Examining trends in emergency medicine journals' publications about racism.

OBJECTIVE: In recent years, the academic medicine community has produced numerous statements and calls to action condemning racism. Though health equity work examining health disparities has expanded, few studies specifically name racism as an operational construct. As emergency departments serve a high proportion of patients with social and economic disadvantage rooted in structural racism, it is critically important that racism be a focus of our academic discourse. This study examines the frequency at which four prominent emergency medicine journals, Annals of Emergency Medicine, Academic Emergency Medicine, the American Journal of Emergency Medicine, and the Western Journal of Emergency Medicine, publish on health disparities and racism. METHODS: This is a descriptive analysis measuring the frequency of publications on health disparities and racism in U.S.-based emergency medicine journals from 2014 to 2021. The search strategies for the concepts of "racism" and "health disparities" used a combination of MeSH and keywords. These search strategies were developed based on prior literature and the MEDLINE/PubMed Health Disparities and Minority Health Search Strategy. Articles identified through the PubMed search were then reviewed by two authors for final inclusion. RESULTS: Since 2014, a total of 6248 articles were published by the four emergency medicine journals over the 8-year study period. Of those, 82 research papers that focused on health disparities were identified and only 16 that focused on racism. Most emergency medicine publications on racism and health disparities were in 2021. CONCLUSIONS: Our findings suggest that the national discourse on racism and calls to action within emergency medicine were followed by an increase in publications on health disparities and racism. Continued investigation is needed to evaluate these trends moving forward.

Fixing the leaky physician-scientist pipeline: Integrated-dedicated research period programs in emergency medicine.

Emergency physicians (EPs) are well positioned to perform medical research. EPs are exposed to a wide range of disease types, medical specialties, and treatment modalities. Furthermore, emergency medicine (EM) serves as the safety net for the U.S. health care system. The diverse exposure provides a vast opportunity for EP to perform many worthwhile research projects. Yet, EM has historically had the lowest amount of funding and a lower number of National Institutes of Health-funded research projects. Many suggest the etiology is a "leaky" educational pipeline with loss of many potential physician-scientists over the training and development course. Current research training options for the EM physician-scientist includes MD-PhD, 4-year EM residency program and postresidency fellowships. While each has its advantages and disadvantages, we describe an additional educational alternative of EM physician-scientists, which we have named the integrated-dedicated research period within an EM residency. We describe the features of these programs and preliminary results from the graduates and current trainees.

Emergency Department Use Among Recently Homeless Adults in a Nationally Representative Sample.

Introduction: In this study we examined the association of homelessness and emergency department (ED) use, considering social, medical, and mental health factors associated with both homelessness and ED use. We hypothesized that social disadvantage alone could account for most of the association between ED use and homelessness. Methods: We used nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Emergency department use within the prior year was categorized into no use (27,674; 76.61%); moderate use (1-4 visits: 7,972; 22.1%); and high use (5 or more visits: 475; 1.32%). We used bivariate analyses followed by multivariable-adjusted logistic regression analyses to identify demographic, social, medical, and mental health characteristics associated with ED use. Results: Among 36,121 respondents, unadjusted logistic regression showed prior-year homelessness was strongly associated with moderate and high prior-year ED use (odds ratio [OR] 2.31 and 7.34, respectively, P < 0.001). After adjusting for sociodemographic factors, the associations of homelessness with moderate/high ED use diminished (adjusted OR [AOR] 1.27 and 1.62, respectively, both P < 0.05). Adjusting for medical/mental health variables, alone, similarly diminished the association between homelessness and moderate/high ED use (AOR 1.26, P < .05 and 2.07, P < 0.001, respectively). In a final stepwise model including social and health variables, homelessness was no longer significantly associated with moderate or high ED use in the prior year. Conclusion: After adjustment for social disadvantage and health problems, we found no statistically significant association between homelessness and ED use. The implications of our findings suggest that ED service delivery must address both health issues and social factors.

A National Snapshot of Social Determinants of Health Documentation in Emergency Departments.

INTRODUCTION: Documentation and measurement of social determinants of health (SDoH) are critical to clinical care and to healthcare delivery system reforms targeting health equity. The SDoH are codified in the International Classification of Disease 10th Rev (ICD-10) Z codes. However, Z codes are listed in only 1-2% of inpatient charts. Little is known about the frequency of Z code utilization specifically among emergency department (ED) patient populations nationally. METHODS: This was a repeated cross-sectional analysis of ED visit data in the United States from the Nationwide Emergency Department Sample from 2016-2019. We characterized the use of Z codes and described associations between Z code use and patient- and hospital-level factors including the following: age; gender; race; insurance status; ED disposition; ED size; hospital urban-rural status; ownership; and clinical conditions. We calculated unadjusted odds ratios for likelihood of Z code reporting for each ED visit. RESULTS: Of approximately 140 million ED visits per year, 0.65% had an associated Z code in 2016, rising to 1.17% by 2019. Visits were more likely to have an associated Z code for adults age <65, male, Black, Medicaid or self-pay patients, and patients admitted to the hospital. Larger EDs, those in metropolitan areas, academic centers, and government-run hospitals were more likely to report Z codes. The most commonly associated clinical conditions were as follows: schizophrenia spectrum and other psychotic disorders; depressive disorder; and alcohol-related disorders. CONCLUSION: There is a paucity of Z code documentation in the health records of ED patients, although use is uptrending. Further research is warranted to better understand the drivers of clinicians' use of Z codes and to improve on their utility.

Intimate partner violence screening during COVID-19.

OBJECTIVES: Emergency Department (ED) screening for intimate partner violence (IPV) is typically nursing-initiated, often with visitors present. Since the onset of the COVID-19 pandemic, we have seen both an increase in societal stress, a known exacerbator of IPV, and the implementation of visitor restriction policies. This combination presents the need for enhanced IPV screening and the opportunity to perform screening in a controlled, patient-only environment. Our goal was to evaluate the frequency of nurse-initiated screening for IPV prior to and during the early months of the COVID-19 pandemic as well as the frequency of positive screens for IPV. METHODS: We conducted a retrospective cross-sectional study evaluating all adults (age >18 years) presenting to a tertiary care center ED. Patients were identified as presenting prior to the COVID-19 pandemic (June 1, 2019 to August 31, 2019) and after the COVID-19 visitor restriction policies (June 1, 2020 to August 31, 2020). Descriptive statistics were performed using chi-square and t-tests compared the demographic variables. Chi-square was used for a bivariate analysis of our primary outcomes (IPV screening performed and screening positive for IPV). Further analysis was done using a binary logistic regression model adjusting for the demographic characteristics. RESULTS: Both the odds of nursing-initiated IPV screening and the odds of verbally screening positive for IPV significantly increased (OR 1.509, 95% CI 1.432-1.600) and (OR 1.375, 95% CI 1.126-1.681) respectively following the implementation of COVID-19 visitor restriction policies. CONCLUSIONS: These findings suggest that nurse-initiated IPV screening should continue to be performed with the patient privately, even after COVID-19 related ED visitor restrictions are removed. These findings also support the hypothesis that the stress related to COVID-19 is contributing to a rise in IPV.

Association of Coded Housing Instability and Hospitalization in the US.

Importance: Housing instability and other social determinants of health are increasingly being documented by clinicians. The most common reasons for hospitalization among patients with coded housing instability, however, are not well understood. Objective: To compare the most common reasons for hospitalization among patients with and without coded housing instability. Design, Setting, and Participants: This cross-sectional, retrospective study identified hospitalizations of patients between age 18 and 99 years using the 2017 to 2019 National Inpatient Sample. Data were analyzed from May to September 2022. Exposures: Housing instability was operationalized using 5 International Classification of Diseases, 10th Revision, Social Determinants of Health Z-Codes addressing problems related to housing: homelessness; inadequate housing; discord with neighbors, lodgers, and landlords; residential institution problems; and other related problems. Main Outcomes and Measures: The primary outcome of interest was reason for inpatient admission. Bivariate comparisons of patient characteristics, primary diagnoses, length of stay, and hospitalization costs among patients with and without coded housing instability were performed. Results: Among the 87 348 604 hospitalizations analyzed, the mean (SD) age was 58 (20) years and patients were more likely to be women (50 174 117 [57.4%]) and White (58 763 014 [67.3%]). Housing instability was coded for 945 090 hospitalizations. Hospitalized patients with housing instability, compared with those without instability, were more likely to be men (668 255 patients with coded instability [70.7%] vs 36 506 229 patients without [42.3%]; P < .001), younger (mean [SD] age 45.5 [14.0] vs 58.4 [20.2] years), Black (235 355 patients [24.9%] vs 12 929 158 patients [15.0%]), Medicaid beneficiaries (521 555 patients [55.2%] vs 15 541 175 patients [18.0%]), uninsured (117 375 patients [12.4%] vs 3 476 841 patients [4.0%]), and discharged against medical advice (28 890 patients [8.4%] vs 451 855 patients [1.6%]). The most common reason for hospitalization among patients with coded housing instability was mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%]), which cost a total of $3.5 billion. Other common reasons included injury (69 270 patients [7.3%]) and circulatory system diseases (64 700 patients [6.8%]). Coded housing instability was also significantly associated with longer mean (SD) hospital stays (6.7 [.06] vs 4.8 [.01] days) and a cost of $9.3 billion. Hospitalized patients with housing instability had 18.6 times greater odds of having a primary diagnosis of mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%] vs 4 470 675 patients [5.2%]; odds ratio, 18.56; 95% CI, 17.86 to 19.29). Conclusions and Relevance: In this cross-sectional study, hospitalizations among patients with coded housing instability had higher admission rates for mental, behavioral, and neurodevelopmental disorders, longer stays, and increased costs. Findings suggest that efforts to improve housing instability, mental and behavioral health, and inpatient hospital utilization across multiple sectors may find areas for synergistic collaboration.

A New Syndemic: Complications of Opioid Use Disorder During a Heat Wave.

BACKGROUND: This case series describes an evolving relationship between the opioid crisis and climate change. As the climate continues to warm, patients with opioid use disorders will be at heightened risk for complications and even death. Little has been written on the specific intersection of heat-related illness and opioid use. OBJECTIVES: This paper highlights a particular vulnerability among people with opioid use disorder to encourage further research and inform care practices among community and health care providers. DISCUSSION: The opioid crisis and climate change have the potential to interact synergistically to contribute to excess burden of death and disease. Socioeconomic marginalization places people with opioid use disorder at greater risk for death and injury due to inadequate access to air conditioning. CONCLUSION: Providers should consider co-occurrence of heatrelated illness in accidental overdoses. Harm-reduction initiatives could include education regarding the risks of use during heatwaves.

Burnout and Perception of Medical School Learning Environments Among Gay, Lesbian, and Bisexual Medical Students.

Importance: The perspectives of gay, lesbian, bisexual (sexual minority [SM]) students about their medical school learning environment and how they relate to burnout is poorly understood. Objective: To understand SM medical students' perceptions of the medical school learning environment and how this is associated with reported burnout. Design, Setting, and Participants: This cross-sectional study included medical students graduating from Association of American Medical Colleges (AAMC)-accredited allopathic US medical schools in 2016 and 2017 and responding to the AAMC Graduation Questionnaire. Data analysis was conducted from June 2021 to March 2022. Exposures: Sexual orientation, based on self-identification, and categorized as bisexual, gay or lesbian, or heterosexual or straight. Main Outcomes and Measures: Primary outcomes included burnout as measured by Oldenburg Burnout Inventory for Medical Students (OLBI-MS; two 24-point scales [range, 0-48], with higher scores indicating greater burnout) and student perceptions of the medical school learning environment (0-5-point scales for emotional climate [range, 0-20] and student-faculty interactions [range, 0-15], with higher scores indicating more positive perceptions). Logistic regression was used to model the association between burnout, SM status, and learning environment while controlling for demographic characteristics. Results: A total of 25 757 respondents (12 527 [48.6%] women; 5347 [20.8%] Asian; 2255 [8.8%] underrepresented in medicine; 15 651 [60.8%] White; 10 726 [41.6%] aged ≤26 years) were included in the analysis: 568 (2.2%) self-identified as bisexual, 854 (3.3%) as gay or lesbian, and 24 335 (94.5%) as heterosexual or straight. Both bisexual students and gay or lesbian students reported less favorable perceptions of their learning environments than heterosexual students (mean [SD] emotional climate score, bisexual students: 8.56 [3.29]; gay or lesbian students: 9.22 [3.33]; heterosexual or straight students: 9.71 [3.20]; P < .001; mean [SD] faculty-student interaction score, bisexual students: 13.46 [3.69]; gay or lesbian students: 14.07 [3.45]; heterosexual or straight students: 14.32 [3.37]; P < .001). Bisexual and gay or lesbian students were more likely to be in the top quartile for burnout scores (bisexual: odds ratio [OR], 1.71; 95% CI, 1.42-2.07; P < .001; gay or lesbian: OR, 1.53; 95% CI, 1.31-1.79; P < .001). This association was attenuated when accounting for student perceptions of the learning environment (bisexual: OR, 1.37; 95% CI, 1.11-1.67; P < .001; gay or lesbian: OR, 1.42; 95% CI, 1.19-1.68; P < .001), with poorer perceptions of the medical school learning environment associated with higher burnout symptoms. Conclusions and Relevance: In this cross-sectional study, SM students had less favorable perceptions of the medical school learning environment compared with heterosexual students. Results suggest the medical school environment may be associated with higher rates of burnout in SM students. Future research should explore interventions to improve the learning environment for SM students.

Using community-based participatory research methods to inform care for patients experiencing homelessness: An opportunity for resident education on health care disparities.

People experiencing homelessness (PEH) suffer higher burdens of chronic illnesses, have higher rates of emergency medicine (ED) use and hospitalization, and ultimately are at increased risk for premature death compared to housed counterparts. Structural racism contributes to a disproportionate burden of homelessness among people of color. PEH experience not only significant medical concerns but also complex social needs that need to be addressed concurrently for effective healing, issues that have been magnified by the COVID-19 pandemic. As health disparities and structural racism intersect among PEH, it is critically important to develop PEH-centered interventions to improve care and health outcomes as part of an effort to dismantle racism. One opportunity to address these disparities in care for PEH is through training ED physicians on methods for identifying and intervening on the unique needs of vulnerable patient groups. The Accreditation Council for Graduate Medical Education has outlined health quality pathways in the clinical learning environment to address health disparities. Community-based participatory research (CBPR) is particularly well suited for this scenario as it allows experiential learning for trainees to work with and understand a diverse group of stakeholders, to deepen their knowledge of local health disparities, and to lead research and measure outcomes of interventions to tackle health disparities. In this paper, we highlight the utility of CBPR in fostering experiential learning for EM residents on tackling health disparities and the importance of community collaboration in trainee-led interventions for comprehensive ED care.

Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency.

BACKGROUND: Organic conditions can often mimic neuropsychiatric disorders, leading to delays in diagnosis and treatment for the most vulnerable populations presenting to the emergency department (ED). CASE REPORT: Here we discuss a case of cryptococcal meningoencephalitis seemingly consistent with psychosis on initial evaluation, and present strategies to recognize and treat this condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to the indolent time course of this disease, initial symptoms of altered mental status and personality changes may be attributed to drug use or psychiatric illness before more overt evidence for increased intracranial pressure and neurologic infection develops. It is important for emergency clinicians to maintain a high level of suspicion for this condition in at-risk patients and reassess them frequently during their ED visit.

The Duty of Mind: Ethical Capacity in a Time of Crisis.

In a disaster, physicians are forced to make challenging and heartbreaking ethical decisions under conditions of physical and emotional exhaustion. Evidence shows that the conditions of stress that mark disasters can undermine the process of ethical decision-making. This results in biased allocation of scarce resources, fewer utilitarian and altruistic decisions, and a wider variation in decisions. Stress also predisposes clinicians to decision strategy errors, such as premature closure, that lead to poor outcomes. The very ability to make sound and ethical decisions is thus a scarce resource. Ethical frameworks underpinning disaster protocols enumerate many physician obligations, but seldom articulate the risk posed by having decisions made ad hoc by decision-makers who are compromised by the stress of the concurrent crisis. We propose, therefore, that a "duty of mind"-the obligation to make critical decisions under the clearest possible state of thought-be added to ethical frameworks for disaster response. Adding the duty of mind to the pillars on which planning is based would force attention to a moral imperative to include decision support tools in disaster planning. By moving the consideration of possible choices to a moment when time and consultation facilitate clear and considered thought, the duty of mind is upheld. (Disaster Med Public Health Preparedness. 2018;12:657-662).

Risk-Benefit Evaluation for Surgery in a Patient with Psychiatric Complications.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Sanitary pad interventions for girls' education in Ghana: a pilot study.

BACKGROUND: Increased education of girls in developing contexts is associated with a number of important positive health, social, and economic outcomes for a community. The event of menarche tends to coincide with girls' transitions from primary to secondary education and may constitute a barrier for continued school attendance and performance. Following the MRC Framework for Complex Interventions, a pilot controlled study was conducted in Ghana to assess the role of sanitary pads in girls' education. METHODS: A sample of 120 schoolgirls between the ages of 12 and 18 from four villages in Ghana participated in a non-randomized trial of sanitary pad provision with education. The trial had three levels of treatment: provision of pads with puberty education; puberty education alone; or control (no pads or education). The primary outcome was school attendance. RESULTS: After 3 months, providing pads with education significantly improved attendance among participants, (lambda 0.824, F = 3.760, p<.001). After 5 months, puberty education alone improved attendance to a similar level (M = 91.26, SD = 7.82) as sites where pads were provided with puberty education (Rural M = 89.74, SD = 9.34; Periurban M = 90.54, SD = 17.37), all of which were higher than control (M = 84.48, SD = 12.39). The total improvement through pads with education intervention after 5 months was a 9% increase in attendance. After 3 months, providing pads with education significantly improved attendance among participants. The changes in attendance at the end of the trial, after 5 months, were found to be significant by site over time. With puberty education alone resulting in a similar attendance level. CONCLUSION: This pilot study demonstrated promising results of a low-cost, rapid-return intervention for girls' education in a developing context. Given the considerable development needs of poorer countries and the potential of young women there, these results suggest that a large-scale cluster randomized trial is warranted. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201202000361337.