Three-Month Symptom Profiles Among Symptomatic Adults With Positive and Negative Severe Acute Respiratory Syndrome Coronavirus 2 Tests: A Prospective Cohort Study From the INSPIRE Group.

BACKGROUND: Long-term symptoms following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are a major concern, yet their prevalence is poorly understood. METHODS: We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (coronavirus disease-positive [COVID+]) with adults who tested negative (COVID-), enrolled within 28 days of a Food and Drug Administration (FDA)-approved SARS-CoV-2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the Centers for Disease Control and Prevention [CDC] Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (ie, fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email. RESULTS: Among the first 1000 participants, 722 were COVID+ and 278 were COVID-. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID+ group than the COVID- group. At 3 months, SARS-CoV-2 symptoms declined in both groups, although were more prevalent in the COVID+ group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID+ and COVID- groups at 3 months. CONCLUSIONS: Approximately half of COVID+ participants, as compared with one-quarter of COVID- participants, had at least 1 SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish long COVID. CLINICAL TRIALS REGISTRATION: NCT04610515.

Development and testing of data infrastructure in the American College of Emergency Physicians' Clinical Emergency Data Registry for opioid-related research.

Objective: Prior research has identified gaps in the capacity of electronic health records (EHRs) to capture the intricacies of opioid-related conditions. We sought to enhance the opioid data infrastructure within the American College of Emergency Physicians' Clinical Emergency Data Registry (CEDR), the largest national emergency medicine registry, through data mapping, validity testing, and feasibility assessment. Methods: We compared the CEDR data dictionary to opioid common data elements identified through prior environmental scans of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Validity and feasibility assessments of CEDR opioid-related data were conducted through the following steps: (1) electronic extraction of CEDR data meeting criteria for an opioid-related emergency care visit, (2) manual chart review assessing the quality of the extracted data, (3) completion of feasibility scorecards, and (4) qualitative interviews with physician reviewers and informatics personnel. Results: We identified several data gaps in the CEDR data dictionary when compared with prior environmental scans including urine drug testing, opioid medication, and social history data elements. Validity testing demonstrated correct or partially correct data for >90% of most extracted CEDR data elements. Factors affecting validity included lack of standardization, data incorrectness, and poor delimitation between emergency department (ED) versus hospital care. Feasibility testing highlighted low-to-moderate feasibility of date and social history data elements, significant EHR platform variation, and inconsistency in the extraction of common national data standards (eg, Logical Observation Identifiers Names and Codes, International Classification of Diseases, Tenth Revision codes). Conclusions: We found that high-priority data elements needed for opioid-related research and clinical quality measurement, such as demographics, medications, and diagnoses, are both valid and can be feasibly captured in a national clinical quality registry. Future work should focus on implementing structured data collection tools, such as standardized documentation templates and adhering to data standards within the EHR that would better characterize ED-specific care for opioid use disorder and related research.

Feasibility and acceptability of electronic administration of patient reported outcomes using mHealth platform in emergency department patients with non-medical opioid use.

BACKGROUND: The emergency department (ED) offers an important opportunity to identify patients with opioid use disorder (OUD) and initiate treatment. However, post-ED follow-up is challenging, and novel approaches to enhance care transitions are urgently needed. Outcomes following ED visits have traditionally focused on overdose, treatment engagement, and mortality with an absence of patient reported outcomes (PROs), for example patient ability to schedule follow-up OUD treatment appointments or pick up a prescription medication, that may better inform evaluation of treatment pathways and near-term outcomes after acute events. In the context of increasing novel secure mobile health (mHealth) platforms, we explored the feasibility and acceptability of electronically collecting PROs from ED patients with non-medical opioid use to enhance care in the ED and transitions of care. METHODS: ED patients with non-medical opioid use or opioid overdose who endorsed willingness and ability to complete electronic surveys after discharge were enrolled from a tertiary, urban academic ED. Participants were enrolled in an mHealth platform, shared electronic health records with researchers, and completed electronic surveys of PROs at baseline, three- and thirty-days post discharge from the hospital, including questions about ability to schedule a follow-up appointment, pick up a prescription medication and overdose risk behaviors. Primary outcomes were measures of feasibility and acceptability of electronic PRO collection among ED patients with non-medical opioid use. RESULTS: Among 1,808 patients assessed for eligibility between June-December 2019, 101 of 130 (78%) eligible adult patients consented to participate. Ninety-six (95%) of 101 patients completed registration in the mHealth platform, and 77/96 (80%) were successful in sharing their electronic health data. Completion rates for the baseline, three-day and thirty-day surveys were 97% (93/96), 49% (47/96) and 42% (40/96). Implementation challenges included short engagement window during ED visit, limited access to smartphones/computers, insufficient battery life of participant phone to access email and password, forgotten emails and passwords, multi-step verification processes for account set-up, and complaints about hospital care, most of which were effectively addressed by study personnel. CONCLUSIONS: ED patients with OUD were willing to share electronic health information and PROs, although implementation challenges were common, and more than half of participants were lost-to-follow-up after hospital discharge at 30 days. Efforts to streamline communication and remove barriers to engagement are needed to improve the collection of PROs and pathways of care in ED patients with OUD. Clinical Trial Registration ClinicalTrials.gov (NCT03985163). Date of Registration: June 10, 2019, Retrospectively registered (First enrollment June 8, 2019). https://clinicaltrials.gov/ct2/show/record/NCT03985163.

Simulating approaches to emergency department pandemic physician staffing during COVID-19.

OBJECTIVE: During pandemics, emergency departments (EDs) are challenged by the need to replace quarantined ED staff and avoid staffing EDs with nonemergency medicine (EM) trained physicians. We sought to design and examine three feasible ED staffing models intended to safely schedule EM physicians to staff three EDs within a health system during a prolonged infectious disease outbreak. METHODS: We conducted simulation analyses examining the strengths and limitations of three ED clinician staffing models: two-team and three-team fixed cohort, and three-team unfixed cohort. Each model was assessed with and without immunity, and by varying infection rates. We assumed a 12-week pandemic disaster requiring a 2-week quarantine. MAIN OUTCOME: The outcome, time to staffing shortage, was defined as depletion of available physicians in both 8- and 12-hour shift duration scenarios. RESULTS: All staffing models initially showed linear physician attrition with higher infection rates resulting in faster staffing shortages. The three-team fixed cohort model without immunity was not viable beyond 11 weeks. The three-team unfixed cohort model without immunity avoided staffing shortage for the duration of the pandemic up to an infection rate of 50 percent. The two-team model without immunity also avoided staffing shortage up to 30 percent infection rate. When accounting for immunity, all models behaved similarly initially but returned to adequate staffing during week 5 of the pandemic. CONCLUSIONS: Simulation analyses reveal fundamental tradeoffs that are critical to designing feasible pandemic disaster staffing models. Emergency physicians should test similar models based on local assumptions and capacity to ensure adequate staffing preparedness for prolonged pandemics.

Fair Play: Application of Normalized Scoring to Emergency Department Throughput Quality Measures in a National Registry.

STUDY OBJECTIVE: The measurement of emergency department (ED) throughput as a patient-centered quality measure is ubiquitous; however, marked heterogeneity exists between EDs, complicating comparisons for payment purposes. We evaluate 4 scoring methodologies for accommodating differences in ED visit volume and heterogeneity among ED groups that staff multiple EDs to improve the validity and "fairness" of ED throughput quality measurement in a national registry, with the goal of developing a volume-adjusted throughput measure that balances variation at the ED group level. METHODS: We conducted an ED group-level analysis using the 2017 American College of Emergency Physicians Clinical Emergency Data Registry data set, which included 548 ED groups inclusive of 889 unique EDs. We calculated ED throughput performance scores for each ED group by using 4 scoring approaches: plurality, simple average, weighted average, and a weighted standardized score. For comparison, ED groups (ie, taxpayer identification numbers) were grouped into 3 types: taxpayer identification numbers with only 1 ED; those with multiple EDs, but no ED with greater than 60,000 visits; and those with multiple EDs and at least 1 ED with greater than 60,000 visits. RESULTS: We found marked differences in the classification of ED throughput performance between scoring approaches. The weighted standardized score (z score) approach resulted in the least skewed and most uniform distribution across the majority of ED types, with a kurtosis of 12.91 for taxpayer identification numbers composed of 1 ED, 2.58 for those with multiple EDs without any supercenter, and 3.56 for those with multiple EDs with at least 1 supercenter, all lower than comparable scoring methods. The plurality and simple average scoring approaches appeared to disproportionally penalize ED groups that staff a single ED or multiple large-volume EDs. CONCLUSION: Application of a weighted standardized (z score) approach to ED throughput measurement resulted in a more balanced variation between different ED group types and reduced distortions in the length-of-stay measurement among ED groups staffing high-volume EDs. This approach may be a more accurate and acceptable method of profiling ED group throughput pay-for-performance programs.

Association between patient-physician gender concordance and patient experience scores. Is there gender bias?

BACKGROUND: Patient satisfaction, a commonly measured indicator of quality of care and patient experience, is often used in physician performance reviews and promotion decisions. Patient satisfaction surveys may introduce gender-related bias. OBJECTIVE: Examine the effect of patient and physician gender concordance on patient satisfaction with emergency care. METHODS: We performed a cross-sectional analysis of electronic health record and Press Ganey patient satisfaction survey data of adult patients discharged from the emergency department (2015-2018). Logistic regression models were used to examine relationships between physician gender, patient gender, and physician-patient gender dyads. Binary outcomes included: perfect care provider score and perfect overall assessment score. RESULTS: Female patients returned surveys more often (n=7 612; 61.55%) and accounted for more visits (n=232 024; 55.26%). Female patients had lower odds of perfect scores for provider score and overall assessment score (OR: 0.852, 95% CI: 0.790, 0.918; OR: 0.782, 95% CI: 0.723, 0.846). Female physicians had 1.102 (95% CI: 1.001, 1.213) times the odds of receiving a perfect provider score. Physician gender did not influence male patients' odds of reporting a perfect care provider score (95% CI: 0.916, 1.158) whereas female patients treated by female physicians had 1.146 times the odds (95% CI: 1.019, 1.289) of a perfect provider score. CONCLUSION: Female patients prefer female emergency physicians but were less satisfied with their physician and emergency department visit overall. Over-representation of female patients on patient satisfaction surveys introduces bias. Patient satisfaction surveys should be deemphasized from physician compensation and promotion decisions.

The cost of waiting: Association of ED boarding with hospitalization costs.

BACKGROUND: Emergency Department (ED) boarding, the practice of holding patients in the ED after they have been admitted to the hospital due to unavailability of inpatient beds, is common and contributes to the public health crisis of ED crowding. Prior work has documented the harms of ED boarding on access and quality of care. Limited studies examine the relationship between ED boarding and an equally important domain of quality-the cost of care. This study evaluates the relationship between ED boarding, ED characteristics and risk-adjusted hospitalization costs utilizing national publicly-reported measures. METHODS: We conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear regression analysis to examine the association between ED boarding and Medicare spending per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation time, and ED patient volume. RESULTS: A total of 2903 hospitals were included in the analysis. ED boarding was significantly correlated with MSPB (r = 0.1774; p-value: < 0.0001). In multivariate regression, ED boarding was also positively associated with MSPB (Beta: 0.00015; p < 0.0001) after adjustment for other hospital level crowding indicators. CONCLUSION: We found a strong relationship between measures of ED crowding, including ED boarding, and risk-adjusted hospital spending. Future work should elucidate the mediators of this relationship. Policymakers and administrators should consider the financial harms of ED boarding when devising strategies to improve hospital care access and flow.

Assessing the readiness of digital data infrastructure for opioid use disorder research.

BACKGROUND: Gaps in electronic health record (EHR) data collection and the paucity of standardized clinical data elements (CDEs) captured from electronic and digital data sources have impeded research efforts aimed at understanding the epidemiology and quality of care for opioid use disorder (OUD). We identified existing CDEs and evaluated their validity and usability, which is required prior to infrastructure implementation within EHRs. METHODS: We conducted (a) a systematic literature review of publications in Medline, Embase and the Web of Science using a combination of at least one term related to OUD and EHR and (b) an environmental scan of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Opioid-related data elements identified within the environmental scan were compared with related data elements contained within nine common health data code systems and each element was graded for alignment with match results categorized as "exact", "partial", or "none." RESULTS: The literature review identified 5186 articles for title search, of which 75 abstracts were included for review and 38 articles were selected for full-text review. Full-text articles yielded 237 CDEs, only 12 (5.06%) of which were opioid-specific. The environmental scan identified 379 potential data elements and value sets across 9 data systems and libraries, among which only 84 (22%) were opioid-specific. We found substantial variability in the types of clinical data elements with limited overlap and no single data system included CDEs across all major data element types such as substance use disorder, OUD, medication and mental health. Relative to common health data code systems, few data elements had an exact match (< 1%), while 61% had a partial match and 38% had no matches. CONCLUSIONS: Despite the increasing ubiquity of EHR data standards and national attention placed on the opioid epidemic, we found substantial fragmentation in the design and construction of OUD related CDEs and little OUD specific CDEs in existing data dictionaries, systems and literature. Given the significant gaps in data collection and reporting, future work should leverage existing structured data elements to create standard workflow processes to improve OUD data capture in EHR systems.

Naloxone Administration Frequency During Emergency Medical Service Events - United States, 2012-2016.

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),† the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis.

National Systematic Legal Review of State Policies on Emergency Medical Services Licensure Levels' Authority to Administer Opioid Antagonists.

OBJECTIVE: Previous research conducted in November 2013 found there were a limited number of states and territories in the United States (US) that authorize emergency medical technicians (EMTs) and emergency medical responders (EMRs) to administer opioid antagonists. Given the continued increase in the number of opioid-related overdoses and deaths, many states have changed their policies to authorize EMTs and EMRs to administer opioid antagonists. The goal of this study is to provide an updated description of policy on EMS licensure levels' authority to administer opioid antagonists for all 50 US states, the District of Columbia (DC), and the Commonwealth of Puerto Rico (PR). METHODS: State law and scopes of practice were systematically reviewed using a multi-tiered approach to determine each state's legally-defined EMS licensure levels and their authority to administer an opioid antagonist. State law, state EMS websites, and state EMS scope of practice documents were identified and searched using Google Advanced Search with Boolean Search Strings. Initial results of the review were sent to each state office of EMS for review and comment. RESULTS: As of September 1, 2017, 49 states and DC authorize EMTs to administer an opioid antagonist. Among the 40 US jurisdictions (39 states and DC) that define the EMR or a comparable first responder licensure level in state law, 37 states and DC authorize their EMRs to administer an opioid antagonist. Paramedics are authorized to administer opioid antagonists in all 50 states, DC, and PR. All 49 of the US jurisdictions (48 states and DC) that define the advanced emergency medical technician (AEMT) or a comparable intermediate EMS licensure level in state law authorize their AEMTs to administer an opioid antagonist. CONCLUSIONS: 49 out of 52 US jurisdictions (50 states, DC, and PR) authorize all existing levels of EMS licensure levels to administer an opioid antagonist. Expanding access to this medication can save lives, especially in communities that have limited advanced life support coverage.

Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing.

BACKGROUND: Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. METHODS: Using data from the National Emergency Medical Services Information System, we examined data from 2012-5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. RESULTS: Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20-29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13-1.22) and for men (aOR = 1.13, 95% CI = 1.10-1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72-0.80 and aOR = 0.85, 95% CI = 0.80-0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68-0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45-3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09-1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). CONCLUSION: This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs.

Prehospital Emergency Care Education for the Nepal Mountaineering Association.

BACKGROUND: Prehospital emergency care training programs are effective in reducing mortality and disability in low-income countries. Implementation of a specifically designed program in the mountainous regions of Nepal has the potential to benefit local populations, trekking and mountaineering guides, and adventure tourists. OBJECTIVE: Our aims were to survey Nepal Mountaineering Association (NMA) members' past experiences with emergencies and medical training, characterize a geographic-specific prehospital emergency care training program, and evaluate the effectiveness and outcome of the program. METHODS: Sixty-two trekking guides, police officers, and students attended the 2-day training program in Pokhara, Nepal in May 2014. Training curriculum was determined in coordination with the NMA. Instructors included Tulane University faculty, surgical residents, and graduate students. Surveys identified participants' experience with emergencies, confidence in providing emergency care, and interest in future trainings. Multiple modalities were utilized to assess trainees' comprehension. RESULTS: Participants rated the program as valuable and expressed desire for additional trainings. Survey results indicated that participants had prior experience with a myriad of emergencies, were more confident in managing traumatic emergencies than medical or environmental, and showed that few had previously received training in cardiopulmonary resuscitation. Areas of instruction included general first responder and geographic-specific content. Participants achieved the course objectives and documented their abilities to successfully manage simulated clinical problems. CONCLUSIONS: The training program, an international collaboration, was documented to be successful by instructors, NMA leadership, and participants. The training program's content matched the participants' specific needs and abilities. Areas for improvement include providing content related to burns, motorcycle injuries, cold-exposure injuries, fever management, and toxicology emergencies.