Consensus-Driven Recommendations to Support Physician Pregnancy, Adoption, Surrogacy, Parental Leave, and Lactation in Emergency Medicine.

The emergency department clinical environment is unique, and guidelines for promoting supportive and equitable workplace cultures ensure success and longevity for pregnant persons and parents in emergency medicine. There is paucity, variability, and dissatisfaction with current parental (historically referred to as maternity and paternity) leave policies. This paper describes the development of consensus-derived recommendations to serve as a framework for emergency departments across the country for incorporating family-friendly policies. Policies that foster a family-inclusive workplace by allowing for professional advancement without sacrificing personal values regardless of sex, gender, and gender identity are critical for emergency medicine recruitment and retention.

Impact of Native Language, English Proficiency, and Language Concordance on Interpersonal Care During Evaluation of Acute Coronary Syndrome.

BACKGROUND: High-quality interpersonal interactions between clinicians and patients can improve communication and reduce health disparities among patients with novice English proficiency (NEP). Yet, little is known about the impact of native language, NEP, and native language concordance on patient on perceptions of interpersonal care in the emergency department (ED). OBJECTIVE: To determine the associations of native language, NEP, and native language concordance with patient perceptions of interpersonal care among patients undergoing evaluation for suspected acute coronary syndrome (ACS) in the ED. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included 1000 patients undergoing evaluation for suspected ACS at an urban ED from 2013 to 2016. MAIN MEASURES: English- and Spanish-speaking patients were surveyed to identify native language, English proficiency (classified as advanced, intermediate, or novice), and perceived language of the treating ED clinician. Patient perceptions of interpersonal care were assessed using the Interpersonal Processes of Care (IPC) survey, a validated 18-item tool for assessing social-psychological domains of patient-clinician interactions. IPC scores ≤ 4 were categorized as sub-optimal (range, 1-5). The associations between native language, English proficiency, and native language concordance with sub-optimal communication were assessed using hierarchical logistic regression adjusted for all three language variables, sociodemographic characteristics, and depression. KEY RESULTS: Nine hundred thirty-three patients (48.0% native non-English-speaking, 55.7% Hispanic) completed the IPC; 522 (57.4%) perceived native language concordance. In unadjusted analyses, non-English native language (OR 1.38, 95% CI 1.04-1.82) and NEP (OR 1.45, 95% CI 1.06-1.98) were associated with sub-optimal communication, whereas language concordance was protective (OR 0.61, 95% CI 0.46-0.81). In fully adjusted analyses, only language concordance remained significantly associated with sub-optimal communication (AOR 0.62, 95% CI 0.42-0.93). CONCLUSIONS: This study suggests that perceived native language concordance acts as a protective factor for patient-clinician interpersonal care in the acute setting, regardless of native language or English proficiency.

Use of Real-Time Information to Predict Future Arrivals in the Emergency Department.

STUDY OBJECTIVE: We aimed to build prediction models for shift-level emergency department (ED) patient volume that could be used to facilitate prediction-driven staffing. We sought to evaluate the predictive power of rich real-time information and understand 1) which real-time information had predictive power and 2) what prediction techniques were appropriate for forecasting ED demand. METHODS: We conducted a retrospective study in an ED site in a large academic hospital in New York City. We examined various prediction techniques, including linear regression, regression trees, extreme gradient boosting, and time series models. By comparing models with and without real-time predictors, we assessed the potential gain in prediction accuracy from real-time information. RESULTS: Real-time predictors improved prediction accuracy on models without contemporary information from 5% to 11%. Among extensive real-time predictors examined, recent patient arrival counts, weather, Google trends, and concurrent patient comorbidity information had significant predictive power. Out of all the forecasting techniques explored, SARIMAX (Seasonal Autoregressive Integrated Moving Average with eXogenous factors) achieved the smallest out-of-sample the root mean square error (RMSE) of 14.656 and mean absolute prediction error (MAPE) of 8.703%. Linear regression was the second best, with out-of-sample RMSE and MAPE equal to 15.366 and 9.109%, respectively. CONCLUSION: Real-time information was effective in improving the prediction accuracy of ED demand. Practice and policy implications for designing staffing paradigms with real-time demand forecasts to reduce ED congestion were discussed.

Emergency Nursing Workforce, Burnout, and Job Turnover in the United States: A National Sample Survey Analysis.

INTRODUCTION: Few studies have examined emergency nurses who have left their job to better understand the reason behind job turnover. It also remains unclear whether emergency nurses differ from other nurses regarding burnout and job turnover reasons. Our study aimed to test differences in reasons for turnover or not currently working between emergency nurses and other nurses; and ascertain factors associated with burnout as a reason for turnover among emergency nurses. METHODS: We conducted a secondary analysis of 2018 National Sample Survey for Registered Nurses data (weighted N = 3,004,589) from Health Resources and Services Administration. Data were analyzed using descriptive statistics, chi-square and t-test, and unadjusted and adjusted logistic regression applying design sampling weights. RESULTS: There were no significant differences in burnout comparing emergency nurses with other nurses. Seven job turnover reasons were endorsed by emergency nurses and were significantly higher than other nurses: insufficient staffing (11.1%, 95% confidence interval [CI] 8.6-14.2, P = .01), physical demands (5.1%, 95% CI 3.4-7.6, P = .44), patient population (4.3%, 95% CI 2.9-6.3, P < .001), better pay elsewhere (11.5%, 95% CI 9-14.7, P < .001), career advancement/promotion (9.6%, 95% CI 7.0-13.2, P = .01), length of commute (5.1%, 95% CI 3.4-7.5, P = .01), and relocation (5%, 95% CI 3.6-7.0, P = .01). Increasing age and increased years since nursing licensure was associated with decreased odds of burnout. DISCUSSION: Several modifiable factors appear associated with job turnover. Interventions and future research should account for unit-specific factors that may precipitate nursing job turnover.

Individual and Joint Effects of Influenza-Like Illness and Vaccinations on Stroke in the Young: A Case-Control Study.

BACKGROUND: Influenza-like illness (ILI) is an acute trigger for stroke, although joint effects of vaccinations and ILI have not yet been explored. METHODS: Data for our case-control study was obtained from MarketScan Commercial Claims and Encounters between 2008 and 2014. Patients 18 to 65 years old who experienced a stroke were matched on age and admission date to a control, defined as patients with head trauma or ankle sprain at an inpatient or emergency department visit. Exposures were ILI in the prior 30 days, and any type of vaccination during the year prior. Our outcome was ischemic and intracerebral hemorrhagic strokes identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. Logistic regression models estimated adjusted odds ratios (aORs) controlling for preventive care visits, diabetes, valvular heart disease, smoking, alcohol abuse, obesity, and hypertension. RESULTS: We identified and matched 24 103 cases 18 to 44 years old and 141 811 45 to 65 years old. Those aged 18 to 44 years had increased stroke risk 30 days after ILI (aOR, 1.68 [95% CI, 1.51-1.86]) and reduced risk with any vaccination in the year prior (aOR, 0.92 [95% CI, 0.87-0.99]). Joint effects indicate that ILI was associated with increased stroke risk among those with (aOR, 1.41 [95% CI, 1.08-1.85]) and without (aOR, 1.73 [95% CI, 1.55-1.94]) vaccinations in the prior year (Pinteraction=0.16). Among those aged 45 to 65 years, adjusted analyses indicate increased stroke risk for those with ILI (aOR, 1.32 [95% CI, 1.26-1.38]), although there was no effect of vaccinations (aOR, 1.00 [95% CI, 0.97-1.02]). Joint effects indicate that ILI was not associated with stroke among those with any vaccination (aOR, 1.07 [95% CI, 0.96-1.18]) but was associated with increased risk among those without vaccinations ([aOR, 1.39 [95% CI, 1.32-1.47]; Pinteraction<0.001). CONCLUSIONS: ILI was associated with increased stroke risk in the young and middle-aged, while vaccinations of any type were associated with decreased risk among the young. Joint effects of ILI and vaccinations indicate vaccinations can reduce the effect of ILI on stroke.

The Impact of the COVID-19 Pandemic on Mental Health, Occupational Functioning, and Professional Retention Among Health Care Workers and First Responders.

BACKGROUND: The COVID-19 pandemic has greatly affected front-line health care workers (HCW) and first responders (FR). The specific components of COVID-19 related occupational stressors (CROS) associated with psychiatric symptoms and reduced occupational functioning or retention remain poorly understood. OBJECTIVES: Examine the relationships between total and factored CROS, psychiatric symptoms, and occupational outcomes. DESIGN: Observational, self-report, single time-point online assessment. PARTICIPANTS: A total of 510 US HCW (N = 301) and FR (N = 200) with occupational duties affected by the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: CROS were assessed using a custom 17-item questionnaire. Post-traumatic stress disorder (PTSD), depression, insomnia, and generalized anxiety symptoms were assessed using the PTSD Checklist-5 (PCL5), Patient Health Questionnaire-9 (PHQ9), Insomnia Severity Index (ISI), and General Anxiety Disorder-7 (GAD7). Respondents' likelihood of leaving current field and occupational functioning were assessed with 2-item PROMIS subscales. Relationships were modeled using multivariable regression. Open-ended responses were coded using rapid template analysis. RESULTS: CROS total scores correlated significantly with all four psychiatric symptom domains (R's = .42-.53), likelihood of leaving one's current occupation (R = .18), and trouble doing usual work (R = .28), all p's < .001. Half of HCW indicated a decreased likelihood of staying in their current occupation as a result of the pandemic. CROS were fit to a 3-factor model consisting of risk, demoralization, and volume factors. All CROS factors were associated with psychiatric symptom burden, but demoralization was most prominently associated with psychiatric symptoms and negative occupational outcomes. Among psychiatric symptoms, PTSD symptoms were most strongly associated with negative occupational outcomes. Open-ended statements emphasized lack of protection and support, increased occupational demands, and emotional impact of work duties. CONCLUSIONS AND RELEVANCE: These results demonstrate potentially treatable psychiatric symptoms in HCW and FR experiencing CROS, impacting both wellbeing and the health care system. Mitigating CROS, particularly by addressing factors driving demoralization, may improve HCW and FR mental health, occupational functioning, and retention.

Psychological Distress After Sudden Cardiac Arrest and Its Impact on Recovery.

PURPOSE OF REVIEW: To summarize the prevalence, correlates, and health consequences of poor mental health in the increasingly sizable population of survivors of Sudden cardiac arrest (CA) and to describe current intervention research in this area. RECENT FINDINGS: After CA many patients report high psychological distress, including depression, generalized anxiety, and posttraumatic stress. Emerging evidence suggests that distressed patients' attention may narrow such that anxious awareness of afferent cardiac signals e.g., changes in heart rate or blood pressure, becomes predominant and a cause for concerned, constant monitoring. This cardiac-specific anxiety followed by behavioral avoidance and physiological hyperreactivity may increase patients' already high risk of secondary cardiovascular disease and undermine their health-related quality of life (HRQoL). Unlike other cardiovascular diseases, no clinical practice guidelines exist for assessing or treating psychological sequelae of CA. Future research should identify modifiable psychological targets to reduce secondary cardiovascular disease risk and improve HRQoL.

Associations between emergency department crowding and perceptions of interpersonal care in patients presenting with suspected acute coronary syndrome.

BACKGROUND: Emergency department (ED) crowding is associated with numerous healthcare issues, but little is known about its effect on psychosocial aspects of patient-provider interactions or interpersonal care. We examined whether ED crowding was associated with perceptions of interpersonal care in patients evaluated for acute coronary syndrome (ACS). METHODS: Patients presenting to a quaternary academic medical centre ED in New York City for evaluation of suspected ACS were enrolled between November 2013 and December 2016. ED crowding was measured using the ED Work Index (EDWIN), which incorporates patient volume, triage category, physician staffing and bed availability. Patients completed the 18-item Interpersonal Processes of Care (IPC) survey, which assesses communication, patient-centred decision-making and interpersonal style. Regression analyses examined associations between EDWIN and IPC scores, adjusting for demographics, comorbidities and depression. RESULTS: Among 933 included patients, 11% experienced ED overcrowding (EDWIN score >2) at admission, 11% experienced ED overcrowding throughout the ED stay and 30% reported suboptimal interpersonal care (defined as per-item IPC score <5). Higher admission EDWIN score was associated with modestly lower IPC score in both unadjusted (ß=-1.70, 95% CI -3.15 to -0.24, p=0.02) and adjusted models (ß = -1.77, 95% CI -3.31 to -0.24, p=0.02). EDWIN score averaged over the entire ED stay was not significantly associated with IPC score (unadjusted ß=-1.30, 95% CI -3.19 to 0.59, p=0.18; adjusted ß=-1.24, 95% CI -3.21 to 0.74, p=0.22). CONCLUSION: Increased crowding at the time of ED admission was associated with poorer perceptions of interpersonal care among patients with suspected ACS.

The Value of Measuring Diabetes Burnout.

PURPOSE OF REVIEW: Diabetes represents a chronic illness with significant physical and psychological morbidities. This review aims to summarize current conceptualizations of diabetes burnout in individuals with diabetes and describe its associated adverse outcomes in this population while proposing possible mechanisms of action and targets of intervention. RECENT FINDINGS: "Diabetes burnout" may result in adverse long-term outcomes including poor treatment compliance, diabetes complications, and depression. Diabetes burnout may impact not only individuals, but also providers, and caregivers and family members of affected individuals. Diabetes burnout may results from sustained cognitive stresses of chronic treatment adherence, assessment of realistic treatment goals, and treatment challenges. Early screening and interdisciplinary approaches for patient-centered diabetes care are critical for sustained diabetes social support. Future work exploring these approaches may identify early support and targeted interventions for the long-term support of individuals with diabetes.

Risk of stroke and myocardial infarction after influenza-like illness in New York State.

BACKGROUND: Influenza may be associated with increased stroke and myocardial infarction (MI) risk. We hypothesized that risk of stroke and MI after influenza-like illness (ILI) would be higher in patients in New York State. We additionally assessed whether this relationship differed across a series of sociodemographic factors. METHODS: A case-crossover analysis of the 2012-2014 New York Statewide Planning and Research Cooperative System (SPARCS) was used to estimate odds of ischemic stroke and MI after ILI. Each patient's case window (the time period preceding event) was compared to their control windows (same dates from the previous 2 years) in conditional logistic regression models used to estimate odds ratios and 95% confidence intervals (OR, 95% CI). We varied the case windows from 15 to 365 days preceding event as compared to control windows constructed using the same dates from the previous 2 years. Analyses were stratified by sex, race, and urban-rural status based on residential zip code. RESULTS: A total of 33,742 patients were identified as having ischemic stroke and 53,094 had MI. ILI events in the 15 days prior were associated with a 39% increase in odds of ischemic stroke (95% CI 1.09-1.77), increasing to an almost 70% increase in odds when looking at ILI events over the last year (95% CI 1.56, 1.83). In contrast, the effect of ILI hospitalization on MI was strongest in the 15 days prior (OR = 1.24, 95% CI 1.06-1.44). The risk of ischemic stroke after ILI was higher among individuals living in rural areas in the 90 days prior to stroke and among men in the year prior to event. In contrast, the association between ILI and MI varied only across race with whites having significantly higher ILI associated MI. CONCLUSION: This study highlights risk period differences for acute cardiovascular events after ILI, indicating possible differences in mechanism behind the risk of stroke after ILI compared to the risk of MI. High risk populations for stroke after ILI include men and people living in rural areas, while whites are at high risk for MI after ILI. Future studies are needed to identify ways to mitigate these risks.

Free-Living Sleep, Food Intake, and Physical Activity in Night and Morning Shift Workers.

Objective: Shift work is associated with risk for adverse health outcomes including cardiovascular disease, type 2 diabetes, cancer, and obesity. Short sleep duration combined with disruptions to the circadian system may alter factors involved with the behavioral regulation of energy intake and expenditure. We aimed to determine how shift work affects sleep, food intake, and physical activity.Methods: This was a field-based observational study using objective assessments of sleep and physical activity and a 24-hour dietary recall in shift workers. Day (n = 12) and night (n = 12) hospital shift workers (nurses and technicians) who were women had their free-living sleep and physical activity tracked via accelerometry, and completed a computer-assisted 24-hour food recall, during a series of work shifts.Results: Compared to day workers, night workers had significantly shorter sleep duration and reported more premature awakenings and feeling less refreshed upon awakening. Daily self-reported energy and macronutrient intakes were not different between groups, although the night shift workers reported a significantly longer total daily eating duration window than day workers. Objectively recorded physical activity levels were not different between groups.Conclusions: The present findings confirm that sleep is disturbed in women night workers, while there are relatively less effects on objectively recorded physical activity and self-reported food intake. We also observed a prolonged daily eating duration in night vs. day workers. These observations can help inform the design of novel behavioral interventions, including, potentially, time restricted feeding approaches (e.g., by limiting daily eating episodes to within a 10-12 h window), to optimize weight management in shift workers.

Novel Use of Telepalliative Care in a New York City Emergency Department During the COVID-19 Pandemic.

BACKGROUND: Coronavirus-2 (COVID-19) is a global pandemic. As of August 21, mortality from COVID-19 has reached almost 200,000 people, with the United States leading the globe in levels of morbidity and mortality. Large volumes of high-acuity patients, particularly those of advanced age and with chronic comorbidities, have significantly increased the need for palliative care resources beyond usual capacity. More specifically, COVID-19 has changed the way we approach patient and family member interactions. DISCUSSION: Concern for nosocomial spread of this infection has resulted in strict visitation restrictions that have left many patients to face this illness, make difficult decisions, and even die, alone in the hospital. To meet the needs of COVID patients, services such as Emergency Medicine and Palliative Care have responded rapidly by adopting novel ways of practicing medicine. We describe the use of telepalliative medicine (TM) implemented in an emergency department (ED) setting to allow family members the ability to interact with their loved ones during critical illness, and even during the end of life. Use of this technology has helped facilitate goals of care discussions, in addition to providing contact and closure for both patients and their loved ones. CONCLUSION: We describe our rapid and ongoing implementation of TM consultation for our ED patients and discuss lessons learned and recommendations for others considering similar care models.

Are patients afraid to go home? Disposition preferences after transient ischaemic attack and minor stroke.

BACKGROUND: Recent evidence suggests clinical equipoise for managing transient ischaemic attack and minor stroke (TIAMS) either via discharge from the emergency department (ED) with rapid outpatient follow-up or inpatient admission. Understanding patient preferences may guide decision-making around disposition after TIAMS that can lead to higher patient satisfaction and adherence. Psychological distress, particularly a sense of vulnerability (eg, 'threat perception') is associated with adverse psychological outcomes following TIAMS and may influence patient disposition preference. We hypothesised patients with higher threat perceptions in the ED would prefer inpatient admission versus early discharge with rapid outpatient follow-up. METHODS: This was a planned secondary analysis of a prospective observational cohort study of ED patients with suspected TIAMS (defined as National Institutes of Health Stroke Scale (NIHSS) score of ≤5). Patients reported disposition preferences and completed a validated scale of threat perception while in the ED (score range: 1-4). RESULTS: 147 TIAMS patients were evaluated (mean age: 59.7±15.4, 45.6% female, 39.5% Hispanic, median NIHSS=1, IQR: 0, 3). A majority of patients (98, 66.7%) preferred inpatient admission compared with discharge from the ED. Overall threat scores were median 1.0 (IQR: 0.43, 1.68). Those preferring admission had similar threat scores compared with those who preferred early disposition (median: 1.00, IQR: 0.43, 1.57) versus 1.00, (IQR: 0.49, 1.68); p=0.40). In a model adjusted for demographic characteristics, threat perceptions remained unassociated with disposition preference. CONCLUSION: Overall, two-thirds of TIAMS patients preferred inpatient admission over discharge. Disposition preference was not associated with higher threat perception in the ED. Further research examining potential drivers of patient disposition preferences may inform patient discussions and optimise patient satisfaction.

Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) Approach.

STUDY OBJECTIVE: Although most transient ischemic attack and minor stroke patients in US emergency departments (EDs) are admitted, experience in other countries suggests that timely outpatient evaluation of transient ischemic attack and minor stroke can be safe. We assess the feasibility and safety of a rapid outpatient stroke clinic for transient ischemic attack and minor stroke: Rapid Access Vascular Evaluation-Neurology (RAVEN). METHODS: Transient ischemic attack and minor stroke patients presenting to the ED with a National Institutes of Health Stroke Scale score of 5 or less and nondisabling deficit were assessed for potential discharge to RAVEN with a protocol incorporating social and medical criteria. Outpatient evaluation by a vascular neurologist, including vessel imaging, was performed within 24 hours at the RAVEN clinic. Participants were evaluated for compliance with clinic attendance and 90-day recurrent transient ischemic attack and minor stroke and hospitalization rates. RESULTS: Between December 2016 and June 2018, 162 transient ischemic attack and minor stroke patients were discharged to RAVEN. One hundred fifty-four patients (95.1%) appeared as scheduled and 101 (66%) had a final diagnosis of transient ischemic attack and minor stroke. Two patients (1.3%) required hospitalization (one for worsening symptoms and another for intracranial arterial stenosis caused by zoster) at RAVEN evaluation. Among the 101 patients with confirmed transient ischemic attack and minor stroke, 18 (19.1%) had returned to an ED or been admitted at 90 days. Five were noted to have had recurrent neurologic symptoms diagnosed as transient ischemic attack (4.9%), whereas one had a recurrent stroke (0.9%). No individuals with transient ischemic attack and minor stroke died, and none received thrombolytics or thrombectomy, during the interval period. These 90-day outcomes were similar to historical published data on transient ischemic attack and minor stroke. CONCLUSION: Rapid outpatient management appears a feasible and safe strategy for transient ischemic attack and minor stroke patients evaluated in the ED, with recurrent stroke and transient ischemic attack rates comparable to historical published data.

Respiratory adjusted shock index for identifying occult shock and level of Care in Sepsis Patients.

OBJECTIVE: Early identification of shock allows for timely resuscitation. Previous studies note the utility of bedside calculations such as the shock index (SI) and quick sepsis-related organ failure assessment (qSOFA) to detect occult shock. Respiratory rate may also be an important marker of occult shock. The goal of our study was to evaluate whether using a modified SI with respiratory rate would improve identification of emergency department sepsis patients admitted to an ICU or stepdown unit. METHODS: A prospective, observational cohort study of the respiratory adjusted shock index (RASI), defined as HR/SBP × RR/10, was conducted. RASI was calculated from triage vital signs and compared to serum lactate. Primary outcome was admission to a higher level of care defined as ICU or stepdown unit. A multivariable logistic regression model including RASI, SI, lactate, age and sex was performed with disposition as the outcome variable. Areas under the curve (AUC) were calculated to detect occult shock and level of care for RASI, SI, and qSOFA. RESULTS: 408 patients were enrolled, 360 were included in the analysis. Regression analysis revealed that lactate (OR 1.55, z = 4.38, p < 0.0001) and RASI (OR 2.27, z = 3.03, p < 0.002) were predictive of need for higher level of care. The AUC for RASI, SI, and qSOFA to detect occult shock were 0.71, 0.6, and 0.61 respectively. RASI also had a significant AUC in predicting level of care at 0.75 compared to SI (0.64) and qSOFA (0.62). CONCLUSIONS: RASI may have utility as a rapid bedside tool for predicting critical illness in sepsis patients.

A survey of the knowledge, attitudes and practices on Zika virus in new York City.

BACKGROUND: Over 900 travel-associated Zika virus cases have been identified in New York City (NYC), New York. A survey was administered in NYC adapted from the Knowledge, Attitudes, and Practices (KAP) survey on Zika virus developed by the World Health Organization (WHO). METHODS: A standardized, self-administered, anonymous questionnaire was administered to a convenience sample in Manhattan and the Bronx from June 30th, 2016 to October 21st, 2016. Responses were grouped into six domains based on the content and structure of the questions and were summarized using descriptive statistics or converted into a continuous knowledge score and assessed for associations with pregnancy status and travel history using linear regression. RESULTS: There were 224 respondents with a mean age of 33 (SD ± 11.6) with 77% (170/224) female and 24% (51/224) pregnant. The majority (98% (213/217)) were unable to identify all of the symptoms associated with acute Zika virus infection and all modes of transmission (97% (213/219)). Most participants (85% (187/219)) identified mosquitoes as a mode of transmission. 95% (116/122) reported an association between Zika virus and microcephaly. The most concerning aspect of Zika virus in 46% (91/200) was the risk of disabilities to babies, and risk of sexual transmission (25% (49/200)). When asked what precautions pregnant persons should to reduce the risk of transmission when traveling to a Zika endemic region, only 27% (50/185) identified using condoms during intercourse or refraining from intercourse while pregnant. Knowledge of Zika transmission is significantly positively associated with pregnancy status, but not with travel history. CONCLUSION: Our results indicate an overall poor understanding of Zika virus symptoms and possible complications, transmission modes, and current recommended prevention guidelines. Pregnancy is positively associated with Knowledge of Zika Transmission, but not other knowledge scores. Reported travel history to Zika endemic regions is not significantly associated with Zika knowledge. There is a need for implementing future public health interventions that particularly focus on protection against Zika transmission, that Zika is sexually transmitted, and risks that the Guillain-Barré Syndrome poses a risk to adults.

Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department.

BACKGROUND: While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions. OBJECTIVE OF THE REVIEW: The goal of this clinical review was to summarize and present recommendations regarding the disposition of TIAMS patients in the ED (e.g., admission vs. discharge). DISCUSSION: An estimated 250,000 to 300,000 TIA events occur each year in the United States, with an estimated near-term risk of subsequent stroke ranging from 3.5% to 10% at 2 days, rising to 17% by 90 days. While popular and easy to use, reliance solely on risk-stratification tools, such as the ABCD2, should not be used to determine whether TIAMS patients can be discharged safely. Additional vascular imaging and advanced brain imaging may improve prediction of short-term neurologic risk. We also review various disposition strategies (e.g., inpatient vs. outpatient/ED observation units) with regard to their association with neurologic outcomes, such as 30-day or 90-day stroke recurrence or new stroke, in addition to other outcomes, such as hospital length of stay and health care costs. CONCLUSIONS: Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.

The presence of companions during emergency department evaluation and its impact on perceptions of clinician-patient communication.

OBJECTIVES: Research in outpatient setting suggests that the presence of companions during a medical encounter can improve clinician-patient communication. It is not known if the presence of companions has a similar effect in the acutely stressful context of the ED. This study tested whether the presence of companions in the ED relate to stronger clinician-patient communication. We further explored effect modification by demographic factors (race/ethnicity, education and language) thought to compromise communication. METHODS: Participants were drawn from an observational cohort study of patients with suspected acute coronary syndrome (n=876) recruited from an urban academic medical centre between 2013 and 2016. Patient interviews occurred both in the ED and post-ED discharge; communication was assessed using the Interpersonal Processes of Care Survey with possible range of scores of 14-70. Companions were categorised as close others (ie, partner/spouse or child), non-close others (eg, neighbour) or no one. RESULTS: Perceptions of clinician-patient communication were high (mean=57.1, SD=10.6;). There was no association between companions (close/non-close/no one) and clinician-patient communication, p=0.262. Demographic factors were unrelated to communication. There was a significant interaction between education and companions. Having a close other in the ED was associated with stronger clinician-patient communication only for patients with high school education or less, p=0.027. CONCLUSIONS: Neither the presence of companions nor demographic factors were related to clinician-patient communication. The interaction effect suggesting that patients completing high school or less have the most to gain from the presence of close others warrants further exploration.

Depressive Symptoms and Perceptions of ED Care in Patients Evaluated for Acute Coronary Syndrome.

INTRODUCTION: Posttraumatic stress disorder (PTSD) develops in 1 out of 8 survivors of acute coronary syndrome (ACS) events, and these persons have a doubling of risk for recurrent ACS and mortality. Overcrowding in the emergency department during ACS evaluation has been associated with increased risk for PTSD, and depressed patients have been found to be particularly vulnerable. Little is known about the mechanisms by which overcrowding increases PTSD risk in depressed patients. Our aim was to evaluate one possible mechanism, patient perception of crowding and care, in depressed and nondepressed ED patients evaluated for ACS. METHODS: We enrolled 912 participants in the REactions to Acute Care and Hospitalization study, an ongoing observational cohort study assessing patients evaluated for ACS. Participants completed the Emergency Department Perceptions questionnaire. Depressive symptoms were screened using the Personal Health Questionnaire Depression Scale. Objective ED crowding was calculated using the Emergency Department Work Index (EDWIN). RESULTS: EDWIN scores did not significantly differ between groups. Although perceptions of ED crowding did not differ between groups, depressed patients perceived the emergency department as more stressful [t = 4.45, P < .001] and perceived poorer care [t = 3.03, P = .003]. Multiple regression modeling found a significant interaction between EDWIN scores and depression, predicting participants' perception of stress in the emergency department (F[7,904] = 7.93, P < .001). DISCUSSION: We found that depressed patients experienced the emergency department as more stressful as objectively measured crowding increased. Our study highlights the complex interplay between cardiovascular disease and mental health in impacting patient health outcomes in the emergency department.

Beta Blocker Administration During Emergency Department Evaluation for Acute Coronary Syndrome Is Associated With Lower Posttraumatic Stress Symptoms 1-Month Later.

We examined whether beta blocker administration in the emergency department (ED) during evaluation for suspected acute coronary syndrome (ACS) was associated with posttraumatic stress disorder (PTSD) symptoms 1-month later. Participants (N = 350) were enrolled in the Reactions to Acute Care and Hospitalization (REACH) study, an ongoing observational cohort study of ED predictors of medical and psychological outcomes after evaluation for suspected ACS. Beta blockade during evaluation in the ED was extracted from medical records, and PTSD symptoms in response to the experience of suspected ACS were assessed 1-month later via telephone. Beta blockade in the ED was associated with lower PTSD symptoms 1-month later, b = -2.80, ß = -.09, p = .045, after adjustment for demographics, preexisting psychological and medical covariates, and participants' distress during ED evaluation. Despite small effects, findings suggest that beta blockade during ED evaluation for suspected ACS-a time period relevant to fear consolidation of the memory of this potentially life-threatening event-may have protective effects for later psychological health.