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STUDY OBJECTIVE: Although an increasing number of emergency departments (ED) offer opioid agonist treatment, naloxone, and other harm reduction measures, little is known about patient perspectives on harm reduction practices delivered in the ED. The objective of this study was to identify patient-focused barriers and facilitators to harm reduction strategies in the ED. METHODS: We conducted semistructured interviews with a convenience sample of individuals in Massachusetts diagnosed with opioid use disorder. We developed an interview guide, and interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. After initial interviews and coding, we triangulated the results among a focus group of 4 individuals with lived experience. RESULTS: We interviewed 25 participants with opioid use disorder, 6 recruited from 1 ED and 19 recruited from opioid agonist treatment clinics. Key themes included accessibility of harm reduction supplies, lack of self-care resulting from withdrawal and hopelessness, the impact of stigma on the likelihood of using harm reduction practices, habit and knowledge, as well as the need for user-centered harm reduction interventions. CONCLUSION: In this study, people with lived experience discussed the characteristics and need for user-centered harm reduction strategies in the ED that centered on reducing stigma, treatment of withdrawal, and availability of harm reduction materials.
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Reducción del Daño , Trastornos Relacionados con Opioides , Humanos , Analgésicos Opioides/uso terapéutico , Trastornos Relacionados con Opioides/prevención & control , Trastornos Relacionados con Opioides/tratamiento farmacológico , Naloxona/uso terapéutico , Investigación CualitativaRESUMEN
STUDY OBJECTIVE: Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. METHODS: We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. RESULTS: Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). CONCLUSIONS: Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.
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STUDY OBJECTIVE: Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index. METHODS: This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization. RESULTS: Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00). CONCLUSIONS: Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.
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Hospitalización , Embolia Pulmonar , Adulto , Humanos , Frecuencia Cardíaca , Estudios Retrospectivos , Servicio de Urgencia en HospitalRESUMEN
STUDY OBJECTIVE: Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology. METHODS: We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks-the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process. RESULTS: We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes. CONCLUSION: In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory.
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Pacientes Ambulatorios , Embolia Pulmonar , Humanos , Atención Ambulatoria , Servicio de Urgencia en Hospital , Miedo , Embolia Pulmonar/terapiaRESUMEN
OBJECTIVE: To identify factors that influence providers' decisions to prescribe antibiotics in patients presenting to the hospital with an asthma exacerbation. METHODS: We performed semi-structured interviews with a purposive sample of providers including sixteen hospitalists, emergency room providers, or pulmonologists, and one focus group with internal medicine residents recruited from one large, urban, teaching hospital and one small, rural, community hospital. Questions were informed by the Theoretical Domains Framework to determine factors that may influence behaviors. Directed content analysis was used to code and analyze transcripts of the interviews. RESULTS: Uncertainty regarding the diagnostic (asthma vs. COPD) and the cause of exacerbation (bacterial vs. viral infection) emerged as the main driver for prescribing behavior. Provider response to uncertainty included: "watchful waiting" or immediate antibiotic prescribing. The following factors played important roles in providers' prescribing decision: 1) awareness/agreement with existing guidelines 2) confidence in their ability to apply the guidelines in challenging cases; 3) perceived risk of patient deterioration without antibiotics; 4) fear of litigation; 5) habit and clinical inertia 6) prescribing within the group 7) lack of information of antibiotic prescribing rates and 8) lack of time and/or resources. CONCLUSIONS: We identified diagnostic uncertainty as the primary determinant of antibiotic prescribing in asthma exacerbations and developed a conceptual model to explain provider responses and factors that influenced their responses. These results enhance our understanding of the factors that can contribute to low-value and wasteful practices like superfluous antibiotic prescribing and will support the development of interventions to de-implement such practices.
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Antibacterianos , Asma , Antibacterianos/uso terapéutico , Asma/diagnóstico , Asma/tratamiento farmacológico , Grupos Focales , Humanos , Pautas de la Práctica en Medicina , Investigación Cualitativa , IncertidumbreRESUMEN
COVID-19 is currently the third leading cause of death in the United States, and unvaccinated people continue to die in high numbers. Vaccine hesitancy and vaccine refusal are fueled by COVID-19 misinformation and disinformation on social media platforms. This online COVID-19 infodemic has deadly consequences. In this editorial, the authors examine the roles that social media companies play in the COVID-19 infodemic and their obligations to end it. They describe how fake news about the virus developed on social media and acknowledge the initially muted response by the scientific community to counteract misinformation. The authors then challenge social media companies to better mitigate the COVID-19 infodemic, describing legal and ethical imperatives to do so. They close with recommendations for better partnerships with community influencers and implementation scientists, and they provide the next steps for all readers to consider. This guest editorial accompanies the Journal of Medical Internet Research special theme issue, "Social Media, Ethics, and COVID-19 Misinformation."
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COVID-19 , Medios de Comunicación Sociales , Comunicación , Humanos , Infodemia , SARS-CoV-2 , Estados UnidosRESUMEN
BACKGROUND: Initial recommendations discouraged high flow nasal cannula (HFNC) in COVID-19 patients, driven by concern for healthcare worker (HCW) exposure. Noting high morbidity and mortality from early invasive mechanical ventilation, we implemented a COVID-19 respiratory protocol employing HFNC in severe COVID-19 and HCW exposed to COVID-19 patients on HFNC wore N95/KN95 masks. Utilization of HFNC increased significantly but questions remained regarding HCW infection rate. METHODS: We performed a retrospective evaluation of employee infections in our healthcare system using the Employee Health Services database and unit records of employees tested between March 15, 2020 and May 23, 2020. We assessed the incidence of infections before and after the implementation of the protocol, stratifying by clinical or non-clinical role as well as inpatient COVID-19 unit. RESULTS: During the study period, 13.9% (228/1635) of employees tested for COVID-19 were positive. Forty-six percent of infections were in non-clinical staff. After implementation of the respiratory protocol, the proportion of positive tests in clinical staff (41.5%) was not higher than that in non-clinical staff (43.8%). Of the clinicians working in the high-risk COVID-19 unit, there was no increase in infections after protocol implementation compared with clinicians working in COVID-19 units that did not use HFNC. CONCLUSION: We found no evidence of increased COVID-19 infections in HCW after the implementation of a respiratory protocol that increased use of HFNC in patients with COVID-19; however, these results are hypothesis generating.
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COVID-19/epidemiología , COVID-19/terapia , Personal de Salud/estadística & datos numéricos , Ventilación no Invasiva/métodos , Enfermedades Profesionales/epidemiología , Cánula , Humanos , Massachusetts/epidemiología , Ventilación no Invasiva/instrumentación , Exposición Profesional , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
STUDY OBJECTIVE: Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta-analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast-enhanced CT versus noncontrast CT. METHODS: We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast. RESULTS: The database search returned 14,691 articles, inclusive of duplicates. Twenty-six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta-analysis demonstrated that, compared with noncontrast CT, contrast-enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all-cause mortality (OR 1.0; 95% CI 0.73 to 1.36). CONCLUSION: We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.