Thoracic ultrasound may improve paramedic diagnostic and management accuracy in undifferentiated respiratory distress.

Objectives: Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations present with similar history and physical examination findings. This complicates both the diagnostic process and the creation of appropriate treatment plans for patients presenting in respiratory distress, particularly in the prehospital setting. Thoracic point-of-care-ultrasound (POCUS) may increase diagnostic accuracy; however, its potential to improve patient management by emergency medical services clinicians is unknown. We aimed to determine whether a brief thoracic POCUS educational intervention would improve prehospital diagnostic accuracy and treatment plans for patients with COPD and CHF exacerbations. Methods: In this prospective pre-/post-study, paramedics completed a thoracic POCUS training program. The pre-test presented history and physical examination data for 10 patients and asked paramedics to diagnose each patient with COPD or CHF exacerbation and to select the appropriate treatment(s). The post-test asked paramedics to interpret ultrasound images in addition to selecting diagnosis and treatment(s). Pre-post differences in average cumulative diagnostic and management accuracy were analyzed using paired two-tailed t-tests. Results: Thirty-three paramedics participated in the study. At baseline, paramedics selected the accurate patient diagnosis and treatment(s) 73% and 60% of the time, respectively. On the post-test, diagnostic accuracy improved by 17% (95% confidence interval [CI]: 11-24, p < 0.001) and appropriate treatment selection improved by 23% (95% CI: 16-28, p < 0.001). Paramedics correctly interpreted ultrasound images 90% of the time. Conclusion: Effective training of paramedics to recognize the clinical scenario of undifferentiated respiratory distress and their associated thoracic ultrasound images may lead to improved treatment plans.

Cost evaluation of continuation of therapy with dalbavancin compared to standard-of-care antibiotics alone in hospitalized persons who inject drugs with severe gram-positive infections.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Persons who inject drugs (PWID) are at risk for severe gram-positive infections and may require prolonged hospitalization and intravenous (IV) antibiotic therapy. Dalbavancin (DBV) is a long-acting lipoglycopeptide that may reduce costs and provide effective treatment in this population. METHODS: This was a retrospective review of PWID with severe gram-positive infections. Patients admitted from January 1, 2017, to November 1, 2019 (standard-of-care [SOC] group) and from November 15, 2019, to March 31, 2022 (DBV group) were included. The primary outcome was the total cost to the healthcare system. Secondary outcomes included hospital days saved and treatment failure. RESULTS: A total of 87 patients were included (37 in the DBV group and 50 in the SOC group). Patients were a median of 34 years old and were predominantly Caucasian (82%). Staphylococcus aureus (82%) was the most common organism, and bacteremia (71%) was the most common type of infection. Compared to the SOC group, the DBV group would have had a median of 14 additional days of hospitalization if they had stayed to complete their therapy (P = 0.014). The median total cost to the healthcare system was significantly lower in the DBV group than in the SOC group ($31,698.00 vs $45,093.50; P = 0.035). The rate of treatment failure was similar between the groups (32.4% in the DBV group vs 36% in the SOC group; P = 0.729). CONCLUSION: DBV is a cost-saving alternative to SOC IV antibiotics for severe gram-positive infections in PWID, with similar treatment outcomes. Larger prospective studies, including other patient populations, may demonstrate additional benefit.

Diagnosis of Ulnar Neuropathy at the Elbow Using Ultrasound - A Comparison to Electrophysiologic Studies.

PURPOSE: Given the relatively high false negative rate of electrodiagnostic studies (EDX) in patients with clinically diagnosed ulnar neuropathy at the elbow (UNE), we sought to determine whether an alternative objective test could more effectively detect UNE. Additionally, we proposed to determine the relationship between the cross-sectional area (CSA) of the ulnar nerve on ultrasound (US), EDX, and clinical symptoms. METHODS: This was a retrospective study of patients presenting with symptomatic UNE. The performance characteristics of EDX versus ultrasound were calculated using the clinical diagnosis of UNE as the reference standard. Standard EDX studies and US of the ulnar nerve were analyzed. Maximal CSA of the ulnar nerve and EDX severity were analyzed for patients with each combination of US-positive/negative and EDX-positive/negative findings. RESULTS: Analysis was performed on 89 patients and 115 nerves with signs and symptoms of cubital tunnel syndrome. In total, 56 (49%) nerves were diagnosed as mild UNE, 32 (28%) nerves were diagnosed as moderate UNE, 17 (15%) nerves were diagnosed as severe UNE, and 10 (8%) nerves were negative for UNE by EDX. Maximal-maximal CSA was highly correlated with disease severity as determined by nerve conduction studies/electromyography. Compared with EDX+/US+, patients with EDX-/US+ showed higher rates of ulnar sensory loss and elbow tenderness with similar rates of positive Tinel and intrinsic muscle atrophy. In this sample of patients with clinically diagnosed UNE, 91.3% of the patients demonstrated positive EDX studies, whereas 94.8% had a positive US. CONCLUSIONS: Ultrasound is an alternative to EDX that could be incorporated clinically in the diagnosis and management of UNE. Ultrasound was able to consistently detect clinically positive cubital tunnel syndrome demonstrating its utility as a confirmatory or supplemental test to the clinical assessment if one is required. Ultrasound additionally may be able to better identify patients with early stages of UNE with negative EDX findings. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Where Does Ultrasound Fit in the Diagnostic Algorithm for Cubital Tunnel Syndrome?

BACKGROUND: Ultrasound (US) has emerged as a promising supplement to electrodiagnostic studies (EDX) in the diagnosis of cubital tunnel syndrome (CuTS) and has potential to be performed by novice operators. Our objective is to understand the discrepancies in assessment between the two modalities and to assess the utility of US in CuTS diagnosis by a novice operator. METHODS: Patients who presented to a single tertiary academic medical center and clinically diagnosed with CuTS were prospectively enrolled. Electrodiagnostic studies were performed along with US measurements of the cross-sectional area (CSA) of the ulnar nerve by both a board-certified physiatrist and novice operator. Electrodiagnostic study and US outcomes were compared among four diagnostic impression groups: EDX-/US-, EDX+/US-, EDX-/US+, and EDX+/US+. RESULTS: Sixteen patients were classified as abnormal by both EDX and US, 14 were classified abnormal by US only, 3 were classified abnormal by EDX only, and 6 were classified normal by both EDX and US (P = .008, K = 0.14). The EDX+/US+ group had a significantly reduced sensory amplitude compared with the EDX-/US+ (P = .04) group. Diagnostic classifications between a board-certified physiatrist and novice operator were in moderate agreement (K = 0.58, P = .08). CONCLUSIONS: Ultrasound detected a greater proportion of patients as abnormal than EDX. A subset of patients with clinical diagnoses of CuTS had normal sensory amplitudes but increased maximum nerve CSAs. Competency in US may be easily acquired with minimal training, suggesting its potential to be extended for use by other members of the health care team.

Identification of Clinical and Demographic Predictors for Treatment Modality in Patients With Carpal Tunnel Syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. There are multiple treatment modalities for CTS. This study examines both clinical and demographic predictors for initial treatment modality of CTS. METHODS: Patients diagnosed with CTS between February 2015 and October 2020 with a hand clinic visit within 6 weeks before treatment were included in our study. Patients completed Patient-Reported Outcomes Measurement Information System Pain Interference, Physical Function, and Depression and had complete data on relevant predictor variables. Primary outcomes were treatment group: (1) injection only; (2) release only; and (3) injection followed by release. Bivariate analyses and multinomial logistic regression was used to identify statistically significant variables and independent predictors associated with the treatment groups, respectively. RESULTS: A total of 1409 patients fit our inclusion criteria. Sex, age, body mass index (BMI), race, ethnicity, Pain Interference, and Depression were statistically significant predictors for treatment group in bivariate analysis (P < .05). In multivariable analysis, adults older than 65 years were less likely to receive either injection only or injection followed by release (odds ratio [OR]: 0.56 and OR: 0.52, respectively; P < .01). Overweight (BMI: ≥25) individuals were less likely to receive injection only (OR: 0.45; P < .01). Women were more likely to have either injection only or injection followed by released (OR: 1.50 and 1.55; P < .01). Similarly, black, Indigenous, or Persons of Color had an increased odds of injection only and injection followed by release (OR: 1.61 and OR: 1.69, respectively; P < .05). CONCLUSIONS: Sex, age, BMI, race, and ethnicity were found to be independent predictors of treatment modality for CTS.

Racial differences in treatment among patients with acute headache evaluated in the emergency department and discharged home.

BACKGROUND: Prior research has demonstrated the widespread presence of racial disparities in emergency department (ED) care and analgesia. We hypothesized that racial disparities continue to exist in ED analgesic prescribing patterns, time to analgesia, and time to provider in the treatment of headache. METHODS: We performed a retrospective cohort study of patients presenting to a large tertiary academic ED with chief complaint of headache. A structured medical record review was conducted to abstract relevant variables of interest. Patient race was categorized as white or Black, Indigenous, or person of color (BIPOC). Descriptive statistics were used to characterize the cohort and stratified analyses were conducted based on patient race and our key outcome measures of analgesic prescribing patterns, time to analgesia, and time to provider in the treatment of headache. RESULTS: White patients were more likely to be assigned an Emergency Severity Index score 2 or 3 and their BIPOC counterparts were more likely to be assigned an ESI score 3 or 4 (p = 0.02). There was no significant difference by race in time to analgesia (p = 0.318), time to provider (p = 0.358), or time to first medication treatment (p = 0.357). However, there were clear differences in prescribing patterns. BIPOC patients were significantly more likely to be treated with acetaminophen (p = 0.042) or ibuprofen (p = 0.015) despite reporting higher pain levels during triage (p < 0.001). White patients were significantly more likely to receive a head CT scan (p < 0.001) or neurology consult (p = 0.003) than their BIPOC counterparts. CONCLUSION: Racial disparities persist in assessment and type of analgesia for patients being treated for headache in a large academic emergency department.

Sports Bra Preferences by Age and Impact of Breast Size on Physical Activity among American Females.

For many females, sports bras are an essential piece of equipment for participation in sports and physical activity. Breast pain or discomfort from lack of support may be a contributing factor to the noted gender disparity in physical activity of females compared to males. Our objective was to evaluate sports bra usage and characterize sports bra preferences of an active female cohort. This multicenter cross-sectional survey study was conducted at five geographically distinct academic centers. Our measure was administered during outpatient sports medicine clinic visits to females aged 11-64 years old. Chi-square tests were used to compare characteristics across subgroups. Our analysis consisted of 438 respondents, with a mean age of 22 ± 12.2 years. More than a quarter (27.4%) reported lack of breast support prevented them from being active or exercising. Age (p = 0.03), breast size (p < 0.0001), and household income (p = 0.01) were significantly associated with greater frequency of physical activity being limited by lack of breast support. Lack of breast support may be an important barrier for young females of specific populations to meeting physical activity recommendations. Further research is needed to improve the understanding of this important piece of sporting equipment for women.

Classification of Comprehensive Neuro-Ophthalmologic Measures of Postacute Concussion.

Importance: Symptom-based methods of concussion diagnosis in contact sports result in underdiagnosis and repeated head injury exposure, increasing the risk of long-term disability. Measures of neuro-ophthalmologic (NO) function have the potential to serve as objective aids, but their diagnostic utility is unknown. Objective: To identify NO measures that accurately differentiate athletes with and without concussion. Design, Setting, and Participants: This cohort study was conducted among athletes with and without concussion who were aged 17 to 22 years between 2016 and 2017. Eye movements and cognitive function were measured a median of 19 days after injury among patients who had an injury meeting the study definition of concussion while playing a sport (retrospectively selected from a concussion clinic), then compared with a control group of participants without concussion (enrolled from 104 noncontact collegiate athlete volunteers without prior head injury). Data analysis was conducted from November 2019 through May 2020. Exposure: Concussion. Main Outcomes and Measures: Classification accuracy of clinically important discriminator eye-tracking (ET) metrics. Participants' eye movements were evaluated with a 12-minute ET procedure, yielding 42 metrics related to smooth pursuit eye movement (SPEM), saccades, dynamic visual acuity, and reaction time. Clinically important discriminator metrics were defined as those with significantly different group differences and area under the receiver operator characteristic curves (AUROCs) of at least 0.70. Results: A total of 34 participants with concussions (mean [SD] age, 19.7 [2.4] years; 20 [63%] men) and 54 participants without concussions (mean [SD] age, 20.8 [2.2] years; 31 [57%] men) completed the study. Six ET metrics (ie, simple reaction time, discriminate reaction time, discriminate visual reaction speed, choice visual reaction speed, and reaction time on 2 measures of dynamic visual acuity 2) were found to be clinically important; all were measures of reaction time, and none were related to SPEM. Combined, these 6 metrics had an AUROC of 0.90 (95% CI, 0.80-0.99), a sensitivity of 77.8%, and a specificity of 92.6%. The 6 metrics remained significant on sensitivity testing. Conclusions and Relevance: In this study, ET measures of slowed visual reaction time had high classification accuracy for concussion. Accurate, objective measures of NO function have the potential to improve concussion recognition and reduce the disability associated with underdiagnosis.

Comparative study of culture, next-generation sequencing, and immunoassay for identification of pathogen in diabetic foot ulcer.

Treatment of deep musculoskeletal infection (MSKI) begins with accurate identification of the offending pathogen, surgical excision/debridement, and a course of culture-directed antibiotics. Despite this, the incidence of recurrent infection continues to rise. A major contributor to this is inaccurate or negative initial cultures. Accurate identification of the main pathogen is paramount to treatment success. This is especially important in treating diabetic foot infections (DFIs) with limb salvage efforts. This study seeks to utilize standard culture, next-generation sequencing (NGS), and immunoassay for newly synthesized antibodies (NSA) to Staphylococcus aureus and Streptococcus agalactiae for diagnosis. This is a level II prospective observational study approved by our IRB. Thirty patients > 18 years of age who presented with a DFI and underwent surgical debridement or amputation by a single academic orthopedic surgeon from October 2018 to September 2019 were enrolled. Intraoperative samples were obtained from the base of the wound and sent for culture, NGS, and a peripheral blood sample was obtained at the time of diagnosis. NGS and culture were highly correlated for S. aureus (κ = 0.86) and S. agalactiae (κ = 1.0), NSA immunoassay and culture demonstrated a fair correlation for S. aureus (κ = 0.18) and S. agalactiae (κ = 0.67), and NGS and NSA immunoassay demonstrated fair correlation for S. aureus (κ = 0.1667) and S. agalactiae (κ = 0.67). Our study demonstrates a high concordance between culture and NGS in identifying the dominant pathogen in DFU. NGS may be a useful adjunct in DFI diagnosis.

Progesterone Treatment Does Not Decrease Serum Levels of Biomarkers of Glial and Neuronal Cell Injury in Moderate and Severe Traumatic Brain Injury Subjects: A Secondary Analysis of the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECT) III Trial.

Early treatment of moderate/severe traumatic brain injury (TBI) with progesterone does not improve clinical outcomes. This is in contrast with findings from pre-clinical studies of progesterone in TBI. To understand the reasons for the negative clinical trial, we investigated whether progesterone treatment has the desired biological effect of decreasing brain cell death. We quantified brain cell death using serum levels of biomarkers of glial and neuronal cell death (glial fibrillary acidic protein [GFAP], ubiquitin carboxy-terminal hydrolase-L1 [UCH-L1], S100 calcium-binding protein B [S100B], and Alpha II Spectrin Breakdown Product 150 [SBDP]) in the Biomarkers of Injury and Outcome-Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (BIO-ProTECT) study. Serum levels of GFAP, UCHL1, S100B, and SBDP were measured at baseline (≤4 h post-injury and before administration of study drug) and at 24 and 48 h post-injury. Serum progesterone levels were measured at 24 and 48 h post-injury. The primary outcome of ProTECT was based on the Glasgow Outcome Scale-Extended assessed at 6 months post-randomization. We found that at baseline, there were no differences in biomarker levels between subjects randomized to progesterone treatment and those randomized to placebo (p > 0.10). Similarly, at 24 and 48 h post-injury, there were no differences in biomarker levels in the progesterone versus placebo groups (p > 0.15). There was no statistically significant correlation between serum progesterone concentrations and biomarker values obtained at 24 and 48 h. When examined as a continuous variable, baseline biomarker levels did not modify the association between progesterone treatment and neurological outcome (p of interaction term >0.39 for all biomarkers). We conclude that progesterone treatment does not decrease levels of biomarkers of glial and neuronal cell death during the first 48 h post-injury.

S100B outperforms clinical decision rules for the identification of intracranial injury on head CT scan after mild traumatic brain injury.

Objective: To compare the classification accuracy of S100B to two clinical decision rules- Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC)-for predicting traumatic intracranial injuries (ICI) after mild traumatic brain injury (mild TBI).Methods: A secondary analysis of a prospective observational study of mild TBI patients was performed. The diagnostic performance of S100B for predicting ICI on head CT was compared to both the CHRR and NOC. Area under receiver operator characteristic (AUC) curves were used and multivariable analysis was used to create a new decision rule based on a combination of S100B and decision rule-related variables.Results: S100B had the highest negative predictive value (97.3%), positive predictive value (7.21%), specificity (33.6%) and positive likelihood ratio (1.3), and the lowest negative likelihood ratio (0.5). The proportion of mild TBI subjects with potentially avoidable head CT scans was highest using S100B (37.7%). The addition of S100B to both clinical decision rules significantly increased AUC. A novel decision rule adding S100B to three decision rule-related variables significantly improved prediction (p < 0.05).Conclusion: Serum S100B outperformed clinical decision rules for identifying mild TBI patients with ICI. Incorporating clinical variables with S100B maximized ICI prediction, but requires validation in an independent cohort.

Emergency Medicine Intern Education for Best Practices in Opioid Prescribing.

INTRODUCTION: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing. METHODS: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education program included opioid prescribing guidelines for common ED disease states associated with moderate pain, clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes. RESULTS: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4305 vs 749) were reduced, P < 0.01. There were no differences in selection of opioid product or total morphine milligram equivalents prescribed when an opioid was used. CONCLUSION: An opioid reduction education program targeting EM interns was associated with a reduction in opioid prescribing in the ED and at discharge. This may be an effective way to influence early prescribing patterns and best practices of EM interns.

MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors in emergency department patients with skin and soft tissue infections.

OBJECTIVES: Skin and soft tissue infections (SSTI) caused by methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in the emergency department (ED). We determined whether MRSA nasal carriage better identifies patients with MRSA wound infection than clinical risk factors or emergency medicine (EM) provider's choice of discharge prescriptions. METHODS: Adult patients presenting to a large academic medical centre ED in the USA with SSTI between May 2010 and November 2011 were screened. Research assistants administered a questionnaire regarding MRSA risk factors, and MRSA nares swab PCR testing, wound culture results and information on antibiotics prescribed at discharge were collected. Measures of classification accuracy for nares swab, individual risk factors and physician's prescription for MRSA coverage were compared with gold standard wound culture. RESULTS: During the study period, 116 patients with SSTI had both wound cultures and nares swabs for MRSA. S. aureus was isolated in 59.5%, most often MRSA (75.4%). Thirty patients (25.9%) had a positive MRSA nares swab and culture for a sensitivity of 57.7% and specificity of 92.2%. Positive predictive value (PPV) for MRSA nares swab was 85.7% and positive likelihood ratio was 7.4, while negative predictive value was 72.8% and negative likelihood ratio 0.5. None of the individual risk factors nor EM provider's prescription for MRSA coverage had a PPV or positive likelihood ratio higher than nares swabs. CONCLUSIONS: MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors or EM provider's choice of antibiotics. MRSA nares swab may be a useful tool in the ED.

Blood-Based Biomarkers for the Identification of Sports-Related Concussion.

Sports-related concussions (SRCs) are common among athletes in the United States. Most athletes who sustain an SRC recover within 7 to 10 days; however, many athletes who sustain the injury do not recover as expected and experience prolonged, persistent symptoms. In this document, the authors provide an overview of the empirical evidence related to the use of blood-based brain biomarkers in the athlete population for diagnosis of SRCs, prognosis of recovery and return to play guidelines, and indications of neurodegeneration. The authors also provide a summary of research challenges, gaps in the literature, and future directions for research.

Evaluation of Nintendo Wii Balance Board as a Tool for Measuring Postural Stability After Sport-Related Concussion.

CONTEXT: Recent changes to postconcussion guidelines indicate that postural-stability assessment may augment traditional neurocognitive testing when making return-to-participation decisions. The Balance Error Scoring System (BESS) has been proposed as 1 measure of balance assessment. A new, freely available software program to accompany the Nintendo Wii Balance Board (WBB) system has recently been developed but has not been tested in concussed patients. OBJECTIVE: To evaluate the feasibility of using the WBB to assess postural stability across 3 time points (baseline and postconcussion days 3 and 7) and to assess concurrent and convergent validity of the WBB with other traditional measures (BESS and Immediate Post-Concussion Assessment and Cognitive Test [ImPACT] battery) of assessing concussion recovery. DESIGN: Cohort study. SETTING: Athletic training room and collegiate sports arena. PATIENTS OR OTHER PARTICIPANTS: We collected preseason baseline data from 403 National Collegiate Athletic Association Division I and III student-athletes participating in contact sports and studied 19 participants (age = 19.2 ± 1.2 years, height = 177.7 ± 8.0 cm, mass = 75.3 ± 16.6 kg, time from baseline to day 3 postconcussion = 27.1 ± 36.6 weeks) who sustained concussions. MAIN OUTCOME MEASURE(S): We assessed balance using single-legged and double-legged stances for both the BESS and WBB, focusing on the double-legged, eyes-closed stance for the WBB, and used ImPACT to assess neurocognition at 3 time points. Descriptive statistics were used to characterize the sample. Mean differences and Spearman rank correlation coefficients were used to determine differences within and between metrics over the 3 time points. Individual-level changes over time were also assessed graphically. RESULTS: The WBB demonstrated mean changes between baseline and day 3 postconcussion and between days 3 and 7 postconcussion. It was correlated with the BESS and ImPACT for several measures and identified 2 cases of abnormal balance postconcussion that would not have been identified via the BESS. CONCLUSIONS: When accompanied by the appropriate analytic software, the WBB may be an alternative for assessing postural stability in concussed student-athletes and may provide additional information to that obtained via the BESS and ImPACT. However, verification among independent samples is required.

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital.

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.

Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations.

To determine the acceptability of alternatives to traditional emergency care, we assessed the proportion of subjects willing to consider alternative modes of transportation and alternative destinations. We further identified patient characteristics associated with willingness to consider these alternatives. We conducted a cross-sectional survey study in the emergency department (ED) of an academic medical center. Research assistants screened all non-critically ill ED patients for eligibility and willingness to participate and administered an interview-based survey that included questions on demographic and clinical characteristics, perceived illness severity, and acceptability of alternatives to traditional emergency care for acute illness and injuries. We calculated the proportions and 95% confidence intervals for subjects who found alternative transport modes and destinations acceptable and developed a log-binomial regression model to identify patient characteristics associated with acceptability of alternative modes of transport and alternative destinations. Complete data were available on 1,058 subjects. Forty-two percent of the study sample arrived to the ED via emergency medical services (EMS). Over two-thirds of the study sample (68.2%) was willing to consider transport via either taxi or medical transport van and 69.0% was willing to consider either transportation to an urgent care center or their primary care physician's office. Other alternatives, including delayed EMS response time, were less frequently endorsed as acceptable alternatives. Subject characteristics associated with willingness to accept alternative modes of transportation included younger age, chief complaint, previous ED use, and place of residence (p < 0.05). Subject characteristics associated with willingness to accept alternative destinations included younger age, non-white race, lower patient acuity, and lower self-perceived illness severity (p < 0.05). In our ED, some patients found alternative transport modes and alternative destinations acceptable. We identified patient-level characteristics associated with willingness to accept alternatives; however, the predictive ability and clinical utility of these factors is limited. Future research should further explore the acceptability and effectiveness of these alternative care delivery options.