Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine.

BACKGROUND: Treating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as 'tranq dope,' is poorly described in literature. Inadequate withdrawal treatment results in a disproportionately high rate of patient-directed discharges (also known as against medical advice dispositions, or AMA). This study aimed to describe a cohort of individuals who received a novel order set for suspected fentanyl and xylazine withdrawal in the ED. METHODS: This is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications. RESULTS: There were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p < 0.001). The AMA rate for this cohort was 3.9 %, whereas the baseline for the population with OUD was 10.7 %. Recorded adverse effects were few and resolved without complication. CONCLUSIONS: Fentanyl and xylazine withdrawal are challenging for patients and providers. A novel tranq dope withdrawal order set may reduce both COWS scores and rate of patient-directed discharge in this cohort of patients, though further investigation is needed to confirm findings.

Making Harm Reduction More Accessible: Fentanyl Test Strip Awareness and Attitudes among Emergency Department Patients Who Use Drugs.

BACKGROUND: Fentanyl test strips (FTS) are a harm reduction method for people to test their drugs for fentanyl. Ideal points for FTS distribution have not been identified. Many people who use drugs have frequent contact with the Emergency Department (ED). We piloted FTS distribution in two urban hospital EDs. METHODS: Between June-December 2021 in Philadelphia, PA, patients with past 30-day drug use completed a survey about drug use, fentanyl attitudes, and FTS; then offered FTS and a brief training. Survey data were analyzed using SPSS for bivariate statistics. RESULTS: Patients (n = 135) were primarily White (68.1%) and male (72.6%). Participants regularly interacted with substance use (57.8%) and benefits coordination (49.6%) services. The most common drugs used were heroin/fentanyl (68.9%), crack cocaine (45.2%) and cannabis (40.0%). Most (98.5%) had heard of fentanyl though few (18.5%) had ever used FTS. Across most drug types, participants were concerned about fentanyl. All accepted FTS training and distribution. Few (9.6%) were somewhat or very concerned about having FTS if stopped by police and this number varied by race (7.6% of White people were somewhat or very concerned, compared to 12.8% of Black people). Most participants were already engaged in risk reduction practices. DISCUSSION: FTS are a widely desired harm reduction tool to facilitate informed decision-making, and non-harm reduction locations are potentially feasible and acceptable distribution sites. Given regular contact with EDs and social services across the sample, FTS should be offered at non-harm reduction locations that come into frequent contact with people who use drugs.

SISTER (system implementation of select transfers in emergency room) model to reduce ED boarding.

OBJECTIVE: This study describes a novel transfer model implemented between an academic, level 1 trauma center (Hospital A) and a nearby affiliate community hospital (Hospital B). Primary outcome is change in boarding hours and percentage of boarders in the Hospital A emergency department. Secondary objectives of this study include how improved flow in the emergency department to reduce boarding improves length of stay, prevents patients from escalating to more acute acuity levels of care, reduces patient morbidity and mortality and therefore improves health care costs as well. METHODS: A retrospective chart review was conducted over a consecutive 14-months period of all patients that presented to main hospital emergency department who were transferred to the Hospital B for inpatient admission. This included analysis of patient cohort characteristics, hospital LOS, return rate to the Hospital A (boomerang), rates of against medical advice (AMA) dispositions, post-discharge recidivism, in addition to enterprise data on total number of boarders, percent of boarders, and total boarding hours. RESULTS: There was a total of 718 transfer encounters during the study period. Percent boarding decreased from 70.6% in the pre-period to 63.8% in the post-period (p < 0.001). Total boarding hours decreased at both the main hospital and the sister hospital with this transfer process. The median length of stay at the sister hospital was 74 h, with 9 upgrades to ICU admissions. Five patients were dispositioned back to the hospital A after admission to hospital B. CONCLUSION: A distributive model was useful in transferring admissions within a healthcare system, reducing number of boarders, percent of boarders, and boarding hours in Hospital A emergency department. Furthermore, the Hospital B was an appropriate location for transfers, based on the low number of ICU transfers and dispositions back to the main hospital.

Can Sudden Cardiac Death Risk in the Young be Identified in the Emergency Department?

Sudden cardiac death in the young is devastating for the family and the community. Although it has diverse etiologies, many are inherited. Discovering the disease in 1 patient offers the chance to save otherwise asymptomatic family members. Although some diseases can be discovered during autopsy, others require electrocardiograms for diagnosis, making it difficult to estimate the prevalence of disease and cause of death. Careful assessment of the history of present illness, family history, and electrocardiogram can guide clinical teams toward sometimes rare and difficult diagnoses. The purpose of this review article is to summarize the bench to bedside diagnosis of inherited dysrhythmia syndromes, which if missed on first presentation to the emergency department, have significant implications for the patient and the entire family.

Safer Pediatric Sedations: Simulation Checklists to Improve Knowledge, Attitudes, and Skills in Emergency Medicine Residents.

Background Pediatric sedation is a low-frequency, high-stakes procedure. This study aimed to train emergency medicine (EM) residents in pediatric procedural sedation through a sedation checklist, enhancing patient safety. Methods EM residents completed a pre-test and a survey on their knowledge and experiences with sedation protocols. Residents were subdivided into four groups: two control groups underwent a pediatric sedation simulation without the aid of a procedural checklist, while two intervention groups were given the procedural checklist to guide their management of the procedure. Following the simulations, a simulation faculty member reviewed sedation management and safety with residents for all groups and answered questions. An improvement analysis was performed via a post-intervention examination among all residents. Results Residents in the intervention group demonstrated an improvement in obtaining more critical actions during the simulation (intervention group critical actions 14, 13 vs non-intervention critical actions 10, 12) and confidence with the procedure (via a Likert scale survey across multiple arenas of pediatric sedation), with only moderately increased scores on the post-test examination (pre-simulation score of 6.28±2.14; post-simulation score of 6.75±1.88). Conclusion The data suggest that a checklist, combined with dedicated training through simulation, improves knowledge, confidence, and skill with regard to pediatric sedations. Further study is required to examine the longitudinal impact of our program on resident performance and patient outcomes.

Descriptive Analysis of Emergency Department Patients With Substance Use Disorders As Seen by Peer Recovery Specialists in Philadelphia.

BACKGROUND: People with substance use disorders have regular contact with the emergency department (ED). Peer recovery specialists with lived experiences of substance use can provide critical linkages to substance use treatment and other services for patients who use drugs. Patient populations seen by peer recovery specialists remain largely undescribed. OBJECTIVE: This paper describes the demographics, substance use patterns, and barriers to treatment of patients seen by peer recovery specialists in an ED in Philadelphia. METHOD: A review of patient records about demographics, the reason for ED visits, housing, primary drug of choice, previous treatment, treatment barriers, and urine toxicology screening results was conducted. RESULTS: Of 228 patients seen between December 1, 2020, and April 8, 2021, those who listed alcohol as their drug of choice (n=56, 24.6%) came to the ED primarily for withdrawal symptoms (n=19, 33.9%). Patients who listed other drug use (n=172, 75.4%) were largely seen for infection (n=57, 33.1%). Polysubstance use was prevalent in patients whose primary drugs of choice were not alcohol. Inpatient treatment was the most common previous treatment previously (n=106, 46.5%) and the most desired treatment preferred for future treatment (n=97, 42.5%). The most common barriers to treatment for patients were medical comorbidities (n=70, 30.7%) and difficulty navigating the healthcare system (n=43, 18.9%). CONCLUSIONS: Patients consulted by peer recovery specialists had distinct demographics, substance use patterns, and perceived goals and barriers to care. These findings highlight the importance of recognizing and treating polysubstance use for people who use drugs and the critical role of peer recovery programs in navigating subsequent care.

The impact of COVID-19 on the sensitivity of D-dimer for pulmonary embolism.

OBJECTIVE: This study seeks to evaluate the test characteristics of D-dimer for pulmonary embolism (PE) in patients with a concurrent diagnosis of COVID-19. We hypothesized that the sensitivity of D-dimer for PE at current institutional cut points would be similar to those without COVID-19. METHODS: This is a multicenter retrospective observational cohort study across five urban and suburban EDs in the same health care system. The electronic health record was queried for all computed tomography pulmonary angiography (CTPA) studies from December 1, 2019, to October 22, 2020. All ED patients who underwent CTPA had D-dimer and COVID-19 testing completed in a single encounter were included in the study. Baseline demographics were obtained. Test characteristics of D-dimer for PE were calculated for patients with and without COVID-19. Additionally, receiver operator characteristics (ROC) curves were constructed for two different D-dimer assays. RESULTS: There were 1158 patient encounters that met criteria for analysis. Performance of D-dimer testing for PE was similar between COVID-19-positive and -negative patients. In COVID-19-positive patients, the sensitivity was 100% (95% confidence interval [CI] = 87.6%-100%), specificity was 11.9% (95% CI = 7.9%-17.1%), and negative predictive value (NPV) was 100%. In COVID-19-negative patients the sensitivity was 97.6% (95% CI = 91.5%-99.7%), specificity was 14.4% (95% CI = 12.1%-17%), and NPV was 98.3% (95% CI = 93.8%-99.6%). For assay 1 the area under the curve (AUC) for COVID-19-positive patients was 0.76 (95% CI = 0.68-0.83), and for COVID-19-negative patients, 0.73 (95% CI = 0.69-0.77). For assay 2, AUC for COVID-19-positive patients was 0.85 (95% CI = 0.77-0.92), and for COVID-19-negative patients, 0.80 (95% CI = 0.77-0.84). Inspection of the ROC curve for assay 1 revealed that 100% sensitivity was maintained up to a threshold of 0.67 FEU (fibrinogen equivalent units; from 0.50 FEU) with an increase in specificity to 29% (from 18.7%), and for assay 2, 100% sensitivity was maintained up to a threshold of 662 D-dimer units (DDU; from 230 DDU) with an increased specificity to 59% (from 6.1%). CONCLUSION: Results from this multicenter retrospective study did not find a significant difference in sensitivity of D-dimer for PE due to concomitant COVID-19 infection. Further study is required to determine if PE can safely be excluded based on D-dimer results alone in patients with suspected or proven COVID-19 or if adjusted D-dimer levels could have a role in management.

Prolonged Duration of Viral Shedding of SARS-CoV-2: A Case Report.

INTRODUCTION: The literature on the clinical course of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) suggests patients continue shedding viral particles typically for an average of 20 days until the body builds immunity against the infection. However, a few cases have shown prolonged duration in viral shedding and highlight the significant increased mortality in these patients. It has also been suggested that multiple strains of SARS-COV-2 exist, keying the possibility to reinfection. CASE REPORT: We present a case of a 57-year-old male who presented twice over 37 days with symptoms related to SARS-COV-2, and only on his second visit was found to be in hypoxemic respiratory failure and cardiogenic shock. He also reportedly had a period of convalescence in between presentations. DISCUSSION: This case highlights the still unclear disease course of SARS-COV-2 and the need for diligence in providing strong follow-up instructions and evaluation for sequelae of the infection.

A Critical Disconnect: Residency Selection Factors Lack Correlation With Intern Performance.

BACKGROUND: Emergency medicine (EM) residency programs want to employ a selection process that will rank best possible applicants for admission into the specialty. OBJECTIVE: We tested if application data are associated with resident performance using EM milestone assessments. We hypothesized that a weak correlation would exist between some selection factors and milestone outcomes. METHODS: Utilizing data from 5 collaborating residency programs, a secondary analysis was performed on residents trained from 2013 to 2018. Factors in the model were gender, underrepresented in medicine status, United States Medical Licensing Examination Step 1 and 2 Clinical Knowledge (CK), Alpha Omega Alpha (AOA), grades (EM, medicine, surgery, pediatrics), advanced degree, Standardized Letter of Evaluation global assessment, rank list position, and controls for year assessed and program. The primary outcomes were milestone level achieved in the core competencies. Multivariate linear regression models were fitted for each of the 23 competencies with comparisons made between each model's results. RESULTS: For the most part, academic performance in medical school (Step 1, 2 CK, grades, AOA) was not associated with residency clinical performance on milestones. Isolated correlations were found between specific milestones (eg, higher surgical grade increased wound care score), but most had no correlation with residency performance. CONCLUSIONS: Our study did not find consistent, meaningful correlations between the most common selection factors and milestones at any point in training. This may indicate our current selection process cannot consistently identify the medical students who are most likely to be high performers as residents.

An Evaluation of Risk Attitudes and Risk Tolerance in Emergency Medicine Residents.

Introduction Previous studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool. Methods First-, second-, and third-year residents of Thomas Jefferson University Hospital's EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health Systems (MHS Inc, New York, USA). Scored reports included information on residents' risk type (one of eight personality types that reflect their temperament and disposition); risk attitudes (domains where residents are more likely to engage in risky behaviors); and an overall risk tolerance indicator (RTi) (a numerical estimate of risk tolerance). RTi scores are reported as means with 95% confidence intervals (CIs). Results There was no significant change in RTi scores in residents across different years of their post-graduate year (PGY) training. PGY-one residents trended towards risk aversion; PGY-two residents were more risk-taking; and PGY-three residents scored in the middle. Conclusion Our pilot assessment of risk types in EM residents highlighted shifts across the years of training. Variations between members of each PGY cohort outweighed any outright differences between classes with regards to absolute risk tolerance. There was an increase in the frequency of health and safety risk-taking attitude with higher PGY class, and this was also the risk attitude that was the prominent domain for resident risk tolerance. The study was limited by sample size and single cross-sectional evaluation.

Cortical Blindness and Altered Mental Status following Routine Hemodialysis, a Case of Iatrogenic Cerebral Air Embolism.

Cerebral air embolism is a known complication from a myriad of iatrogenic causes. This case describes a 60-year-old female presenting from hemodialysis with altered mental status, bilateral homonymous hemianopia, and repetitive speech. A noncontrast head CT revealed air in the vein of Galen and the deep cerebral veins of the left thalamus and occipital sulcus, a complication from air being introduced into the patient via improper flushing of dialysis tubing. The retrograde flow of air bubbles in the upright patient during dialysis was likely responsible for the air embolus lodging in the cerebral vasculature. This patient was transferred to receive hyperbaric therapy, whereupon the patient survived with residual attention and spatial deficits.

Teaching the Emergency Department Patient Experience: Needs Assessment from the CORD-EM Task Force.

INTRODUCTION: Since the creation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction (PS) scores, patient experience (PE) has become a metric that can profoundly affect the fiscal balance of hospital systems, reputation of entire departments and welfare of individual physicians. While government and hospital mandates demonstrate the prominence of PE as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PE in categorical emergency medicine (EM) residencies. METHODS: This was a prospective survey analysis of the Council of Emergency Medicine Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department, and questions regarding the presence and types of PS evaluative data and PE education they provide. RESULTS: We obtained 168 responses from 139 individual residencies, representing 72% of all categorical EM residencies. This survey found that only 27% of responding residencies provide PS data to their residents. Of those programs, 61% offer simulation scores, 39% provide third-party attending data on cases with resident participation, 37% provide third-party acquired data specifically about residents and 37% provide internally acquired quantitative data. Only 35% of residencies reported having any organized PE curricula. Of the programs that provide an organized PE curriculum, most offer multiple modalities; 96% provide didactic lectures, 49% small group sessions, 47% simulation sessions and 27% specifically use standardized patient encounters in their simulation sessions. CONCLUSION: The majority of categorical EM residencies do not provide either PS data or any organized PE curriculum. Those that do use a heterogeneous set of data collection modalities and educational techniques. American Osteopathic Association and Accreditation Council for Graduate Medical Education residencies show no significant differences in their resident PS data provision or formal curricula. Further work is needed to improve education given the high stakes of PS scores in the emergency physician's career.

"Let Me Tell You About My " Provider Self-Disclosure in the Emergency Department Builds Patient Rapport.

INTRODUCTION: As patients become increasingly involved in their medical care, physician-patient communication gains importance. A previous study showed that physician self-disclosure (SD) of personal information by primary care providers decreased patient rating of the provider communication skills. OBJECTIVE: The objective of this study was to explore the incidence and impact of emergency department (ED) provider self-disclosure on patients' rating of provider communication skills. METHODS: A survey was administered to 520 adult patients or parents of pediatric patients in a large tertiary care ED during the summer of 2014. The instrument asked patients whether the provider self-disclosed and subsequently asked patients to rate providers' communication skills. We compared patients' ratings of communication measurements between encounters where self-disclosure occurred to those where it did not. RESULTS: Patients reported provider SD in 18.9% of interactions. Provider SD was associated with more positive patient perception of provider communication skills (p<0.05), more positive ratings of provider rapport (p<0.05) and higher satisfaction with provider communication (p<0.05). Patients who noted SD scored their providers' communication skills as "excellent" (63.4%) compared to patients without self-disclosure (47.1%). Patients reported that they would like to hear about their providers' experiences with a similar chief complaint (64.4% of patients), their providers' education (49%), family (33%), personal life (21%) or an injury/ailment unlike their own (18%). Patients responded that providers self-disclose to make patients comfortable/at ease and to build rapport. CONCLUSION: Provider self-disclosure in the ED is common and is associated with higher ratings of provider communication, rapport, and patient satisfaction.

Academic Primer Series: Five Key Papers for Consulting Clinician Educators.

INTRODUCTION: Clinician educators are often asked to perform consultations for colleagues. Invitations to consult and advise others on local problems can help foster great collaborations between centers, and allows for an exchange of ideas between programs. In this article, the authors identify and summarize several key papers to assist emerging clinician educators with the consultation process. METHODS: A consensus-building process was used to generate a list of key papers that describe the importance and significance of educational consulting, informed by social media sources. A three-round voting methodology, akin to a Delphi study, determined the most impactful papers from the larger list. RESULTS: Summaries of the five most highly rated papers on education consultation are presented in this paper. These papers were determined by a mixed group of junior and senior faculty members, who have summarized these papers with respect to their relevance for their peer groups. CONCLUSION: Five key papers on the educational consultation process are presented in this paper. These papers offer background and perspective to help junior faculty gain a grasp of consultation processes.

An assessment of emotional intelligence in emergency medicine resident physicians.

OBJECTIVES: To define the emotional intelligence (EI) profile of emergency medicine (EM) residents, and identify resident EI strengths and weaknesses. METHODS: First-, second-, and third-year residents (post-graduate years [PGY] 1, 2, and 3, respectively) of Thomas Jefferson University Hospital's EM Program completed the Emotional Quotient Inventory (EQ-i 2.0), a validated instrument offered by Multi-Health Systems. Reported scores included total mean EI, 5 composite scores, and 15 subscales of EI. Scores are reported as means with 95% CIs. The unpaired, two-sample t-test was used to evaluate differences in means. RESULTS: Thirty-five residents completed the assessment (response rate 97.2%). Scores were normed to the general population (mean 100, SD 15). Total mean EI for the cohort was 103 (95%CI,100-108). EI was higher in female (107) than male (101) residents. PGY-2s demonstrated the lowest mean EI (95) versus PGY-1s (104) and PGY-3s (110). The difference in PGY-3 EI (110; 95%CI,103-116) and PGY-1 EI (95, 95%CI,87-104) was statistically significant (unpaired t-test, p<0.01). Highest composite scores were in interpersonal skills (107; 95%CI,100-108) and stress management (105; 95%CI,101-109). Subscale cohort strengths included self-actualization (107); empathy (107); interpersonal relationships (106); impulse control (106); and stress tolerance (106). Lowest subscale score was in assertiveness (98). Self-regard (89), assertiveness (88), and independence (90) were areas in which PGY-2s attained relatively lower scores (unpaired t-test, p<0.05) compared to their peers and the general population. PGY-3's scored highest in nearly all subscales. CONCLUSIONS: The EQ-i offers insight into training that may assist in developing EM residents, specifically in self-regard, assertiveness, and self-expression. Further study is required to ascertain if patterns in level of training are idiosyncratic or relate to the natural maturation of residents.

A Delphi Method Analysis to Create an Emergency Medicine Educational Patient Satisfaction Survey.

INTRODUCTION: Feedback on patient satisfaction (PS) as a means to monitor and improve performance in patient communication is lacking in residency training. A physician's promotion, compensation and job satisfaction may be impacted by his individual PS scores, once he is in practice. Many communication and satisfaction surveys exist but none focus on the emergency department setting for educational purposes. The goal of this project was to create an emergency medicine-based educational PS survey with strong evidence for content validity. METHODS: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM analysis determined the structure, content and appropriate use of the tool. The group used four-point Likert-type scales and Lynn's criteria for content validity to determine relevant questions from the stated goals. RESULTS: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A 10-question, single-page survey with an additional page of qualitative questions and demographic questions was selected. Thirty one questions were judged to be relevant from an original 48-question list. Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%. CONCLUSION: The DM produced a consensus survey with content validity evidence. Future work will be needed to obtain evidence for response process, internal structure and construct validity.