Bridging the Gap: Evaluation of an Electrocardiogram Curriculum for Advanced Practice Clinicians.

Background: Training programs for advanced practice providers (APP) often have significant variability in their curriculum, including electrocardiogram (ECG) education. Despite limitations in formal ECG training, APPs in the emergency department (ED) may be the first practitioner to interpret an ECG. Foundations of Emergency Medicine (FoEM) offers free, open-access curricula that are widely used for resident education. We sought to improve APP ECG interpretation skills by implementing the FoEM ECG I course. Methods: This was a single-site, pre- and post-intervention study of 23 APPs at our high-acuity, urban ED. In the fall of 2020, APP learners enrolled in a FoEM ECG I course led by faculty and senior resident instructors. The course consisted of six virtual, small-group, active-learning ECG workshops. Participants completed a 15-question multiple-choice test before, immediately after, and six months post-intervention to quantify knowledge acquisition. Additionally, a pre- and post-intervention knowledge, attitudes, and practices survey was administered on ECG interpretation skills and to evaluate the course. We evaluated change in ECG knowledge scores using a Wilcoxon signed-rank test. Changes in self-assessed knowledge were evaluated using an ordinal logistic mixed-effects regression. Results: A total of 23 APPs enrolled in the course. Knowledge assessments showed APPs improved from the pre-test (median 9/15, interquartile range [IQR] 7-11) to the post-test (median 12/15, IQR 10-13; P = 0.001). Test scores did not significantly change from the post-test to the delayed post-test (median 12/15, IQR 12-13; P = 0.30). Respondents' subjective rating of their skill did not significantly change (P = 0.06). Respondents reported no change in their likelihood of approaching an attending when uncertain of the correct interpretation of an ECG (P = 0.16). Overall, 91% were satisfied with the course and 96% agreed that the course difficulty was appropriate. Conclusion: The FoEM ECG course provided a standardized curriculum that improved APP knowledge for interpreting ECGs. Despite this, the course did not alter APPs' willingness to approach physicians for guidance with interpretation of abnormal ECGs. These findings may inform expansion of this concept for other programs who desire formalized APP ECG education.

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia.

OBJECTIVE: To describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU). METHODS: This is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130-135 mmol/L) to moderate (121-129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism. RESULTS: 188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect -10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions. CONCLUSION: Management of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

Access to, Experience with, and Attitudes towards Take Home Naloxone: An Online Survey.

The opioid public health crisis continues to burden individuals, communities, and economies. Public health opinion has emphasized the need for increased access to harm reduction services, but there is a dearth of information on the views and experiences of people who use opioids. Our study aimed to investigate the prevalence of naloxone use, attitudes, and experiences with naloxone among an online community of people who use drugs. We performed a cross-sectional survey looking at experiences with and attitudes towards take-home naloxone. Data is presented descriptively, with analysis of the differences between people who do and do not use opioids using the χ2 and Fisher's exact tests. There were 1,143 respondents, of whom 70% were from the United States. Only 38% of participants who use opioids had received naloxone training, but 56% of these individuals said that they felt comfortable using a naloxone kit. Nearly all respondents (95%) said they would be willing to use naloxone on someone who had overdosed and approximately 90% would want naloxone used on them in case of an overdose. Regarding harm reduction, 24% of respondents said they had access to safe use programs, and 33% said they had access to clean needle exchange programs. A majority of the participants who use opioids were in favor of having naloxone with them when using drugs and believed naloxone should be freely available. This study demonstrates the receptiveness of take-home naloxone and highlights the need for better implementation of naloxone within communities that use opioids.

Hydrofluoric acid ingestions: Retrospective evaluations from cases reported to the National Poison Data System 2007-2017.

Background: Hydrofluoric acid (HF) is associated with systemic toxicity, particularly with high-concentration formulations. However, most existing data describe dermal exposures; there is a paucity of data related to outcomes after ingestions. Objective: To determine the morbidity and mortality associated with HF ingestions as reported to the National Poison Data System (NPDS). A secondary objective is to assess for clinical criteria that are associated with serious outcomes after HF ingestion. Methods: We performed a retrospective review of HF ingestions reported to the NPDS from 2007 to 2017. Data including patient demographics, exposure and caller sites, electrolyte abnormalities, treatments, and serious (moderate or major effect or death as documented in NPDS) and non-serious outcomes were abstracted from case narratives. Cases meeting the criteria for a qualifiable HF ingestion were included in the study. Results: During the study period, there were 653 HF ingestions reported to NPDS, of which 142 were included in the final data analysis. Most HF exposures occurred in men (68.3%), and the most common exposure site was at the exposed individual's own residence (78.2%). Nearly half of all exposures (46.5%) were due to transfer into a non-labeled secondary storage container. Total of 45.8% of the cases resulted in a serious outcome. Electrolyte disturbances were associated with an increased risk of a serious outcome. Hypocalcemia was the most frequently reported electrolyte abnormality, occurring in 24.6% of cases. Nine (6.3%) individuals died. Conclusions: Mortality after HF ingestion is low. However, a large cohort of exposures occurred after the transfer of HF to secondary containers. Targeted interventions to reduce this practice are necessary to decrease hazardous chemical exposures.

Low- versus high-dose nitroglycerin infusion in the management of acute pulmonary edema.

BACKGROUND: Nitroglycerin (NTG) is commonly used for the management of pulmonary edema in acute heart failure presentations. Although commonly initiated at low infusion rates, higher infusion rates have favorable pharmacodynamic properties and may improve outcomes in the management of acute pulmonary edema. OBJECTIVES: To characterize the clinical outcomes including the time to resolution of severe hypertension when using an initial low dose (<100 µg/min) versus high-dose (≥100 µg/min) strategy. METHODS: This was a retrospective study performed at a single, tertiary academic emergency department in Atlanta, GA. We describe the blood pressure effects and key safety outcomes (intubation, hypotension, intensive care unit admissions) during the first hour of treatment of acute pulmonary edema. RESULTS: 41 patients were included in the final sample. 27 (66%) received low dose NTG and 14 (34%) received high dose NTG. The high dose group reached their blood pressure faster on average (hazard ratio = 3.5, 95% CI: 1.2-10.1). 8/14 (57%) of patients in the high dose group reached their BP target within the first hour of treatment, compared to 6/27 (22%) in the low dose group. Observed incidence of safety outcomes were similar between the two groups. CONCLUSIONS: Higher initial NTG doses may be an effective way to decrease times to achieve blood pressure targets and should be the focus of future trials.

Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research.

AIMS: Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS: A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS: A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS: As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.

Electronic Advisories Increase Naloxone Prescribing Across Health Care Settings.

BACKGROUND: Naloxone is a life-saving, yet underprescribed, medication that is recommended to be provided to patients at high risk of opioid overdose. OBJECTIVE: We set out to evaluate the changes in prescriber practices due to the use of an electronic health record (EHR) advisory that prompted opioid prescribers to co-prescribe naloxone when prescribing a high-dose opioid. It also provided prescribers with guidance on decreasing opioid doses for safety. DESIGN: This was a retrospective chart abstraction study looking at all opioid prescriptions and all naloxone prescriptions written as emergency department (ED) discharge, inpatient hospital discharge, or outpatient medications, between July 1, 2018, and February 1, 2020. The EHR advisory went live on June 1, 2019. SUBJECTS: Included in the analysis were all adult patients seen in the abovementioned settings at a large county hospital and associated outpatient clinics. MAIN MEASURES: We performed an interrupted time series analysis looking at naloxone prescriptions and daily opioid dosing in morphine milligram equivalents (MMEs), before and after initiation of the EHR advisory. KEY RESULTS: The EHR advisory was associated with changes in prescribers' behavior, leading to increased naloxone prescriptions and decreased prescribed opioid doses. CONCLUSIONS: EHR advisories are an effective systems-level intervention to enhance the safety of prescribed opioids and increase rates of naloxone prescribing.

The Impact of Virtual Care in an Emergency Department Observation Unit.

STUDY OBJECTIVE(S): We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care. METHODS: In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used. RESULTS: Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413). CONCLUSION: Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.

Use of person-centered goals to direct interdisciplinary care for military service members and Veterans with chronic mTBI and co-occurring psychological conditions.

Objective: To explore the use of person-centered goals (PCGs) to direct interdisciplinary care to support PCG attainment in military service members and Veterans (SM/Vs) with chronic mild traumatic brain injury (mTBI) and co-occurring psychological conditions. Methods: A retrospective chart review was completed for 146 United States military SM/Vs reporting chronic symptoms following mTBI and co-occurring psychological conditions who received care in the SHARE Military Initiative intensive outpatient program, a donor-funded program administered by a not-for-profit hospital, between April 1, 2015 and March 31, 2019. PCGs were used to direct care consisting of individual and group-based interventions and therapies delivered by an interdisciplinary, co-located team including behavioral health, case management, neurology or physiatry, nursing, occupational therapy, physical therapy, recreation therapy, speech-language pathology, and transition support. The primary outcome measure was PCG attainment measured via goal attainment scaling. Results: Increased PCG attainment was demonstrated at program discharge and throughout the first year following program discharge. Predictors of goal attainment at discharge included longer participation in treatment, greater reduction in depressive symptoms and greater improvement in adjustment at discharge, male gender, and higher cognitive and physical abilities on admission. Conclusions: This sample of military SM/Vs with mTBI and co-occurring psychological conditions who received intensive, interdisciplinary, PCG directed care demonstrated increased PCG attainment at program discharge which further increased with transition support over the year post-discharge. Results suggest PGC goal directed care is a feasible, promising methodology of individualizing treatment in this population. This exploratory study lays a foundation for future prospective, controlled, comparative effectiveness research that will further understanding of the effectiveness of intensive, interdisciplinary, PCG directed care.

Elevated methemoglobin levels in patients treated with hydroxocobalamin: a case series and in-vitro analysis.

BACKGROUND: Historically, the first step in treating cyanide (CN-) toxicity utilized antidotes to induce methemoglobinemia. This is concerning in patients who are already hypoxemic or have elevated carboxyhemoglobin. Hydroxocobalamin (OHCbl) is now the first-line antidote for CN- toxicity and is not known to induce methemoglobinemia. We observed elevated methemoglobin (MetHb) levels in several patients treated with OHCbl and sought to investigate the incidence of MetHb formation following administration of OHCbl. METHODS: Chart review: A single-center, retrospective case series of patients who received 5 or 10 g of hydroxocobalamin from 01/01/2011 through 04/30/2019. Data was analyzed using descriptive statistics. In-vitro study: Discarded blood was separated into whole blood and plasma samples. OHCbl and normal saline was added to reach 0×, 1×, 2×, and 4× peak therapeutic concentrations and analyzed at times 0, 2, and 4 h after administration. RESULTS: Chart review: Twenty-seven cases of OHCbl administration were identified. The median age was 53 years (IQR 38 - 64) and 20 (74.1%) were male. Exposure to a house fire or smoke inhalation was the reason for OHCbl administration in 21 (77.8%) patients. Five (18.5%) patients received 10 g of OHCbl while the rest received 5 g. Six (22.2%) patients developed methemoglobinemia, all after 5 g OHCbl administration; four had been exposed to fire and smoke, two received the medication for severe acidosis of unknown etiology not related to fire or smoke. The median peak level was 7.1% (IQR 2.2 - 16.4%) at a median time of 11.4 h post-administration. Two patients received methylene blue (MB), neither responded. Death occurred in 17 (63%) cases. In-vitro study: We observed a dose dependent elevation in total hemoglobin but did not detect any increase in MetHb. CONCLUSION: We observed a noteworthy temporal association between the formation of methemoglobinemia and the administration of hydroxocobalamin. This does not appear to be an artifact of the CO-oximeters. This could have profound implications for patients who are already hypoxemic or have impaired oxygen carrying capacity from carboxyhemoglobin.

The association of indoor heat exposure with diabetes and respiratory 9-1-1 calls through emergency medical dispatch and services documentation.

BACKGROUND: People with pre-existing medical conditions, who spend a large proportion of their time indoors, are at risk of emergent morbidities from elevated indoor heat exposures. In this study, indoor heat of structures wherein exposed people received Grady Emergency Services based care in Atlanta, GA, U.S., was measured from May to September 2016. METHOD: ology: In this case-control study, analyses were conducted to investigate the effect of indoor heat on the odds of 9-1-1 calls for diabetic (n = 90 cases) and separately, for respiratory (n = 126 cases), conditions versus heat-insensitive emergencies (n = 698 controls). Generalized Additive Models considered both linear and non-linear indoor heat and health outcome associations using thin-plate regression splines. RESULTS: Hotter and more humid indoor conditions were non-linearly associated with an increasing likelihood of receiving emergency care for complications of diabetes and severe respiratory distress. Higher heat indices were associated with increased odds of a diabetes (odds ratio for change from 30 to 31 °C: 1.12, 95% CI: 1.08-1.16) or respiratory 9-1-1 medical call versus control (odds ratio for change from 34 to 35 °C: 1.18, 95% CI: 1.09-1.28) call. Both diabetic and respiratory distress patients were more likely to be African-American and/or have comorbidities. CONCLUSIONS: In this study, the statistical association of indoor heat exposure with emergency morbidities (diabetic, respiratory) was demonstrated. The study also showcased the value and utility of data gathered by emergency medical dispatch and services from inaccessible private indoor sources (i.e., domiciles) for environmental health.

Hormonal contraceptive use moderates the association between worry and error-related brain activity.

Uncovering mechanisms that can help explain the experience and impact of anxiety in women is important for improving etiological models and treatments to meet the needs of unique individuals. An enlarged error-related negativity (ERN) - an electrophysiological marker of cognitive control-related error monitoring- represents one indicator of neural processes more strongly related to anxiety in women than men. In this study, we further examined this association in women by testing the moderating effect of hormonal contraceptive (HC) use on the relationship between worry - i.e., a transdiagnostic cognitive dimension of anxiety - and the ERN. Results revealed that HCs moderated the worry-ERN association. Specifically, we found a significant and large relationship between worry and enlarged ERN in women using HCs, which was smaller and nonsignificant in naturally cycling women (i.e., those not using HCs). These findings suggest that the interplay among HC use, error-related cognitive control, and worry represents a novel mechanism for better characterizing the expression and impact of worry in women.

Adverse Childhood Experiences and Healthcare Utilization of Children in Pediatric Emergency Departments.

OBJECTIVE: To determine the prevalence of adverse childhood experiences (ACEs) and healthcare utilization patterns of children seen in pediatric emergency departments (PEDs). STUDY DESIGN: In this cross-sectional study, caregivers of patients who presented to 2 urban PEDs completed a survey regarding their children's ACEs, health care utilization patterns, and acceptance of PED-based ACEs screening and resources. Inclusion criteria were English-speaking caregivers of patients 0-17 years of age not requiring acute stabilization. Prevalence estimates were compared with national and state data from the National Survey of Children's Health by calculating risk differences and 95% CIs. The association of cumulative ACEs with caregiver-reported health care utilization patterns was evaluated using ORs. RESULTS: Among 1000 participants, 28.1% (95% CI 25.3-30.9) had 1 ACE; 17.8% (95% CI15.4-20.2) had ≥2 ACEs. Notably, children with higher cumulative ACEs were seen in the PED more frequently (0, 1, ≥2 visits) (OR 1.18, 95% CI 1.06-1.30, P = .002) and more likely to seek care in PEDs for sick visits (OR 1.16, 95% CI 1.04-1.30, P = .01). About 9% of children exposed to ACEs did not have a primary care provider. Over 85% of caregivers reported never discussing ACEs with their primary care provider. Most caregivers felt comfortable addressing ACEs in PEDs (84.4%) and would use referral resources (90.4%). CONCLUSIONS: Given higher PED utilization in children with more ACEs and caregiver acceptance of PED-based screening and intervention, PEDs may represent a strategic and opportune setting to both assess and respond to ACEs among vulnerable populations.

The Effect of Nighttime Rental Restrictions on E-Scooter Injuries at a Large Urban Tertiary Care Center.

Safety policy for e-scooters in the United States tends to vary by municipality, and the effects of safety interventions have not been well studied. We reviewed medical records at a large, urban tertiary care and trauma center in Atlanta, Georgia with the goal of identifying trends in e-scooter injury and the effects of Atlanta's nighttime ban on e-scooter rentals on injuries treated in the emergency department (ED). Records from all ED visits occurring between June 2018 through August 2020 were reviewed. To account for ambiguity in medical records, confidence levels of either "certain" or "possible" were assigned using a set of predefined criteria to categorize patient injuries as being associated with an e-scooter. A total of 380 patients categorized as having certain e-scooter related injuries were identified. The average age of these patients was 31 years old, 65% were male, 41% had head injuries, 20% of injuries were associated with the built environment, and approximately 20% were admitted to the hospital. Approximately 19% of patients with injuries associated with e-scooters noted to be clinically intoxicated or have a serum ethanol level exceeding 80 mg/dL. The implementation of a nighttime rental ban on e-scooter rentals reduced the proportion of patients with e-scooter injuries with times of arrival during the hours of the ban from 32% to 22%, however this effect was not significant (p = 0.16). More research is needed to understand how e-scooter use patterns are affected by the nighttime rental ban.

The impact of emergency department observation units on a health system.

IMPORTANCE: Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. OBJECTIVE: To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. METHODS: A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. RESULTS: The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. CONCLUSION: Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.

Intentional suspected suicide exposures by poisoning among adolescents from 2009 to 2018 reported to the Georgia Poison Center and compared nationally.

This retrospective chart review aimed to report the incidence and characteristics of intentional suspected suicide among 13- to 19-year-olds reported to the Georgia Poison Center (GPC) and compared nationally from 2009 to 2018. Of the 19 733 cases reported to the GPC, 74.9% were females. The total number of cases more than doubled from 2009 to 2018, increasing annually by 10%. Majority (90.1%) of the cases occurred in the home, and 60.4% of the cases resulted in either no effect or minor effect. More than half (66.5%) of the cases involved only one substance. Pharmaceuticals made up 94.5% of the substances used, with analgesics accounting for 42.10% and antidepressants at 20.77%. A significant difference was found in substances used between males and females (P < .001). Females were more likely to use analgesics (45.17% vs 32.90%), and males were more likely to use sedatives/hypnotics/antipsychotics (20.45% vs 13.58%). While the majority of the GPC patients were females, the GPC was more likely to have fewer female patients (74.7% vs 75.7%) and more male patients (25.3% vs 24.3%) than other poison centers. Intentional suspected suicide exposures by poisoning are on the rise and higher among females, demonstrating a need for strengthened intervention and prevention strategies.

Radiation Emergency Readiness Among US Medical Toxicologists: A Survey.

INTRODUCTION: Large scale radiologic and nuclear disasters are rare; however, recent events such as the Fukushima Daiichi nuclear reactor emergency in Japan and current global political tensions have highlighted the need for health-care providers with expertise in managing radiation injuries. Medical Toxicologists have the ability to collaborate with other specialists in filling this critical role. METHODS: We conducted a cross-sectional survey to assess the attitudes, experiences, and knowledge of medical toxicologists through the assistance of the American College of Medical Toxicology. RESULTS: The survey was completed by 114 medical toxicologists during the enrollment period. Medical toxicologists who had a willingness to participate in radiologic or nuclear emergencies or who had taken care of patients contaminated with radioactive material were more likely to perform well on the knowledge assessment. CONCLUSION: We identified that there is a group of medical toxicologists who have the willingness, experience, and knowledge to help manage patients in the event of a radiologic or nuclear emergency.

A prospective cross-sectional study examining the documented evaluation of patients at high risk for mild traumatic brain injury.

OBJECTIVES: Annually, the CDC reports that 2.5 million Emergency Department (ED) visits occur due to Traumatic Brain Injuries (TBI) with nearly 75% classified as mild TBI (mTBI). Generally, these injuries are thought to be under recognized. This study was done to determine the proportion of patients, who were considered high risk for an mTBI, that had documentation of an mTBI evaluation. METHODS: A prospective cross-section of patients was identified using a 3-question screen at the time of triage: did an injury occur; was the mechanism consistent with mTBI; and was there a period of altered mental status. Chart review was completed for these patients who were thought to meet a minimum threshold warranting an evaluation for mTBI. RESULTS: 38,621 patients were screened over 16 weeks, of whom 441 (1.14%) were identified as being high risk for having an mTBI and met inclusion criteria. Recommended portions of an mTBI evaluation occurred in fewer than 50% of patients. In total, 98 subjects were diagnosed with an mTBI, and 49 received mTBI discharge instructions. The odds ratio for the subgroup of patients who had documented criteria sufficient for diagnosis revealed that an isolated head injury increased a patient's odds of a documented diagnosis by 2.1 times (95%, 1.3-3.4). CONCLUSIONS: Many patients with a possible mTBI did not have significant portions of an mTBI evaluation documented, and roughly half of the patients with a documented mTBI diagnosis did not receive discharge education. Changes in clinicians' approach to mTBI must occur to ensure patients receive appropriate evaluations, management, and education.

Regional Variations in Rehabilitation Outcomes of Adult Patients With Traumatic Brain Injury: A Uniform Data System for Medical Rehabilitation Investigation.

OBJECTIVES: To examine regional differences in rehabilitation outcomes among adult patients with moderate-to-severe traumatic brain injury (TBI) who received care at an inpatient rehabilitation facility (IRF). DESIGN: We conducted a secondary analysis of a large, multi-center dataset from the Uniform Data System for Medical Rehabilitation. SETTING: More than 70% of all IRFs in the United States. PARTICIPANTS: Adult TBI patients (N=175,358) aged 18 years or older who were admitted and discharged from an IRF in the United States between 2004 and 2014. Qualifying etiology included traumatic brain dysfunction Impairment Group codes 02.21 (traumatic, open injury) and 02.22 (traumatic, closed injury). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge functional status (total, cognitive, motor), length of stay, and discharge to home. RESULTS: Patient and clinical characteristics varied significantly by geographic location, as did median functional status, length of stay, and percentage of patients discharged home. The region where IRF care was received, race and ethnicity, age, occurrence of 1 or more falls during the IRF stay, case mix group, and insurance status were associated with discharge functional status, length of stay, and discharge to home. CONCLUSIONS: Our findings provide evidence of geographic differences in outcomes and potential disparities in care of TBI patients who received IRF care. More research is needed to identify TBI patients at risk for poor discharge outcomes to inform development and testing of interventions to reduce disparities in outcomes for these patients.