

PMID:34430711 | PMC:PMC8369944 | DOI:10.1002/hsr2.337

Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-analysis

Tue, 07/27/2021 - 05:00

J Neurotrauma. 2021 Jul 27. doi: 10.1089/neu.2021.0102. Online ahead of print.

ABSTRACT

This study aimed to investigate whether early surgical decompression was associated with favourable neurological recovery in patients with traumatic spinal cord injury (tSCI). We searched PubMed and Embase from the database inception through December 2020 and selected studies comparing the impact of early versus late surgical decompression on neurological recovery as assessed by American Spinal Injury Association Impairment Scale (AIS) for adult patients sustaining tSCI. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Subgroup analysis and meta-regression analysis was conducted to identify significant outcome moderator. We included 26 studies involving 3,574 patients in the meta-analysis. The pooled results demonstrated significant association between early surgical decompression and an improvement of at least one AIS grade (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.41-2.41; I2, 48.06%). The benefits of early surgical decompression were consistently observed across different subgroups, including patients with cervical or thoracolumbar injury and patients with complete or incomplete injury. The meta-regression analysis indicated that cut-off timing defining early versus late decompression was a significant effect moderator, with early decompression performed before post-tSCI 8 or 12 h associated with greatest benefits (OR, 3.37; 95% CI, 1.74-6.50; I2, 53.52%). No obvious publication bias was detected by the funnel plot. In conclusion, early surgical decompression was associated with favourable neurological recovery for tSCI patients. However, there was a lack of high-quality evidence and the results need further examination.

PMID:34314253 | DOI:10.1089/neu.2021.0102

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial

Mon, 06/21/2021 - 05:00

Circ Cardiovasc Qual Outcomes. 2021 Jun 21:CIRCOUTCOMES120007600. doi: 10.1161/CIRCOUTCOMES.120.007600. Online ahead of print.

ABSTRACT

BACKGROUND: The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.

METHODS: This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes.

RESULTS: We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled.

CONCLUSIONS: Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE.

REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.

PMID:34148351 | DOI:10.1161/CIRCOUTCOMES.120.007600

A Simplified Comorbidity Evaluation Predicting Clinical Outcomes Among Patients With Coronavirus Disease 2019

Wed, 05/19/2021 - 05:00

J Clin Med Res. 2021 Apr;13(4):237-244. doi: 10.14740/jocmr4476. Epub 2021 Apr 27.

ABSTRACT

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) have shown a range of clinical outcomes. Previous studies have reported that patient comorbidities are predictive of worse clinical outcomes, especially when patients have multiple chronic diseases. We aim to: 1) derive a simplified comorbidity evaluation and determine its accuracy of predicting clinical outcomes (i.e., hospital admission, intensive care unit (ICU) admission, ventilation, and in-hospital mortality); and 2) determine its performance accuracy in comparison to well-established comorbidity indexes.

METHODS: This was a single-center retrospective observational study. We enrolled all emergency department (ED) patients with COVID-19 from March 1, 2020, to December 31, 2020. A simplified comorbidity evaluation (COVID-related high-risk chronic condition (CCC)) was derived to predict different clinical outcomes using multivariate logistic regressions. In addition, chronic diseases included in the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) were scored, and its accuracy of predicting COVID-19 clinical outcomes was also compared with the CCC.

RESULTS: Data were retrieved from 90,549 ED patient visits during the study period, among which 3,864 patients were COVID-19 positive. Forty-seven point nine percent (1,851/3,864) were admitted to the hospital, 9.4% (364) patients were admitted to the ICU, 6.2% (238) received invasive mechanical ventilation, and 4.6% (177) patients died in the hospital. The CCC evaluation correlated well with the four studied clinical outcomes. The adjusted odds ratios of predicting in-hospital death from CCC was 2.84 (95% confidence interval (CI): 1.81 - 4.45, P < 0.001). C-statistics of CCC predicting in-hospital all-cause mortality was 0.73 (0.69 - 0.76), similar to those of the CCI's (0.72) and ECI's (0.71, P = 0.0513).

CONCLUSIONS: CCC can accurately predict clinical outcomes among patients with COVID-19. Its performance accuracies for such predictions are not inferior to those of the CCI or ECI's.

PMID:34007362 | PMC:PMC8110217 | DOI:10.14740/jocmr4476

Association between burnout and wellness culture among emergency medicine providers

Mon, 04/12/2021 - 05:00

Clin Exp Emerg Med. 2021 Mar;8(1):55-64. doi: 10.15441/ceem.20.074. Epub 2021 Mar 31.

ABSTRACT

OBJECTIVE: Burnout is a common occurrence among healthcare providers and has been associated with provider wellness culture. However, this association has not been extensively studied among emergency medicine (EM) providers. We aim to determine the association between EM provider burnout and their culture of wellness, and to elicit the independent wellness culture domains most predictive of burnout prevention.

METHODS: This was a multi-center observational study. We enrolled EM physicians and advanced practice providers from sixteen different emergency departments (EDs). Provider wellness culture and burnout surveys were performed. The wellness culture domains included in this study are personal/organizational value alignment, provider appreciation, leadership quality, self-controlled scheduling, peer support, and family support. Correlations between each wellness culture domain and burnout were analyzed by Pearson correlation co-efficiency, and their associations were measured by multivariate logistic regression with adjustments of other confounders.

RESULTS: A total of 242 ED provider surveys were entered for final analysis. The overall burnout rate was 54% (130/242). Moderate correlations were found between burnout and two wellness culture domains (value alignment: r=-0.43, P<0.001 and provider appreciation: r=-0.49, P<0.001). The adjusted odds ratio of provider appreciation associated with burnout was 0.44 (95% confidence interval, 0.25-0.77; P=0.004), adjusted odds ratio of family support was 0.67 (95% confidence interval, 0.48-0.95; P=0.025).

CONCLUSION: ED providers have a relatively high burnout rate. Provider burnout might have certain associations with wellness culture domains. Provider appreciation and family support seem to play important roles in burnout protection.

PMID:33845524 | DOI:10.15441/ceem.20.074

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

Tue, 03/09/2021 - 05:00

Scand J Trauma Resusc Emerg Med. 2021 Mar 8;29(1):44. doi: 10.1186/s13049-021-00858-6.

ABSTRACT

INTRODUCTION: This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS: We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.

RESULTS: Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42-11.02, p: 0.02). That is, when the studies not accounting for the variable of "time to intervention" in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.

CONCLUSIONS: The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

PMID:33685486 | PMC:PMC7938460 | DOI:10.1186/s13049-021-00858-6

The Role of Using HEART Score to Risk Stratify Chest Pain Among Emergency Department High Utilizers.

Wed, 12/30/2020 - 18:30
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The Role of Using HEART Score to Risk Stratify Chest Pain Among Emergency Department High Utilizers.

High Blood Press Cardiovasc Prev. 2020 Dec 28;:

Authors: Schrader CD, Meyering SH, Kumar D, Alanis N, D'Etienne JP, Shaikh S, Vo V, Kamaria AR, Huettner N, Wang H

Abstract
The HEART score is used to effectively risk stratify undifferentiated chest pain patients in the Emergency Department (ED). It is unclear whether such risk stratification can be applied among ED high utilizers. We aim to determine the efficacy and safety of using the HEART score to predict 30-day short-term major adverse cardiac events (MACE) in ED high utilizers. We conducted a retrospective, observational study in which ED high utilizers were defined as patients who had four or more ED visits within the past 12 months. ED high utilizers presenting at the study ED with chest pain were enrolled. Patients in which the HEART score was utilized were placed in the HEART group and patients with no HEART scores documented were placed to the usual care group. Hospital admissions and cardiac stress tests performed during the index hospitalizations, and 30-day MACE rates were analyzed and compared between the HEART and usual care groups. From January 1, 2017 to December 31, 2019, a total of 8,315 patient visits from ED high utilizers were enrolled. In the HEART group, 49% of ED visits were admitted with 20% receiving stress tests. A 30-day MACE outcome occurred among 1.4% of visits. In the usual care group, 44% of ED visits were admitted, with only 9% receiving index stress tests and a 1.5% of 30-day MACE occurrence (p=0.727). The study showed that similar short-term MACE outcomes occurred between patients using HEART scores and usual care to risk stratify chest pain among ED high utilizers.

PMID: 33369723 [PubMed - as supplied by publisher]

Synergistic effects of emergency physician empathy and burnout on patient satisfaction: a prospective observational study.

Wed, 12/02/2020 - 12:47
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Synergistic effects of emergency physician empathy and burnout on patient satisfaction: a prospective observational study.

Emerg Med J. 2020 Nov 25;:

Authors: Byrd J, Knowles H, Moore S, Acker V, Bell S, Alanis N, Zhou Y, d'Etienne JP, Kline JA, Wang H

Abstract
BACKGROUND: Physician empathy and burnout have been shown to be independently associated with patient satisfaction. However, their correlations were uncertain in previous studies. We aimed to determine correlations among empathy, burnout, and patient satisfaction, and further analyse interactions among these factors.
METHOD: A single centre prospective observational study was conducted from December 2018 to August 2019 at JPS Health Network, USA. Emergency physician (EP) self-assessed empathy and burnout were measured by the Jefferson Scale of Empathy (JSE) and the Copenhagen Burnout Inventory (CBI) separately. We assessed patient perception of physician empathy and patient satisfaction with their treating physician by the Jefferson Scale of Patient Perception of Physician Empathy and a patient assessed satisfaction survey. Spearman's correlation was used to determine associations among JSE, patient assessed physician empathy, CBI and patient satisfaction. Additionally, JSE, patient assessed physician empathy and CBI predictive of patient satisfaction were measured by multivariate logistic regression analysis.
RESULTS: A total of 28 EPs and 423 patients were enrolled. Patient satisfaction had a weak correlation with JSE (ρ=0.11) but showed a strong correlation with patient assessed physician empathy (ρ=0.60). CBI showed no correlation with patient satisfaction (ρ<0.1). However, when JSE, patient assessed physician empathy and CBI were analysed together in relation to patient satisfaction, adjusted odds ratios (AOR) was 3.85 (95% CI 1.36 to 10.88) with high patient assessed physician empathy alone; AOR was 7.17 (2.62-19.67) when high patient assessed physician empathy was combined with low CBI; and AOR was 8.37 (3.07-22.83) when high patient assessed physician empathy, low CBI and high JSE were combined.
CONCLUSION: Patient assessed physician empathy had a strong positive correlation with patient satisfaction. Moreover, higher patient satisfaction was achieved from EPs of high patient assessed physician empathy, low CBI and high JSE, indicating a positive synergistic effect. These findings suggest different interventions might be applied to EPs of different wellness features to maximise patient satisfaction.

PMID: 33239313 [PubMed - as supplied by publisher]

Dedicated homeless clinics reduce inappropriate emergency department utilization.

Wed, 11/11/2020 - 07:34
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Dedicated homeless clinics reduce inappropriate emergency department utilization.

J Am Coll Emerg Physicians Open. 2020 Oct;1(5):829-836

Authors: Holmes CT, Holmes KA, MacDonald A, Lonergan FR, Hunt JJ, Shaikh S, Cheeti R, D'Etienne JP, Zenarosa NR, Wang H

Abstract
Background: The homeless patient population is known to have a high occurrence of inappropriate emergency department (ED) utilization. The study hospital initiated a dedicated homeless clinic targeting patients experiencing homelessness with a combination of special features. We aim to determine whether this mode of care can reduce inappropriate ED utilization among homeless patients.
Methods: We conducted a retrospective observational study from July 1, 2017 to Dec 31, 2017. The study enrolled all homeless patients who visited any hospital regular clinic, dedicated homeless clinic, and ED at least once during the study period. ED homeless patients were divided into four groups (A: no clinic visits; B: those who only visited hospital regular clinic; C: those who only visited dedicated homeless clinic; and D: those who visited both hospital regular clinic and dedicated homeless clinic). The New York University algorithm was used to determine appropriate ED utilization. We compared inappropriate ED utilization among patients from these groups. Multivariate logistic regression was used to determine the risks of different clinical visits in association with inappropriate ED utilization.
Results: A total of 16,323 clinic and 8511 ED visits occurred among 5022 unique homeless patients, in which 2450 unique patients were seen in hospital regular clinic, 784 patients in dedicated homeless clinic, 688 patients in both hospital regular clinic and dedicated homeless clinic, and 1110 patients with no clinic visits. Twenty-nine percent (230/784) of patients from dedicated homeless clinic utilized the ED, among which 21% (175/844) of their ED visits were considered inappropriate. In contrast, 40% of patients from hospital regular clinic utilized the ED, among which 29% were inappropriate (P < 0.001). The adjusted odds ratio (OR) was 0.61 (95% confidence interval [CI] = 0.50-0.74, P < 0.001) on dedicated homeless clinic predicting inappropriate ED visits in multivariate logistic regression.
Conclusion: Implementing a dedicated homeless clinic with these features can reduce ED inappropriate utilization among patients experiencing homelessness.

PMID: 33145527 [PubMed]

Lung Ultrasound for COVID-19 Evaluation in the Emergency Department: Is It Feasible?

Wed, 10/07/2020 - 01:05

Lung Ultrasound for COVID-19 Evaluation in the Emergency Department: Is It Feasible?

Ann Emerg Med. 2020 10;76(4):552-553

Authors: Wolfshohl J, Shedd A, Chou EH, d'Etienne JP

PMID: 33012385 [PubMed - in process]

Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department.

Wed, 10/07/2020 - 01:05

Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department.

BMJ Open. 2020 Oct 01;10(10):e038078

Authors: Kline J, Adler D, Alanis N, Bledsoe J, Courtney D, D'Etienne J, B Diercks D, Garrett J, Jones AE, MacKenzie D, Madsen T, Matuskowitz A, Mumma B, Nordenholz K, Pagenhardt J, Runyon M, Stubblefield W, Willoughby C

Abstract
INTRODUCTION: In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED.
METHODS AND ANALYSIS: This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017.
ETHICS AND DISSEMINATION: All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.

PMID: 33004396 [PubMed - in process]

Building RAFT: Trafficking Screening Tool Derivation and Validation Methods.

Wed, 10/07/2020 - 01:05
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Building RAFT: Trafficking Screening Tool Derivation and Validation Methods.

Acad Emerg Med. 2020 04;27(4):297-304

Authors: Chisolm-Straker M, Singer E, Rothman EF, Clesca C, Strong D, Loo GT, Sze JJ, d'Etienne JP, Alanis N, Richardson LD

Abstract
BACKGROUND: Labor and sex trafficking have long impacted the patients who seek care in emergency departments (ED) across the United States. Increasing social and legislative pressures have led to multiple calls for screening for trafficking in the clinical care setting, but adoption of unvalidated screening tools for trafficking recognition is unwise for individual patient care and population-level data. Development of a valid screening tool for a social malady that is largely "invisible" to most clinicians requires significant investments. Valid screening tool development is largely a poorly understood process in the antitrafficking field and among clinicians who would use the tools.
METHODS: The authors describe the study design and procedures for reliable data collection and analysis in the development of RAFT (Rapid Appraisal for Trafficking). In a five-ED, randomized, prospective study, RAFT will be derived and validated as a labor and sex trafficking screening tool for use among adult ED patients. Using a novel method of ED patient-participant randomization, intensively trained data collectors use qualitative data to assess subjects for a lifetime experience of human trafficking.
CONCLUSION: Study methodology transparency encourages investigative rigor and integrity and will allow other sites to reproduce and externally validate this study's findings.

PMID: 31725176 [PubMed - indexed for MEDLINE]

Two-step predictive model for early detection of emergency department patients with prolonged stay and its management implications.

Sun, 02/23/2020 - 16:10
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Two-step predictive model for early detection of emergency department patients with prolonged stay and its management implications.

Am J Emerg Med. 2020 Jan 30;:

Authors: d'Etienne JP, Zhou Y, Kan C, Shaikh S, Ho AF, Suley E, Blustein EC, Schrader CD, Zenarosa NR, Wang H

Abstract
OBJECTIVE: To develop a novel model for predicting Emergency Department (ED) prolonged length of stay (LOS) patients upon triage completion, and further investigate the benefit of a targeted intervention for patients with prolonged ED LOS.
MATERIALS AND METHODS: A two-step model to predict patients with prolonged ED LOS (>16 h) was constructed. This model was initially used to predict ED resource usage and was subsequently adapted to predict patient ED LOS based on the number of ED resources using binary logistic regressions and was validated internally with accuracy. Finally, a discrete event simulation was used to move patients with predicted prolonged ED LOS directly to a virtual Clinical Decision Unit (CDU). The changes of ED crowding status (Overcrowding, Crowding, and Not-Crowding) and savings of ED bed-hour equivalents were estimated as the measures of the efficacy of this intervention.
RESULTS: We screened a total of 123,975 patient visits with final enrollment of 110,471 patient visits. The overall accuracy of the final model predicting prolonged patient LOS was 67.8%. The C-index of this model ranges from 0.72 to 0.82. By implementing the proposed intervention, the simulation showed a 12% (1044/8760) reduction of ED overcrowded status - an equivalent savings of 129.3 ED bed-hours per day.
CONCLUSIONS: Early prediction of prolonged ED LOS patients and subsequent (simulated) early CDU transfer could lead to more efficiently utilization of ED resources and improved efficacy of ED operations. This study provides evidence to support the implementation of this novel intervention into real healthcare practice.

PMID: 32063427 [PubMed - as supplied by publisher]

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

Fri, 07/12/2019 - 00:24
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Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

BMC Health Serv Res. 2019 Jul 04;19(1):451

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, Ho AF, D'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
BACKGROUND: It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients.
METHODS: This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions.
RESULT: A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001).
CONCLUSIONS: Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

PMID: 31272442 [PubMed - in process]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Thu, 07/04/2019 - 21:46
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Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Association between emergency physician self-reported empathy and patient satisfaction.

Wed, 01/30/2019 - 08:21
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Association between emergency physician self-reported empathy and patient satisfaction.

PLoS One. 2018;13(9):e0204113

Authors: Wang H, Kline JA, Jackson BE, Laureano-Phillips J, Robinson RD, Cowden CD, d'Etienne JP, Arze SE, Zenarosa NR

Abstract
BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.
OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.
RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED.
METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.
RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).
CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

PMID: 30212564 [PubMed - in process]

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study

Tue, 07/14/2015 - 05:00

Emerg Med Int. 2015;2015:401757. doi: 10.1155/2015/401757. Epub 2015 Jun 8.

ABSTRACT

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

PMID:26167302 | PMC:PMC4475699 | DOI:10.1155/2015/401757

Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis

Sat, 01/07/2012 - 05:00

West J Emerg Med. 2011 Nov;12(4):426-32. doi: 10.5811/westjem.2011.3.2023.

ABSTRACT

INTRODUCTION: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.

METHODS: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.

RESULTS: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively.

CONCLUSION: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

PMID:22224132 | PMC:PMC3236159 | DOI:10.5811/westjem.2011.3.2023