Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study.

STUDY OBJECTIVE: We implemented a whole person care-informed intervention delivered by substance use navigators (SUN) for emergency department (ED) patients with substance use disorders. METHODS: This was an implementation study of adult patients discharged from 3 public hospital EDs between September 1, 2021 through January 31, 2022 with cocaine, methamphetamine, alcohol, and opioid use-related diagnoses. The primary effectiveness outcome was treatment engagement within 30 days of ED discharge among patients with and without the SUN intervention. We used logistic regression and nearest neighbor propensity score matching without replacement to control for confounding effects. RESULTS: There were 1,328 patients in the cohort, and 119 (9.0%) received the SUN intervention; 50.4% of patients in the SUN intervention group and 15.9% of patients without the SUN intervention were engaged in outpatient treatment within 30 days of ED discharge (difference in proportions: 34.5%, 95% confidence interval [CI] 25.3% to 43.8%). In the unadjusted analysis, the SUN intervention was associated with higher rates of treatment engagement after ED discharge for patients with alcohol, opioid, and cocaine-related diagnoses; patients with methamphetamine-related diagnoses had low engagement rates with or without the SUN intervention. In addition, the SUN intervention was associated with higher odds of treatment engagement in the multivariable model (aOR 3.7, 95% CI 2.4 to 5.8) and in the propensity score-matched analysis (OR 2.1, 95% CI 1.2 to 3.5). CONCLUSION: A whole person care-informed intervention delivered by SUNs for ED patients with substance use disorders was strongly associated with higher engagement rates in addiction treatment after discharge.

Indirect signs of aortic dissection on POC-TTE despite an ADD-RS of 0 and D-dimer < 500 ng/mL.

Aortic dissection (AD) is a "can't miss" diagnosis for emergency physicians. An algorithm combining the Aortic Dissection Detection Risk Score (ADD-RS) with D-dimer has been proposed as a high-sensitivity clinical decision tool for AD that can determine the need for advanced imaging. Here we present a case of a 48-year-old male who presented to the emergency department (ED) with chest pain and dyspnea. He had an ADD-RS score of 0 and negative D-dimer, which placed him in the low-risk category not requiring further advanced imaging. Despite this, he was found to have a pericardial effusion and dilated aortic root on point-of-care transthoracic echocardiogram (POC-TTE). These findings increased suspicion for AD and prompted the emergency physician to order a computed tomography angiography (CTA), revealing a thoracic AD. The patient successfully underwent surgical repair. This case demonstrates that the ADD-RS + D-dimer algorithm would have erroneously ruled out AD, without the inclusion of indirect findings of AD from the POC-TTE. This highlights the value of using POC-TTE as an adjunct to the ADD-RS + D-dimer algorithm in the diagnostic evaluation of AD and how giving more weight to indirect signs of AD on POC-TTE could potentially increase the sensitivity of the combined ADD-RS + D-dimer + POC-TTE algorithm.

A Rare Case of Acute Right-Sided Colonic Diverticulitis Presenting as Pancreatitis.

BACKGROUND: This case report highlights the clinical presentation, radiologic findings, and medical management of a case of right colonic diverticulitis (RCD) with concomitant pancreatitis, a rare and easily missed entity in the emergency department (ED) of Western hemisphere countries. In our report, we present and discuss a case of RCD that led to pancreatitis in a female Asian patient. We review the epidemiology, diagnosis, and management of this disorder, and also discuss some complications associated with RCD. The importance of considering this pathologic entity within the ED differential even in those patients presumed to be at low risk for this condition is also explained, as this can prevent inappropriate surgical intervention for this presentation. CASE REPORT: We describe a 40-year-old Asian woman presenting for evaluation of epigastric pain and vomiting. She was initially thought to have cholecystitis or food poisoning, but had a normal ultrasound evaluation and ultimately had co-presenting RCD and pancreatitis diagnosed after computed tomography scanning. The patient was admitted and made a full recovery after receiving medical therapy and maintaining bowel rest. This is, to our knowledge, the first reported case of RCD and concomitant pancreatitis found in the modern literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe epigastric pain in young Asian patients with minimal risk factors may be RCD. This condition presents much like appendicitis, cholecystitis, or food poisoning, but must be considered among early differential diagnoses and evaluated appropriately in order to prevent unnecessary interventions.

Using Systems Thinking and Complexity Theory to understand and improve Emergency Medicine: Lessons from COVID-19 in a safety net health system.

RATIONALE: COVID-19 has fundamentally changed the practice of Emergency Medicine (EM). Care delivery on the front lines has historically depended upon ostensibly reliable input-output models for staffing, supplies, policies, and therapies. Challenged by the complexity of healthcare during the pandemic, the fallibility of these reductionist models was quickly revealed. Providers and systems quickly had to reconceptualize their dependence on the wider, complex system in which healthcare operates and find adaptive solutions to rapid changes. AIMS/METHOD: This papers seeks to review and describe how Systems Thinking and Complexity Theory (ST/CT)-concepts, principles, and tools that can be used to understand and impact our constantly evolving health system-can be applied to better understand and enact change in complex settings such as during COVID-19. Some of these ST/CT are described through the real world example of the Alameda Health System Vaccine Taskforce. RESULTS: ST/CT concepts such as Unintended Consequences, Interrelationships, Emergent Behavior, Feedback Loops, and Path Dependence can help EM providers and planners understand the context in which their system operates. Key principles such as Collaboration, Iterative Learning, and Transformational Leadership can help these actors respond to current and future challenges. The integration of these concepts and principles into the Learning Health System offers a model for tying these key concepts and principles together into an adaptive, cross-sectoral organizational approach. CONCLUSION: By integrating ST/CT into the practice of EM, we can not only improve our ability to care for patients but also our capacity to understand and strengthen our wider systems of care.

Intracranial Hemorrhage Presenting With ST-Segment Elevation and T-Wave Inversion Concerning for Acute Myocardial Infarction.

Acute neurologic injury and increased intracranial pressure are associated with electrocardiographic (ECG) changes that include rhythm disturbances as well as ECG mimics of myocardial ischemia, such as focal or diffuse ST-segment or T-wave abnormalities. Both the mechanism and significance of these ECG changes are not clear. The authors report a case of a patient with a complex medical history who became hypotensive after he presented with acute intracranial hemorrhage. A subsequent ECG showing ST-segment elevation in the inferior and lateral leads was concerning for acute myocardial infarction. ST-segment elevation in the setting of acute intracranial hemorrhage can lead to diagnostic confusion and/or premature narrowing of the differential diagnosis. This case report starts with an example of this exact scenario, provides a concise overview of potential mechanisms, and concludes with several possible strategies that the emergency provider can use to identify this effect in an undifferentiated patient.

Navigating systems ideas for health practice: Towards a common learning device.

Systems thinking and reference to complexity science have gained currency in health sector practice and research. The extent to which such ideas might represent a mere passing fad or might more usefully be mobilized to tackle wicked problems in health systems is a concern underpinning this paper. Developing the usefulness of the systems idea requires appreciating how systems ideas are used essentially as constructs conceptually bounded by practitioners. Systems are used for purposes of understanding and engaging the reality of health issues, with the intent of transforming the reality into one that is more manageable, equitable, and sustainable. We examine some manifestations of the systems idea in health practice and the traditions of systems practice that variously make use of them. This provides a platform for proposing a systems thinking in (health) practice heuristic: a learning device supporting how different tools and methods can address "wicked problems" in health praxis. The device is built on the use of "conversation" as a metaphor to help practitioners use systems ideas in tandem with existing disciplinary and professional skills and methods. We consider how the application of the heuristic requires, and helps to develop, human characteristics of humility, empathy, and recognition of fallibility.

The application of systems thinking concepts, methods, and tools to global health practices: An analysis of case studies.

OBJECTIVES: This review of systems thinking (ST) case studies seeks to compile and analyse cases from ST literature and provide practitioners with a reference for ST in health practice. Particular attention was given to (1) reviewing the frequency and use of key ST terms, methods, and tools in the context of health, and (2) extracting and analysing longitudinal themes across cases. METHODS: A systematic search of databases was conducted, and a total of 36 case studies were identified. A combination of integrative and inductive qualitative approaches to analysis was used. RESULTS: Most cases identified took place in high-income countries and applied ST retrospectively. The most commonly used ST terms were agent/stakeholder/actor (n = 29), interdependent/interconnected (n = 28), emergence (n = 26), and adaptability/adaptation (n = 26). Common ST methods and tools were largely underutilized. Social network analysis was the most commonly used method (n = 4), and innovation or change management history was the most frequently used tool (n = 11). Four overarching themes were identified; the importance of the interdependent and interconnected nature of a health system, characteristics of leaders in a complex adaptive system, the benefits of using ST, and barriers to implementing ST. CONCLUSIONS: This review revealed that while much has been written about the potential benefits of applying ST to health, it has yet to completely transition from theory to practice. There is however evidence of the practical use of an ST lens as well as specific methods and tools. With clear examples of ST applications, the global health community will be better equipped to understand and address key health challenges.

Thinking about complexity in health: A systematic review of the key systems thinking and complexity ideas in health.

RATIONALE, AIMS, AND OBJECTIVES: As the Sustainable Development Goals are rolled out worldwide, development leaders will be looking to the experiences of the past to improve implementation in the future. Systems thinking and complexity science (ST/CS) propose that health and the health system are composed of dynamic actors constantly evolving in response to each other and their context. While offering practical guidance for steering the next development agenda, there is no consensus as to how these important ideas are discussed in relation to health. This systematic review sought to identify and describe some of the key terms, concepts, and methods in recent ST/CS literature. METHOD: Using the search terms "systems thinkin * AND health OR complexity theor* AND health OR complex adaptive system* AND health," we identified 516 relevant full texts out of 3982 titles across the search period (2002-2015). RESULTS: The peak number of articles were published in 2014 (83) with journals specifically focused on medicine/healthcare (265) and particularly the Journal of Evaluation in Clinical Practice (37) representing the largest number by volume. Dynamic/dynamical systems (n = 332), emergence (n = 294), complex adaptive system(s) (n = 270), and interdependent/interconnected (n = 263) were the most common terms with systems dynamic modelling (58) and agent-based modelling (43) as the most common methods. CONCLUSIONS: The review offered several important conclusions. First, while there was no core ST/CS "canon," certain terms appeared frequently across the reviewed texts. Second, even as these ideas are gaining traction in academic and practitioner communities, most are concentrated in a few journals. Finally, articles on ST/CS remain largely theoretical illustrating the need for further study and practical application. Given the challenge posed by the next phase of development, gaining a better understanding of ST/CS ideas and their use may lead to improvements in the implementation and practice of the Sustainable Development Goals.