Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA.

BACKGROUND: In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes. METHODS: This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020). RESULTS: Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase. CONCLUSION: We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

The 24-Hour Workday for New York State Home Health Care Workers: Institutional Racism in Health Care Delivery.

Racism named as a public health issue largely focuses on those at the care-receiving end of health care. Home health care workers (HHCWs) are predominantly Black, immigrant, and women; in New York state it is illegal for HHCWs to work 24 consecutive hours, but homecare agencies assign HHCWs to 24-hour shifts and only pay for 13 hours of work. The demanding work of HHCWs increases their risk for and experiences of injury, depression, cardiovascular disease, and cerebrovascular events. This manifestation of exploitation illustrates that racism affects health care workers as well as the public.

Human trafficking of children and adolescents: recognition and response in the emergency department.

Labor and sex trafficking impact children of all ages, genders, and nationalities. Trafficked patients present to the emergency department for illnesses and injuries both related and unrelated to their trafficking experiences. Emergency clinicians are not meant to be experts in labor and sex trafficking, but they must know enough to be able to identify patients at risk for trafficking and ensure that these patients have the opportunity to be connected to relevant services and support. This issue reviews the ways in which youth are trafficked, the indicators of trafficking, and the evidence-based and best-practice recommendations for addressing suspected or confirmed trafficking in the pediatric and adolescent patient populations.

An Annotated Bibliography on Human Trafficking for the Mental Health Clinician.

OBJECTIVE: This annotated bibliography provides an overview of sentinel and influential literature about human trafficking for general mental health practitioners. METHODS: A modified participatory ranking methodology was used to create the list of articles. RESULTS: We identified 25 articles relevant to trafficking and mental health which covered the topics of epidemiology, treatment, identification, policy, and research methodology. CONCLUSIONS: The articles presented cover a broad range of trafficking types and topics. However, there is a dearth of literature about labor trafficking and the trafficking of men, boys, transgender, and nonbinary people.

Child trafficking and exploitation: Historical roots, preventive policies, and the Pediatrician's role.

Pediatricians are uniquely and well positioned to recognize risk factors for and experiences of labor and sex trafficking in children. While clinical and social interventions are well discussed in the literature, the underlying mechanisms that cause and contribute to trafficking are poorly addressed among healthcare professionals. A "colorblind" or otherwise "apolitical" approach to trafficking prevention is ineffective and may be detrimental to the patient-practitioner relationship. Pediatricians must be historico-socially aware of the contexts in which they practice to improve the health of pediatric populations. This article addresses the relevant trafficking legal terminology that may be unfamiliar to most pediatricians and focuses on a few "ism"-schisms (capitalism, racism, sexism, cis-heteronormativity, nativism, and classism) that create vulnerability to trafficking in pediatric populations. The article closes with some intervention recommendations and many more prevention-measure recommendations.

Validation of a screening tool for labor and sex trafficking among emergency department patients.

OBJECTIVE: Patients with labor and sex trafficking experiences seek healthcare while and after being trafficked. Their trafficking experiences are often unrecognized by clinicians who lack a validated tool to systematically screen for trafficking. We aimed to derive and validate a brief, comprehensive trafficking screening tool for use in healthcare settings. METHODS: Patients were randomly selected to participate in this prospective study based on time of arrival. Data collectors administered 5 dichotomous index questions and a reference standard trafficking assessment tool that requires 30 to 60 minutes to administer. Data collection was from June 2016 to January 2021. Data from patients in 5 New York City (NYC) emergency departments (EDs) were used for tool psychometric derivation, and data from patients in a Fort Worth ED were used for external validation. Clinically stable ED adults (aged ≥18 years) were eligible to participate. Candidate questions were selected from the Trafficking Victim Identification Tool (TVIT). The study outcome measurement was a determination of a participant having a lifetime experience of labor and/or sex trafficking based on the interpretation of the reference standard interview, the TVIT. RESULTS: Overall, 4127 ED patients were enrolled. In the derivation group, the reference standard identified 36 (1.1%) as positive for a labor and/or sex trafficking experience. In the validation group, 12 (1.4%) were positive by the reference standard. Rapid Appraisal for Trafficking (RAFT) is a new 4-item trafficking screening tool: in the derivation group, RAFT was 89% sensitive (95% confidence interval [CI], 79%-99%) and 74% specific (95% CI, 73%-76%) and in the external validation group, RAFT was 100% sensitive (95% CI, 100%-100%) and 61% specific (95% CI, 56%-65%). CONCLUSIONS: The rapid, 4-item RAFT screening tool demonstrated good sensitivity compared with the existing, resource-intensive reference standard tool. RAFT may enhance the detection of human trafficking in EDs. Additional multicenter studies and research on RAFT's implementation are needed.

Histories of trauma: A qualitative analysis of lifetime traumatic experiences among emergency department patients.

OBJECTIVE: Emergency medicine clinicians are excellent at identifying and treating physical trauma as a chief complaint, but are often unaware of patients' previous experiences of trauma. The purpose of this study was to describe emergency department (ED) patients' lifetime experiences of trauma. METHODS: The investigative team used framework analysis to examine 1,282 participants' open-ended responses to the Vera Institute's Trafficking Victim Identification Tool questions. Of these, 204 participants were found to have experienced at least one form of trauma; none of these participants were assessed positive for a human trafficking experience. RESULTS: From 204 participants, 343 instances of trauma were recorded and analyzed. Of the 204 patient-participants who reported trauma, 96 experienced one form of trauma and 108 experienced two or more. Three major themes emerged: work trauma (experiences of trauma originating in the workplace), coercion (being manipulated into activities), and trauma connections (some forms of trauma were commonly experienced with other kinds of trauma). A fourth, less prominent, theme was disclosure as witness (participants witnessing trauma). CONCLUSION: ED patients have experienced many forms of lifetime trauma and, in this study, were willing to share about their experiences while in the acute care setting. Given the common experience of trauma among the ED patients in this investigation, more work is needed to examine if and how trauma-informed care principles should be employed in the ED. Additionally, the ED may be an underutilized data source for researchers seeking participants with experiences of trauma and/or a point of connection for trauma survivors to be linked to trauma care services.

Diagnosed and Undiagnosed COVID-19 in US Emergency Department Health Care Personnel: A Cross-sectional Analysis.

STUDY OBJECTIVE: We determine the percentage of diagnosed and undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among a sample of US emergency department (ED) health care personnel before July 2020. METHODS: This was a cross-sectional analysis of ED health care personnel in 20 geographically diverse university-affiliated EDs from May 13, to July 8, 2020, including case counts of prior laboratory-confirmed coronavirus disease 2019 (COVID-19) diagnoses among all ED health care personnel, and then point-in-time serology (with confirmatory testing) and reverse transcriptase-polymerase chain reaction testing in a sample of volunteers without a previous COVID-19 diagnosis. Health care staff were categorized as clinical (physicians, advanced practice providers, and nurses) and nonclinical (clerks, social workers, and case managers). Previously undiagnosed infection was based on positive SARS-CoV-2 serology or reverse transcriptase-polymerase chain reaction result among health care personnel without prior diagnosis. RESULTS: Diagnosed COVID-19 occurred in 2.8% of health care personnel (193/6,788), and the prevalence was similar for nonclinical and clinical staff (3.8% versus 2.7%; odds ratio 1.5; 95% confidence interval 0.7 to 3.2). Among 1,606 health care personnel without previously diagnosed COVID-19, 29 (1.8%) had evidence of current or past SARS-CoV-2 infection. Most (62%; 18/29) who were seropositive did not think they had been infected, 76% (19/25) recalled COVID-19-compatible symptoms, and 89% (17/19) continued to work while symptomatic. Accounting for both diagnosed and undiagnosed infections, 4.6% (95% confidence interval 2.8% to 7.5%) of ED health care personnel were estimated to have been infected with SARS-CoV-2, with 38% of those infections undiagnosed. CONCLUSION: In late spring and early summer 2020, the estimated prevalence of severe acute respiratory syndrome coronavirus 2 infection was 4.6%, and greater than one third of infections were undiagnosed. Undiagnosed SARS-CoV-2 infection may pose substantial risk for transmission to other staff and patients.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021.

OBJECTIVES: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. METHODS: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. RESULTS: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). CONCLUSION: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

Exception From Informed Consent: How IRB Reviewers Assess Community Consultation and Public Disclosure.

Exception from Informed Consent (EFIC) regulations detail specific circumstances in which Institutional Review Boards (IRB) can approve studies where obtaining informed consent is not possible prior to subject enrollment. To better understand how IRB members evaluate community consultation (CC) and public disclosure (PD) processes and results, semi-structured interviews of EFIC-experienced IRB members were conducted and analyzed using thematic analysis. Interviews with 11 IRB members revealed similar approaches to reviewing EFIC studies. Most use summaries of CC activities to determine community members' attitudes; none reported using specific criteria nor recalled any CC reviews that resulted in modifications to or denials of EFIC studies. Most interviewees thought metrics based on Community VOICES's domains (feasibility, participant selection, quality of communication, community perceptions, investigator/IRB perceptions) would be helpful. IRB members had similar experiences and concerns about reviewing EFIC studies. Development of metrics to assess CC processes may be useful to IRBs reviewing EFIC studies.

Building RAFT: Trafficking Screening Tool Derivation and Validation Methods.

BACKGROUND: Labor and sex trafficking have long impacted the patients who seek care in emergency departments (ED) across the United States. Increasing social and legislative pressures have led to multiple calls for screening for trafficking in the clinical care setting, but adoption of unvalidated screening tools for trafficking recognition is unwise for individual patient care and population-level data. Development of a valid screening tool for a social malady that is largely "invisible" to most clinicians requires significant investments. Valid screening tool development is largely a poorly understood process in the antitrafficking field and among clinicians who would use the tools. METHODS: The authors describe the study design and procedures for reliable data collection and analysis in the development of RAFT (Rapid Appraisal for Trafficking). In a five-ED, randomized, prospective study, RAFT will be derived and validated as a labor and sex trafficking screening tool for use among adult ED patients. Using a novel method of ED patient-participant randomization, intensively trained data collectors use qualitative data to assess subjects for a lifetime experience of human trafficking. CONCLUSION: Study methodology transparency encourages investigative rigor and integrity and will allow other sites to reproduce and externally validate this study's findings.

Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do.

STUDY OBJECTIVE: We explore self-reported knowledge, attitudes, and behaviors of emergency physicians in regard to the care of transgender and gender-nonconforming patients to identify opportunities to improve care of this population. METHODS: From July to August 2016, we electronically surveyed the American College of Emergency Physicians' Emergency Medicine Practice-Based Research Network of 654 active emergency physician participants. We performed frequency tabulations to analyze the closed-ended response items. RESULTS: Of the 399 respondents (61% response rate), 88.0% reported caring for transgender and gender-nonconforming patients in the emergency department (ED), although 82.5% had no formal training about this population. The majority of physicians (86.0%) were comfortable asking about personal pronouns. Only 26.1% of respondents knew the most common gender-affirming surgery for female-to-male patients; 9.8% knew the most common nonhormone gender-affirming medication that male-to-female patients use. Almost no respondents (<3%) were aware of emergency medicine practitioners' performing inappropriate examinations on transgender and gender-nonconforming patients. CONCLUSION: Although transgender and gender-nonconforming people represent a minority of ED patients nationwide, the majority of respondents reported personally providing care to members of this population. Most respondents lacked basic clinical knowledge about transgender and gender-nonconforming care.

A Theory-based Didactic Offering Physicians a Method for Learning and Teaching Others About Human Trafficking.

Emergency clinicians are on the frontlines of identifying and caring for trafficked persons. However, most emergency providers have never received training on trafficking, and studies report a significant knowledge gap involving this important topic. Workshops often employ a "train-the-trainer" model to address clinicians' knowledge gaps involving various topics (including trafficking). By offering participants knowledge and skills needed to both understand relevant content and teach this content to future learners, this model aims at promoting widespread dissemination of essential information. However, current train-the-trainer workshops typically involve full or multiday sessions and employ multimodal instructional techniques, making them time and resource intensive for both participants and facilitators. To address these challenges, we created a 50-minute train-the-trainer workshop to teach emergency clinicians the knowledge and skills needed to recognize and care for trafficked patients while providing instructional techniques to teach learners this content in the clinical environment. Learning theory and principles informed the choice of instructional methods and were employed when designing the paper-based learning guides that functioned as this intervention's primary instructional resource. Guides contained detailed scripts used to perform role-playing exercises. These "scripted guides" were designed for participants to learn important content while simultaneously practicing techniques to teach this content to one another. They provided the scaffolding necessary to independently direct learning during the workshop (with minimal facilitator intervention), while also being carefully formatted and organized to create an accessible tool for future use during clinical teaching. The session was implemented at the 2018 Society for Academic Emergency Medicine Annual Meeting in Indianapolis, Indiana. Based on participants' self-assessment using a retrospective pre-post test, the workshop was successful in creating a train-the-trainer model that is brief, requiring minimal facilitator resources and offers instruction on both content knowledge and instructional methods to disseminate this knowledge to future learners.

Transgender and Gender Nonconforming in Emergency Departments: A Qualitative Report of Patient Experiences.

Background: Individuals who have a transgender or gender nonconforming (TGGNC) experience belong to a marginalized segment of the U.S. population, and healthcare can be difficult for them to navigate. Although emergency departments (EDs) traditionally serve as healthcare "safety nets" for vulnerable populations, quantitative studies outside the United States have found that TGGNC-experienced persons tend to avoid EDs and/or have negative experiences. This qualitative study primarily describes the ED experiences of people with a TGGNC history; furthermore, the study explores reasons why this population avoids U.S. EDs and their recommendations for improvements to ED care. Methods: This qualitative study used data about TGGNC-historied persons' experiences in U.S. EDs from retrospective, anonymous, written surveys (paper or web based). National data collection took place from June 2012 through December 2014. Participant responses (n=240) were examined using thematic analysis. Results: Using a framework that recognized positive and negative responses, the themes of Self-Efficacy and Power Inequity surfaced. These themes exposed the tension between patients with TGGNC experiences and clinicians who were perceived to lack training in this area, resulting in negative patient experiences. When practitioners had specific training about this population, participants reported positive care experiences. Conclusions: This study indicates that many TGGNC-historied persons who use U.S. EDs have negative experiences, largely due to lack of provider sensitivity toward and training about this patient population. Data from this investigation suggest that training of U.S. ED providers and institutional support would help improve care for this marginalized group.