Violence in the emergency department: a quantitative survey study of healthcare providers in India.

BACKGROUND: Workplace violence (WPV) in Emergency Departments (EDs) is an increasingly recognized challenge healthcare providers face in low-resource settings. While studies have highlighted the increased prevalence of WPV in healthcare, most of the existing research has been conducted in developed countries with established laws and repercussions for violence against healthcare providers. More data on WPV against ED providers practicing in low-resource settings is necessary to understand these providers' unique challenges. OBJECTIVE: This study aims to gain insight into the incidence and characteristics of WPV among ED healthcare providers in India. METHODS: This study was conducted at two EDs in geographically distinct regions of India. A survey was designed to assess violence in EDs among healthcare providers. Surveys were distributed to ED workplace providers, completed by hand, and returned anonymously. Data was entered and stored in the RedCAP database to facilitate analysis. RESULTS: Two hundred surveys were completed by physicians, nurses, and paramedics in Indian EDs. Most reported events involved verbal abuse (68%), followed by physical abuse (26%), outside confrontation (17%), and stalking (5%). By far, the most common perpetrators of violence against healthcare workers were bystanders including patient family members or other accompanying individuals. Notably, reporting was limited, with most cases conveyed to ED or hospital administration. CONCLUSION: These results underscore the prevalence of WPV among Indian ED healthcare providers. High rates of verbal abuse followed by physical abuse are of concern. Most perpetrators of WPV against healthcare providers in this study were patient family members or bystanders rather than the patients themselves. It is imperative to prioritize implementing prevention strategies to create safer work environments for healthcare workers.

Let Us Just Ask People What They Think: Community Perceptions and Recommendations about Coronavirus Vaccination.

Introduction: Despite widespread efforts to promote coronavirus disease 2019 vaccination in the United States, a significant segment of the population is still unvaccinated or incompletely vaccinated. Objective: The objective of this study was to understand attitudes toward the vaccine in patients presenting to an urban emergency department. Methods: We used a qualitative analysis and semistructured interviews with a convenience sample of patients presenting to an urban emergency department from January 18, 2021, to March 14, 2021. Our final sample consisted of 32 people. Results: We found that people trusted their own medical providers rather than popular or political figures. Critiques of the vaccination program highlighted difficulties in navigation and perceptions of inequity. Conclusions: Equitable distribution strategies and honest messaging may facilitate acceptance of the coronavirus disease 2019 vaccine. Trustworthy sources for vaccine knowledge should be used to target populations in which vaccine hesitancy is a persistent concern.

Assessing Health and Human Services Needs to Support an Integrated Health in All Policies Plan for Prince George's County, Maryland.

With evolving demographics and a changing health system landscape, the Prince George's County Council, acting as the County Board of Health, is considering its future policy approaches and resource allocations related to health and well-being. To inform this path forward, the authors of this study used primary and secondary data to describe both the health needs of county residents and drivers of health within the county, inclusive of the social, economic, built, natural, and health service environments. This study integrates these findings, an analysis of budget documents, and a review of promising practices from other communities to situate recommendations in a Health in All Policies framework to foster aligned and integrated planning and budgeting across the county to promote health and well-being. Findings from the assessment indicate a shared interest among leaders and residents to embrace a holistic strategy for health and well-being in the county. Inefficient uses of the health care system are identified, highlighting a need to rebalance investments in health care use and drivers of health. Additionally, challenges in navigating health and human services and inequities in drivers of health across communities are noted, signaling broader concerns related to residents' access to health and human services that influence health and well-being outcomes. Recommendations are provided for several paths forward for the county to pursue a more integrated policy approach to influence health and well-being outcomes.

The perceived work environment and well-being: A survey of emergency health care workers during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, health care provider well-being was affected by various challenges in the work environment. The purpose of this study was to evaluate the relationship between the perceived work environment and mental well-being of a sample of emergency physicians (EPs), emergency medicine (EM) nurses, and emergency medical services (EMS) providers during the pandemic. METHODS: We surveyed attending EPs, resident EPs, EM nurses, and EMS providers from 10 academic sites across the United States. We used latent class analysis (LCA) to estimate the effect of the perceived work environment on screening positive for depression/anxiety and burnout controlling for respondent characteristics. We tested possible predictors in the multivariate regression models and included the predictors that were significant in the final model. RESULTS: Our final sample included 701 emergency health care workers. Almost 23% of respondents screened positive for depression/anxiety and 39.7% for burnout. Nurses were significantly more likely to screen positive for depression/anxiety (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.11-3.86) and burnout (aOR 2.05, 95% CI 1.22-3.49) compared to attendings. The LCA analysis identified four subgroups of our respondents that differed in their responses to the work environment questions. These groups were identified as Work Environment Risk Group 1, an overall good work environment; Risk Group 2, inadequate resources; Risk Group 3, lack of perceived organizational support; and Risk Group 4, an overall poor work environment. Participants in the two groups who perceived their work conditions as most adverse were significantly more likely to screen positive for depression/anxiety (aOR 1.89, 95% CI 1.05-3.42; and aOR 2.04, 95% CI 1.14-3.66) compared to participants working in environments perceived as less adverse. CONCLUSIONS: We found a strong association between a perceived adverse working environment and poor mental health, particularly when organizational support was deemed inadequate. Targeted strategies to promote better perceptions of the workplace are needed.

In their own words: Experiences of emergency health care workers during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, a substantial number of emergency health care workers (HCWs) have screened positive for anxiety, depression, risk of posttraumatic stress disorder, and burnout. The purpose of this qualitative study was to describe the impact of COVID-19 on emergency care providers' health and well-being using personal perspectives. We conducted in-depth interviews with emergency physicians, emergency medicine nurses, and emergency medical services providers at 10 collaborating sites across the United States between September 21, 2020, and October 26, 2020. METHODS: We developed a conceptual framework that described the relationship between the work environment and employee health. We used qualitative content analysis to evaluate our interview transcripts classified the domains, themes, and subthemes that emerged from the transcribed interviews. RESULTS: We interviewed 32 emergency HCWs. They described difficult working conditions, such as constrained physical space, inadequate personnel protective equipment, and care protocols that kept changing. Organizational leadership was largely viewed as unprepared, distant, and unsupportive of employees. Providers expressed high moral distress caused by ethically challenging situations, such as the perception of not being able to provide the normal standard of care and emotional support to patients and their families at all times, being responsible for too many sick patients, relying on inexperienced staff to treat infected patients, and caring for patients that put their own health and the health of their families at risk. Moral distress was commonly experienced by emergency HCWs, exacerbated by an unsupportive organizational environment. CONCLUSIONS: Future preparedness efforts should include mechanisms to support frontline HCWs when faced with ethical challenges in addition to an adverse working environment caused by a pandemic such as COVID-19.

Reflect and Reset: Black Academic Voices Call the Graduate Medical Education Community to Action.

The COVID-19 pandemic highlighted the great achievements that the biomedical community can accomplish, but raised the question: Can the same medical community that developed a complex vaccine in less than a year during a pandemic help to defeat social injustice and ameliorate the epidemic of health inequity? In this article, the authors, a group of Black academics, call on the graduate medical education (GME) community to reset its trajectory toward solutions for achieving diversity, improving inclusion, and combating racism using education as the new vector. Sponsoring institutions, which include universities, academic medical centers, teaching hospitals, and teaching health centers, are the center of the creation and dissemination of scholarship. They are often the main sources of care for many historically marginalized communities. The GME learning environment must provide the next generation of medical professionals with an understanding of how racism continues to have a destructive influence on health care professionals and their patients. Residents have the practical experience of longitudinal patient care, and a significant portion of an individual's professional identity is formed during GME; therefore, this is a key time to address explicit stereotyping and to identify implicit bias at the individual level. The authors propose 3 main reset strategies for GME-incorporating inclusive pedagogy and structural competency into education, building a diverse and inclusive learning environment, and activating community engagement-as well as tactics that sponsoring institutions can adapt to address racism at the individual learner, medical education program, and institutional levels. Sustained, comprehensive, and systematic implementation of multiple tactics could make a significant impact. It is an academic and moral imperative for the medical community to contribute to the design and implementation of solutions that directly address racism, shifting how resident physicians are educated and modeling just and inclusive behaviors for the next generation of medical leaders.

Characteristics and expectations among emergency department patients in India.

In India, and many low-middle income countries (LMICs), emergency medicine (EM) remains a poorly defined specialty and an unregulated field of clinical practice. Recognition of the attitudes, understanding, and expectations of patients presenting to Indian EDs will be crucial to the continued development of EM as a specialty. This is a multicenter, prospective, cross sectional study of adult and pediatric patients presenting to the ED in three geographically distinct regions of India. Participants were surveyed about their expectations regarding the type of care that they expected to receive, previous treatment options they have utilized, basic understanding of ED operations, factors contributing to their decision to seek ED care, and basic demographic information. 779 patients were approached to participate in the study, of which 698 (90%) completed the survey. Common ways that patients reported learning about the ED were referral from another healthcare provider (45%) and recommendation by a family member (61%). Participants chose the ED was because they thought they would be seen quickly (89%), would receive acute pain management (45%), their regular outpatient care was closed (45%), or were sent by another doctor (45%). Patients expected to wait 0.3 hours (18 minutes) on average to see a doctor in the ED. Over 75% or patients expected to see a specialist consultant in the ED and 12% expected to see their personal physician. Eighty-five percent of patients were triaged as moderate or high acuity, and 74% of patients were admitted. This study found that ED in India is utilized by a population with an extremely high acuity of medical illness that attempts to access healthcare through multiple avenues. Patients most frequently visit the ED due to a referral from another healthcare provider or family member. Most patients are aware of the existence of the ED, though understanding of available services may be lacking. Future research should focus on community outreach and education initiatives on ED services.

Self-prescribing of antibiotics by patients seeking care in Indian emergency departments.

STUDY OBJECTIVE: Antibiotic resistance is a global health threat. India has one of the highest rates of antibiotic use in the world. The objective of this study was to evaluate the prevalence of self-prescribed antibiotic use of patients presenting with febrile and infectious disease-related complaints to Indian emergency departments. METHODS: This was a prospective observational study conducted at 6 Indian emergency departments (EDs) between January 1, 2019 and December 31, 2019. Adult patients who presented with a chief complaint of febrile illness or infectious disease complaints were included. Our principal outcomes of interest were self-prescribed use of antibiotics within the prior 6 months or for the presenting complaint. We queried respondents about source of antibiotics as well as about demographic characteristics that influenced use. RESULTS: A total of 1421 patients were enrolled. Sixty percent (n = 856) of respondents reported using antibiotics in the prior 6 months or for their current complaint. Those who reported self-prescribing antibiotics either in the past or currently had at least some college education (P < 0.001), tended to use the pharmacy (P < 0.001) or the ED (P = 0.001) for their care when sick, and were more likely to have some comorbid conditions (P = 0.014) as compared to the group that did not self-prescribe antibiotics. The most common reason respondents reported self-prescribing antibiotics was because they did not want to wait to see their doctor (n = 278, 33%). Thirty-five percent of patients who were self-prescribed antibiotics before presentation did not receive and were not prescribed antibiotics in the ED, at discharge, or both. CONCLUSIONS: Self-prescribing of antibiotics occurs commonly in India. This use increases the risk for resistance due to inappropriate or unnecessary use. Promotion of antibiotic stewardship is needed to curtail such use.

Prevalence of undiagnosed HIV, hepatitis B, and hepatitis C among patients in an Indian emergency department.

OBJECTIVES: HIV, hepatitis B, and hepatitis C remain significant causes of morbidity and mortality in low resource settings. Emergency department (ED)-based screening has proven effective in decreasing the spread of undiagnosed disease, although such programs are rare in low-middle income countries. METHODS: A prospective, cross sectional study of all adult patients presenting to the ED in a 600-bed teaching hospital in Tamil Nadu, India. This study used an opt-in strategy in which patients were offered testing at the end of their ED visit. Costs of testing were paid out of pocket by patients. Patients with known HIV, hepatitis B, or hepatitis C were excluded from the study. RESULTS: During the study period 26,465 patients presented to the ED, and 18,286 patients consented to participate (68.9%). Among the 18,286 patients tested, 174 were positive for either HIV (39, 0.21%), hepatitis C (52, 0.28%), or hepatitis B (83, 0.45%). Three patients tested positive for both HIV and hepatitis C, and 1 patient tested positive for both HIV and hepatitis B. A total of 69.2% of patients with HIV, 61.2% of patients with hepatitis B, and 83% of patients with hepatitis C presented for reasons unrelated to their underlying diagnosis. CONCLUSION: Although limited to only 1 hospital in southern India, this study represents the largest ED-based screening program for HIV, hepatitis B, and hepatitis C ever conducted in India or any other low-middle income countries. The majority of patients presented for reasons unrelated to their underlying diagnosis. Future research is needed on implementation strategies, cost feasibility, and linkage to care.

The Impact of Social Determinants of Health on Medication Adherence: a Systematic Review and Meta-analysis.

BACKGROUND: Medication adherence (MA) is critical to successful chronic disease management. It is not clear how social determinants of health (SDH) impact MA. We conducted a systematic review and meta-analysis to summarize the evidence on the relationship between SDH and MA. METHODS: We conducted a systematic review of the literature using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format. A literature search was performed using three databases: PubMed, Scopus, and Cochrane Clinical Trials Register in December of 2018. Included studies were completed in the USA, included adults aged 18 years and older, measured at least one social determinant of health, and medication adherence was the primary outcome measure. Data from included full texts were independently extracted using a standardized data extraction form. We then conducted a meta-analysis and pooled the odds ratios from the included studies for each social determinant as well as for all SDH factors collectively. RESULTS: A total of 3137 unduplicated abstracts were identified from our database searches. A total of 173 were selected for full text review after evaluating the abstract. A total of 29 articles were included for this systematic review. Economic-related SDH factors and MA were mostly commonly examined. The meta-analysis revealed a significant relationship between food insecurity (aOR = 0.56; 95% CI 0.42-0.7), housing instability (aOR = 0.64; 95% CI 0.44-0.93), and social determinants overall (aOR = 0.75; 95% CI 0.65-0.88) and medication adherence. DISCUSSION: Food insecurity and housing instability most consistently impacted medication adherence. Although included studies were heterogenous and varied widely in SDH and MA measurements, adverse social determinants overall were significantly associated with lower MA. The relationship between SDH and MA warrants more attention and research by health care providers and policymakers.

Patients Presenting with Bull-related Injuries to a Southern Indian Emergency Department.

INTRODUCTION: Bull-related injuries are commonly observed in rural areas of India as result of the animal's use in sporting events as well as for agricultural purposes. These patients need early resuscitation due to complications from severe injuries. Previous work examining the epidemiology of bull-related injuries is limited, with most studies focusing on injuries in Spain and Latin America. There is scant literature examining the prevalence of such injuries in India. The objective of this study was to evaluate the demographic and clinical characteristics of bull-related injuries at a hospital in Tamil Nadu, India. METHODS: This was a prospective, observational study of patients who presented to an emergency department (ED) in Madurai, India, with a reported history of bull-related injuries between June 2017 and March 2019. We recorded information about patient demographics, location of injury, disposition, initial Injury Severity Score (ISS), and transport time. RESULTS: Our sample included a total of 42 patients. Almost a third of patients who presented were between the ages of 20-30 years (31%, n = 13), and most were male (86%, n = 36). Approximately 59% of patients (n = 25) had provoked injuries, occurring as a result of active participation during sporting activities. Injuries to the trunk were most common (55%, n = 23), followed by injuries to the perineum (19%, n = 19). The majority of patients (59.5%) had penetrating injuries (n = 25), The mean ISS was 10.1 (standard deviation 6.3). Five (12%) patients had a complication after injury including intra-abdominal abscess formation, peritonitis, and sepsis. Two patients died as a result of septicemia from peritonitis. CONCLUSION: Bull-related injuries may result in significant morbidity and mortality. Education of the population about the dangers of bull injuries from sporting events and the need for early transportation to the ED have the potential for significant reduction in morbidity and mortality.

A qualitative study of workplace violence among healthcare providers in emergency departments in India.

BACKGROUND: Emergency department (ED) workplace violence is increasingly recognized as an important issue for ED providers. Most studies have occurred in developed countries with established laws and repercussions for violence against healthcare providers. There is a paucity of data on workplace violence against ED providers in less developed countries. The aim of this study was to learn more about workplace violence among healthcare providers in EDs in India. RESULTS: Semi-structured interviews were conducted in-person with physicians, nurses, and paramedics in Indian EDs. Interviews were coded independently using the NVivo qualitative research software. A hybrid thematic analysis approach was used to determine dominant themes. Sixty-three interviews were conducted at 7 sites across India. Interview participants include attending physicians (11), resident physicians (36), nurses (10), and paramedics (5). Events were most often described as involving accompanying persons to the patient, not the patient themselves. Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence. ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death. Decreased levels of health literacy among patients often contribute as the financial stressors of paying for medical care. Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED. Communication strategies were frequently proposed as interventions to mitigate violence in the future including both provider communication as well as public awareness campaigns. CONCLUSION: Workplace violence is a frequent reality for this sample of Indian ED healthcare providers. Alarming levels of verbal and physical abuse and their impact on patient care are described. This qualitative study identified unique challenges to Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behavior in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves. Further investigation into preventive strategies is needed.

Operation Navajeevan: A Public-Private Partnership Model for Disaster Relief in Kozhikode, India.

INTRODUCTION: In August 2018, India's southern state of Kerala experienced its worst flooding in over a century. This report describes the relief efforts in Kozhikode, a coastal region of Kerala, where Operation Navajeevan was initiated. SOURCES: Data were collected from a centralized database at the command center in the District Medical Office as well as first-hand accounts from providers who participated in the relief effort. OBSERVATIONS: From August 15 through September 8, 2018, 36,846 flood victims were seen at 280 relief camps. The most common cause for presentation was exacerbation of an on-going chronic medical condition (18,490; 50.2%). Other common presentations included acute respiratory infection (7,451; 20.2%), traumatic injuries (3,736; 10.4%), and psychiatric illness (5,327; 14.5%). ANALYSIS: The prevalence of chronic disease exacerbation as the primary presentation during Operation Navajeevan represents an epidemiologic shift in disaster relief in India. It is foreseeable that as access to health care improves in low- and middle-income countries (LMICs), and climate change increases the prevalence of extreme weather events around the world, that this trend will continue.

Postgraduate Diploma in Emergency Medicine in India.

BACKGROUND: In India, and other low- and middle-income countries (LMICs), the majority of emergency care is provided by frontline providers without specialty training in emergency medicine. In order to fill this need, we developed the Indian Postgraduate Diploma in Emergency Medicine (PGDEM), a 1-year skills-focused course for practicing doctors. This article describes the curriculum development and implementation as well as the follow-up survey conducted to gauge the impact of the course. METHODS: Programme graduates were surveyed via e-mail. All participation was voluntary and survey data remained anonymous. RESULTS: A total of 98.1% of graduates reported that the skills and knowledge they gained during the programme were important to their current job; 94.7% reported using their training from the course on a regular basis. Graduates reported an improvement in confidence performing all procedures taught during the course. Respondents work in a variety of medical specialties, including emergency medicine (50.0%), cardiology (5.8%), internal medicine (11.5%) and family medicine (23.1%). DISCUSSION: PGDEM graduates overwhelmingly view the knowledge and skills they learned as essential training that they use on a regular basis and practice in a variety of medical specialties after completing the course. The PGDEM represents a unique model to provide training in emergency medicine and acute care to the frontline doctors who are frequently responsible for providing emergency care in LMICs. The PGDEM training model can be scaled up rapidly, with the potential to increase capacity in developing emergency care systems.