Cross-sectional analysis of healthcare worker mental health and utilisation of a digital mental health platform from 2020 to 2023.

BACKGROUND: Healthcare worker (HCW) anxiety and depression worsened during the pandemic, prompting the expansion of digital mental health platforms as potential solutions offering online assessments, access to resources and counselling. The use of these digital engagement tools may reflect tendencies and trends for the mental health needs of HCWs. OBJECTIVES: This retrospective, cross-sectional study investigated the association between the use of an online mental health platform within a large academic health system and measures of that system's COVID-19 burden during the first 3 years of the pandemic. METHODS: The study investigated the use of Cobalt, an online mental health platform, comprising deidentified mental health assessments and utilisation metrics. Cobalt, serves as an online mental health resource broadly available to health system employees, offering online evidence-based tools, coaching, therapy options and asynchronous content (podcasts, articles, videos and more). The analyses use validated mental health assessments (Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) and post-traumatic stress disorder (PTSD)) alongside publicly available COVID-19 data. Statistical analyses employed univariate linear regression with Stata SE Statistical Software. RESULTS: Between March 2020 and March 2023, 43 308 independent user sessions were created on Cobalt, a majority being anonymous sessions (72%, n=31 151). Mental health assessments, including PHQ-4, PHQ-9, GAD-7 and primary care-PTSD, totalled 9462 over the time period. Risk for self-harm was noted in 17.1% of PHQ-9 assessments. Additionally, 4418 appointments were scheduled with mental health counsellors and clinicians. No significant associations were identified between COVID-19 case burden and Cobalt utilisation or assessment scores. CONCLUSION: Cobalt emerged as an important access point for assessing the collective mental health of the workforce, witnessing increased engagement over time. Notably, the study indicates the nuanced nature of HCW assessments of anxiety, depression and PTSD, with mental health scores reflecting moderate decreases in depression and anxiety but signalling potential increases in PTSD. Tailored resources are imperative, acknowledging varied mental health needs within the healthcare workforce. Ultimately, this investigation lays the groundwork for continued exploration of the impact and effectiveness of digital platforms in supporting HCW mental health.

Interrogating and Uprooting Systemic Racism in the Emergency Department.

This Viewpoint discusses how recognizing systemic racism in emergency departments will allow for the mitigation of racial and ethnic disparities and promote equitable treatment for all patients.

Digital Engagement Strategy and Health Care Worker Mental Health: A Randomized Clinical Trial.

Importance: The health care workforce continues to experience high rates of depression and anxiety. Finding ways to effectively support the mental health and well-being of health care workers is challenging. Objective: To test the effectiveness of remote, pushed digital assessments and engagement to improve depression and anxiety among health care workers compared with usual care. Design, Setting, and Participants: This was a 9-month randomized clinical trial with a 6-month intervention period. Participants were health care workers with self-reported daily access to a smartphone and at least 4 clinical hours per week. Participants were randomized to usual care or the intervention between January 2022 and March 2023. Data analyses were conducted between May and July 2023. Interventions: All participants completed baseline, 6-month, and 9-month mental health, well-being, and burnout assessments. The control group had open access to a web-based mental health platform. Participants in the intervention group received monthly text messaging about mental health, mental health assessments, and linkages to care. Main Outcomes and Measures: The primary outcomes were mean change in depression and anxiety scores at 6 months from baseline. Secondary outcomes include mean change in well-being, burnout, and self-reported workplace productivity. Results: In this study, 1275 participants were randomized (642 [50.4%] to the intervention group and 633 [49.6%] to control group). Participants had a mean (SD) age of 38.6 (10.9) years, 1063 participants (83.4%) were female, 320 (25.1%) self-identified as Black, and 793 (62.2%) self-identified as White. Across the groups, the mean difference in depression score was significantly different at 6 months (-0.96 [95% CI, -1.52 to -0.40]) and at 9 months (-1.14 [95% CI, -1.69 to -0.58]). The mean difference in anxiety score from baseline to 6 months was statistically significantly larger for those in the intervention group vs usual care (-0.71 [95% CI, -1.25 to -0.17]) and held true at 9 months (-1.06 [95% CI, -1.59 to -0.52]). Conclusions and Relevance: In a trial of health care workers, a proactive digital engagement strategy, including pushed text messaging, mobile mental health assessments, and connection to care, improved depression and anxiety over a 6-month period compared with simply making the same resources available for individuals to find and use. Trial Registration: ClinicalTrials.gov Identifier: NCT05028075.

Perspectives of Black Patients on Racism Within Emergency Care.

Importance: Numerous Black individuals experience racism persistently throughout their lives, with repercussions extending into health care settings. The perspectives of Black individuals regarding emergency department (ED) care, racism, and patient-centered approaches for dismantling structural racism remain less explored. Objective: To qualitatively explore the perspectives and experiences of Black patients related to race, racism, and health care following a recent ED visit. Design, Setting, and Participants: In this qualitative study, the audio from semistructured interviews of Black patients discharged from an academic urban ED between August 2021 to April 2022 were recorded, transcribed, and analyzed using thematic analysis. Main Outcomes and Measures: The main outcomes encompassed the main themes from the analysis of the interviews with Black patients regarding their perspectives on race, racism, and clinical care. Results: A total of 25 Black patients (20 [80%] female; mean [SD] age, 44.6 [12.9] years) discharged from the ED were interviewed. Three broad domains were identified: (1) racism in health care; (2) ED clinical care; and (3) recommendations for improvement. Within these domains, the first 2 were grouped into specific themes. Within the first domain, racism in health care, 7 themes were identified using thematic analysis: (1) a history of medical racism; (2) dismissiveness; (3) patient expectations on encountering racism; (4) medical mistrust; (5) health literacy; (6) postencounter outcomes, and (7) discrimination beyond but associated with race. Within the second theme, ED clinical care, 5 themes were identified using the same thematic analysis method: (1) discharge plan; (2) patient experience; (3) waiting room perceptions; (4) medication treatment; and (5) pain management. The third domain, recommendations for improvement, incorporated patient-generated suggestions for enhancing the Black patient experience. Conclusions and Relevance: In this qualitative study, the fabric of clinical care delivery in the ED was intricately woven with Black patients' experiences of racism. Patients expressed a pervasive sense of mistrust, skepticism, and dismissiveness at the system level. Instances of racism were consistently highlighted by patients from their entry to the ED to discharge. These perspectives illuminate the pervasive nature of racism in clinical care, providing valuable insights for exploring patient-centered approaches to foster antiracist cultures in the ED and throughout the broader medical landscape.

Patient perceptions of behavioral flags in the emergency department: A qualitative analysis.

BACKGROUND: To combat increasing levels of violence in the emergency department (ED), hospitals have implemented several safety measures, including behavioral flags. These electronic health record (EHR)-based notifications alert future clinicians of past incidents of potentially threatening patient behavior, but observed racial disparities in their placement may unintentionally introduce bias in patient care. Little is known about how patients perceive these flags and the disparities that have been found in their placement. OBJECTIVE: This study aims to investigate patient perceptions and perceived benefits and harms associated with the use of behavioral flags. METHODS: Twenty-five semistructured qualitative interviews were conducted with a convenience sample of patients in the ED of a large, urban, academic medical center who did not have a behavioral flag in their EHR. Interviews lasted 10-20 min and were recorded then transcribed. Thematic analysis of deidentified transcripts took place in NVivo 20 software (QSR International) using a general inductive approach. RESULTS: Participant perceptions of behavioral flags varied, with both positive and negative opinions being shared. Five key themes, each with subthemes, were identified: (1) benefits of behavioral flags, (2) concerns and potential harms of flags, (3) transparency with patients, (4) equity, and (5) ideas for improvement. CONCLUSIONS: Patient perspectives on the use of behavioral flags in the ED vary. While many saw flags as a helpful tool to mitigate violence, concerns around negative impacts on care, transparency, and equity were also shared. Insights from this stakeholder perspective may allow for health systems to make flags more effective without compromising equity or patient ideals.

Investigating the Feasibility of Using a Wearable Device to Measure Physiologic Health Data in Emergency Nurses and Residents: Observational Cohort Study.

BACKGROUND: Emergency departments play a pivotal role in the US health care system, with high use rates and inherent stress placed on patients, patient care, and clinicians. The impact of the emergency department environment on the health and well-being of emergency residents and nurses can be seen in worsening rates of burnout and cardiovascular health. Research on clinician health has historically been completed outside of clinical areas and not personalized to the individual. The expansion of digital technology, specifically wearable devices, may enhance the ability to understand how health care environments impact clinicians. OBJECTIVE: The primary objective of this pilot study was to assess the feasibility and acceptability of using wearable devices to measure and record physiologic data from emergency nurses and resident physicians. Understanding strategies that are accepted and used by clinicians is critical prior to launching larger investigations aimed at improving outcomes. METHODS: This was a longitudinal pilot study conducted at an academic, urban, level 1 trauma center. A total of 20 participants, including emergency medicine resident physicians and nurses, were equipped with a wearable device (WHOOP band) and access to a mobile health platform for 6 weeks. Baseline surveys assessed burnout, mental health, and expectations of the device and experience. Participants provided open-ended feedback on the device and platform, contributing to the assessment of acceptance, adoption, and use of the wearable device. Secondary measures explored early signs and variations in heart rate variability, sleep, recovery, burnout, and mental health assessments. RESULTS: Of the 20 participants, 10 consistently used the wearable device. Feedback highlighted varying experiences with the device, with a preference for more common wearables like the Apple Watch or Fitbit. Resident physicians demonstrated higher engagement with the device and platform as compared with nurses. Baseline mental health assessments indicated mild anxiety and depressive symptoms among participants. The Professional Fulfillment Index revealed low professional fulfillment, moderate workplace exhaustion, and interpersonal disengagement. CONCLUSIONS: This pilot study underscores the potential of wearable devices in monitoring emergency clinicians' physiologic data but reveals challenges related to device preferences and engagement. The key takeaway is the necessity to optimize device and platform design for clinician use. Larger, randomized trials are recommended to further explore and refine strategies for leveraging wearable technology to support the well-being of the emergency workforce.

Medical Students' Perceptions on Identifying and Addressing Emotional Responses in Emergency Medicine: Pilot Investigation.

BACKGROUND: Training in acute care, such as emergency medicine (EM), where exposure to critically ill and injured patients is high, impacts the well-being of trainees and contributes to burnout. Investigating how, and if, trainees prepare for these situations is necessary to ensure they are supported. OBJECTIVE: This study aimed to evaluate medical students' perspectives and emotional preparedness for handling acute care and trauma. METHODS: We conducted a pilot investigation using a remote digital survey of medical students during their EM clerkship at a large, urban academic institution. The primary outcome of interest was student-reported preparedness and comfort in handling trauma and critical care patient encounters. Secondary outcomes included awareness of well-being resources and comfort in accessing digital well-being resources. RESULTS: A total of 57 medical students completed the voluntary digital survey, and half of the students (n=28, 49%) reported having witnessed the care of a critically ill or a penetrating trauma patient (eg, a victim of gun violence). A majority (n=40, 70%) had thought about how these events may impact them, and over half felt unprepared to identify the emotional impact these cases may have on them (n=31, 54%) or address the emotional or mental health impact (n=36, 63%). Less than a quarter (n=14, 25%) were aware of digital mental health resources, and 58% (n=33) did not feel fully comfortable connecting with resources if needed. Students who had previously witnessed critical care were significantly more likely to report feeling well prepared in identifying the emotional impact and addressing this impact. CONCLUSIONS: In this cross-sectional survey, students did not feel fully prepared to identify or address the emotional impact of working in EM. Additionally, they lacked awareness of or comfort with accessing digital institutional resources meant to support their well-being, such as a large web-based platform. These findings can help inform and guide interventions by educational and academic leaders. The aim would be to create and promote environments that empower students with tools to identify their own emotions and connect to well-being resources.

Identifying Patient Characteristics Associated With Opioid Use to Inform Surgical Pain Management.

Objective: Balancing surgical pain management and opioid stewardship is complex. Identifying patient-level variables associated with low or no use can inform tailored prescribing. Methods: A prospective, observational study investigating surgical procedures, prescription data, and patient-reported outcomes at an academic health system in Pennsylvania. Surgical patients were consented following surgery, and prospective data were captured using automated text messaging (May 1, 2021-February 29, 2022). The primary outcome was opioid use. Results: Three thousand six hundred three (30.2%) patients consented. Variation in patient reported used included 28.1% of men reported zero use versus 24.3% of women, 20.5% of Black patients reported zero use versus 27.2% of white patients. Opioid-naïve patients reported more zero use as compared with chronic use (29.7% vs 9.8%). Patients reporting higher use had more telephone calls and office visits within 30 days but no change in emergency department utilization or admissions. Higher discharge pain score was associated with higher use. In the adjusted analysis, opioid use relative to the guideline, higher use was associated with age, male sex, obesity, discharge pain score, and history of mental health disorder. In the adjusted model, younger age and being opioid-naïve to be associated with low to zero use across procedures. Conclusions: Younger age, being opioid-naïve, and lower discharge pain score are associated with low or no postoperative opioid use. These characteristics can be used by clinicians to help tailor opioid prescribing to specific patients to reduce the risk of prolonged exposure and unused `ts in the community.

Investigating Social Media to Evaluate Emergency Medicine Physicians' Emotional Well-being During COVID-19.

Importance: Emergency medicine (EM) physicians experience tremendous emotional health strain, which has been exacerbated during COVID-19, and many have taken to social media to express themselves. Objective: To analyze social media content from academic EM physicians and resident physicians to investigate changes in content and language as indicators of their emotional well-being. Design, Setting, and Participants: This cross-sectional study used machine learning and natural language processing of Twitter posts from self-described academic EM physicians and resident physicians between March 2018 and March 2022. Participants included academic EM physicians and resident physicians with publicly accessible posts (at least 300 total words across the posts) from the US counties with the top 10 COVID-19 case burdens. Data analysis was performed from June to September 2022. Exposure: Being an EM physician or resident physician who posted on Twitter. Main Outcomes and Measures: Social media content themes during the prepandemic period, during the pandemic, and across the phases of the pandemic were analyzed. Psychological constructs evaluated included anxiety, anger, depression, and loneliness. Positive and negative language sentiment within posts was measured. Results: This study identified 471 physicians with a total of 198 867 posts (mean [SD], 11 403 [18 998] words across posts; median [IQR], 3445 [1100-11 591] words across posts). The top 5 prepandemic themes included free open-access medical education (Cohen d, 0.44; 95% CI, 0.38-0.50), residency education (Cohen d, 0.43; 95% CI, 0.37-0.49), gun violence (Cohen d, 0.37; 95% CI, 0.32-0.44), quality improvement in health care (Cohen d, 0.33; 95% CI, 0.27-0.39), and professional resident associations (Cohen d, 0.33; 95% CI, 0.27-0.39). During the pandemic, themes were significantly related to healthy behaviors during COVID-19 (Cohen d, 0.83; 95% CI, 0.77-0.90), pandemic response (Cohen d, 0.71; 95% CI, 0.65-0.77), vaccines and vaccination (Cohen d, 0.60; 95% CI, 0.53-0.66), unstable housing and homelessness (Cohen d, 0.40; 95% CI, 0.34-0.47), and emotional support for others (Cohen d, 0.40; 95% CI, 0.34-0.46). Across the phases of the pandemic, thematic content within social media posts changed significantly. Compared with the prepandemic period, there was significantly less positive, and concordantly more negative, language used during COVID-19. Estimates of loneliness, anxiety, anger, and depression also increased significantly during COVID-19. Conclusions and Relevance: In this cross-sectional study, key thematic shifts and increases in language related to anxiety, anger, depression, and loneliness were identified in the content posted on social media by academic EM physicians and resident physicians during the pandemic. Social media may provide a real-time and evolving landscape to evaluate thematic content and linguistics related to emotions and sentiment for health care workers.

Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety.

Importance: Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety. Objective: To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care. Design, Setting, and Participants: In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022. Main Outcomes and Measures: Themes and subthemes of nursing perspectives on EHR behavioral flags were identified. Results: This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19-related strain and burnout). Conclusions and Relevance: In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

State and Federal Legislators' Responses on Social Media to the Mental Health and Burnout of Health Care Workers Throughout the COVID-19 Pandemic: Natural Language Processing and Sentiment Analysis.

Background: Burnout and the mental health burden of the COVID-19 pandemic have disproportionately impacted health care workers. The links between state policies, federal regulations, COVID-19 case counts, strains on health care systems, and the mental health of health care workers continue to evolve. The language used by state and federal legislators in public-facing venues such as social media is important, as it impacts public opinion and behavior, and it also reflects current policy-leader opinions and planned legislation. Objective: The objective of this study was to examine legislators' social media content on Twitter and Facebook throughout the COVID-19 pandemic to thematically characterize policy makers' attitudes and perspectives related to mental health and burnout in the health care workforce. Methods: Legislators' social media posts about mental health and burnout in the health care workforce were collected from January 2020 to November 2021 using Quorum, a digital database of policy-related documents. The total number of relevant social media posts per state legislator per calendar month was calculated and compared with COVID-19 case volume. Differences between themes expressed in Democratic and Republican posts were estimated using the Pearson chi-square test. Words within social media posts most associated with each political party were determined. Machine-learning was used to evaluate naturally occurring themes in the burnout- and mental health-related social media posts. Results: A total of 4165 social media posts (1400 tweets and 2765 Facebook posts) were generated by 2047 unique state and federal legislators and 38 government entities. The majority of posts (n=2319, 55.68%) were generated by Democrats, followed by Republicans (n=1600, 40.34%). Among both parties, the volume of burnout-related posts was greatest during the initial COVID-19 surge. However, there was significant variation in the themes expressed by the 2 major political parties. Themes most correlated with Democratic posts were (1) frontline care and burnout, (2) vaccines, (3) COVID-19 outbreaks, and (4) mental health services. Themes most correlated with Republican social media posts were (1) legislation, (2) call for local action, (3) government support, and (4) health care worker testing and mental health. Conclusions: State and federal legislators use social media to share opinions and thoughts on key topics, including burnout and mental health strain among health care workers. Variations in the volume of posts indicated that a focus on burnout and the mental health of the health care workforce existed early in the pandemic but has waned. Significant differences emerged in the content posted by the 2 major US political parties, underscoring how each prioritized different aspects of the crisis.

A Randomized Trial of Incentivization to Maximize Retention for Real-Time Symptom and Activity Monitoring Using Ecological Momentary Assessment in Pediatric Concussion.

OBJECTIVE: The aims of this study were to determine the incentivization strategy that maximizes patient adherence to report symptoms and activity via ecological momentary assessment (EMA) after pediatric concussion, and assess the feasibility of tracking concussed youth using EMA from the emergency department (ED) setting. METHODS: This study was a randomized controlled trial of participants ages 13 to 18 years with concussion presenting to an urban, academic pediatric ED within 5 days of injury. Participants were randomized to 1 of 4 incentive arms: 2 dynamic (loss-based and streak) and 2 control flat-rate (monetary and electronic device). Participants reported symptoms 3 times per day and cognitive activity once each evening for 3 weeks. Physical activity (step count) and sleep were monitored using a Fitbit (kept by participants in the device flat-rate arm). The primary outcome was proportion of prompts to which participants responded. Secondary outcomes included differential response rates by demographics, and comparison of outcome determination between EMA and subsequent clinical visits. RESULTS: Thirty participants were enrolled, with a median age of 15.5 years and 60% female. Median cumulative proportion of prompts responded to was 68.3% (interquartile range, 47.6%-82.5%) in the dynamic arms versus 54.0% (interquartile range. 20.6%-68.3%) in the flat-rate arms, P = 0.065. There were nonsignificant differences in median response by sex (65.9% for female vs 40.0% for male, P = 0.072), race/ethnicity (61.9% for non-Hispanic White vs 43.7% for non-Hispanic Black participants, P = 0.097), and insurance (61.9% for private insurance vs 47.6% for public insurance, P = 0.305). Recovery at 3 weeks was discernible for all but 2 participants (93.3%) using EMA data, compared with only 9 participants (30.0%) ( P < 0.001) from clinical visits. CONCLUSIONS: Dynamic incentivization showed higher rates of response to tridaily symptom prompts compared with flat-rate incentivization. These data show tracking concussed youth using EMA from the ED is feasible using a dynamic incentivization strategy, with improved ability to discern outcomes compared with prospective monitoring using follow-up clinical visits.

Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System.

BACKGROUND: Previous studies have demonstrated racial disparities in opioid prescribing in emergency departments and after surgical procedures. Orthopaedic surgeons account for a large proportion of dispensed opioid prescriptions, yet there are few data investigating whether racial or ethnic disparities exist in opioid dispensing after orthopaedic procedures. QUESTIONS/PURPOSES: (1) Are Black, Hispanic or Latino, or Asian or Pacific Islander (PI) patients less likely than non-Hispanic White patients to receive an opioid prescription after an orthopaedic procedure in an academic United States health system? (2) Of the patients who do receive a postoperative opioid prescription, do Black, Hispanic or Latino, or Asian or PI patients receive a lower analgesic dose than non-Hispanic White patients when analyzed by type of procedure performed? METHODS: Between January 2017 and March 2021, 60,782 patients underwent an orthopaedic surgical procedure at one of the six Penn Medicine healthcare system hospitals. Of these patients, we considered patients who had not been prescribed an opioid within 1 year eligible for the study, resulting in 61% (36,854) of patients. A total of 40% (24,106) of patients were excluded because they did not undergo one of the top eight most-common orthopaedic procedures studied or their procedure was not performed by a Penn Medicine faculty member. Missing data consisted of 382 patients who had no race or ethnicity listed in their record or declined to provide a race or ethnicity; these patients were excluded. This left 12,366 patients for analysis. Sixty-five percent (8076) of patients identified as non-Hispanic White, 27% (3289) identified as Black, 3% (372) identified as Hispanic or Latino, 3% (318) identified as Asian or PI, and 3% (311) identified as another race ("other"). Prescription dosages were converted to total morphine milligram equivalents for analysis. Statistical differences in receipt of a postoperative opioid prescription were assessed with multivariate logistic regression models within procedure, adjusted for age, gender, and type of healthcare insurance. Kruskal-Wallis tests were used to assess for differences in the total morphine milligram equivalent dosage of the prescription, stratified by procedure. RESULTS: Almost all patients (95% [11,770 of 12,366]) received an opioid prescription. After risk adjustment, we found no differences in the odds of Black (odds ratio 0.94 [95% confidence interval 0.78 to 1.15]; p = 0.68), Hispanic or Latino (OR 0.75 [95% CI 0.47 to 1.20]; p = 0.18), Asian or PI (OR 1.00 [95% CI 0.58 to 1.74]; p = 0.96), or other-race patients (OR 1.33 [95% CI 0.72 to 2.47]; p = 0.26) receiving a postoperative opioid prescription compared with non-Hispanic White patients. There were no race or ethnicity differences in the median morphine milligram equivalent dose of postoperative opioid analgesics prescribed (p > 0.1 for all eight procedures) based on procedure. CONCLUSION: In this academic health system, we did not find any differences in opioid prescribing after common orthopaedic procedures by patient race or ethnicity. A potential explanation is the use of surgical pathways in our orthopaedic department. Formal standardized opioid prescribing guidelines may reduce variability in opioid prescribing. LEVEL OF EVIDENCE: Level III, therapeutic study.

Boarding in US Academic Emergency Departments During the COVID-19 Pandemic.

STUDY OBJECTIVE: The first 2 years of the COVID-19 pandemic brought substantial and dynamic changes to emergency department volumes and throughput. The objective of this study was to describe changes in ED boarding among US academic EDs across the duration of the COVID-19 pandemic. METHODS: We conducted a retrospective analysis of monthly data collected from a convenience sample of academic departments of emergency medicine. The study period was from January 2019 to December 2021. The primary outcome was total boarding hours, and secondary outcomes included patient volume stratified by ED disposition. We used multivariable linear panel regression models with fixed effects for individual EDs to estimate adjusted means for 3-month quarters. RESULTS: Of the 73 academic departments of emergency medicine contacted, 34 (46.6%) participated, comprising 43 individual EDs in 25 states. The adjusted mean total boarding hours per month significantly decreased during the second quarter of 2020 (4,449 hours; 95% confidence interval [CI] 3,189 to 5,710) compared to the first quarter of 2019 (8,521 hours; 95% CI 7,845 to 9,197). Beginning in the second quarter of 2021, total boarding hours significantly increased beyond pre-pandemic levels, peaking during the fourth quarter of 2021 (12,127 hours; 95% CI 10,925 to 13,328). CONCLUSIONS: A sustained and considerable increase in boarding observed in selected US academic EDs during later phases of the COVID-19 pandemic may reflect ongoing stresses to the health care system, with potential consequences for patient outcomes as well as clinician well-being.

Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department.

Importance: Behavioral flags in the electronic health record (EHR) are designed to alert clinicians of potentially unsafe or aggressive patients. These flags may introduce bias, and understanding how they are used is important to ensure equitable care. Objective: To investigate the incidence of behavioral flags and assess whether there were differences between Black and White patients and whether the flags were associated with differences in emergency department (ED) clinical care. Design, Setting, and Participants: This was a retrospective cohort study of EHR data of adult patients (aged ≥18 years) from 3 Philadelphia, Pennsylvania, EDs within a single health system between January 1, 2017, and December 31, 2019. Secondary analyses excluded patients with sickle cell disease and high ED care utilization. Data were analyzed from February 1 to April 4, 2022. Main Outcomes and Measures: The primary outcome of interest was the presence of an EHR behavioral flag. Secondary measures included variation of flags across sex, race, age, insurance status, triage status, ED clinical care metrics (eg, laboratory, medication, and radiology orders), ED disposition (discharge, admission, or observation), and length of key intervals during ED care. Results: Participating EDs had 195 601 eligible patients (110 890 [56.7%] female patients; 113 638 Black patients [58.1%]; 81 963 White patients [41.9%]; median [IQR] age, 42 [28-60] years), with 426 858 ED visits. Among these, 683 patients (0.3%) had a behavioral flag notification in the EHR (3.5 flags per 1000 patients), and it was present for 6851 ED visits (16 flagged visits per 1000 visits). Patient differences between those with a flag and those without included male sex (56.1% vs 43.3%), Black race (71.2% vs 56.7%), and insurance status, particularly Medicaid insurance (74.5% vs 36.3%). Flag use varied across sites. Black patients received flags at a rate of 4.0 per 1000 patients, and White patients received flags at a rate of 2.4 per 1000 patients (P < .001). Among patients with a flag, Black patients, compared with White patients, had longer waiting times to be placed in a room (median [IQR] time, 28.0 [10.5-89.4] minutes vs 18.2 [7.2-75.1] minutes; P < .001), longer waiting times to see a clinician (median [IQR] time, 42.1 [18.8-105.5] minutes vs 33.3 [15.3-84.5] minutes; P < .001), and shorter lengths of stay (median [IQR] time, 274 [135-471] minutes vs 305 [154-491] minutes; P = .01). Black patients with a flag underwent fewer laboratory (eg, 2449 Black patients with 0 orders [43.4%] vs 441 White patients with 0 orders [36.7%]; P < .001) and imaging (eg, 3541 Black patients with no imaging [62.7%] vs 675 White patients with no imaging [56.2%]; P < .001) tests compared with White patients with a flag. Conclusions and Relevance: This cohort study found significant differences in ED clinical care metrics, including that flagged patients had longer wait times and were less likely to undergo laboratory testing and imaging, which was amplified in Black patients.

Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients.

PURPOSE: Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors. DESIGN: Semi-structured interviews of patients prescribed naloxone at ED discharge. SETTINGS: Three urban academic EDs in Philadelphia, PA. PARTICIPANTS: 25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose. METHODS: Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes. RESULTS: We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone. CONCLUSIONS: Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.

Emergency medicine resident perspectives on well-being during COVID-19: a qualitative study.

BACKGROUND: Emergency medicine (EM) clinician well-being has been negatively impacted throughout the COVID-19 pandemic. Resident physicians are particularly vulnerable yet less is known about their perspectives. METHODS: The objective of this study was to use qualitative methods to understand EM residents' perspectives on well-being during COVID-19. EM residents at an urban, academic institution in the USA were recruited via email and participated in virtual, semi-structured interviews between November 2020 and February 2021. Interviews were conducted by a trained qualitative researcher, recorded, transcribed and de-identified by a third party vendor. All transcripts were double coded by two trained study team members using thematic analysis to identify the themes and interviews were stopped when no new themes emerged. RESULTS: Seventeen semi-structured interviews were conducted until thematic saturation was reached with residents in their first 4 years of training: 6 postgraduate year (PGY)-1 (35%), 6 PGY-2 (35%), 2 PGY-3 (12%) and 3 PGY-4 (18%). Five themes were identified: (1) isolation from peers in training contrasting with a collective call to action, (2) desire for increased acknowledgement and structured leadership support, (3) concerns about personal needs and safety within the clinical environment, (4) fear of missed educational opportunities and lack of professional development and (5) need for enhanced mental and physical health resources. CONCLUSIONS: This qualitative study elucidated factors inside and outside of the clinical environment which impacted EM resident well-being. The findings suggest that programme and health system leadership can focus on supporting peer-to-peer and faculty connections, structured guidance and mentorship on resident career development and develop programmes which bolster resident on-shift support and acknowledgement. These lessons can be used by training programmes to better support residents, but the generalisability is limited due to the single-centre design and participation.