Disruptions in Sleep Health and Independent Associations with Psychological Distress in Close Family Members of Cardiac Arrest Survivors: A Prospective Study.

Background: While recent guidelines have noted the deleterious effects of poor sleep on cardiovascular health, the upstream impact of cardiac arrest-induced psychological distress on sleep health metrics among families of cardiac arrest survivors remains unknown. Methods: Sleep health of close family members of consecutive cardiac arrest patients admitted at an academic center (8/16/2021 - 6/28/2023) was self-reported on the Pittsburgh Sleep Quality Index (PSQI) scale. The baseline PSQI administered during hospitalization was cued to sleep in the month before cardiac arrest. It was then repeated one month after cardiac arrest, along with the Patient Health Questionnaire-8 (PHQ-8) to assess depression severity. Multivariable linear regressions estimated the associations of one-month total PHQ-8 scores with changes in global PSQI scores between baseline and one month with higher scores indicating deteriorations. A prioritization exercise of potential interventions categorized into family's information and well-being needs to alleviate psychological distress was conducted at one month. Results: In our sample of 102 close family members (mean age 52±15 years, 70% female, 21% Black, 33% Hispanic), mean global PSQI scores showed a significant decline between baseline and one month after cardiac arrest (6.2±3.8 vs. 7.4±4.1; p<0.01). This deterioration was notable for sleep quality, duration, and daytime dysfunction components. Higher PHQ-8 scores were significantly associated with higher change in PSQI scores, after adjusting for family members' age, sex, race/ethnicity, and patient's discharge disposition [ß=0.4 (95% C.I 0.24, 0.48); p<0.01]. Most (n=72, 76%) prioritized interventions supporting information over well-being needs to reduce psychological distress after cardiac arrest. Conclusions: There was a significant decline in sleep health among close family members of cardiac arrest survivors in the acute phase following the event. Psychological distress was associated with this sleep disruption. Further investigation into their temporal associations is needed to develop targeted interventions to support families during this period of uncertainty. WHAT IS KNOWN: Sleep health has been identified as a key element in maintaining cardiovascular health.Close family members of critically ill patients experience suboptimal sleep health and psychological distress may contribute to it. WHAT THE STUDY ADDS: It is breaking new ground in understanding the sleep health dynamics of close family members of cardiac arrest survivors, a critical but often overlooked group of caregivers.The study highlights significant associations between psychological distress and poor sleep that further deteriorates within the first month after a loved one's cardiac arrest.Families of cardiac arrest survivors expressed a high priority for information-based interventions to help alleviate psychological distress during the initial month following the cardiac event emphasizing the need for targeted, accessible, resources to address their psychological and potentially sleep-related challenges.

Consensus-Driven Recommendations to Support Physician Pregnancy, Adoption, Surrogacy, Parental Leave, and Lactation in Emergency Medicine.

The emergency department clinical environment is unique, and guidelines for promoting supportive and equitable workplace cultures ensure success and longevity for pregnant persons and parents in emergency medicine. There is paucity, variability, and dissatisfaction with current parental (historically referred to as maternity and paternity) leave policies. This paper describes the development of consensus-derived recommendations to serve as a framework for emergency departments across the country for incorporating family-friendly policies. Policies that foster a family-inclusive workplace by allowing for professional advancement without sacrificing personal values regardless of sex, gender, and gender identity are critical for emergency medicine recruitment and retention.

Sleep Disturbance and Burnout in Emergency Department Health Care Workers.

This cross-sectional study examines the association of sleep disturbances with burnout among emergency medicine health care workers.

The relative contribution of COVID-19 infection versus COVID-19 related occupational stressors to insomnia in healthcare workers.

Objective/Background: Healthcare workers have experienced high rates of psychiatric symptom burden and occupational attrition during the COVID-19 pandemic. Identifying contributory factors can inform prevention and mitigation measures. Here, we explore the potential contributions of occupational stressors vs COVID-19 infection to insomnia symptoms in US healthcare workers.Patients/Methods: An online self-report survey was collected between September 2020 and July 2022 from N = 594 US healthcare workers, with longitudinal follow-up up to 9 months. Assessments included the Insomnia Severity Index (ISI), the PTSD Checklist for DSM-5 (PCL-5), and a 13-item scale assessing COVID-19 related occupational stressors. Results: Insomnia was common (45% of participants reported at least moderate and 9.2% reported severe symptoms at one or more timepoint) and significantly associated with difficulty completing work-related tasks, increased likelihood of occupational attrition, and thoughts of suicide or self-harm (all p<.0001). In multivariable regression with age, gender, and family COVID-19 history as covariates, past two-week COVID-related occupational stressors, peak COVID-related occupational stressors, and personal history of COVID-19 infection were all significantly related to past two-week ISI scores (ß = 1.7 ± 0.14SE, ß = 0.08 ± 0.03, and ß = 0.69 ± 0.22 respectively). Although similar results were found for the PCL-5, when ISI and PCL-5 items were separated by factor, COVID-19 infection was significantly related only to the factor consisting of sleep-related items. Conclusions: Both recent occupational stress and personal history of COVID-19 infection were significantly associated with insomnia in healthcare workers. These results suggest that both addressing occupational stressors and reducing rate of COVID-19 infection are important to protect healthcare workers and the healthcare workforce.

Emergency Nursing Workforce, Burnout, and Job Turnover in the United States: A National Sample Survey Analysis.

INTRODUCTION: Few studies have examined emergency nurses who have left their job to better understand the reason behind job turnover. It also remains unclear whether emergency nurses differ from other nurses regarding burnout and job turnover reasons. Our study aimed to test differences in reasons for turnover or not currently working between emergency nurses and other nurses; and ascertain factors associated with burnout as a reason for turnover among emergency nurses. METHODS: We conducted a secondary analysis of 2018 National Sample Survey for Registered Nurses data (weighted N = 3,004,589) from Health Resources and Services Administration. Data were analyzed using descriptive statistics, chi-square and t-test, and unadjusted and adjusted logistic regression applying design sampling weights. RESULTS: There were no significant differences in burnout comparing emergency nurses with other nurses. Seven job turnover reasons were endorsed by emergency nurses and were significantly higher than other nurses: insufficient staffing (11.1%, 95% confidence interval [CI] 8.6-14.2, P = .01), physical demands (5.1%, 95% CI 3.4-7.6, P = .44), patient population (4.3%, 95% CI 2.9-6.3, P < .001), better pay elsewhere (11.5%, 95% CI 9-14.7, P < .001), career advancement/promotion (9.6%, 95% CI 7.0-13.2, P = .01), length of commute (5.1%, 95% CI 3.4-7.5, P = .01), and relocation (5%, 95% CI 3.6-7.0, P = .01). Increasing age and increased years since nursing licensure was associated with decreased odds of burnout. DISCUSSION: Several modifiable factors appear associated with job turnover. Interventions and future research should account for unit-specific factors that may precipitate nursing job turnover.

An evidence-based approach to emergency department patients at risk for posttraumatic stress disorder symptoms.

Approximately one-quarter of emergency department patients who are injured or experience medical emergencies will develop clinically significant posttraumatic stress disorder (PTSD) symptoms, which can evolve into PTSD. Emergency clinicians and rapid response teams (eg, trauma, cardiac, stroke) can play a critical role in recognizing symptoms of posttraumatic stress and providing early distress management techniques, screening, and referral to services that may mitigate the development of PTSD. This review summarizes the existing literature on psychological distress related to events that trigger the need for emergency care and synthesizes cutting-edge approaches that may impact patient outcomes.

Examining the prevalence and health impairment associated with subthreshold PTSD symptoms (PTSS) among frontline healthcare workers during the COVID-19 pandemic.

The COVID-19 pandemic has increased healthcare workers' (HCWs) risk for posttraumatic stress disorder (PTSD). Although subthreshold PTSD symptoms (PTSS) are common and increase vulnerability for health impairments, they have received little attention. We examined the prevalence of subthreshold PTSS and their relationship to physical health symptoms and sleep problems among HCWs during the pandemic's second wave (01/21-02/21). Participants (N = 852; 63.1% male; Mage = 38.34) completed the Short-Form PTSD Checklist (SF-PCL), the Cohen-Hoberman Inventory of Physical Symptoms, and the PROMIS Sleep-Related Impairment-Short-Form 4a. We created three groups with the SF-PCL: scores ≥11 = probable PTSD (5.5%); scores between 1 and 10 = subthreshold PTSS (55.3%); scores of 0 = no PTSS (39.2%). After controlling for demographics, occupational characteristics, and COVID-19 status, HCWs with subthreshold PTSS experienced greater physical health symptoms and sleep problems than HCWs with no PTSS. While HCWs with PTSD reported the greatest health impairment, HCWs with subthreshold PTSS reported 88% more physical health symptoms and 36% more sleep problems than HCWs with no PTSS. Subthreshold PTSS are common and increase risk for health impairment. Interventions addressing HCWs' mental health in response to the COVID-19 pandemic must include subthreshold PTSS to ensure their effectiveness.

Use of Real-Time Information to Predict Future Arrivals in the Emergency Department.

STUDY OBJECTIVE: We aimed to build prediction models for shift-level emergency department (ED) patient volume that could be used to facilitate prediction-driven staffing. We sought to evaluate the predictive power of rich real-time information and understand 1) which real-time information had predictive power and 2) what prediction techniques were appropriate for forecasting ED demand. METHODS: We conducted a retrospective study in an ED site in a large academic hospital in New York City. We examined various prediction techniques, including linear regression, regression trees, extreme gradient boosting, and time series models. By comparing models with and without real-time predictors, we assessed the potential gain in prediction accuracy from real-time information. RESULTS: Real-time predictors improved prediction accuracy on models without contemporary information from 5% to 11%. Among extensive real-time predictors examined, recent patient arrival counts, weather, Google trends, and concurrent patient comorbidity information had significant predictive power. Out of all the forecasting techniques explored, SARIMAX (Seasonal Autoregressive Integrated Moving Average with eXogenous factors) achieved the smallest out-of-sample the root mean square error (RMSE) of 14.656 and mean absolute prediction error (MAPE) of 8.703%. Linear regression was the second best, with out-of-sample RMSE and MAPE equal to 15.366 and 9.109%, respectively. CONCLUSION: Real-time information was effective in improving the prediction accuracy of ED demand. Practice and policy implications for designing staffing paradigms with real-time demand forecasts to reduce ED congestion were discussed.

Impact of Native Language, English Proficiency, and Language Concordance on Interpersonal Care During Evaluation of Acute Coronary Syndrome.

BACKGROUND: High-quality interpersonal interactions between clinicians and patients can improve communication and reduce health disparities among patients with novice English proficiency (NEP). Yet, little is known about the impact of native language, NEP, and native language concordance on patient on perceptions of interpersonal care in the emergency department (ED). OBJECTIVE: To determine the associations of native language, NEP, and native language concordance with patient perceptions of interpersonal care among patients undergoing evaluation for suspected acute coronary syndrome (ACS) in the ED. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included 1000 patients undergoing evaluation for suspected ACS at an urban ED from 2013 to 2016. MAIN MEASURES: English- and Spanish-speaking patients were surveyed to identify native language, English proficiency (classified as advanced, intermediate, or novice), and perceived language of the treating ED clinician. Patient perceptions of interpersonal care were assessed using the Interpersonal Processes of Care (IPC) survey, a validated 18-item tool for assessing social-psychological domains of patient-clinician interactions. IPC scores ≤ 4 were categorized as sub-optimal (range, 1-5). The associations between native language, English proficiency, and native language concordance with sub-optimal communication were assessed using hierarchical logistic regression adjusted for all three language variables, sociodemographic characteristics, and depression. KEY RESULTS: Nine hundred thirty-three patients (48.0% native non-English-speaking, 55.7% Hispanic) completed the IPC; 522 (57.4%) perceived native language concordance. In unadjusted analyses, non-English native language (OR 1.38, 95% CI 1.04-1.82) and NEP (OR 1.45, 95% CI 1.06-1.98) were associated with sub-optimal communication, whereas language concordance was protective (OR 0.61, 95% CI 0.46-0.81). In fully adjusted analyses, only language concordance remained significantly associated with sub-optimal communication (AOR 0.62, 95% CI 0.42-0.93). CONCLUSIONS: This study suggests that perceived native language concordance acts as a protective factor for patient-clinician interpersonal care in the acute setting, regardless of native language or English proficiency.

The relative contribution of COVID-19 infection versus COVID-19 related occupational stressors to insomnia in healthcare workers.

Objective/Background: Healthcare workers have experienced high rates of psychiatric symptom burden and occupational attrition during the COVID-19 pandemic. Identifying contributory factors can inform prevention and mitigation measures. Here, we explore the potential contributions of occupational stressors vs COVID-19 infection to insomnia symptoms in US healthcare workers. Patients/Methods: An online self-report survey was collected between September 2020 and July 2022 from N=594 US healthcare workers, with longitudinal follow-up up to 9 months. Assessments included the Insomnia Severity Index (ISI), the PTSD Checklist for DSM-5 (PCL-5), and a 13-item scale assessing COVID-19 related occupational stressors. Results: Insomnia was common (45% of participants reported at least moderate and 9.2% reported severe symptoms at one or more timepoint) and significantly associated with difficulty completing work-related tasks, increased likelihood of occupational attrition, and thoughts of suicide or self-harm (all p<.0001). In multivariable regression with age, gender, and family COVID-19 history as covariates, past two-week COVID-related occupational stressors, peak COVID-related occupational stressors, and personal history of COVID-19 infection were all significantly related to past two-week ISI scores (ß=1.7±0.14SE, ß=0.08±0.03, and ß=0.69±0.22 respectively). Although similar results were found for the PCL-5, when ISI and PCL-5 items were separated by factor, COVID-19 infection was significantly related only to the factor consisting of sleep-related items. Conclusions: Both recent occupational stress and personal history of COVID-19 infection were significantly associated with insomnia in healthcare workers. These results suggest that both addressing occupational stressors and reducing rates of COVID-19 infection are important to protect healthcare workers and the healthcare workforce.

COVID-19 vaccine controversy: A cross-sectional analysis of factors associated with COVID-19 vaccine acceptance amongst emergency department patients in New York City.

Objective: Understanding variables associated with coronavirus disease 2019 (COVID-19) vaccine confidence and hesitancy may inform strategies to improve vaccine uptake in clinical settings such as the emergency department (ED). We aim to identify factors contributing to COVID-19 vaccine acceptance and to assess patient attitudes surrounding offering COVID-19 vaccines in the ED. Methods: We conducted a survey of a convenience sample of patients and patient visitors over the age 18 years, who were native English or Spanish speakers. The survey was conducted from March through August 2021 at 3 EDs in New York City. The survey was administered via an electronic format, and participants provided verbal consent. Results: Our sample size was 377. Individuals with post-graduate degrees viewed vaccines positively (Prevalence Ratio [PR], 1.63; 95% Confidence Interval [CI], 1.07-2.47).  Of the various high-risk medical conditions associated with adverse COVID-19 infection outcomes, diabetes was the only condition associated with more positive views of vaccines (PR, 1.37; CI, 1.17-1.59). Of all participants, 71.21% stated that they believed offering a COVID-19 vaccine in the ED was a good idea. Of unvaccinated participants, 21.80% stated they would get vaccinated if it were offered to them in the ED. Conclusion: EDs can serve as a safety net for vulnerable populations and can act as an access point for vaccination.

Psychological Distress After Sudden Cardiac Arrest and Its Impact on Recovery.

PURPOSE OF REVIEW: To summarize the prevalence, correlates, and health consequences of poor mental health in the increasingly sizable population of survivors of Sudden cardiac arrest (CA) and to describe current intervention research in this area. RECENT FINDINGS: After CA many patients report high psychological distress, including depression, generalized anxiety, and posttraumatic stress. Emerging evidence suggests that distressed patients' attention may narrow such that anxious awareness of afferent cardiac signals e.g., changes in heart rate or blood pressure, becomes predominant and a cause for concerned, constant monitoring. This cardiac-specific anxiety followed by behavioral avoidance and physiological hyperreactivity may increase patients' already high risk of secondary cardiovascular disease and undermine their health-related quality of life (HRQoL). Unlike other cardiovascular diseases, no clinical practice guidelines exist for assessing or treating psychological sequelae of CA. Future research should identify modifiable psychological targets to reduce secondary cardiovascular disease risk and improve HRQoL.

Individual and Joint Effects of Influenza-Like Illness and Vaccinations on Stroke in the Young: A Case-Control Study.

BACKGROUND: Influenza-like illness (ILI) is an acute trigger for stroke, although joint effects of vaccinations and ILI have not yet been explored. METHODS: Data for our case-control study was obtained from MarketScan Commercial Claims and Encounters between 2008 and 2014. Patients 18 to 65 years old who experienced a stroke were matched on age and admission date to a control, defined as patients with head trauma or ankle sprain at an inpatient or emergency department visit. Exposures were ILI in the prior 30 days, and any type of vaccination during the year prior. Our outcome was ischemic and intracerebral hemorrhagic strokes identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. Logistic regression models estimated adjusted odds ratios (aORs) controlling for preventive care visits, diabetes, valvular heart disease, smoking, alcohol abuse, obesity, and hypertension. RESULTS: We identified and matched 24 103 cases 18 to 44 years old and 141 811 45 to 65 years old. Those aged 18 to 44 years had increased stroke risk 30 days after ILI (aOR, 1.68 [95% CI, 1.51-1.86]) and reduced risk with any vaccination in the year prior (aOR, 0.92 [95% CI, 0.87-0.99]). Joint effects indicate that ILI was associated with increased stroke risk among those with (aOR, 1.41 [95% CI, 1.08-1.85]) and without (aOR, 1.73 [95% CI, 1.55-1.94]) vaccinations in the prior year (Pinteraction=0.16). Among those aged 45 to 65 years, adjusted analyses indicate increased stroke risk for those with ILI (aOR, 1.32 [95% CI, 1.26-1.38]), although there was no effect of vaccinations (aOR, 1.00 [95% CI, 0.97-1.02]). Joint effects indicate that ILI was not associated with stroke among those with any vaccination (aOR, 1.07 [95% CI, 0.96-1.18]) but was associated with increased risk among those without vaccinations ([aOR, 1.39 [95% CI, 1.32-1.47]; Pinteraction<0.001). CONCLUSIONS: ILI was associated with increased stroke risk in the young and middle-aged, while vaccinations of any type were associated with decreased risk among the young. Joint effects of ILI and vaccinations indicate vaccinations can reduce the effect of ILI on stroke.

Evaluation of emergency department visits for mental health complaints during the COVID-19 pandemic.

Background: The COVID-19 pandemic has resulted in over 6 million deaths worldwide as of March 2022. Adverse psychological effects on patients and the general public linked to the pandemic have been well documented. Methods: We conducted a retrospective analysis of adult emergency department (ED) encounters with diagnoses of anxiety, depression, and suicidal ideation using International Classification of Diseases, Tenth Revision (ICD-10) codes at a tertiary care hospital in New York City from March 15 through July 31, 2020 and compared it with ED encounters during the same time period in the previous 3 years (2017-2019). The relative risk (RR) of these diagnoses was calculated comparing a prepandemic sample to a pandemic sample, accounting for total volume of ED visits. Results: A total of 2816 patient encounters met the inclusion criteria. The study period in 2020 had 31.5% lower overall ED volume seen during the same time period in the previous 3 years (27,874 vs average 40,716 ED encounters). The risk of presenting with anxiety during the study period in 2020 compared to prior 3 years was 1.40 (95% confidence interval [CI] 1.21-1.63), for depression was 1.47 (95% CI 1.28-1.69), and for suicidal ideation was 1.05 (95% CI 0.90-1.23). There was an increase in admissions for depression during the pandemic period (15.2% increase, 95% CI 4.6%-25.7%). Conclusion: There was a relative increase in patients presenting to the ED with complaints of anxiety and depression during the height of the COVID-19 pandemic, while absolute numbers remained stable. Our results highlight the importance of acute care-based mental health resources and interventions to support patients during this pandemic.

Impact of COVID-19 on Emergency Medicine Residency Programs: A Cross-Sectional Study in New York State.

INTRODUCTION: The 2019 novel coronavirus pandemic has caused significant disruptions in the clinical operations of hospitals as well as clinical education, training, and research at academic centers. New York State was among the first and largest epicenters of the pandemic, resulting in significant disruptions across its 29 emergency medicine (EM) residency programs. We conducted a cross-sectional observational study of EM residency programs in New York State to assess the impact of the pandemic on resident education and training programs. METHODS: We surveyed a cross-sectional sample of residency programs throughout New York State in June 2020, in the timeframe immediately after the state's first "wave" of the pandemic. The survey was distributed to program leadership and elicited information on pandemic-prompted curricular modifications and other educational changes. The survey covered topics related to disruptions in medical education and sought details on solutions to educational issues encountered by programs. RESULTS: Of the 29 accredited EM residency programs in New York State, leadership from 22 (76%) responded. Of these participating programs, 11 (50%) experienced high pandemic impact on clinical services, 21 (95%) canceled their own trainees' off-service rotations, 22 (100%) canceled or postponed visiting medical student rotations, 22 (100%) adopted virtual conference formats (most within the first week of the pandemic wave), and 11 (50%) stopped all prospective research (excluding COVID-19 research), while most programs continued retrospective research. CONCLUSION: This study highlights the profound educational impact of the pandemic on residency programs in one of the hardest- and earliest-hit regions in the United States. Specifically, it highlights the ubiquity of virtual conferencing, the significant impact on research, and the concerns about canceled rotations and missed training opportunities for residents, as well as prehospital and non-physician practitioner trainees. This data should be used to prompt discussion regarding the necessity of alternate educational modalities for pandemic times and the sequelae of implementing these plans.

Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study.

OBJECTIVE: Decision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED). METHODS: We conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low-risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis. RESULTS: We approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow-up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs. CONCLUSIONS: ECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.

Associations between emergency department crowding and perceptions of interpersonal care in patients presenting with suspected acute coronary syndrome.

BACKGROUND: Emergency department (ED) crowding is associated with numerous healthcare issues, but little is known about its effect on psychosocial aspects of patient-provider interactions or interpersonal care. We examined whether ED crowding was associated with perceptions of interpersonal care in patients evaluated for acute coronary syndrome (ACS). METHODS: Patients presenting to a quaternary academic medical centre ED in New York City for evaluation of suspected ACS were enrolled between November 2013 and December 2016. ED crowding was measured using the ED Work Index (EDWIN), which incorporates patient volume, triage category, physician staffing and bed availability. Patients completed the 18-item Interpersonal Processes of Care (IPC) survey, which assesses communication, patient-centred decision-making and interpersonal style. Regression analyses examined associations between EDWIN and IPC scores, adjusting for demographics, comorbidities and depression. RESULTS: Among 933 included patients, 11% experienced ED overcrowding (EDWIN score >2) at admission, 11% experienced ED overcrowding throughout the ED stay and 30% reported suboptimal interpersonal care (defined as per-item IPC score <5). Higher admission EDWIN score was associated with modestly lower IPC score in both unadjusted (ß=-1.70, 95% CI -3.15 to -0.24, p=0.02) and adjusted models (ß = -1.77, 95% CI -3.31 to -0.24, p=0.02). EDWIN score averaged over the entire ED stay was not significantly associated with IPC score (unadjusted ß=-1.30, 95% CI -3.19 to 0.59, p=0.18; adjusted ß=-1.24, 95% CI -3.21 to 0.74, p=0.22). CONCLUSION: Increased crowding at the time of ED admission was associated with poorer perceptions of interpersonal care among patients with suspected ACS.