"COVID gave him an opportunity to tighten the reins around my throat": perceptions of COVID-19 movement restrictions among survivors of intimate partner violence.

BACKGROUND: Intimate Partner Violence (IPV) poses a serious public health threat globally and within the United States. Preliminary evidence highlighted surges in IPV during the COVID-19 pandemic. The pandemic offers a unique context, with many states and countries enacting movement-restrictions (i.e., shelter-in-place orders) that exacerbated IPV. Although these movement restrictions and other infection control methods (i.e., isolation, quarantine orders) have proven successful in reducing the spread of COVID-19, their impacts on IPV have not been thoroughly investigated. Specifically, public health measures restricting movement reinforce and socially legitimize isolation and coercive control tactics enacted by perpetrators of abuse. The purpose of this study was to understand the impacts of COVID-19, including the impacts of movement restrictions (i.e., shelter in place orders, quarantine, isolation orders) on experiences of IPV from the perspective of survivors. METHODS: In-depth interviews were conducted with ten survivors who presented at a large, public hospital or sought community IPV resources (i.e., domestic violence shelter, therapy services) in Atlanta, Georgia between March and December 2020. Thematic analysis was carried out to describe the impact of COVID-19 movement restrictions on IPV and help-seeking behaviors among survivors, in addition to identifying resources to improve IPV response during pandemics. RESULTS: Through discussion of their experiences, survivors indicated how movement restrictions, social distancing measures, and the repercussions of the pandemic influenced their relationship challenges, including the occurrence of new or a higher frequency and/or severity of IPV episodes. Survivors cited relationship challenges that were amplified by either movement restrictions or consequences of COVID-19, including reinforced control tactics, and increased financial or life stressors resulting from the pandemic. COVID-19 movement restrictions catalyzed new relationships quickly and sparked new or intensified violence in existing relationships, revealing gaps in IPV support services. CONCLUSION: These findings suggest COVID-19 movement restrictions and social distancing measures amplify IPV and experiences of trauma due to new or exacerbated relationship challenges. Further, results highlight how partners cited COVID-19 movement restrictions to justify methods of coercive control. Public health professionals engaged in pandemic preparedness must give serious consideration to how social distancing measures may amplify trauma in those experiencing IPV.

Do Gender Differences Exist Among Victims of Head and Neck Injuries due to Intimate Partner Violence?

PURPOSE: The frequency of intimate partner violence (IPV) is much lower in males than females. Data regarding IPV-related injuries patterns and characteristics in males are scant. The purpose of this study was to characterize and compare patterns of IPV-related head and neck injuries between men and women. MATERIALS AND METHODS: This cross-sectional study reviewed cases of IPV at Grady Memorial Hospital in Atlanta, Georgia from January 2016 to August 2019. The study sample was collected from electronic medical records by identifying IPV subjects using a natural language processing algorithm and then cross-referencing the trauma registry to identify patients who sustained head and neck injuries. The primary analyses of interest were to measure the association between gender and the following covariates: age, race, insurance status, setting of injury, day of injury, social history, report of physical abuse, mechanism of injury, injury location, brain injuries, soft tissue injuries, facial fractures, other associated injuries, Glasgow Coma Scale, Injury Severity Score, hospital length of stay, intensive care unit length of stay, and discharge status. Univariate and bivariate analyses were calculated. Statistical significance was P < .05. RESULTS: One hundred fifty six patients met inclusion criteria. There were 120 (76.9%) female patients with a mean age of 34.5 years (range, 16 to 67 years). There were 36 (23%) male patients with a mean age of 43.8 years (range, 18 to 77 years). Women were statistically more likely than men to have government-subsidized insurance (47 [39.2%] vs 7 [19.4%]; P = .03), positive alcohol exposure (27 [22.5%] vs 19 [52.8%]; P = .0001), positive illicit drugs toxicology screen (25 [20.8%] vs 13 [36.1%]; P < .02), report physical abuse (24 [20%] vs 0; P = .004), have subarachnoid hemorrhage (14 [11.7%] vs 0; P = .04), and/or lower extremity injuries (39 [32.5%] vs 5 [13.9%]; P = .03). CONCLUSION: Males tend not to report physical abuse; this behavior contributes to IPV under-reporting in males.

National Awards and Female Emergency Physicians in the United States: Is the "Recognition Gap" Closing?

BACKGROUND: Gender inequities in recognition, compensation, promotion, and leadership roles exist in emergency medicine. Formal recognition in the workplace and opportunities for advancement are vulnerable to bias. OBJECTIVE: To examine the gender distribution of national awards in emergency medicine, to analyze whether there is a gap, and to highlight notable trends. METHODS: Recipients of the major award categories between 2001 and 2020 were examined for the 3 main national emergency medicine organizations. The gender distribution of award winners by year was compared with the gender distribution of female faculty in emergency medicine departments using data from the Association of American Medical Colleges and a chi-squared analysis. RESULTS: The gender gap in award winners has decreased over time, but men are still disproportionately given national awards over women. In all 3 organizations, women represented a smaller proportion of award winners than men when compared with the national proportion of women in academic emergency medicine. Advocacy awards were the one category where women were more likely to be recognized. Women were notably least likely to receive clinical and leadership awards. CONCLUSIONS: The gender gap in emergency medicine awards has narrowed in the last 20 years but still exists. This discrepancy is an example of how bias can compound over time to generate gaps in recognition, career advancement, and promotion. The pipeline to award nominations should be addressed at the individual, departmental, awards committee, and organizational levels. © 2021 Elsevier Inc.

Medical Mismanagement in Southern US Immigration and Customs Enforcement Detention Facilities: A Thematic Analysis of Secondary Medical Records.

Detention facilities in the southern US hold a large percentage of individuals detained in the US and have amassed numerous reports of medical mismanagement. The purpose of this study was to evaluate expert declarations of individuals residing in these facilities to assess the appropriateness of medical care provided. We analyzed 38 medical expert declarations from individuals in detention from 2020 to 2021. A thematic analysis was conducted to explore the management of medical conditions. Major themes include inadequate workup, management and treatment of medical conditions, psychiatric conditions, and medical symptoms. Subthemes identified include incorrect workup, failure to refer to a specialist, incorrect medications and/or treatments, missed or incorrect diagnoses, and exacerbation of chronic conditions. This study supports growing evidence of medical mismanagement and neglect of individuals while in immigration detention. Enhanced oversight and accountability around medical care in these facilities is critical to ensure the quality of medical care delivered meets the standard of care.

Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research.

AIMS: Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS: A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS: A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS: As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.

A Novel Technique to Identify Intimate Partner Violence in a Hospital Setting.

INTRODUCTION: Intimate partner violence (IPV) is defined as sexual, physical, psychological, or economic violence that occurs between current or former intimate partners. Victims of IPV may seek care for violence-related injuries in healthcare settings, which makes recognition and intervention in these facilities critical. In this study our goal was to develop an algorithm using natural language processing (NLP) to identify cases of IPV within emergency department (ED) settings. METHODS: In this observational cohort study, we extracted unstructured physician and advanced practice provider, nursing, and social worker notes from hospital electronic health records (EHR). The recorded clinical notes and patient narratives were screened for a set of 23 situational terms, derived from the literature on IPV (ie, assault by spouse), along with an additional set of 49 extended situational terms, extracted from known IPV cases (ie, attack by spouse). We compared the effectiveness of the proposed model with detection of IPV-related International Classification of Diseases, 10th Revision, codes. RESULTS: We included in the analysis a total of 1,064,735 patient encounters (405,303 patients who visited the ED of a Level I trauma center) from January 2012-August 2020. The outcome was identification of an IPV-related encounter. In this study we used information embedded in unstructured EHR data to develop a NLP algorithm that employs clinical notes to identify IPV visits to the ED. Using a set of 23 situational terms along with 49 extended situational terms, the algorithm successfully identified 7,399 IPV-related encounters representing 5,975 patients; the algorithm achieved 99.5% precision in detecting positive cases in our sample of 1,064,735 ED encounters. CONCLUSION: Using a set of pre-defined IPV-related terms, we successfully developed a novel natural language processing algorithm capable of identifying intimate partner violence.

WOMen profEssioNal developmenT oUtcome Metrics in Academic Emergency Medicine: Results from the WOMENTUM Modified Delphi Study.

INTRODUCTION: To address persistent gender inequities in academic medicine, women professional development groups (PDG) have been developed to support the advancement of women in medicine. While these programs have shown promising outcomes, long-term evaluative metrics do not currently exist. The objective of this study was to establish metrics to assess women's PDGs. METHODS: This was a modified Delphi study that included an expert panel of current and past emergency department (ED) chairs and Academy for Women in Academic Emergency Medicine (AWAEM) presidents. The panel completed three iterative surveys to develop and rank metrics to assess women PDGs. Metrics established by the expert panel were also distributed for member-checking to women EM faculty. RESULTS: The expert panel ranked 11 metrics with high to moderate consensus ranking with three metrics receiving greater than 90% consensus: gender equity strategy and plan; recruitment; and compensation. Members ranked 12 metrics with high consensus with three metrics receiving greater than 90% consensus: gender equity strategy and plan; compensation; and gender equity in promotion rates among faculty. Participants emphasized that departments should be responsible for leading gender equity efforts with PDGs providing a supportive role. CONCLUSION: In this study, we identified metrics that can be used to assess academic EDs' gender equity initiatives and the advisory efforts of a departmental women's PDG. These metrics can be tailored to individual departmental/institutional needs, as well as to a PDG's mission. Importantly, PDGs can use metrics to develop and assess programming, acknowledging that many metrics are the responsibility of the department rather than the PDG.

Barriers to Accessing Acute Care for Newly Arrived Refugees.

INTRODUCTION: Over the past decade, the number of refugees arriving in the United States (U.S.) has increased dramatically. Refugees arrive with unmet health needs and may face barriers when seeking care. However, little is known about how refugees perceive and access care when acutely ill. The goal of this study was to understand barriers to access of acute care by newly arrived refugees, and identify potential improvements from refugees and resettlement agencies. METHODS: This was an in-depth, qualitative interview study of refugees and employees from refugee resettlement and post-resettlement agencies in a city in the Northeast U.S. Interviews were audiotaped, transcribed, and coded independently by two investigators. Interviews were conducted until thematic saturation was reached. We analyzed transcripts using a modified grounded theory approach. RESULTS: Interviews were completed with 16 refugees and 12 employees from refugee resettlement/post-resettlement agencies. Participants reported several barriers to accessing acute care including challenges understanding the U.S. healthcare system, difficulty scheduling timely outpatient acute care visits, significant language barriers in all acute care settings, and confusion over the intricacies of health insurance. The novelty and complexity of the U.S. healthcare system drives refugees to resettlement agencies for assistance. Resettlement agency employees express concern with directing refugees to appropriate levels of care and report challenges obtaining timely access to sick visits. While receiving emergency department (ED) care, refugees experience communication barriers due to limitations in consistent interpretation services. CONCLUSION: Refugees face multiple barriers when accessing acute care. Interventions in the ED, outpatient settings, and in resettlement agencies, have the potential to reduce barriers to care. Examples could include interpretation services that allow for clinic phone scheduling and easier access to interpreter services within the ED. Additionally, extending the Refugee Medical Assistance program may limit gaps in insurance coverage and avoid insurance-related barriers to seeking care.

Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department.

BACKGROUND: Transesophageal echocardiography (TEE) has been proposed as a modality to assess patients in the setting of cardiac arrest, both during resuscitation care and following return of spontaneous circulation (ROSC). In this study we aimed to assess the feasibility and clinical impact of TEE during the emergency department (ED) evaluation during out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: We conducted a prospective observational study consisting of a convenience sample of adult patients presenting to the ED of an urban university medical center with non-traumatic OHCA. TEE was performed by emergency physicians following intubation. Images and clinical data were analyzed. TEE was used intra-arrest in order to assist in diagnosis, assess cardiac activity and determine CPR quality by assessing area of maximal compression (AMC), using a 4 view protocol. RESULTS: A total of 33 OHCA patients were enrolled over a one-year period, 21 patients (64%) presented with ongoing CPR and 12 (36%) presented with ROSC. The 4-view protocol was completed in 100% of the cases, with an average time from ED arrival to TEE of 12 min (min 3 max 30 SD 8.16). Fine ventricular fibrillation (VF) was recognized in 4 (12%) cases thought to be in asystole, leading to defibrillation, and 2 cases of pseudo-PEA were identified. Right ventricular (RV) dilation, was seen in 12 (57%) intraarrest cases. Intra-cardiac thrombus was found in one case, leading to thrombolysis. The AMC was identified over the aortic root or LVOT in 53% of cases. TEE was found to have diagnostic, therapeutic or prognostic clinical impact in 32 of the 33 cases (97%). CONCLUSIONS: TEE is feasible and clinically impactful during OHCA management. Resuscitative TEE may allow for characterization of cardiac activity, including identification of pseudo-PEA and fine VF, determination of reversible pathology, and optimization of CPR quality.

Implicit Bias Education and Emergency Medicine Training: Step One? Awareness.

OBJECTIVE: Prior research suggests that health care providers are susceptible to implicit biases, specifically prowhite biases, and that these may contribute to health care disparities by influencing physician behavior. Despite these findings, implicit bias training is not currently embedded into emergency medicine (EM) residency training and few studies exist that evaluate the effectiveness of implicit bias training on awareness during residency conference. We sought to conduct a mixed-methods program evaluation of a formalized educational intervention targeted on the topic of implicit bias. METHODS: We used a design thinking framework to develop a curricular intervention. The intervention consisted of taking the Harvard Implicit Association Test (IAT) on race to introduce the concept of implicit bias, followed by a facilitated discussion to explore participant's perceptions on whether implicit bias may lead to variations in care. The facilitated discussion was audio recorded, transcribed, and coded for emerging themes. An online survey assessed participant awareness of these topics before and after the intervention and was analyzed using paired t-tests. RESULTS: After the intervention, participant's awareness of their individual implicit biases increased by 33.3% (p = 0.003) and their awareness of how their IAT results influences how they deliver care to patients increased by 9.1% (p = 0.03). Emerging themes included skepticism of the implicit bias test results with the desire to have "neutral" results, acknowledgment that pattern recognition may lead to "blind spots" in care, recognition that bias exists on a personal and systemic level, and interest in regular educational interventions to address implicit bias. CONCLUSIONS: This novel educational intervention on implicit bias resulted in improvement in participants' awareness of their implicit biases and how it may affect their patient care. Our intervention can serve as a model for other residency programs to develop and implement an intervention to create awareness of implicit bias and its potential impact on patient care.