Survey of Vaccine Hesitancy in Patients Visiting Three Tertiary-care Emergency Departments in Southeast Louisiana.

Objectives: Vaccine hesitancy has been a barrier to achieving herd immunity during the coronavirus 2019 (COVID-19) pandemic. Having low socioeconomic status and education levels, and being a person of color, are associated with higher COVID-19 infection risk and worse outcomes. These same groups are associated with higher vaccine hesitancy. The state of Louisiana has one of the lowest vaccination rates in the country. In this study we aimed to identify demographic, perspective, and health behavior factors associated with vaccine hesitancy in emergency departments (ED) in Southeast Louisiana. Methods: A cross-sectional survey was distributed at three tertiary-care hospital EDs. Patients >18 years old and not in acute distress were recruited between April-July 2021. The 37-item questionnaire addressed socioeconomic demographics, social determinants of health, COVID-19 safety practices, thoughts and perceptions on COVID-19 and vaccines, sources of COVID-19 and vaccine information, and trust in the healthcare system. Results: Overall, 247 patients completed our survey. Of those, 29.6% reported they were vaccine hesitant. These respondents were significantly more likely, when compared to vaccine-acceptant respondents, to never have married, to have some college education, make less than <$25,000 in household earnings yearly, be unsure whether vaccines prevent disease, not have discussed the COVID-19 vaccine with their primary care doctor, and to prefer to do their own research for COVID-19 vaccine information. We observed no statistically significant differences based on gender, race/ethnicity, parental status, area of living, or their perceived risk of needing hospitalization for treatment or dying from the virus. Conclusion: Vaccine hesitancy was associated with multiple socioeconomic factors, perspectives, and beliefs. Vaccine-hesitant individuals were more uncertain about the safety of the COVID-19 vaccine, the feasibility of obtaining the vaccine, and its efficacy. Public health interventions aimed at these findings and improving public trust in healthcare systems are needed to increase vaccine acceptance.

Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis.

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria® which outlines imaging options based on location of pain.

Seamens' Sign: a novel electrocardiogram prediction tool for left ventricular hypertrophy.

Introduction: Patients with left ventricular hypertrophy (LVH) diagnosed by electrocardiogram (ECG) have increased mortality and higher risk for life-threatening cardiovascular disease. ECGs offer an opportunity to identify patients with increased risk for potential risk-modifying therapy. We developed a novel, quick, easy to use ECG screening criterion (Seamens' Sign) for LVH. This new criterion was defined as the presence of QRS complexes touching or overlapping in two contiguous precordial leads. Methods: This study was a retrospective chart review of 2,184 patient records of patients who had an ECG performed in the emergency department and a transthoracic echocardiogram performed within 90 days. The primary outcome was whether Seamens' Sign was noninferior in confirming LVH compared to other common diagnostic criteria. Test characteristics were calculated for each of the LVH criteria. Inter-rater agreement was assessed on a random sample using Cohen's Kappa. Results: Median age was 63, 52% of patients were male and there was a 35% prevalence of LVH by transthoracic echocardiogram (TTE). Nine percent were positive for LVH on ECG based on Seamens' Sign. Seamens' Sign had a specificity of 0.92. Tests assessing noninferiority indicated Seamens' Sign was non-inferior to all criteria (p < 0.001) except for Cornell criterion for women (p = 0.98). Seamens' Sign had 90% (0.81-1.00) inter-rater agreement, the highest of all criteria in this study. Conclusion: When compared to both the Sokolow-Lyon criteria and the Cornell criterion for men, Seamens' Sign is noninferior in ruling in LVH on ECG. Additionally, Seamens' Sign has higher inter-rater agreement compared to both Sokolow-Lyon criteria as well as the Cornell criteria for men and women, perhaps related to its ease of use.

Abdominal Pain in the Emergency Department: Missed Diagnoses.

Abdominal pain is the most common chief complaint in the Emergency Department. Abdominal pain is caused by a variety of gastrointestinal and nongastrointestinal disorders. Some frequently missed conditions include biliary pathology, appendicitis, diverticulitis, and urogenital pathology. The Emergency Medicine clinician must consider all aspects of the patient's presentation including history, physical examination, laboratory testing, and imaging. If no diagnosis is identified, close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge. Strict verbal and written return precautions should be provided to the patient.

Abdominal Pain in the Immunocompromised Patient.

Abdominal pain in an immunocompromised patient represents a common clinical scenario that may have uncommon causes. Evaluation relies first on identifying the immunocompromise, whether due to congenital immunodeficiencies, malignancy, hematopoietic stem cell transplant, solid organ transplant, or human immunodeficiency virus/acquired immunodeficiency syndrome. Based on this determination, the emergency physician may then build a focused differential of pathophysiologic possibilities. Careful evaluation is necessary given the absence of classic physical examination findings, and liberal use of laboratory and cross-sectional imaging is prudent. Conservative evaluation and disposition of these high-risk patients is important to consider.

A novel wellness intervention: A virtual hangout from coast to coast using video conferencing platforms to increase physician wellness during the COVID-19 pandemic.

Within the context of the evolving SARS-CoV-2 pandemic, we sought to design a project to increase social connectivity among emergency medicine physicians with ties to Vanderbilt University Medical Center. Our project aimed to promote physician wellness through fostering and maintaining community at one large academic institution.

Emergency Medicine Program Directors' Perspectives on Changes to Step 1 Scoring: Does It Help or Hurt Applicants?

INTRODUCTION: The United States Medical Licensing Examination (USMLE) Step 1 score is one of the few standardized metrics used to objectively review applicants for residency. In February 2020 the USMLE program announced that the numerical Step 1 scoring would be changed to a binary (Pass/Fail) system. In this study we sought to characterize how this change in score reporting will impact the application review process for emergency medicine (EM) program directors (PD). METHODS: In March 2020 we electronically distributed a validated anonymous survey to EM PDs at 236 US EM residency programs accredited by the Accreditation Council for Graduate Medical Education. RESULTS: Of 236 EM PDs, 121 responded (51.3% response rate). Overall, 72.7% believed binary Step 1 scoring would make the process of objectively comparing applicants more difficult. A minority (19.8%) believed it was a good idea, and 33.1% felt it would improve medical student well-being. The majority (88.4%) reported that they will increase their emphasis on Step 2 Clinical Knowledge (CK) for resident selection, and 85% plan to require Step 2 CK scores at application submission time. CONCLUSION: Our study suggests most EM PDs disapprove of the new Step 1 scoring. As more objective data is peeled away from the residency application, EM PDs will be left to rely more heavily on the few remaining measures, including Step 2 CK and standardized letters of evaluation. Further changes are needed to promote equity and improve the overall quality of the application process for students and PDs.

Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials.

Importance: Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an alternative class of fluids for volume expansion, do not cause acidosis and, therefore, may lead to faster resolution of DKA than saline. Objective: To compare the clinical effects of balanced crystalloids with the clinical effects of saline for the acute treatment of adults with DKA. Design, Setting, and Participants: This study was a subgroup analysis of adults with DKA in 2 previously reported companion trials-Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). These trials, conducted between January 2016 and March 2017 in an academic medical center in the US, were pragmatic, multiple-crossover, cluster, randomized clinical trials comparing balanced crystalloids vs saline in emergency department (ED) and intensive care unit (ICU) patients. This study included adults who presented to the ED with DKA, defined as a clinical diagnosis of DKA, plasma glucose greater than 250 mg/dL, plasma bicarbonate less than or equal to 18 mmol/L, and anion gap greater than 10 mmol/L. Data analysis was performed from January to April 2020. Interventions: Balanced crystalloids (clinician's choice of Ringer lactate solution or Plasma-Lyte A solution) vs saline for fluid administration in the ED and ICU according to the same cluster-randomized multiple-crossover schedule. Main Outcomes and Measures: The primary outcome was time between ED presentation and DKA resolution, as defined by American Diabetes Association criteria. The secondary outcome was time between initiation and discontinuation of continuous insulin infusion. Results: Among 172 adults included in this secondary analysis of cluster trials, 94 were assigned to balanced crystalloids and 78 to saline. The median (interquartile range [IQR]) age was 29 (24-45) years, and 90 (52.3%) were women. The median (IQR) volume of isotonic fluid administered in the ED and ICU was 4478 (3000-6372) mL. Cumulative incidence analysis revealed shorter time to DKA resolution in the balanced crystalloids group (median time to resolution: 13.0 hours; IQR: 9.5-18.8 hours) than the saline group (median: 16.9 hours; IQR: 11.9-34.5 hours) (adjusted hazard ratio [aHR] = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed shorter time to insulin infusion discontinuation in the balanced crystalloids group (median: 9.8 hours; IQR: 5.1-17.0 hours) than the saline group (median: 13.4 hours; IQR: 11.0-17.9 hours) (aHR = 1.45; 95% CI, 1.03-2.03; P = .03). Conclusions and Relevance: In this secondary analysis of 2 cluster randomized clinical trials, compared with saline, treatment with balanced crystalloids resulted in more rapid resolution of DKA, suggesting that balanced crystalloids may be preferred over saline for acute management of adults with DKA. Trial Registration: ClinicalTrials.gov Identifiers: NCT02614040; NCT02444988.

A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults.

OBJECTIVES: The objective of the study was to assess whether ondansetron has superior nausea reduction compared with metoclopramide, promethazine, or saline placebo in emergency department (ED) adults. METHODS: This randomized, placebo-controlled, double-blinded superiority trial was intended to enroll a convenience sample of 600 patients. Nausea was evaluated on a 100-mm visual analog scale (VAS) at baseline and 30 minutes after treatment. Patients with a minimum preenrollment VAS of 40 mm were randomized to intravenous ondansetron 4 mg, metoclopramide 10 mg, promethazine 12.5 mg, or saline placebo. A 12-mm VAS improvement in nausea severity was deemed clinically important. We measured potential drug adverse effects at baseline and 30 minutes. Patients received approximately 500 mL of saline hydration during the initial 30 minutes. RESULTS: Of 180 subjects who consented, 163 completed the study. The median age was 32 years (interquartile range, 23-47), and 68% were female. The median 30-minute VAS reductions (95% confidence intervals) and saline volume given for ondansetron, metoclopramide, promethazine, and saline were -22 (-32 to -15), -30 (-38 to -25.5), -29 (-40 to -21), and -16 (-25 to -3), and 500, 500, 500, and 450, respectively. The median 30-minute VAS differences (95% confidence intervals) between ondansetron and metoclopramide, promethazine, and saline were -8 (-18.5 to 3), -7 (-21 to -5.5), and 6 (-7 to 20), respectively. We compared the antiemetic efficacy across all treatments with the Kruskal-Wallis test (P = .16). CONCLUSIONS: Our study shows no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults. Early study termination may have limited detection of ondansetron's superior nausea reduction over saline.

Emergency medicine residency applicant perceptions of unethical recruiting practices and illegal questioning in the match.

OBJECTIVES: The authors hypothesized that unethical recruiting practices and illegal questioning occur during emergency medicine (EM) resident recruitment. The objectives were to estimate the prevalence of specific unethical recruiting practices and illegal questioning by EM programs based on the perceptions of residency applicants and to measure the effect of these perceptions on applicant appraisal of programs. METHODS: This was a cross-sectional survey of all applicants who matched to U.S. EM programs in 2005 and 2006. The survey questionnaire was developed by the study authors and was validated by pretesting on a small group representative of the study population. The survey addressed specific questions regarding program recruiting behaviors and interview questioning. The hyperlink to the secure anonymous online survey questionnaire was distributed to all EM program directors, asking them in turn to forward the hyperlink to their newly matched incoming residency class. All data were calculated with Score method with continuity correction and reported in proportions with 95% confidence intervals (CIs). RESULTS: The authors received 671 survey responses. Among respondents, 56 (8.3%, 95% CI = 6.4% to 10.7%) stated that they were specifically asked to disclose at least one program's position on their rank list by a program representative, and 44 (6.6%, 95% CI = 4.9% to 8.9%) reported that they matched at a program residing lower on their rank list than at least one other program that had informed the applicant they were ranked to match. Furthermore, 201 respondents (30.0%, 95% CI = 26.5% to 33.7%) believed that they were asked at least one illegal question during their interviews, the most common of which was inquiry into their marital status (189 respondents: 28.2%, 95% CI = 24.8% to 31.9%). Respondents were 11 times more likely to move a program to a lower position of preference on their rank order list (12.2%, 95% CI = 9.8% to 15.0%) rather than a higher position (1.1%, 95% CI = 0.5% to 2.3%) as a result of perceiving unethical recruiting behaviors or illegal questioning. CONCLUSIONS: These results demonstrate that among survey respondents, some perceived unethical recruiting behaviors and illegal questioning in the 2005 and 2006 Match. Perceptions of such behaviors appeared to have a negative impact on applicant appraisal of EM residency programs.

Kaizen: a method of process improvement in the emergency department.

INTRODUCTION: Recent position statements from health care organizations have placed a strong emphasis on continuous quality improvement (CQI). CQI finds many of its roots in kaizen, which emphasizes small, low-cost, low-risk improvements. Based on the successful Kaizen Programs at organizations such as Toyota, the authors thought the emergency department (ED) would be an ideal environment to benefit from such a program. OBJECTIVES: The authors sought to create a CQI program using a suggestion-based model that did not require a large time commitment, was easy to implement, and had the potential to empower all physicians in the department. It would not take the place of other improvement efforts, but instead augment them. The hypothesis was that such a program would foster sustainable engagement of emergency physicians in system improvement efforts and lead to a continuous stream of low-cost implementable system improvement interventions. METHODS: A CQI program was created for the physician staff of the Department of Emergency Medicine at Vanderbilt University Medical Center, focusing on a suggestion-based model using kaizen philosophy. Lectures teaching kaizen philosophy were presented. Over the past 4 years, a methodology was developed utilizing a Web-based application, the Kaizen Tracker, which aids in the submission and implementation of suggestions that are called kaizen initiatives (KIs). The characteristics of the KIs submitted, details regarding resident and faculty participation, and the effectiveness of the Kaizen Tracker were retrospectively reviewed. RESULTS: There were 169, 105, and 101 KIs placed in the postimplementation calendar years 2006, 2007, and 2008, respectively. Seventy-six percent of KIs submitted thus far have identified a "process problem." Fifty-three percent of KIs submitted have led to operational changes within the ED. Ninety-three percent of the resident physicians entered at least one KI, and 73% of these residents submitted more than one KI. Sixty-nine percent of the attendings entered at least one KI, and 89% of these attendings submitted more than one KI. CONCLUSIONS: Over the past 4 years, the Kaizen Program at Vanderbilt has been widely and frequently used within the ED. It has resulted in over 400 changes in our adult ED system and has met the challenge of using CQI to drive ED improvements. There are limitations to this study, including the fact that its impact on patient outcomes remains unknown. However, this Kaizen Program may be an excellent tool for other departments to assist with quality improvement and should be studied with a multicenter prospective approach.

Modeling the effects of functional performance and post-transplant comorbidities on health-related quality of life after heart transplantation.

BACKGROUND: Health-related quality of life and functional performance are important outcome measures following heart transplantation. This study investigates the impact of pre-transplant functional performance and post-transplant rejection episodes, obesity and osteopenia on post-transplant health-related quality of life and functional performance. METHODS: Functional performance and health-related quality of life were measured in 70 adult heart transplant recipients. A composite health-related quality of life outcome measure was computed via principal component analysis. Iterative, multiple regression-based path analysis was used to develop an integrated model of variables that affect post-transplant functional performance and health-related quality of life. RESULTS: Functional performance, as measured by the Karnofsky scale, improved markedly during the first 6 months post-transplant and was then sustained for up to 3 years. Rejection Grade > or =2 was negatively associated with health-related quality of life, measured by Short Form-36 and reversed Psychosocial Adjustment to Illness Scale scores. Patients with osteopenia had lower Short Form-36 physical scores and obese patients had lower functional performance. Path analysis demonstrated a negative direct effect of obesity (beta = - 0.28, p < 0.05) on post-transplant functional performance. Post-transplant functional performance had a positive direct effect on the health-related quality of life composite score (beta = 0.48, p < 0.001), and prior rejection episodes grade > or =2 had a negative direct effect on this measure (beta = -0.29, p < 0.05). Either directly or through effects mediated by functional performance, moderate-to-severe rejection, obesity and osteopenia negatively impact health-related quality of life. These findings indicate that efforts should be made to devise immunosuppressive regimens that reduce the incidence of acute rejection, weight gain and osteopenia after heart transplantation.