Racial disparities in patients hospitalized for COVID-19.

BACKGROUND: The COVID-19 pandemic has demonstrated the significance of health disparities across populations with older adults and minoritized groups being disproportionately affected. Data during the COVID-19 pandemic demonstrated higher infection rates, hospitalization rates, morbidity, and potentially greater mortality in Black, Hispanic, and Native Americans compared to Whites. METHODS: This is a retrospective cohort study of de-identified patient data from 178 hospitals across the United States. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Outcomes were stratified by sex and racial groups. RESULTS: Of 45,360 patients, 22% were Black, 35% were Hispanic, 37% were White, and 6% were Other. The overall mortality rate was 15% across all groups but was 17% for White patients, 10% for Black patients, 14% for Hispanic patients, and 15% for patients categorized as Other. However, White patients have higher median age on admission (71 years) compared to Blacks (60 years), Hispanics (57 years), and Other (61 years). Race remained statistically significant in a multivariable model that included age, sex, and race. 6484 patients required ICU admission, intubation, and hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (p < 0.0001, z-test for proportions). CONCLUSIONS: In this national study of admitted patients with COVID-19, White patients admitted were older on average compared to other racial/ethnic groups and had a higher mortality rate compared to non-Whites hospitalized for COVID-19. Black patients were significantly more likely to require admission to the ICU, mechanical ventilation, and hemodynamic support. These COVID-19 health disparities highlight the importance of addressing social and structural determinants of health.

Impact of emergency department arrival time on door-to-needle time in patients with acute stroke.

Background: This study aimed to identify which emergency department (ED) factors impact door-to-needle (DTN) time in acute stroke patients eligible for intravenous thrombolysis. The purpose of analyzing emergency department factors is to determine whether any modifiable factors could shorten the time to thrombolytics, thereby increasing the odds of improved clinical outcomes. Methods: This was a prospective observational quality registry study that included all patients that received alteplase for stroke. These data are our hospital data from the national Get With The Guidelines Registry. The Get With The Guidelines® Stroke Registry is a hospital-based program focused on improving care for patients diagnosed with a stroke. The program has over five million patients, and hospitals can access their own program data. The registry promotes the use of and adherence to scientific treatment guidelines to improve patient outcomes. The time of patient arrival to the ED was captured via the timestamp in the electronic health record. Arriving between Friday 6 p.m. and Monday 6 a.m. was classified as "weekend," regardless of the time of arrival. Time to CT, time-to-lab, and presence of a dedicated stroke team were also recorded. Emergency medical services (EMS) run sheets were used to verify arrival via ambulance. Results: Forty-nine percent of the cohort presented during the day shift, 24% during the night shift, and 27% on the weekend. A total of 85% were brought by EMS, and 15% of patients were walk-ins. The median DTN time during the day shift was 37 min (IQR 26-51, range 10-117). The median DTN time during the night shift was 59 min (IQR 39-89, range 34-195). When a dedicated stroke team was present, the median DTN time was 36 min, compared to 51 min when they were not present. The median door-to-CT time was 24 min (IQR 18-31 min). On univariate analyses, arriving during the night shift (P < 0.0001), arriving as a walk-in (P = 0.0080), and longer time-to-CT (P < 0.0001) were all associated with longer DTN time. Conversely, the presence of a dedicated stroke team was associated with a significantly shorter DTN time (P < 0.0001). Conclusion: Factors that contribute most to a delay in DTN time include arrival during the night shift, lack of a dedicated stroke team, longer time-to-CT read, and arrival as a walk-in. All of these are addressable factors from an operational standpoint and should be considered when performing quality improvement of hospital protocols.

Systolic blood pressure in acute ischemic stroke and impact on clinical outcomes.

CONTEXT: Stroke is one of the largest healthcare burdens in the United States and globally. It continues to be one of the leading causes of morbidity and mortality. Patients with acute ischemic stroke (AIS) often present with elevated blood pressure (BP). OBJECTIVES: The objective of our study was to evaluate the association of systolic blood pressure (SBP) in the emergency department (ED) with stroke severity in patients with AIS. METHODS: This observational study was conducted at an ED with an annual census of 80,000 visits, approximately half (400) of which are for AIS. The cohort consisted of adult patients who presented to the ED within 24 h of stroke symptom onset. BP was measured at triage by a nurse blinded to the study. Stroke severity was measured utilizing the National Institutes of Health Stroke Scale (NIHSS). Statistical analyses were performed utilizing JMP 14.0. This study was approved by our medical school's institutional review board. RESULTS: Patients with higher SBP had significantly lower NIHSS scores (p=0.0038). This association was significant even after adjusting for age and gender. By contrast, diastolic blood pressure (DBP) did not appear to impact stroke severity. There was no difference in the DBP values between men and women. Higher SBP was also significantly associated with being discharged home as well as being less likely to die in the hospital or discharged to hospice. The DBP did not demonstrate this association. Neither the SDP nor the DBP were significantly associated with the hospital length of stay (LOS). In multivariate models that included age, gender, basal metabolic index (BMI), comorbidities, and ED presentation, elevated SBP was associated with better prognosis. CONCLUSIONS: In this cohort of patients presenting with stroke-like symptoms to the ED, higher SBP was associated with lower stroke severity and higher rates of being discharged to home rather than hospice or death.

Gender disparity in stoke: Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage.

OBJECTIVE: To determine what if any differences in presentation exist between men and women who present with acute intracerebral hemorrhage (ICH) to the emergency department (ED). METHODS: This was an IRB approved prospective cohort study of ED patients presenting with acute intracerebral hemorrhage. Statistical analyses were performed in JMP 14.1. Non parametric methods were used for skewed variables. The study was conducted in a comprehensive stroke center. The independent variable was the ICH score, and the dependent variable of interest was ultimate disposition (death or hospice vs. home or skilled nursing facility). RESULTS: The cohort consisted of 129 patients (54 women and 75 men). The median age was 71 years (IQR 58-81). The baseline co-morbidities were similar between both men and women and whether or not they were independent in their activities of daily living prior to experiencing their ICH. The overall median ICH score for women was 2, IQR 1-4, and 1 for men, IQR 1-2 (P = 0.0369) . A higher ICH score was significantly associated with in-hospital death and or hospice status (P = .0095, 95% CI 0.6340 - 0.4825). Conversely, a lower ICH score was significantly associated with being discharged home (P< 0.001, 95% CI -0.1694 to -0.0759). CONCLUSION: Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage. A higher ICH score is significantly associated with the worse outcomes of death and/or hospice.

Compartment Syndrome Secondary to Vascular Transection from a Knee Dislocation.

Acute knee dislocation is a rare orthopedic injury with an incidence of <0.02% annually. The authors discuss a case involving a vascular injury sustained from a mechanical fall at home causing compartment syndrome. The case illustrates known complications associated with knee dislocations: vascular injury and compartment syndrome as well as the high suspicion needed in certain patient populations, such as Down's syndrome. It highlights the importance of rapid diagnosis, a complete physical exam, and the need to involve consultants in a timely fashion. A high index of suspicion for vascular injury following trauma to the knee, regardless of the mechanism is imperative.

Physician-Perceived Barriers to Treating Opioid Use Disorder in the Emergency Department.

Objective We aimed to assess physicians' perceptions of barriers to starting medication-assisted treatment (MAT) in the Emergency Department (ED), views of the utility of MAT, and abilities to link patients with opioid use disorder (OUD) to MAT programs in their respective communities. Methods This was a cross-sectional survey study of American emergency medicine (EM) physicians with a self-administered online survey via SurveyMonkey (Survey Monkey, San Mateo, California). The survey was emailed to the Council of Residency Directors in Emergency Medicine (CORD) listserv and HCA Healthcare affiliated EM residency programs' listservs. Attendings and residents of all post-graduate years participated. Questions assessed perceptions of barriers to starting OUD patients on MAT, knowledge of the X-waiver, and knowledge of MAT details. Statistics were performed with JMP software (SAS Institute Inc., Cary, NC) using the two-tailed Z-test for proportions. Results There were 98 responses, with 33% female, 55% resident physicians, and an overall 17% response rate. Residents were more eager to start OUD patients on MAT (71% vs 52%, p=0.04) than attendings but were less familiar with the X-waiver (38% vs 73%, p=0.001) or where community outpatient MAT facilities were (21% vs 43%, p=0.02). Conclusion Barriers in the ED were identified as a shortage of qualified prescribers, the lengthy X-waiver process, and the poor availability of outpatient MAT resources. EM residents showed more willingness to prescribe MAT but lacked a core understanding of the process. This shows an area of improvement for residency training as well as advocacy among attendings.

Ruptured Hepatic Artery Aneurysm.

Aneurysmal ruptures are a life-threatening pathology, and while the aorta is the principal location, any aneurysmal rupture can be fatal. Most result from chronic diseases, such as hypertension, diabetes, and vasculitis. Nevertheless, a rupture can result in acute decompensation and must be recognized and addressed quickly to limit morbidity and mortality. The authors describe a case of a 66-year-old female who presented to the emergency department (ED) for abdominal pain and syncope. Even though imaging did not explicitly show the specific site of rupture of the hepatic artery, the positive Rapid Ultrasound for Shock and Hypotension (RUSH) exam and aortic dissection on computed tomography angiography along with her clinical picture (hypotension, abdominal pain, decreased capillary refill, grey skin) raised our suspicions for critical pathology. Exploratory laparotomy revealed a ruptured hepatic artery aneurysm. Her hospital course was complicated by ischemic necrosis of the gallbladder, spleen, and liver, requiring cholecystectomy, splenectomy, and partial hepatectomy, but she was discharged to rehabilitation and expected to make a recovery. This case displays the importance of using ultrasonography early to aid in expedited diagnosis and treatment as well as maintaining a high suspicion for vascular pathology in the setting of hemorrhagic shock.