Emergency Department Patients' COVID-19 Vaccination Status and Self-Reported Barriers.

INTRODUCTION: This study surveyed adult emergency department (ED) patients and the adult companions of pediatric patients to determine whether rates of coronavirus disease 2019 (COVID-19) vaccination were comparable to that of the general population in the region. This study also sought to identify self-reported barriers to vaccination and possible areas for intervention. METHODS: A survey was administered to 607 adult ED patients or the adult companions of pediatric patients from three different regional hospitals to assess their COVID-19 vaccination status, COVID-19 vaccine barriers, and demographic information. RESULTS: Of the 2,267 adult patients/companions considered for enrollment, we approached 730 individuals about participating in the study. Of the individuals approached, 607 (41% male; mean age 47.0+17.4 years) consented to participate. A total of 403 (66.4%) participants had received at least one vaccine dose as compared to 70% of the adult population in the county where the three hospitals were located. Of those, 382 (94.8%) were fully vaccinated and among the individuals who were partially vaccinated the majority (17 of 21) had an appointment for their second dose. Of those approached, 204 (33.6%) were not vaccinated, with 66 (10.9% of the total population) expressing an interest in becoming vaccinated while the remaining 138 did not want to be vaccinated. Of those who wanted to be vaccinated 32% were waiting for more safety data, and of those who did not want to be vaccinated 26% were concerned about side effects and risks and 28% were waiting for more safety data. CONCLUSION: Adult ED patients and adult companions of pediatric ED patients were vaccinated at a slightly lower rate than the general population in our county. A small but significant proportion of those who were unvaccinated expressed the desire to be vaccinated, indicating that the ED may be a suitable location to introduce a COVID-19 vaccination program.

Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms.

OBJECTIVE: The Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days). METHODS: This prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8-18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived. RESULTS: Out of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation. CONCLUSION: The Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.

Migrating Swollen Joint and Lyme Disease: A Case Report.

This article discusses a case involving a pediatric patient who presented to a large urban children's hospital in the Northeastern United States with complaints of migratory monoarticular joint swelling. The patient had presented with a swollen and painful left knee but with no other associated symptoms. He was nontoxic appearing, afebrile, and had normal vital signs. On examination, he was noted to have a tender and swollen left knee that was not erythematous, bruised, or warm to the touch. There was a history of fevers over the summer after returning home from a camping trip in a park located in the northeastern United States. A plain film knee x-ray showed signs of joint effusion but no osseous abnormalities. A bedside ultrasonography of the knee showed a pocket of fluid in the joint space. With parental consent, the left knee joint was aspirated under direct ultrasound guidance, with collection of dark yellow synovial fluid. This was sent for analysis that included cultures, Gram stain, crystal analysis, and Lyme antigens. The patient was admitted, and his symptoms improved during his hospitalization. The results were positive for Lyme and he was discharged home on a 3-week course of Amoxicillin with complete resolution of his symptoms.

Recommended Musculoskeletal and Sports Medicine Model Curriculum for Emergency Medicine Residency Training.

ABSTRACT: Musculoskeletal and sports medicine conditions are common in the emergency department (ED). Emergency physicians may not be receiving adequate education to achieve clinical competency in musculoskeletal medicine during residency training. This article aims to provide a standardized musculoskeletal and sports medicine curriculum for emergency medicine training. Broad curriculum goals include proficiency in evaluating and managing patients presenting to the ED with acute and chronic musculoskeletal complaints and other medical conditions related to or affected by physical exertion, sports participation, or environmental exposure. Specific objectives focus on knowledge of these disorders, physical examination skills, procedural skills including musculoskeletal ultrasound, appropriate consultation and referral, and patient education for these conditions. Educational methods will consist of didactics; online self-directed learning modules; simulation; and supervised clinical experiences in the ED, primary care sports medicine clinics, and orthopedic clinics if available. Curriculum implementation is expected to vary across programs due to differences in residency program structure and resources.

Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial.

Importance: Sport-related concussion (SRC) is a significant public health problem without an effective treatment. Objective: To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC. Design, Setting, and Participants: This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen. Interventions: After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobic exercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website. Main Outcomes and Measures: Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (<30 days) or delayed (≥30 days) recovery. Results: A total of 103 participants were included (aerobic exercise: n = 52; 24 female [46%]; stretching, n = 51; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas stretching participants recovered in 17 (IQR, 13-23) days (P = .009 by Mann-Whitney test). There was a nonsignificant lower incidence of delayed recovery in the aerobic exercise group (2 participants [4%] in the aerobic group vs 7 [14%] in the placebo group; P = .08). Conclusions and Relevance: This is, to our knowledge, the first RCT to show that individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery. Trial Registration: ClinicalTrials.gov identifier: NCT02710123.

Emergency Department Crowding and Time at the Bedside: A Wearable Technology Feasibility Study.

INTRODUCTION: ED crowding is a public health crisis, limiting quality and access to lifesaving care. The purpose of this study was to (1) evaluate the feasibility of radio-frequency identification tags to measure clinician-patient contact and (2) to test the relationship between ED occupancy and clinician-patient contact time. METHODS: In this 4-week observational study, radio-frequency identification tags were worn by emergency clinicians in a 21-bay urban teaching hospital emergency department. The time-motion data were merged with electronic medical repository patient information (N = 3,237) to adjust for occupancy, age, gender, and acuity. Qualitative themes were generated from focus group (N = 39) debriefings of the quantitative results. RESULTS: Data were collected on 56,342 total clinician events. Adjusting for patient age, increasing ED occupancy increased the number of times the attending physician entered and left the patient room (b = 0 .008, 95% confidence interval [CI] = [0.001-0.016], P = 0.03). There was no relationship for patient gender, triage acuity, shift at arrival, disposition to home, or discharge diagnosis category with either total minutes or number of encounters per patient visit. No time-motion and occupancy associations were observed for nurses, residents, or nurse practitioners/physician assistants. Debriefings indicated occupancy influenced the quality of care, despite maintaining the same quantity of contact time. DISCUSSION: The physical environment and clinician privacy concerns limit the feasibility of wearable tracking technology in the emergency setting. Attending physician care becomes more fragmented with increasing ED occupancy. Other clinicians report changes in the quality of care, whereas the quantity of time and encounters were unchanged with occupancy rates.