HEAL Network

Abstract

Background ST-segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door-to-ECG (D2E) time of 10minutes. Methods and Results This 3-year descriptive retrospective cohort study, including 676 ED-diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10minutes. We also identified characteristics associated with D2E>10minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7minutes (IQR:4-16; range: 0-1407minutes; range of ED medians: 5-11minutes). Proportion of patients with D2E>10minutes was 37.9% (ED range: 21.5%-57.1%). Patients with D2E>10minutes, compared to those with D2E≤10minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non-English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%. Conclusions Examining D2E>10minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.

View details for DOI 10.1161/JAHA.121.024067

View details for PubMedID 35492001

Abstract

Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting ED-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.

View details for DOI 10.1111/acem.14513

View details for PubMedID 35475533

Abstract

Emergency departments face unforeseen surges in patients classified as low acuity during pandemics such as the coronavirus disease pandemic. Streamlining patient flow using telemedicine in an alternative care area can reduce crowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment use. This quality improvement project describes critical elements and processes in the operationalization of a telemedicine-enabled drive-through and walk-in garage care system to improve ED throughput and conserve personal protective equipment during 3 coronavirus disease surges in 2020.Standardized workflows were established for the operationalization of the telemedicine-enabled drive-through and walk-in garage care system for patients presenting with respiratory illness as quality improvement during disaster. Statistical control charts present interrupted time series data on the ED length of stay and personal protective equipment use in the week before and after deployment in March, July, and November 2020.Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the telemedicine-enabled drive-through and walk-in garage care system. On average, the ED length of stay decreased 17%, from 4.24 hours during the week before opening to 3.54 hours during the telemedicine-enabled drive-through and walk-in garage care system operation. There was an estimated 25% to 41% reduction in personal protective equipment use during this time.Lessons learned from this telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce crowding, improve throughput, and conserve personal protective equipment during a pandemic.

View details for DOI 10.1016/j.jen.2021.05.010

View details for Web of Science ID 000762175400001

View details for PubMedID 34303530

View details for PubMedCentralID PMC8173460

Abstract

Background: Observational analyses have noted an association between obesity and poor clinical outcome from Coronavirus Disease 2019 (COVID-19). The mechanism for this finding remains unclear.Methods: We analyzed data from 22,915 COVID-19 patients hospitalized in non-intensive care units using the American Heart Association National COVID Registry of adult COVID-19 admissions from March 2020 to April 2021. A multivariable Poisson model adjusted for age, sex, medical history, admission respiratory status, hospitalization characteristics, and select laboratory findings was used to calculate length of stay (LOS) as a function of body mass index (BMI) category. Additionally, 5,327 patients admitted to intensive care units were similarly analyzed for comparison.Results: Relative to normal BMI subjects, overweight, class I obese, and class II obese patients had approximately half-day reductions in LOS (-0.469 days, P<0.01; -0.480 days, P<0.01; -0.578 days, P<0.01, respectively).Conclusion: The model identified a dose-dependent, inverse relationship between BMI category and LOS for COVID-19, which was not seen when the model was applied to critically ill patients.

View details for DOI 10.7570/jomes22042

View details for PubMedID 36058896

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is a major causal risk factor for ASCVD. Current evidence overwhelmingly demonstrates that lowering LDL-C reduces the risk of secondary cardiovascular events in patients with previous myocardial infarction or stroke. There is no lower limit for LDL-C: large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL. As 'Time is plaque' in patients with ASCVD, early, sustained reductions in LDL-C are critical to slow or halt disease progression. However, despite use of lipid-lowering medications, <30% of patients with ASCVD achieve guideline-recommended reductions in LDL-C, resulting in a substantial societal burden of preventable cardiovascular events and early mortality. LDL-C goals are not met due to several factors: lipid-lowering therapy is not initiated and intensified as directed by clinical guidelines (clinical inertia); most patients do not adhere to prescribed medications; and high-risk patients are frequently denied access to add-on therapies by their insurance providers. Promoting patient and clinician education, multidisciplinary collaboration, and other interventions may help to overcome these barriers. Ultimately, achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers.

View details for DOI 10.1080/00325481.2022.2117498

View details for PubMedID 36004573

Abstract

Background Social and environmental factors play an important role in the rising health care burden of cardiovascular disease. The Centers for Disease Control and Prevention developed the Social Vulnerability Index (SVI) from US census data as a tool for public health officials to identify communities in need of support in the setting of a hazardous event. SVI (ranging from a least vulnerable score of 0 to a most vulnerable score of 1) ranks communities on 15 social factors including unemployment, minoritized groups status, and disability, and groups them under 4 broad themes: socioeconomic status, housing and transportation, minoritized groups, and household composition. We sought to assess the association of SVI with self-reported prevalent cardiovascular comorbidities and atherosclerotic cardiovascular disease (ASCVD). Methods and Results We performed a retrospective cohort analysis of adults (≥18years) in the Behavioral Risk Factor Surveillance System 2016 to 2019. Data regarding self-reported prevalent cardiovascular comorbidities (including diabetes, hypertension, hyperlipidemia, smoking, substance use), and ASCVD was captured using participants' response to a structured telephonic interview. We divided states on the basis of the tertile of SVI (first-participant lives in the least vulnerable group of states, 0-0.32; to third-participant lives in the most vulnerable group of states, 0.54-1.0). Multivariable logistic regression models adjusting for age, race and ethnicity, sex, employment, income, health care coverage, and association with federal poverty line were constructed to assess the association of SVI with cardiovascular comorbidities. Our study sample consisted of 1745999 participants ≥18years of age. States in the highest (third) tertile of social vulnerability had predominantly Black and Hispanic adults, lower levels of education, lower income, higher rates of unemployment, and higher rates of prevalent comorbidities including hypertension, diabetes, chronic kidney disease, hyperlipidemia, substance use, and ASCVD. In multivariable logistic regression models, individuals living in states in the third tertile of SVI had higher odds of having hypertension (odds ratio (OR), 1.14 [95% CI, 1.11-1.17]), diabetes (OR, 1.12 [95% CI, 1.09-1.15]), hyperlipidemia (OR, 1.09 [95% CI, 1.06-1.12]), chronic kidney disease (OR, 1.17 [95% CI, 1.12-1.23]), smoking (OR, 1.05 [95% CI, 1.03-1.07]), and ASCVD (OR, 1.15 [95% CI, 1.12-1.19]), compared with those living in the first tertile of SVI. Conclusions SVI varies across the US states and is associated with prevalent cardiovascular comorbidities and ASCVD, independent of age, race and ethnicity, sex, employment, income, and health care coverage. SVI may be a useful assessment tool for health policy makers and health systems researchers examining multilevel influences on cardiovascular-related health behaviors and identifying communities for targeted interventions pertaining to social determinants of health.

View details for DOI 10.1161/JAHA.121.024414

View details for PubMedID 35904206

View details for DOI 10.1016/j.jacc.2022.05.014

View details for PubMedID 35835499

Abstract

Importance: Patient safety reporting systems (PSRSs) are designed to decrease the risk of harm to patients due to medical errors. Owing to the voluntary nature of PSRSs, implicit bias of the reporter may affect the management of safety events reported. Stanford Alert For Events (SAFE) is the PSRS used at Stanford Health Care.Objective: To examine whether variation exists in the content of SAFE reports based on demographic characteristics of physicians who are the subject of the event report.Design, Setting, and Participants: This retrospective qualitative analysis from a single academic medical center evaluated SAFE reports from March 2011 to February 2020. Event reports were coded by theme and categorized by severity (scale of 1 to 3, with 1 being the lowest and 3 the highest). The reports were then analyzed from October 2020 to February 2022 and categorized by physician gender, race and ethnicity, and faculty rank. A total of 501 patient safety events were collected from the adult hospital during the study period, and 100 were excluded owing to incompleteness of information.Main Outcomes and Measures: This qualitative study had no planned outcome.Results: A qualitative analysis was performed on 401 reports representing 187 physicians (138 [73.8%] male and 49 [26.2%] female). In terms of race and ethnicity, 4 physicians (2.1%) were African American, 49 (26.2%) were Asian; 7 (3.7%), Hispanic or Latinx; 108 (57.7%), White; and 19 (10.2%), declined to state. Female physicians had disproportionate representation among reports referencing communication and conversational issues and the lowest severity level. Male physicians had disproportionate representation for ignoring or omitting procedures, process issues, and physical intimidation. African American physicians had disproportionate representation for lack of communication and process issues. Asian physicians had disproportionate representation for lack of communication, process issues, conversational conduct, and the lowest severity level. Latinx physicians had disproportionate representation for conversational conduct. White physicians had disproportionate representation for ignoring or omitting procedures, verbal abuse, physical intimidation, and the highest severity level.Conclusions and Relevance: In this qualitative study, female physicians and physicians who were members of racial and ethnic minority groups were more likely to be reported for low-severity communication issues compared with their male and White counterparts, respectively. These findings suggest that there may be a lower threshold for reporting events when the subject of the report is female and/or a member of a racial or ethnic minority group. Restructuring the reporting and management of patient safety events may be needed to facilitate conflict resolution in a manner that reduces implicit bias and fosters team cohesion.

View details for DOI 10.1001/jamanetworkopen.2022.13234

View details for PubMedID 35594045

Abstract

OBJECTIVES: Despite evidence of the central importance of communication to patient experience, health outcomes, and provider wellness, communication training for clinicians is not a standard part of clinical education. The study explores the impact of an 8-hour relationship-centered communication (RCC) training program on patient experience and provider wellness.METHODS: 636 healthcare providers participated in 48 workshops conducted January-August 2018. 481 (76%) agreed to participate in research. Participants completed a pre/post assessment that included a wellness survey, the Professional Fulfillment Index (PFI). We conducted chi-squared analyses comparing wellness data immediately prior to the course to 3 months following course participation. Patient experience, assessed using Press Ganey likelihood to recommend care provider (PG-LTR CP) scores, were examined prior to an individual's course participation and following participation up to September 2019.RESULTS: 104 participants completed the three-month PFI (22% response rate). Participants demonstrated marked improvements in professional wellness after 3 months. In bivariate analyses, PG-LTRCP significantly increased and persisted more than 7 months following program completion.CONCLUSIONS: The RCC training program, a low-cost communication intervention, led to significant, beneficial changes in provider wellness and patient experience.PRACTICE IMPLICATIONS: Implementing a RCC course for providers may improve patient experience and provider wellness.

View details for DOI 10.1016/j.pec.2021.10.025

View details for PubMedID 34772532

Abstract

Women physicians and those from racial and ethnic groups underrepresented in medicine face unique barriers to career advancement in academic medicine, especially in specialties that lack diversity such as radiology. One such barrier is the effect of unconscious bias on the ability of faculty from these groups to find effective sponsors. Given the central role of sponsorship in career advancement, departments are called upon to implement formal sponsorship programs to address inequities stemming from bias.

View details for DOI 10.2214/AJR.21.26481

View details for PubMedID 34467782

Abstract

BACKGROUND: Faculty diversity is a high-priority goal for academic emergency medicine. Most administrators currently monitor faculty diversity using aggregate data, which may obscure underrepresentation by rank. We apply the Rank Equity Index (REI), to EM faculty data to assess rank progression.METHODS: We calculated the REI (% faculty cohort higher rank / % faculty cohort lower rank) for EM faculty. We performed REI analyses by faculty gender (women, men) and race/ethnicity (white, Black, Hispanic/Latinx, Asian). We compared: Professor/ Assistant Professor, Professor/ Associate Professor, and Associate Professor/ Assistant Professor to establish rank parity for gender and race/ethnicity. Parity is an REI of 1.0.RESULTS: REI analysis by gender demonstrates that women faculty did not achieve parity at any rank comparison in any study year. REI analysis by race/ethnicity demonstrates that all faculty of color are below parity at the assistant to associate professor promotion. Latinx faculty are at parity for associate professor to professor, but Asian and Black faculty do not achieve parity in any comparison. Intersecting gender and race/ethnicity in the REI analysis demonstrates that Asian women have the lowest REIs among all faculty ranks and races/ethnicities. Men of all races/ethnicities achieved parity in two of three rank comparisons, except for Black men, who did not achieve parity in any comparison.CONCLUSIONS: REI analysis demonstrates EM women faculty and faculty of color are not achieving rank parity and are disadvantaged at the first tier of promotion. A preliminary longitudinal trend analysis suggests little progress. Asian women and Black men experience the most rank inequity. REI analysis identifies a need for focused faculty development to enhance our most vulnerable faculty's rank progression, suggesting that targeted recruitment and retention efforts of women faculty of all races/ethnicities and faculty of color, in particular, will improve diversity at every tier of faculty rank.

View details for DOI 10.1111/acem.14268

View details for PubMedID 33909327

Abstract

BACKGROUND: Patient-reported satisfaction scores, including the Press Ganey surveys, are increasingly used as measures for quality healthcare among surgical subspecialties. However, the influence of surgeon sociodemographics is not clear.METHODS: This cross-sectional study analyzed Press Ganey surveys linked to outpatient surgical visits at a single academic institution from January 2015 to December 2018 as they related to surgeon age, gender, and race. The primary outcome variable was achievement of a top-box score (5/5) on likelihood to recommend surgeon queries. Secondary analysis examined the relationship of likelihood to recommend surgeon to other survey questions, such as those regarding surgeon courtesy, concern, understandability, patient inclusion in medical decision making, and patient confidence in surgeon. chi2 tests and generalized estimating equation regression models were run to assess correlation.RESULTS: In bivariate analysis of 36,840 surveys, non-Hispanic white surgeons were more likely to receive likelihood to recommend surgeon top-box ratings than Asian (P < .001) or underrepresented minority surgeons (P < .001). Additionally, male gender (P < .01) and older surgeon age (P < .001) were associated with higher top-box scores. However, in multivariate generalized estimating equation analysis, the effect of age was no longer significant, but female gender continued to be associated with lower odds of top-box likelihood to recommend surgeon ratings (odds ratio 0.83; 95% confidence interval, 0.70%-0.99%), as did Asian compared with white race (odds ratio 0.78; 95% confidence interval, 0.65%-0.95%). Likelihood to recommend surgeon scores correlated most closely with patients' "confidence" in the surgeon rather than measures of courtesy, concern, understandability, or inclusion in medical decision making.CONCLUSION: Top-box scores varied by surgeon race and gender in correlation with patients' perceived confidence in the provider. Interpretation of Press Ganey scores should account for potential bias in patient satisfaction surveys based on surgeon demographics.

View details for DOI 10.1016/j.surg.2020.12.006

View details for PubMedID 33531133