Mpox Surveillance Based on Rash Characteristics - 13 Emergency Departments, United States, June-December 2023.

In 2022, a global mpox outbreak occurred, primarily affecting gay and bisexual men who have sex with men (GBMSM). To screen for mpox's reemergence and investigate potentially unsuspected cases among non-GBMSM, prospective surveillance of patients aged ≥3 months with an mpox-compatible rash (vesicular, pustular, ulcerated, or crusted) was conducted at 13 U.S. emergency departments (EDs) during June-December 2023. Demographic, historical, and illness characteristics were collected using questionnaires and electronic health records. Lesions were tested for monkeypox virus using polymerase chain reaction. Among 196 enrolled persons, the median age was 37.5 years (IQR = 21.0-53.5 years); 39 (19.9%) were aged <16 years, and 108 (55.1%) were male. Among all enrollees, 13 (6.6%) were GBMSM. Overall, approximately one half (46.4%) and one quarter (23.5%) of enrolled persons were non-Hispanic White and non-Hispanic Black or African American, respectively, and 38.8% reported Hispanic or Latino (Hispanic) ethnicity. Unstable housing was reported by 21 (10.7%) enrollees, and 24 (12.2%) lacked health insurance. The prevalence of mpox among ED patients evaluated for an mpox-compatible rash was 1.5% (95% CI = 0.3%-4.4%); all persons with a confirmed mpox diagnosis identified as GBMSM and reported being HIV-negative, not being vaccinated against mpox, and having engaged in sex with one or more partners met through smartphone dating applications. No cases were identified among women, children, or unhoused persons. Clinicians should remain vigilant for mpox and educate persons at risk for mpox about modifying behaviors that increase risk and the importance of receiving 2 appropriately spaced doses of JYNNEOS vaccine to prevent mpox.

Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients.

STUDY OBJECTIVE: Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients. METHODS: We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3). RESULTS: For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill. CONCLUSION: We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.

BACKGROUND: Incident reports submitted during times of organizational stress may reveal unique insights. PURPOSE: To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. METHODS: We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. RESULTS: Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19. CONCLUSIONS: Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

Digital Tools Designed to Obtain the History of Present Illness From Patients: Scoping Review.

BACKGROUND: Many medical conditions, perhaps 80% of them, can be diagnosed by taking a thorough history of present illness (HPI). However, in the clinical setting, situational factors such as interruptions and time pressure may cause interactions with patients to be brief and fragmented. One solution for improving clinicians' ability to collect a thorough HPI and maximize efficiency and quality of care could be to use a digital tool to obtain the HPI before face-to-face evaluation by a clinician. OBJECTIVE: Our objective was to identify and characterize digital tools that have been designed to obtain the HPI directly from patients or caregivers and present this information to clinicians before a face-to-face encounter. We also sought to describe outcomes reported in testing of these tools, especially those related to usability, efficiency, and quality of care. METHODS: We conducted a scoping review using predefined search terms in the following databases: MEDLINE, CINAHL, PsycINFO, Web of Science, Embase, IEEE Xplore Digital Library, ACM Digital Library, and ProQuest Dissertations & Theses Global. Two reviewers screened titles and abstracts for relevance, performed full-text reviews of articles meeting the inclusion criteria, and used a pile-sorting procedure to identify distinguishing characteristics of the tools. Information describing the tools was primarily obtained from identified peer-reviewed sources; in addition, supplementary information was obtained from tool websites and through direct communications with tool creators. RESULTS: We identified 18 tools meeting the inclusion criteria. Of these 18 tools, 14 (78%) used primarily closed-ended and multiple-choice questions, 1 (6%) used free-text input, and 3 (17%) used conversational (chatbot) style. More than half (10/18, 56%) of the tools were tailored to specific patient subpopulations; the remaining (8/18, 44%) tools did not specify a target subpopulation. Of the 18 tools, 7 (39%) included multilingual support, and 12 (67%) had the capability to transfer data directly into the electronic health record. Studies of the tools reported on various outcome measures related to usability, efficiency, and quality of care. CONCLUSIONS: The HPI tools we identified (N=18) varied greatly in their purpose and functionality. There was no consensus on how patient-generated information should be collected or presented to clinicians. Existing tools have undergone inconsistent levels of testing, with a wide variety of different outcome measures used in evaluation, including some related to usability, efficiency, and quality of care. There is substantial interest in using digital tools to obtain the HPI from patients, but the outcomes measured have been inconsistent. Future research should focus on whether using HPI tools can lead to improved patient experience and health outcomes, although surrogate end points could instead be used so long as patient safety is monitored.

Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL).

PURPOSE: To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. METHODS: This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017-2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. RESULTS: 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%-42.6%) for XR, 19.1% (IQR 11.4%-24.9%) for CT, and 0.09% (IQR 0%-0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%-61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%-81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: -12.7%, -4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: -7.3%, -1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: -5.9%, -0;5%), CT (20.1% vs 17.7%; 95% CI: -5.1%, -0.4%) or MRI (0.8% vs 0.7%, 95% CI: -0.4%, -0.3%). CONCLUSIONS: Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.

Quantifying Emergency Physician Interruptions due to Electrocardiogram Review.

BACKGROUND: Interruptions are recognized as potentially harmful to safety and efficiency, and are especially prevalent in the emergency department (ED) setting. Policies urging immediate review of all electrocardiograms (ECGs) may lead to numerous and frequent interruptions. OBJECTIVE: We assessed the role of ECG review as a source of ED interruptions to characterize a potential target for interventions. METHODS: We analyzed emergency physician time use during the course of a clinical shift using a time-and-motion design. A research assistant observed a convenience sample of shifts, observing and logging transitions between different tasks using an electronic device. Instances of ECG review were tallied, with start and ending times of ECG review recorded to the nearest second. An ECG review was considered an interruption if the immediate prior and subsequent tasks were the same. RESULTS: Twenty shifts were observed for a total of 149 h. There were 211 ECG reviews, (mean rate 1.4 per hour), with more frequent review among physicians staffing a zone with higher-acuity patients (2.8 per hour), where clustering of multiple ECG reviews in succession was more common. Seventy-five percent of ECG reviews required < 30 s. Of all 211 ECG reviews, 102 (48%) were an interruption. The tasks most frequently interrupted were electronic medical record system use (68 of 102, 67%) and communicating with ED staff in person (18 of 102, 18%). CONCLUSIONS: Review of ECGs was a substantial driver of interruptions for emergency physicians. Interventions to integrate ECG review more naturally into physician workflow may improve patient safety by reducing these interruptions.

Child and Family Perspectives on Adjustment to and Coping With Pediatric Inflammatory Bowel Disease.

OBJECTIVES: Children with inflammatory bowel disease (IBD) are at increased risk for poor mental health. The etiology of this risk is not clear, though may be related to the disease, its treatment, and/or the experience of these. We sought to describe the challenges that children with IBD and their families face in living with a chronic condition and undergoing repeated intravenous infusions; and identify coping mechanisms to understand how medical systems may support resilience. METHODS: Semistructured qualitative interviews with 18 patient-guardian dyads at a tertiary outpatient infusion center, explored feelings related to IBD, the infusion process, and coping. Interviews were recorded, transcribed, and analyzed in ATLAS.ti. Two coders identified themes; developed a codebook and coded transcripts using the constant comparative method; and described themes/patterns. RESULTS: Participants identified challenges related to IBD (unpredictable nature, disrupted normalcy, treatment decisions, managing relationships, life transitions) and a subset of challenges related to the infusion procedure (anxiety of unknown, managing pain/anxiety during IV placement, logistics). Participants coped through social support, cognitive strategies (positive attitude) and/or behavioral strategies for managing emotions (preparation for intravenous [IV] placement), and confidence in the medical care. By employing these coping strategies, participants came to accept IBD, adapt to the "new norm," and learned life lessons and resilience. CONCLUSIONS: To support coping, clinical teams might provide anticipatory guidance to decrease anxiety of the unknown and identify cognitive-behavioral strategies for managing emotions. Delivery systems that build relationships, maintain normalcy, and consider needs of the family may further facilitate coping.

Child and Parent Perspectives on the Acceptability of Virtual Reality to Mitigate Medical Trauma in an Infusion Center.

INTRODUCTION: Children may experience medical trauma when undergoing medical procedures even when procedures are minor. While virtual reality (VR) is effective for managing procedural pain and anxiety, few studies address how families feel about using VR. We explore pediatric patient and guardian views regarding the acceptability of using VR during procedures to mitigate medical trauma. METHODS: Semi-structured qualitative interviews with 18 patient-guardian dyads at a tertiary outpatient infusion center for inflammatory bowel disease (IBD) treatment. Interviews explored how VR may change the infusion experience, including benefits, risks, and recommendations for clinical integration. Interviews were recorded, transcribed, and analyzed in ATLAS.ti. Two coders used a 3-step coding approach to: (1) identify themes; (2) develop a codebook and code transcripts using the constant comparative method; and (3) describe themes/patterns. RESULTS: Potential benefits of VR were distraction from infusion-related anxiety and pain and generating excitement for the appointment. Potential challenges were VR-side effects (dizziness, nausea), limited mobility during the procedure, disorientation/immersion leading to shock upon IV-placement, and a lost opportunity to build coping skills. Families queried when VR should first be introduced and when during the appointment use would be optimal. Parents expressed concerns about pushing VR when their child was already under stress. A limited number of families doubted the utility of VR. CONCLUSIONS: Patients and parents found VR to be an acceptable option for helping to manage medical trauma during infusions but highlighted that the VR experience must be carefully crafted to avoid unintended consequences, including lost opportunities to build resilience.

Primary Care Physicians in the Merit-Based Incentive Payment System (MIPS): a Qualitative Investigation of Participants' Experiences, Self-Reported Practice Changes, and Suggestions for Program Administrators.

BACKGROUND: While both administrators of pay-for-performance programs and practicing physicians strive to improve healthcare quality, they sometimes disagree on the best approach. The Medicare Access and CHIP Reauthorization Act of 2015 mandated the creation of the Merit-Based Incentive Payment System (MIPS), a program that incentivizes more than 700,000 physician participants to report on four domains of care, including healthcare quality. While MIPS performance scores were recently released, little is known about how primary care physicians (PCPs) and their practices are being affected by the program and what actions they are taking in response to MIPS. OBJECTIVES: To (1) describe PCP perspectives and self-reported practice changes related to quality measurement under MIPS and (2) disseminate PCP suggestions for improving the program. DESIGN: Qualitative study employing semi-structured interviews. PARTICIPANTS: Twenty PCPs trained in internal medicine or family medicine who were expected to report under MIPS for calendar year 2017 were interviewed between October 2017 and June 2018. Eight PCPs self-reported to be knowledgeable about MIPS. Seven PCPs worked in small practices. KEY RESULTS: Most PCPs identified advantages of quality measurement under MIPS, including the creation of practice-level systems for quality improvement. However, they also cited disadvantages, including administrative burdens and fears that practices serving vulnerable patients could be penalized. Many participants reported using technology or altering staffing to help with data collection and performance improvement. A few participants were considering selling small practices or joining larger ones to avoid administrative tasks. Suggestions for improving MIPS included simplifying the program to reduce administrative burdens, protecting practices serving vulnerable populations, and improving communication between program administrators and PCPs. CONCLUSIONS: MIPS is succeeding in nudging PCPs to develop quality measurement and improvement systems, but PCPs are concerned that administrative burdens are leading to the diversion of clinical resources away from patient-centered care and negatively impacting patient and clinician satisfaction. Program administrators should improve communication with participants and consider simplifying the program to make it less burdensome. Future work should be done to investigate how technical assistance programs can target PCPs that serve vulnerable patient populations and are having difficulty adapting to MIPS.

Understanding uptake of information about innovations among emergency department clinicians during the COVID-19 pandemic.

Objectives: Early in the COVID-19 pandemic, little was known about managing sick patients, but emergency department (ED) clinicians had to decide which treatments and care processes to adopt. Our objective was to describe how ED clinicians learned about innovations and how they assessed them for credibility during the pandemic. Methods: We purposively sampled clinicians from hospital-based EDs to conduct focus groups with ED clinicians and staff. We used both inductive and deductive approaches to conduct thematic analysis of transcripts. Results: We conducted focus groups with clinicians from eight EDs across the United States. We found that ED clinicians in our sample relied on friends and colleagues or departmental and institutional leadership for information on innovations. They used social media sources when they came from credible accounts but did not directly seek information from professional societies. Clinicians reported a range of challenges to obtain credible information during the pandemic, including a fractured and changing information environment, policies misaligned across clinical sites or that conflicted with clinical knowledge, high patient volume, fear of harming patients, and untimely information. Facilitators included access to experienced and trusted colleagues and leaders and practicing at multiple EDs. Conclusion: Participants cited anecdotal evidence, institutional practice, and word-of-mouth-rather than peer-reviewed evidence and professional society communications-as their primary sources of information about care innovations during the early phases of the pandemic. These results underscore the importance of developing trusted local mechanisms and wider networks to identify and vet information for frontline clinicians during rapidly emerging public health emergencies.

Mpox Discourse on Twitter by Sexual Minority Men and Gender-Diverse Individuals: Infodemiological Study Using BERTopic.

BACKGROUND: The mpox outbreak resulted in 32,063 cases and 58 deaths in the United States and 95,912 cases worldwide from May 2022 to March 2024 according to the US Centers for Disease Control and Prevention (CDC). Like other disease outbreaks (eg, HIV) with perceived community associations, mpox can create the risk of stigma, exacerbate homophobia, and potentially hinder health care access and social equity. However, the existing literature on mpox has limited representation of the perspective of sexual minority men and gender-diverse (SMMGD) individuals. OBJECTIVE: To fill this gap, this study aimed to synthesize themes of discussions among SMMGD individuals and listen to SMMGD voices for identifying problems in current public health communication surrounding mpox to improve inclusivity, equity, and justice. METHODS: We analyzed mpox-related posts (N=8688) posted between October 2020 and September 2022 by 2326 users who self-identified on Twitter/X as SMMGD and were geolocated in the United States. We applied BERTopic (a topic-modeling technique) on the tweets, validated the machine-generated topics through human labeling and annotations, and conducted content analysis of the tweets in each topic. Geographic analysis was performed on the size of the most prominent topic across US states in relation to the University of California, Los Angeles (UCLA) lesbian, gay, and bisexual (LGB) social climate index. RESULTS: BERTopic identified 11 topics, which annotators labeled as mpox health activism (n=2590, 29.81%), mpox vaccination (n=2242, 25.81%), and adverse events (n=85, 0.98%); sarcasm, jokes, and emotional expressions (n=1220, 14.04%); COVID-19 and mpox (n=636, 7.32%); government or public health response (n=532, 6.12%); mpox symptoms (n=238, 2.74%); case reports (n=192, 2.21%); puns on the naming of the virus (ie, mpox; n=75, 0.86%); media publicity (n=59, 0.68%); and mpox in children (n=58, 0.67%). Spearman rank correlation indicated significant negative correlation (ρ=-0.322, P=.03) between the topic size of health activism and the UCLA LGB social climate index at the US state level. CONCLUSIONS: Discussions among SMMGD individuals on mpox encompass both utilitarian (eg, vaccine access, case reports, and mpox symptoms) and emotionally charged (ie, promoting awareness, advocating against homophobia, misinformation/disinformation, and health stigma) themes. Mpox health activism is more prevalent in US states with lower LGB social acceptance, suggesting a resilient communicative pattern among SMMGD individuals in the face of public health oppression. Our method for social listening could facilitate future public health efforts, providing a cost-effective way to capture the perspective of impacted populations. This study illuminates SMMGD engagement with the mpox discourse, underscoring the need for more inclusive public health programming. Findings also highlight the social impact of mpox: health stigma. Our findings could inform interventions to optimize the delivery of informational and tangible health resources leveraging computational mixed-method analyses (eg, BERTopic) and big data.

Health activism, vaccine, and mpox discourse: BERTopic based mixed-method analyses of tweets from sexual minority men and gender diverse (SMMGD) individuals in the U.S.

Objectives: To synthesize discussions among sexual minority men and gender diverse (SMMGD) individuals on mpox, given limited representation of SMMGD voices in existing mpox literature. Methods: BERTopic (a topic modeling technique) was employed with human validations to analyze mpox-related tweets (n = 8,688; October 2020-September 2022) from 2,326 self-identified SMMGD individuals in the U.S.; followed by content analysis and geographic analysis. Results: BERTopic identified 11 topics: health activism (29.81%); mpox vaccination (25.81%) and adverse events (0.98%); sarcasm, jokes, emotional expressions (14.04%); COVID-19 and mpox (7.32%); government/public health response (6.12%); mpox symptoms (2.74%); case reports (2.21%); puns on the virus' naming (i.e., monkeypox; 0.86%); media publicity (0.68%); mpox in children (0.67%). Mpox health activism negatively correlated with LGB social climate index at U.S. state level, ρ = -0.322, p = 0.031. Conclusions: SMMGD discussions on mpox encompassed utilitarian (e.g., vaccine access, case reports, mpox symptoms) and emotionally-charged themes-advocating against homophobia, misinformation, and stigma. Mpox health activism was more prevalent in states with lower LGB social acceptance. Public Health Implications: Findings illuminate SMMGD engagement with mpox discourse, underscoring the need for more inclusive health communication strategies in infectious disease outbreaks to control associated stigma.

Emergency department computed tomography utilization in the United States and Canada.

STUDY OBJECTIVE: We compare secular trends in computed tomography (CT) utilization in emergency departments (EDs) in the United States and Ontario, Canada. METHODS: Using a systematic survey in the US (The National Hospital Ambulatory Medical Care Survey) and administrative databases in Ontario, we performed a retrospective study of ED visits from 2003 to 2008. We calculated utilization overall, by visit characteristics, and for 5 clinical conditions in which CT is commonly indicated: abdominal pain, complex abdominal pain (abdominal pain, age ≥65 years, urgent to most urgent triage), admitted complex abdominal pain (abdominal pain, age ≥65 years, urgent to most urgent triage, and admitted to hospital), headache, and chest pain/shortness of breath. US data were weighted to produce national estimates. RESULTS: On-site CT was available for 97% (95% confidence interval [CI] 95% to 99%) of visits in the United States compared with 80% (95% CI 80% to 80%) in Ontario. Visits were more frequently triaged as higher acuity in the United States than in Ontario, with 15.1% (95% CI 13.9% to 16.4%) of US visits categorized as most urgent versus 11.8% (95% CI 11.8% to 11.8%) in Ontario. The proportion of all ED visits in which CT was performed was 11.4% (95% CI 10.8% to 12.0%) in the United States versus 5.9% (95% CI 5.9% to 5.9%) in Ontario. The proportion for children was 4.7% (95% CI 4.3% to 5.1%) in the United States versus 1.4% (95% CI 1.4% to 1.4%) in Ontario. The rate of visits involving CT per year increased faster from 2003 to 2008 in the United States (odds ratio 2.00; 95% CI 1.81 to 2.21) than Ontario (odds ratio 1.69; 95% CI 1.68 to 1.70). Over time, all subgroups experienced increases in CT rate except Ontario children younger than 10 years, who experienced a significant decrease. United States-Ontario differences in CT proportions were significant among patients presenting with headache, abdominal pain, chest pain/shortness of breath, and complex abdominal pain. Proportions for visits involving admitted complex abdominal pain in the two jurisdictions were indistinguishable: 45.8% in the United States (95% CI 39.9% to 51.7%) versus 44.7% (95% CI 44.4% to 45.0%) in Ontario. CONCLUSION: CT was more readily available in US EDs, and US clinicians used the technology more frequently than their colleagues in Ontario for nearly every category of patients, including children. CT utilization increased over time in both jurisdictions, but faster in the United States. Different demographic features between the two jurisdictions, including triage severity, frequency of hospitalization, and availability of CT scanners, likely account for at least some of the differences in CT utilization. Investigation of both clinical and nonclinical reasons for the differences in CT utilization between the United States and Canada would be a fruitful area for further research.

The impact of positive reinforcement on teamwork climate, resiliency, and burnout during the COVID-19 pandemic: The TEAM-ICU (Transforming Employee Attitudes via Messaging strengthens Interconnection, Communication, and Unity) pilot study.

Burnout is an internationally recognized occupational phenomenon that negatively impacts the healthcare workforce and its recipients. The aim of this pilot study was to test whether positive reinforcement and integrating a language of support among co-workers can enhance resiliency, facilitate psychological wellness, and encourage hope. This embedded mixed methods prospective, behavioral, interventional study evaluated the effects of positive feedback on wellness among intensive care unit clinicians during the COVID-19 pandemic in a single center, quaternary care medical center. The deliberate positive feedback paradigm has the potential to augment resiliency and improve attitudes toward a teamwork climate. The routine use of deliberate positivity may represent a scalable, low-cost initiative to enhance wellness in a healthcare organization.

Patient and Visit Characteristics Associated With Physical Restraint Use in the Emergency Department.

Objective Physical restraints are used in emergency departments (EDs) to address behavioral emergencies in situations in which less restrictive methods have failed. The objective of this study was to evaluate for associations between patient/visit characteristics and physical restraint use. Study Design This study was designed as a cross-sectional, retrospective study of all encounters at Kaiser Permanente Northern California EDs from January 1, 2016, to December 31, 2019, to evaluate differences in patient and visit characteristics between visits involving physical restraint use and those without. Methods Using electronic health record data, this study identified physical restraint use among ED encounters and extracted demographic, clinical, and facility characteristics. The authors calculated odds ratios for physical restraint placement, adjusting for patient and visit characteristics and accounting for within-patient clustering. Results Among 4,410,816 encounters (representing 1,791,673 patients), 6369 encounters (0.1%) involved physical restraint use among 5,554 patients (0.3%). Variables associated with the lowest odds of physical restraint included female sex, presentation to the ED in more recent years, and presence of intentional self-harm/suicidal ideation. Variables associated with the highest odds of physical restraint included higher visit acuity and weekend presentations to the ED. Discussion This study, which leveraged a large, diverse patient sample generalizable to the Northern California population, found several patient and visit characteristics associated with physical restraint use in the ED. Conclusion Results of this study may help identify patient groups and situational factors that are most likely to lead to physical restraint use and structural factors contributing to disparities in care, thereby informing interventions to reduce physical restraint use when possible.

Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.

Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively. Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation. Conclusion: If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.

Comprehensive Pharmacist-led Transitions-of-care Medication Management around Hospital Discharge Adds Modest Cost Relative to Usual Care: Time-and-Motion Cost Analysis.

Optimal medication management is important during hospitalization and at discharge because post-discharge adverse drug events (ADEs) are common, often preventable, and contribute to patient harms, healthcare utilization, and costs. Conduct a cost analysis of a comprehensive pharmacist-led transitions-of-care medication management intervention for older adults during and after hospital discharge. Twelve intervention components addressed medication reconciliation, medication review, and medication adherence. Trained, experienced pharmacists delivered the intervention to older adults with chronic comorbidities at 2 large U.S. academic centers. To quantify and categorize time spent on the intervention, we conducted a time-and-motion analysis of study pharmacists over 36 sequential workdays (14 519 min) involving 117 patients. For 40 patients' hospitalizations, we observed all intervention activities. We used the median minutes spent and pharmacist wages nationally to calculate cost per hospitalization (2020 U.S. dollars) from the hospital perspective, relative to usual care. Pharmacists spent a median of 66.9 min per hospitalization (interquartile range 46.1-90.1), equating to $101 ($86 to $116 in sensitivity analyses). In unadjusted analyses, study site was associated with time spent (medians 111 and 51.8 min) while patient primary language, discharge disposition, number of outpatient medications, and patient age were not. In this cost analysis, comprehensive medication management around discharge cost about $101 per hospitalization, with variation across sites. This cost is at least an order of magnitude less than published costs associated with ADEs, hospital readmissions, or other interventions designed to reduce readmissions. Work is ongoing to assess the current intervention's effectiveness.

Artificial intelligence applications used in the clinical response to COVID-19: A scoping review.

Research into using artificial intelligence (AI) in health care is growing and several observers predicted that AI would play a key role in the clinical response to the COVID-19. Many AI models have been proposed though previous reviews have identified only a few applications used in clinical practice. In this study, we aim to (1) identify and characterize AI applications used in the clinical response to COVID-19; (2) examine the timing, location, and extent of their use; (3) examine how they relate to pre-pandemic applications and the U.S. regulatory approval process; and (4) characterize the evidence that is available to support their use. We searched academic and grey literature sources to identify 66 AI applications that performed a wide range of diagnostic, prognostic, and triage functions in the clinical response to COVID-19. Many were deployed early in the pandemic and most were used in the U.S., other high-income countries, or China. While some applications were used to care for hundreds of thousands of patients, others were used to an unknown or limited extent. We found studies supporting the use of 39 applications, though few of these were independent evaluations and we found no clinical trials evaluating any application's impact on patient health. Due to limited evidence, it is impossible to determine the extent to which the clinical use of AI in the pandemic response has benefited patients overall. Further research is needed, particularly independent evaluations on AI application performance and health impacts in real-world care settings.

The impact of mandatory conflict of interest disclosures on editors' manuscript acceptance decisions: A cross-sectional observational study.

Objective: Although current ethical standards mandate conflict of interest (COI) disclosure by authors of peer-reviewed publications, it is unknown whether disclosure affects a manuscript's fate. Our objective was to identify associations between author COI disclosure and editorial decision to publish. Methods: We performed a cross-sectional observational study of editorial decisions for original research and brief research report manuscripts submitted to Annals of Emergency Medicine between June 2014 and January 2018 using data from the journal's editorial decision software and data from a prior study that characterized author COI for the same manuscripts. Outcomes of interest included final editor decision to publish (primary), initial editor decision, and number of revisions. We compared outcomes for manuscripts with COI versus those without and by type of COI (commercial/government/other). Results: Out of 1312 manuscripts in the sample, 65.1% had no COI declarations, and 34.9% had one or more. Overall likelihood of editorial decision to publish was 13.5% (115/854) for articles without COI and 26.9% (123/458) for those with COI. Overall likelihood of editorial decision to publish was 19.8% (19/96) for articles with commercial COI only versus 33.3% (35/105) for those with government COI only. Conclusions: Articles with author-reported COI were more likely to be published than those without such a declaration. Additionally, results suggest that reports of government COI are associated with improved chance of publication. Authorities should consider relaxing COI requirements temporarily to allow investigators to perform larger scale, randomized controlled studies of the impact of mandated COI disclosure.