Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged From the Emergency Department With Supplemental Oxygen.

STUDY OBJECTIVE: To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. METHODS: This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. RESULTS: Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). CONCLUSION: COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.

Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department.

BACKGROUND: Sepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance. OBJECTIVE: To evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients. METHODS: We performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups. RESULTS: Of the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = -0.406; 95% CI = -0.809, -0.003; p = 0.048) and time of triage to physician (coeff = -0.543; 95% CI = -0.864, -0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups. CONCLUSION: EMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.

The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events.

OBJECTIVES: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation. MATERIALS AND METHODS: A retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year. RESULTS: Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals. CONCLUSIONS: For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.

National trends in mental health-related emergency department visits by children and adults, 2009-2015.

OBJECTIVES: Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. METHODS: Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. RESULTS: Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. CONCLUSIONS: Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

BACKGROUND: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. METHODS: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. RESULTS: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001). CONCLUSIONS: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Opioid prescribing patterns in emergency departments and future opioid use in adolescent patients.

OBJECTIVE: Evidence suggests that exposure to opioids in adolescence increases risk of future opioid use. We evaluate if exposure to high versus low intensity opioid prescribers in the Emergency Department (ED) influences the risk of future opioid use in adolescents. METHODS: Retrospective study of opioid-naïve patients 10 to 17 years seen in one of 14 EDs between January 2013 and December 2014. We categorized ED providers into quartiles according to the proportion of encounters resulting in opioid prescriptions. Primary outcome was use of opioids in the subsequent 12 months. Analysis adjusted for patient characteristics and compared future use of opioids for patients seen by the lowest versus the highest prescribing quartiles. RESULTS: We included 9,688 patient encounters evaluated by the lowest opioid prescribing physician quartile versus 9,467 in the highest. The highest quartile gave opioid prescriptions to 14.9% of their patients compared to 2.8% for the lowest quartile. No association with future opioid use was found for patients evaluated by low versus high prescriber quartiles (OR 0.99, 95% CI 0.90-1.08). Patients with increasing age (OR 2.15, 95% CI 1.92-2.42) and white versus Hispanic ethnicity (OR 1.55, 95% CI 1.33-1.80) were associated with recurrent opioid use. CONCLUSION: We found no association between high intensity opioid prescribers and recurrent 12 month use of opioids in opioid-naïve adolescents seen in the ED. This likely reflects various factors that put adolescents at risk for recurrent opioid use and may indicate the importance of the second prescription from primary care after initial exposure to opioids.

Adolescents' Willingness to Commit to Safe Use and Disposal of Prescription Opioids.

Introduction and aims: Leftover pills from prescriptions written in emergency departments are a key source of misused opioids among adolescents. Recently, the AMA has proposed emphasizing safe use and disposal of opioids, but patient perceptions on this proposed solution are largely unknown. In this study, we evaluate the willingness of adolescents to commit to pill security and safe opioid use in a clinical setting. Design and methods: In this prospective survey study conducted in an urban emergency department, a consecutive sample of adolescent patients between 15 and 22 years were asked about their exposure to opioids and attitudes toward the potential harm of opioid use/misuse and whether they were willing to consider to committing to pill security and safe opioid use in a clinical setting. We then assessed if willingness to commit varied based on attitude toward opioid misuse or previous experience with prescription opioids. Results: Eighty-one percent (91/113) of eligible patients agreed to participate. Overall 29.7% of adolescents had received a prescription for opioids and 40.7% had leftover pills. 87.9% were willing to commit to take opioids only as prescribed and 83.5% were willing to commit to disposing leftover opioids. Willingness did not vary by previous exposure to prescription opioids or attitudes toward recreational opioid use. Discussion and conclusions: Adolescents are highly willing to commit to safe opioid use and disposal regardless of previous exposure to opioids or attitude toward opioid misuse.

Association of age and opioid use for adolescents and young adults in community emergency departments.

OBJECTIVES: Adolescents and young adults are at high risk for opioid misuse and abuse. The emergency department (ED) plays a key role in treatment of acute and chronic pain and is a primary place that this patient population is exposed to prescription opioids. We evaluate the effect of patient age on use of opioids for adolescents and young adults in community EDs. METHODS: Retrospective cohort study of adolescent and young adult encounters in 14 community EDs from 2013 to 2014. We evaluate the percent of ED encounters with parenteral and/or oral opioids administered, morphine milligram equivalents per ED patient encounter, and percent of patient encounters discharged with an opioid prescription. Age was the main exposure. The association between outcomes and age was examined using bivariate and multivariate logistic regression adjusting for measurable confounders. RESULTS: There were 259,632 adolescent and young adult encounters in our sample, average age 17.6 years, with 15.8% given opioids. Increasing patient age was associated with a significant increase in the percent of encounters with opioids given (AOR, 1.11; 95% CI 1.10-1.11), morphine milligram equivalents administered (ß 0.38; 95% CI 0.33-0.43 for parenteral and ß 0.26; 95% CI 0.23-0.28 for oral), and percent of patients receiving outpatient prescriptions (AOR, 1.14; 95% CI 1.13-1.14). Significant variability also existed between medical centers (AOR, 2.02; 95% CI 1.86-2.20). CONCLUSION: For adolescent and young adult patients in the ED, there is a significant association between opioid prescribing and increasing age. This describes an opportunity to reduce opioid use in older adolescents and young adults.

Involving end-users in the design of an audit and feedback intervention in the emergency department setting - a mixed methods study.

BACKGROUND: Long length of stays (LOS) in emergency departments (ED) negatively affect quality of care. Ordering of inappropriate diagnostic tests contributes to long LOS and reduces quality of care. One strategy to change practice patterns is to use performance feedback dashboards for physicians. While this strategy has proven to be successful in multiple settings, the most effective ways to deliver such interventions remain unknown. Involving end-users in the process is likely important for a successful design and implementation of a performance dashboard within a specific workplace culture. This mixed methods study aimed to develop design requirements for an ED performance dashboard and to understand the role of culture and social networks in the adoption process. METHODS: We performed 13 semi-structured interviews with attending physicians in different roles within a single public ED in the U.S. to get an in-depth understanding of physicians' needs and concerns. Principles of human-centered design were used to translate these interviews into design requirements and to iteratively develop a front-end performance feedback dashboard. Pre- and post- surveys were used to evaluate the effect of the dashboard on physicians' motivation and to measure their perception of the usefulness of the dashboard. Data on the ED culture and underlying social network were collected. Outcomes were compared between physicians involved in the human-centered design process, those with exposure to the design process through the ED social network, and those with limited exposure. RESULTS: Key design requirements obtained from the interviews were ease of access, drilldown functionality, customization, and a visual data display including monthly time-trends and blinded peer-comparisons. Identified barriers included concerns about unintended consequences and the veracity of underlying data. The surveys revealed that the ED culture and social network are associated with reported usefulness of the dashboard. Additionally, physicians' motivation was differentially affected by the dashboard based on their position in the social network. CONCLUSIONS: This study demonstrates the feasibility of designing a performance feedback dashboard using a human-centered design approach in the ED setting. Additionally, we show preliminary evidence that the culture and underlying social network are of key importance for successful adoption of a dashboard.

Emergency Department Contribution to the Prescription Opioid Epidemic.

STUDY OBJECTIVE: We characterize the relative contribution of emergency departments (EDs) to national opioid prescribing, estimate trends in opioid prescribing by site of care (ED, office-based, and inpatient), and examine whether higher-risk opioid users receive a disproportionate quantity of their opioids from ED settings. METHODS: This was a retrospective analysis of the nationally representative Medical Expenditure Panel Survey from 1996 to 2012. Individuals younger than 18 years and with malignancy diagnoses were excluded. All prescriptions were standardized through conversion to milligrams of morphine equivalents. Reported estimates are adjusted with multivariable regression analysis. RESULTS: From 1996 to 2012, 47,081 patient-years (survey-weighted population of 483,654,902 patient-years) surveyed by the Medical Expenditure Panel Survey received at least 1 opioid prescription. During the same period, we observed a 471% increase in the total quantity of opioids (measured by total milligrams of morphine equivalents) prescribed in the United States. The proportion of opioids from office-based prescriptions was high and increased throughout the study period (71% of the total in 1996 to 83% in 2012). The amount of opioids originating from the ED was modest and declined throughout the study period (7.4% in 1996 versus 4.4% in 2012). For people in the top 5% of opioid consumption, ED prescriptions accounted for only 2.4% of their total milligrams of morphine equivalents compared with 87.8% from office visits. CONCLUSION: Between 1996 and 2012, opioid prescribing for noncancer patients in the United States significantly increased. The majority of this growth was attributable to office visits and refills of previously prescribed opioids. The relative contribution of EDs to the prescription opioid problem was modest and declining. Thus, further efforts to reduce the quantity of opioids prescribed may have limited effect in the ED and should focus on office-based settings. EDs could instead focus on developing and disseminating tools to help providers identify high-risk individuals and refer them to treatment.

Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study.

STUDY OBJECTIVE: We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low-risk chest pain. METHODS: We created a Web-based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin-level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3-item Fear of Malpractice scale. RESULTS: Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety-five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms "very low risk" and "low risk" only when their probability estimates were less than 1%. CONCLUSION: The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.

Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014.

STUDY OBJECTIVE: We determine the incidence of and trends in enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) during the past decade. METHODS: We obtained a comprehensive list of all EMTALA investigations conducted between 2005 and 2014 directly from the Centers for Medicare & Medicaid Services (CMS) through a Freedom of Information Act request. Characteristics of EMTALA investigations and resulting citation for violations during the study period are described. RESULTS: Between 2005 and 2014, there were 4,772 investigations, of which 2,118 (44%) resulted in citations for EMTALA deficiencies at 1,498 (62%) of 2,417 hospitals investigated. Investigations were conducted at 43% of hospitals with CMS provider agreements, and citations issued at 27%. On average, 9% of hospitals were investigated and 4.3% were cited for EMTALA violation annually. The proportion of hospitals subject to EMTALA investigation decreased from 10.8% to 7.2%, and citations from 5.3% to 3.2%, between 2005 and 2014. There were 3.9 EMTALA investigations and 1.7 citations per million emergency department (ED) visits during the study period. CONCLUSION: We report the first national estimates of EMTALA enforcement activities in more than a decade. Although EMTALA investigations and citations were common at the hospital level, they were rare at the ED-visit level. CMS actively pursued EMTALA investigations and issued citations throughout the study period, with half of hospitals subject to EMTALA investigations and a quarter receiving a citation for EMTALA violation, although there was a declining trend in enforcement. Further investigation is needed to determine the effect of EMTALA on access to or quality of emergency care.

HIV Prevention and Treatment: The Evolving Role of the Emergency Department.

Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.

Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians.

Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient's capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.

Success of ultrasound-guided versus landmark-guided arthrocentesis of hip, ankle, and wrist in a cadaver model.

PURPOSE: The objectives of this study were to evaluate emergency medicine resident-performed ultrasound for diagnosis of effusions, compare the success of a landmark-guided (LM) approach with an ultrasound-guided (US) technique for hip, ankle and wrist arthrocentesis, and compare change in provider confidence with LM and US arthrocentesis. METHODS: After a brief video on LM and US arthrocentesis, residents were asked to identify artificially created effusions in the hip, ankle and wrist in a cadaver model and to perform US and LM arthrocentesis of the effusions. Outcomes included success of joint aspiration, time to aspiration, and number of attempts. Residents were surveyed regarding their confidence in identifying effusions with ultrasound and performing LM and US arthrocentesis. RESULTS: Eighteen residents completed the study. Sensitivity of ultrasound for detecting joint effusion was 86% and specificity was 90%. Residents were successful with ultrasound in 96% of attempts and with landmark 89% of attempts (p=0.257). Median number of attempts was 1 with ultrasound and 2 with landmarks (p=0.12). Median time to success with ultrasound was 38s and 51s with landmarks (p=0.23). After the session, confidence in both US and LM arthrocentesis improved significantly, however the post intervention confidence in US arthrocentesis was higher than LM (4.3 vs. 3.8, p<0.001). CONCLUSIONS: EM residents were able to successfully identify joint effusions with ultrasound, however we were unable to detect significant differences in actual procedural success between the two modalities. Further studies are needed to define the role of ultrasound for arthrocentesis in the emergency department.

Exposure to and Use of Electronic Cigarettes: Does Language Matter?

OBJECTIVES: To determine whether patients who are English proficient become aware of e-cigarettes through different marketing tactics and have dissimilar patterns of use than patients who are non-English speaking. DESIGN: This was a cross-sectional study surveying adult English- and Spanish-speaking patients. ANOVA and chi-squared tests were used to examine differences between groups. SETTING: A large public, safety-net hospital in Los Angeles County, California. RESULTS: Respondents (N=1899) were predominately Hispanic (78%), foreign-born (68%), and reported Spanish as a primary language (64%). Native English speakers reported the highest use of e-cigarettes (26%), followed by non-native (13%) and non-English speakers (2%) (P<.001). In terms of marketing, native and non-native English speakers were more likely to have friends and family as sources of e-cigarette information (P<.001). Native speakers were more likely to see advertisements for e-cigarettes on storefronts (P=.004) and on billboards (P<.001). Non-English speakers were most likely to learn about e-cigarettes on the news (P<.001) and in advertisements on the television and radio (P=.002). Differences in reasons for use were not significant between the three groups. CONCLUSIONS: Native and non-native English speakers become aware of e-cigarettes through different mechanisms and use e-cigarettes at a significantly higher rate than non-English speakers. These results highlight an opportunity for public health programs to concentrate on specific channels of communication that introduce patient populations to e-cigarettes to slow the spread of e-cigarette usage.

What Predicts Performance? A Multicenter Study Examining the Association Between Resident Performance, Rank List Position, and United States Medical Licensing Examination Step 1 Scores.

BACKGROUND: Each application cycle, emergency medicine (EM) residency programs attempt to predict which applicants will be most successful in residency and rank them accordingly on their program's Rank Order List (ROL). OBJECTIVE: Determine if ROL position, participation in a medical student rotation at their respective program, or United States Medical Licensing Examination (USMLE) Step 1 rank within a class is predictive of residency performance. METHODS: All full-time EM faculty at Los Angeles County + University of Southern California (LAC + USC), Harbor-UCLA (Harbor), Alameda Health System-Highland (Highland), and the University of California-Irvine (UCI) ranked each resident in the classes of 2013 and 2014 at time of graduation. From these anonymous surveys, a graduation ROL was created, and using Spearman's rho, was compared with the program's adjusted ROL, USMLE Step 1 rank, and whether the resident participated in a medical student rotation. RESULTS: A total of 93 residents were evaluated. Graduation ROL position did not correlate with adjusted ROL position (Rho = 0.14, p = 0.19) or USMLE Step 1 rank (Rho = 0.15, p = 0.14). Interestingly, among the subgroup of residents who rotated as medical students, adjusted ROL position demonstrated significant correlation with final ranking on graduation ROL (Rho = 0.31, p = 0.03). CONCLUSIONS: USMLE Step 1 score rank and adjusted ROL position did not predict resident performance at time of graduation. However, adjusted ROL position was predictive of future residency success in the subgroup of residents who had completed a sub-internship at their respective programs. These findings should guide the future selection of EM residents.

The Absence of Gallstones on Point-of-Care Ultrasound Rules Out Acute Cholecystitis.

BACKGROUND: Cholelithiasis affects an estimated 20 million people in the United States yearly; 20% of symptomatic patients will develop acute cholecystitis (AC). A recent single-center study estimating test characteristics of point-of-care ultrasonography (POCUS) for the detection of AC, as defined by gallstones plus sonographic Murphy's or pericholecystic fluid or gallbladder wall-thickening, resulted in a sensitivity and specificity of 87% (95% confidence interval [CI] 66-97) and 82% (95% CI 74-88), respectively. No prior studies have been conducted to estimate the test characteristics of POCUS for the purpose of excluding acute calculous cholecystitis. OBJECTIVE: To determine whether the finding of gallstones alone on POCUS has high sensitivity, high negative predictive value, and low negative likelihood ratio for the exclusion of AC. METHODS: We conducted an analysis using data from a prospective cross-sectional single-center study of POCUS test to estimate the test characteristics using a simplified definition of a positive test - the presence of gallstones alone. Clinical follow-up and pathology reports were used as the reference standard. Test characteristics were calculated and compared to the standard definition, gallstones plus one secondary finding. RESULTS: The overall prevalence of AC was 14% (23 pathology-confirmed cases of 164 included patients). The sensitivity of the simplified definition was 100% (95% CI 85.7-100), negative predictive value 100% (95% CI 92.2-100), and negative likelihood ratio was < 0.1, compared to a sensitivity of 87% (95% CI 66-97%), negative predictive value 97% (95% CI 93-99%), and negative likelihood ratio of 0.16 (95% CI 0.06-0.5). CONCLUSION: Simplifying the definition of the test findings on POCUS to gallstones alone has excellent sensitivity and negative predictive value for the exclusion of AC. This finding, if broadly validated prospectively, confirms the practice of excluding acute calculous cholecystitis using POCUS in emergency department patients.

Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial.

STUDY OBJECTIVE: Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population. METHODS: We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction. RESULTS: Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends. CONCLUSION: The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.