Combatting the opioid epidemic: Baltimore's experience and lessons learned.

In the midst of a national opioid crisis, Baltimore City witnessed 393 deaths from drug and alcohol overdose in 2015. With an estimated 25 000 residents who are addicted to heroin or other opioids, Baltimore has been profoundly affected by the opioid epidemic. Other resources have commented on federal, state-based, and provider responses to the opioid crisis. This article examines what may be done at the city level based on the experiences of the Baltimore City Health Department. Local jurisdictions must play a critical role in addressing the U.S. opioid crisis through public health coalitions, overdose prevention, treatment expansion, and anti-stigma education.

Evaluating the impact of Affordable Care Act repeal on America's opioid epidemic.

In this month's Editorial, Health Commissioner of the City of Baltimore Leana S. Wen and co-authors discuss why the United States needs Medicaid to address its epidemic of opioid abuse.

Measles, social media and surveillance in Baltimore City.

Background: Baltimore City was faced with two potential measles outbreaks in 2015. Both cases occurred in the wake of national media attention paid to the Disneyland outbreaks of the same year. Methods: A comparative case study approach was used applying qualitative data to elicit best practices in infectious disease protocols in the age of social media. The research also used search engine data from Google Trends to track constituent engagement over time. Results: Across the two case studies, the Baltimore City Health Department identified a number of best practices to inform the public via social media and minimize levels of misinformation and panic. These practices included clarity in messaging across platforms and public health jurisdictions; pre-emptor alerts of potential measles cases to control and shape the media messaging; and targeted, in-person outreach to engage groups in a culturally competent manner. Conclusions: The Baltimore City Health Department's response drew out a critical need for re-examining infectious disease protocols in the age of social media (e.g. contact notification, quarantine, media sensitivity) and anti-vaccination movements that pose new obstacles to government intervention. The benefits and challenges of greater connectivity between providers, patients, and public health officers are discussed.

The Emergency Medicine Workforce: Profile and Projections.

BACKGROUND: The landscape of the emergency medicine workforce has changed dramatically over the last few decades. The growth in emergency medicine residency programs has significantly increased the number of emergency medicine specialists now staffing emergency departments (EDs) throughout the country. Despite this increase in available providers, rising patient volumes, an aging population, ED overcrowding and inefficiency, increased regulation, and other factors have resulted in the continued need for additional emergency physicians. OBJECTIVES: To review current available data on patient volumes and characteristics, the overall physician workforce, the current emergency physician workforce, the impact of physician extenders and scribes on the practice of emergency medicine, and project emergency physician staffing needs into the future. DISCUSSION AND PROJECTIONS: We project that within the next 5 to 10 years, there will be enough board-certified or -eligible emergency physicians to provide care to all patients in the U.S. EDs. However, low-volume rural EDs will continue to have difficulty attracting emergency medicine specialists without significant incentives. CONCLUSIONS: There remains a shortage of board-certified emergency physicians, but it is decreasing every year. The use of physicians from other specialties to staff EDs has long been based on the theory that there is a long-standing shortage of available American Board of Emergency Medicine/American Osteopathic Board of Emergency Medicine physicians, both now and in the future. Our investigation shows that this is not supported by current data. Although there will always be regional and rural physician shortages, these are mirrored by all other specialties and are even more pressing in primary care.

Emergency department characteristics and capabilities in Beijing, China.

BACKGROUND: Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care. OBJECTIVES: We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China. METHODS: Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008. RESULTS: Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000-118,508). The vast majority (91%; 95% confidence interval [CI] 78-98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32-67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21-54%) of respondents considered their ED over capacity. CONCLUSIONS: Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs.

The provision of diagnosis at emergency department discharge: a pilot study.

OBJECTIVES: Understanding the cause of patients' symptoms usually involves identification of a pathological diagnosis. Anecdotal reports suggest that emergency department (ED) providers do not prioritise giving pathological diagnoses, and often reiterate the patient's symptom as the discharge 'diagnosis'. Our pilot study sought to identify the proportion of patients at a large teaching hospital who receive a symptomatic versus pathological diagnosis at ED discharge. METHODS: We performed a chart review of all adult patients who were discharged from an urban ED in the USA, with an 88,000 annual visit volume. All charts of patients presenting with the three most common ED chief complaints (chest pain, abdominal pain and headache) were reviewed by two reviewers. Charts were coded as either symptomatic or pathological diagnosis based on the discharge diagnosis provided by the attending physician. Those with discrepant coding by the two reviewers were subject to review by a third adjudicator. RESULTS: 797 charts met the inclusion criteria. Five charts (0.6%) were coded differently by the two reviewers; a discussion with the third reviewer resulted in consensus in all cases. For patients presenting with chest pain, abdominal pain and headache, the proportion that received a pathological ED discharge diagnosis were 17%, 43% and 41%, respectively. CONCLUSIONS: According to our pilot study, most patients are discharged from the ED without a pathological diagnosis that explains the likely cause of their symptoms. Future studies will investigate whether this finding is consistent across institutions, and whether provision of a pathological diagnosis affects clinical outcomes and patient satisfaction.

Procedure competence versus number performed: a survey of graduate emergency medicine specialists in a developing nation.

BACKGROUND: Emergency medicine (EM) training programmes are being conducted around the world but no study has assessed the procedural competence of developing nations' EM trainees. OBJECTIVES: To quantify the number of core procedures and resuscitations performed and describe the perceived procedural competency of graduates of Africa's first EM registrarship at the University of Cape Town/Stellenbosch University (UCT/SUN) in Cape Town, South Africa. METHODS: All 30 graduates from the first four classes in the UCT/SUN EM programme (2007-10) were asked to complete a written, self-administered survey on the number of procedures needed for competency, the number of procedures performed during registrarship and the perceived competence in each procedure ranked on a five-point Likert scale. The procedures selected were the 10 core procedures and four types of resuscitations as defined by the US-based Residency Review Committee. Results were compiled and analysed using descriptive statistics. RESULTS: Twenty-seven (90%) completed surveys. For most core procedures and all resuscitations, the number of procedures reported by respondents far exceeded the Residency Review Committee minimum. The three procedures not meeting the minimum were internal cardiac pacing, cricothyrotomy and periocardiocentesis. Respondents reported perceived competence in most procedures and all resuscitations. CONCLUSIONS: EM trainees in a South Africa registrarship report a high number of procedures performed for most procedures and all resuscitations. As medical education moves to the era of direct observation and other methods of assessment, more studies are needed to define and ensure procedural competence in trainees of nascent EM programmes.

Characteristics and capabilities of emergency departments in Abuja, Nigeria.

OBJECTIVES: Emergency departments (ED) are the basic unit of international emergency medicine, but often differ in fundamental features. This study sought to describe and characterise ED in the capital city of Nigeria, Abuja. METHODS: All ED open 24 h/day 7 days/week to the general public were surveyed using the national ED inventories survey instrument (http://www.emnet-nedi.org). ED staff were asked about ED characteristics with reference to calendar year 2008. RESULTS: Twenty-four ED participated (83% response). All were located in hospitals, which ranged in size from six to 250 beds. The majority (92% CI 73% to 100%) had a contiguous layout with medical and surgical care provided in one area. All ED saw both adults and children, with a median of 1500 annual visits (IQR 648-2328). Almost half of respondents (46%; CI 26% to 67%) thought their ED operated under capacity, none thought that their ED was over capacity. Only 4% of ED surveyed had dedicated CT scanners, 25% had cardiac monitoring and none had negative-pressure rooms. There was wide variation in the types of emergencies that were identified as being treatable 24 h/day 7 days/week; these appeared to correlate with ED consultant availability. CONCLUSIONS: Although ED location and layout in Abuja do not differ greatly from that in a typical US city, ED utilisation was lower and fewer resources and capabilities were available. The lack of technological and human resources raise questions about what critical technologies are needed in resource-limited settings, and whether Nigeria should consider training emergency medicine physicians to meet its workforce needs.