Ultrasound Performed by Emergency Physicians for Deep Vein Thrombosis: A Systematic Review.

Introduction: Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of lower extremity deep vein thrombosis (DVT). Systematic reviews suggested good sensitivity and specificity overall for EP-performed POCUS for DVT diagnosis, yet high levels of heterogeneity were reported. Methods: In this systematic review and meta-analysis, we aimed to provide the most up-to-date estimates of the accuracy of EP-performed POCUS for diagnosis of DVT and to explore potential correlations with test performance. We performed systematic searches in MEDLINE and Embase for original, primary data articles from January 2012-June 2021 comparing the efficacy of POCUS performed by EPs to the local standard. Quality Assessment of Diagnostic Accuracy Studies-2 for individual articles are reported. We obtained summary measures of sensitivity, specificity, and their corresponding 95% confidence intervals (CI) using bivariate mixed-effects regression models. We performed meta-regression, subgroup, and sensitivity analyses as planned in the protocol CRD42021268799 submitted to PROSPERO. Results: Fifteen publications fit the inclusion criteria, totaling 2,511 examinations. Pooled sensitivity and specificity were 90% (95% CI 82%-95%) and 95% (CI 91%-97%), respectively. Subgroup analyses by EP experience found significantly better accuracy for exams performed by EP specialists (93%, CI 88%-97%) vs trainees (77%, CI 60%-94%). Specificity for EP specialists (97%, CI 94%-99%) was higher than for trainees (87%, CI 76%-99%, P = 0.01). Three-point compression ultrasound (CUS) was more sensitive than two-point CUS but was only statistically significant when limited to EP specialists (92% vs 88%, P = 0.07, and 95% vs 88%, P = 0.02, respectively). Conclusion: Point-of-care ultrasound performed by emergency physicians is sensitive and specific for the diagnosis of suspected DVT when performed by trained attending EPs. Three-point compression ultrasound examination may be more sensitive than two-point CUS.

Assessment of Trauma Team Activation Fees by US Region and Hospital Ownership.

Importance: Trauma centers must be readily equipped to handle a variety of life-threatening injuries and consequently may charge a fee for the activation of their trauma team. Regional and hospital-related variations in trauma activation fees across the US have not been formally assessed. Objective: To evaluate the variability of trauma activation fees from trauma centers across the US and examine whether certain hospital characteristics are associated with higher activation fees. Design, Setting, and Participants: This cross-sectional study used data from the American College of Surgeons website to identify all trauma centers in the US that were listed as verified from inception of the verification database through March 4, 2022 (N = 546). Five military hospitals were excluded, and trauma activation fees could not be found for 18 trauma centers; the remaining 523 hospitals were included in the analysis. Each hospital's publicly available chargemaster (a comprehensive list of a hospital's products, procedures, and services) was searched to obtain its trauma activation fees. Two levels of trauma activation fees were recorded: tier 1 (full activation) and tier 2 (partial activation). Hospital-specific data were obtained from the American Hospital Association website. All data were collected between January 2 and March 11, 2022. Linear regression analyses were performed to assess potential associations between hospital characteristics (type of control [for profit, government, church, or other nonprofit], hospital system [owner], number of staffed beds, and academic vs nonacademic status) and trauma activation fees. Main Outcomes and Measures: Median and mean trauma activation fees nationally and stratified by location, hospital system, and other hospital characteristics. Results: Of 523 trauma centers included in the analysis, most were located in the Midwest (180 centers) and West (129 centers). There were 176 adult level I trauma centers and 200 adult level II trauma centers; 69 centers had for-profit status, and 415 were academic. Overall, the median (IQR) tier 1 trauma activation fee was $9500 ($5601-$17 805), and the mean (SD) tier 1 trauma activation fee was $13 349 ($11 034); these fees ranged from $1000 to $61 734. Median (IQR) trauma activation fees were highest in the West ($18 099 [$10 741-$$27 607]), especially in California, where the median (IQR) activation fee was $24 057 ($15 979-$33 618). Trauma activation fees were also higher at for-profit hospitals, most of which were owned by the HCA Healthcare system, which had 43 trauma centers and a median (IQR) tier 1 trauma activation fee of $29 999 ($20 196-$37 589). Conclusions And Relevance: In this study, trauma activation fees varied widely among hospitals in the US. Regional variation in these fees was substantial, with hospitals in the West charging substantially more than those in other locations. In addition, for-profit hospitals charged more than other types of hospitals. These findings suggest that some patients with serious traumatic injuries will incur disproportionately high trauma activation fees depending on the trauma center to which they are brought. Therefore, standardization of trauma activation fees is warranted.

Ultrasound-Guided Trigger Point Injections for the Treatment of Neck and Back Pain in the Emergency Department: A Randomized Trial.

OBJECTIVES: Patients frequently present to the emergency department (ED) with neck or back pain, which can be difficult to treat. We sought to compare ultrasound-guided trigger point injection (TPI) to standard medications for patients with neck or back pain. METHODS: We performed a single-center, open label, randomized controlled trial on ED patients with neck or back pain from myofascial pain syndrome comparing ultrasound-guided TPIs to those who received the combination of a nonsteroidal anti-inflammatory drug (NSAID) and a muscle relaxant (MR). The primary outcome of this study was the reduction in mean pain score at the time of ED disposition. RESULTS: In total, we analyzed 196 patients. At the time of ED disposition, patients in the TPI group had a mean reduction in their pain scores of 45.0 mm as compared to 49.9 mm in the NSAID plus MR group (difference: 4.9 [95% confidence interval (CI) -3.0 to 12.7], P = .22). At the first reassessment, patients in the TPI group had greater pain reduction by 10.7 mm (95% CI 3.1 to 18.4). The rate of rescue therapy use was higher in the NSAID plus MR group (difference: 17.5% [95% CI 4.4 to 36.2]). CONCLUSIONS: We found no difference in pain reduction at the time of ED disposition between patients randomized to the ultrasound-guided TPI group as compared to those who received an NSAID plus a MR. However, patients in the TPI group had greater pain reduction at the time of first reassessment and lower rates of rescue therapy use.

Evaluation of Telehealth Visit Attendance After Implementation of a Patient Navigator Program.

Importance: The dramatic rise in use of telehealth accelerated by COVID-19 created new telehealth-specific challenges as patients and clinicians adapted to technical aspects of video visits. Objective: To evaluate a telehealth patient navigator pilot program to assist patients in overcoming barriers to video visit access. Design, Setting, and Participants: This quality improvement study investigated visit attendance outcomes among those who received navigator outreach (intervention group) compared with those who did not (comparator group) at 2 US academic primary care clinics during a 12-week study period from April to July 2021. Eligible participants had a scheduled video visit without previous successful telehealth visits. Interventions: The navigator contacted patients with next-day scheduled video appointments by phone to offer technical assistance and answer questions on accessing the appointment. Main Outcomes and Measures: The primary outcome was appointment attendance following the intervention. Return on investment (ROI) accounting for increased clinic adherence and costs of implementation was examined as a secondary outcome. Results: A total 4066 patients had video appointments scheduled (2553 [62.8%] women; median [IQR] age: intervention, 55 years [38-66 years] vs comparator, 52 years [36-66 years]; P = .02). Patients who received the navigator intervention had significantly increased odds of attending their appointments (odds ratio, 2.0; 95% CI, 1.6-2.6) when compared with the comparator group, with an absolute increase of 9% in appointment attendance for the navigator group (949 of 1035 patients [91.6%] vs 2511 of 3031 patients [82.8%]). The program's ROI was $11 387 over the 12-week period. Conclusions and Relevance: In this quality improvement study, we found that a telehealth navigator program was associated with significant improvement in video visit adherence with a net financial gain. Our findings have relevance for efforts to reduce barriers to telehealth-based health care and increase equity.

Point of care ultrasound needle guidance to assist diagnosis of acute gluteal compartment syndrome.

Gluteal compartments can be difficult to assess for acute compartment syndrome (ACS) compared to other fascial compartments due to their anatomy and rarity of presentation. Point-of-care ultrasound (POCUS) needle guidance may assist in obtaining accurate compartment pressure measurements within the gluteal compartments. We present a case in which a 69-year-old woman presented following a fall resulting in a superior prosthetic hip dislocation. One-hour post hip-reduction, the patient began to experience severe pain of the right leg, swelling to the gluteal region, and numbness to her foot. With consideration of a developing gluteal compartment syndrome in mind, POCUS was used to guide the needle of a compartmental pressure monitor system into the gluteal maximus and medius-minimus compartments which demonstrated elevated compartment pressures consistent with ACS. The patient was subsequently taken for emergent fasciotomy and hematoma evacuation. There has been limited investigation into compartment pressure measurement under US guidance versus a palpation/landmark-guided technique. This case shows the feasibility of US needle guidance when assessing compartment pressures for this uncommon diagnosis.

An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States.

BACKGROUND: Clinicians must be aware of the structural forces that affect their patients to appropriately address their unique health care needs. This study aimed to assess the participation of global emergency medicine (GEM) fellowship programs in formal social determinants of health (SDH) and structural competency (SC) training to evaluate the existence and procedures of such programs. METHODS: A cross-sectional study conducted with a short, online survey with questions regarding the presence of curriculum focused on SDH, SC, educational metrics, and the desire for further formal training in this domain was sent to all 25 GEM fellowship directors through the Global Emergency Medicine Fellowship Consortium (GEMFC) email listserv. RESULTS: Eighty percent (20/25) of GEM fellowship directors responded to the survey. All (20/20) of participating fellowship programs included SDH and SC training in their didactic curriculum, and eight of 20 (40%) programs offered similar training for faculty. Additionally, 19 of 20 (95%) of respondents indicated interest in an open-source tool for emergency medicine (EM) fellowship training in SDH and SC. CONCLUSIONS: While multiple GEM programs offer formal training on SDH and SC, gaps exist regarding similar training for faculty. Additionally, there is a lack of metrics to determine fellows' comfort with the content of this training. As a majority of GEMFC programs requested, an open-source tool would allow a uniform curriculum and measurement of EM fellowship training in SDH and SC.

Can a low-cost exercise monitor provide useful heart rate monitoring for use in low-resource emergency departments?

OBJECTIVE: Our objective was to study the clinical monitoring capabilities of a low-cost fitness wristband while measuring patient satisfaction with a mobility permitting device in the emergency department. METHODS: Patients enrolled were on continuous three-lead telemetry monitoring in a high acuity zone of the emergency department. Patients were given a fitness band to wear while simultaneously monitored with standard three-lead monitor. A brief survey was conducted upon study end, and data was compared between wristband and three-lead telemetry. Median heart rate (HR) values were calculated, a Bland-Altman plot was generated, and sensitivity and specificity were calculated for comparison of the formal telemetry and the inexpensive wristband. RESULTS: Thirty-four patients with an average age of 61.5 years were enrolled. From June to October 2019, over 100 hours of data were collected. In comparison for comfort, participants scored 9.5 of 10, preferring wristband over telemetry. Using a correlation coefficient graph, we found a significant disparity of HR readings within a telemetry range of 40 to 140 beats/min. An R-value of 0.36 was detected. Using a Bland-Altman plot, we observed a significant difference in HR between the telemetry monitor and the wristband. The sensitivity and specificity of the wristband to detect bradycardia (HR <60 beats/min) were 76% and 86%, respectively, while the sensitivity and specificity of the wristband to detect tachycardia (HR >100 beats/min) were 92% and 51%, respectively. CONCLUSION: Inexpensive fitness bands cannot be a suitable tool for monitoring patient's HR because of inaccuracy in detecting bradycardia or tachycardia.

Developing a pulse oximetry home monitoring protocol for patients suspected with COVID-19 after emergency department discharge.

OBJECTIVES: Patients with COVID-19 can present to the emergency department (ED) without immediate indication for admission, but with concern for decompensation. Clinical experience has demonstrated that critical illness may present later in the disease course and hypoxia is often the first indication of disease progression. The objectives of this study are to (a) assess feasibility and describe a protocol for ED-based outpatient pulse-oximetry monitoring with structured follow-up and (b) determine rates of ED return, hospitalisation and hypoxia among participants. METHODS: Prospective observational study of patients presenting to a single academic ED in Boston with suspected COVID-19. Eligible patients were adults being discharged from the ED with presumed COVID-19. Exclusion criteria included resting oxygen saturation <92%, ambulatory oxygen saturation <90%, heart rate >110 beats per minute or inability to use the device. Study personnel made scripted phone calls on postdischarge days 1, 3 and 7 to review the pulse-oximetry readings and to evaluate for decompensation. Return visit and admission information were collected via medical record and 28-day follow-up calls. RESULTS: 81 patients were enrolled of which 10 (12%) developed hypoxia after their initial discharge from the ED. Overall, 23 (28%) of the 81 patients returned to the ED at least once and 10 of those who returned (43%) were admitted. We successfully contacted 76/81 (94%) of subjects via phone at least once for follow-up assessment. DISCUSSION: Patients are eager and willing to participate in home monitoring systems and are comfortable with using technology, which will allow providers and health systems to extend our hospitals capabilities for tracking patient populations in times of crisis. CONCLUSIONS: It is feasible to implement an outpatient pulse-oximetry monitoring protocol to monitor patients discharged from the ED with confirmed or suspected COVID-19.

TeleConnect: digitally connecting physicians across the health care system.

OBJECTIVES: Prior to the coronavirus disease 2019 (COVID-19) pandemic, introductions between primary care physicians (PCPs) and specialists were conducted in person. These important meetings were integral to patient care, facilitated care coordination, and improved the managed care of the patient. During COVID-19 and beyond, these important relationships should be fostered via digital means. We aimed to identify opportunities of digital health integration for the optimization of physician integration. STUDY DESIGN: Cross-sectional study. METHODS: Prior to COVID-19, we conducted a survey of PCPs at a large multidisciplinary group with more than 1500 physicians that staffs multiple hospitals within a health system. The survey was sent via email with only 1 reminder. RESULTS: Thirty-six PCPs responded to the survey; 25% (9/36) were very satisfied and 19.4% (7/36) were moderately satisfied with the current in-person introductions. The PCPs found introductions to specialists helpful; 83.7% (31/37) wanted to "put a name to the face," and 64.9% (24/37) wanted to "understand the range of service provided by the specialist." Fifty-one percent (19/37) and 54% (20/37) said "I can better manage patient care and know when to refer to a specialist" and "I learn more about a particular specialist," respectively, with specialist introductions. If made easy, 67.6% (25/37) of PCPs would be interested in TeleConnect to facilitate introductions to specialists. CONCLUSIONS: Referrals between PCPs and specialists have been an integral aspect of medical care within managed care organizations. With the advent of technology during COVID-19, and along with this brief survey, the need for digital means to introduce PCPs and specialists is underscored.

Use of ultra-low cost fitness trackers as clinical monitors in low resource emergency departments.

In low resource hospitals, strained staffing ratios and lack of telemetry can put patients at risk for clinical deterioration and unexpected cardiac arrest. While traditional telemetry systems can provide real-time continuous vital signs, they are too expensive for widespread use in these settings. At the same time, developed countries such as the United States have been increasingly utilizing remote monitoring systems to shift patient care from hospital to home. While the context is dramatically different, the challenge of monitoring patients in otherwise unmonitored settings is the same. At-home monitoring solutions range from highly comprehensive and expensive systems to inexpensive fitness trackers. In the field of global health, the adoption of this technology has been somewhat limited. We believe that low cost fitness trackers present an opportunity to address the challenge of vital sign monitoring in resource-poor settings at a fraction of the cost of existing technical solutions.

Point of Care Image Capture with a Custom Smartphone Application: Experience with an Encounter-Based Workflow.

Medical documentation is one of the primary methods by which physicians share clinical information and impressions over time with one another. As the adage says, "a picture is worth a thousand words," and physicians have started leveraging consumer mobile technology to share images with one another. However, image sharing often uses short message service texting and similar methods, which can be noncompliant with privacy regulations and can also limit the ability to communicate information longitudinally and across specialties. Sharing of such information is increasingly important, however, as smaller practices are joining to create large geographically spread out health care networks. To this end, we developed an application to acquire and store images via smartphone and seamlessly transfer into the patient's electronic medical record (EMR) to enable digital consults and longitudinal evaluation in a private and compliant method.

Using the Boston Syncope Observation Management Pathway to Reduce Hospital Admission and Adverse Outcomes.

INTRODUCTION: In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions. METHODS: This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher's exact test. RESULTS: In the "before" phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001). CONCLUSION: A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED.

Cultural Competency Training in Emergency Medicine.

BACKGROUND: The Emergency Department is widely regarded as the epicenter of medical care for diverse and largely disparate types of patients. Physicians must be aware of the cultural diversity of their patient population to appropriately address their medical needs. A better understanding of residency preparedness in cultural competency can lead to better training opportunities and patient care. OBJECTIVE: The objective of this study was to assess residency and faculty exposure to formal cultural competency programs and assess future needs for diversity education. METHODS: A short survey was sent to all 168 Accreditation Council for Graduate Medical Education program directors through the Council of Emergency Medicine Residency Directors listserv. The survey included drop-down options in addition to open-ended input. Descriptive and bivariate analyses were used to analyze data. RESULTS: The response rate was 43.5% (73/168). Of the 68.5% (50/73) of residency programs that include cultural competency education, 90% (45/50) utilized structured didactics. Of these programs, 86.0% (43/50) included race and ethnicity education, whereas only 40.0% (20/50) included education on patients with limited English proficiency. Resident comfort with cultural competency was unmeasured by most programs (83.6%: 61/73). Of all respondents, 93.2% (68/73) were interested in a universal open-source cultural competency curriculum. CONCLUSIONS: The majority of the programs in our sample have formal resident didactics on cultural competency. Some faculty members also receive cultural competency training. There are gaps, however, in types of cultural competency training, and many programs have expressed interest in a universal open-source tool to improve cultural competency for Emergency Medicine residents.