Assessment and Diagnosis of Mental Illness in EDs Among Individuals Without a Home: Findings from the National Hospital Ambulatory Care Survey

Introduction: Homeless individuals lack resources for primary healthcare and as a result use the emergency department (ED) as a social safety net. Our primary objective in this study was to identify the differences between features of visits to United States (US) EDs made by patients without a home and patients who live in a private residence presenting with mental health symptoms or no mental health symptoms at triage. Methods: Data for this study come from the 2009-2017 National Health and Ambulatory Medical Care Survey, a nationally representative cross-sectional survey of ED visits in the US. We examined differences in waiting time, length of visit, and triage score among homeless patients, and privately housed and nursing home residents. We used logistic regression to determine the odds of receiving a mental health diagnosis. Residence, age, gender, race, urgency, and whether the person was seen in the ED in the previous 72 hours were controlled. Results: Homeless individuals made up less than 1% of all ED visits during this period. Of these visits, 47.2% resulted in a mental health diagnosis compared to those who live in a private residence. Adjusting for age, race, gender, triage score, and whether the person had been seen in the prior 72 hours, homeless individuals were still six times more likely to receive a mental health diagnosis despite reporting no mental health symptoms compared to individuals who lived in a private residence. Homeless individuals reporting mental health symptoms were two times more likely to receive a mental health diagnosis compared to privately housed and nursing home residents. Conclusions: Homeless individuals are more likely to receive a mental health diagnosis in the ED whether or not they present with mental health symptoms at triage. This study suggests that homelessness as a status impacts how these individuals receive care in the ED. Community coordination is needed to expand treatment options for individuals experiencing emergent mental health symptoms.

This Article Corrects: “The Effects of Implementing a “Waterfall” Emergency Physician Attending Schedule”

N/A

Accuracy of Landmark-guided Glenohumeral Joint Injections as Assessed by Ultrasound in Anterior Shoulder Dislocations

Introduction: To determine the accuracy of landmark-guided shoulder joint injections (LGI) with point-of-care ultrasound for patients with anterior shoulder dislocations. Methods: Patients with anterior shoulder dislocations who underwent LGI were enrolled at our tertiary-care and trauma center. LGI attempts were recorded by an ultrasound fellowship-trained ED physician who determined if they were placed successfully. Pain and satisfaction scores were recorded. Results: A total of 34 patients with anterior shoulder dislocation and their treating ED physicians were enrolled. 41.1% of all LGI were determined to be misplaced (n=14). Patients with successful LGI had a greater decrease in mean pain scores post-LGI. Conclusions: LGI had a substantial failure rate in our study. Using ultrasound-guidance to assist intra-articular injections may increase its accuracy and thus reduce pain and the need for subsequent procedural sedation.

“Friction by Definition”: Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center

Introduction: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. Methods: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. Results: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). Conclusions: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

Survey-based Evaluation of Resident and Attending Financial Literacy

Introduction: Physician finances are linked to wellness and burnout. However, few physicians receive financial management education. We sought to determine the financial literacy and educational need of attending and resident physician at an academic emergency medicine (EM) residency. Methods: We performed a cross-sectional, survey study at an academic EM residency. We devised a 49-question survey with four major domains: demographics (16 questions); Likert-scale questions evaluating value placed on personal finances (3 questions); Likert-scale questions evaluating perceived financial literacy (11 questions); and a financial literacy test based on previously developed and widely used financial literacy questions (19 questions). We administered the survey to EM attendings and residents. We analyzed the data using descriptive statistics and compared attending and resident test question responses. Results: A total of 44 residents and 24 attendings responded to the survey. Few (9.0% of residents, 12.5% of attendings) reported prior formal financial education. However, most respondents (70.5% of residents and 79.2% of attendings) participated in financial self-learning. On a five-point Likert scale (not at all important: very important), respondents felt that financial independence (4.7 ± 0.8) and their finances (4.7±0.8) were important for their well-being. Additionally, they valued being prepared for retirement (4.7±0.9). Regarding perceived financial literacy (very uncomfortable: very comfortable), respondents had the lowest comfort level with investing in the stock market (2.7±1.5), applying for a mortgage (2.8±1.6), and managing their retirement (3.0±1.4). Residents scored significantly lower than attendings on the financial literacy test (70.8% vs 79.6%, P<0.01), and residents scored lower on questions pertaining to investment (78.8% v 88.9%, P<0.01) and insurance and taxes (47.0% v 70.8%, P<0.01). Overall, respondents scored lower on questions about retirement (58.8%, P<0.01) and insurance and taxes (54.7%, P<0.01). Conclusion: Emergency physicians’ value of financial literacy exceeded confidence in financial literacy, and residents reported poorer confidence than attendings. We identified deficiencies in emergency physicians’ financial literacy for retirement, insurance, and taxes.

A Retrospective Cohort Study of Acute Epiglottitis in Adults

Introduction: Adult epiglottitis is a disease process distinct from pediatric epiglottitis in microbiology, presentation, and clinical course. While traditionally considered more indolent and benign than in children, adult epiglottitis remains a cause of acute airway compromise with a mortality rate from 1-20%. Our objective was to characterize the disease course and evaluate the rate and type of airway management in this population at a tertiary, academic referral center. Methods: We conducted a retrospective chart review of all adult patients (age ≥ 18) who were definitively diagnosed with infectious “epiglottitis,” “supraglottitis,” or “epiglottic abscess” by direct or indirect laryngoscopy during a nine-year period. Double data abstraction and a standardized data collection form were used to assess patient demographic characteristics, presenting features, and clinical course. The primary outcome was airway intervention by intubation, cricothyroidotomy, or tracheostomy, and the secondary outcome was mortality related to the disease. Results: Seventy patients met inclusion criteria. The mean age was 50.2 years (standard deviation ± 16.7), 60% of the patients were male, and 14.3% were diabetic. Fifty percent had symptoms that were present for ≥ 48 hours; 38.6% had voice changes, 13.1% had stridor, 12.9% had fever, 45.7% had odynophagia, and 47.1% had dysphagia noted in the ED. Twelve patients (17.1%) received an acute airway intervention including three who underwent emergent cricothyroidotomy, and one who had a tracheostomy. Two patients died and one suffered anoxic brain injury related to complications following difficult airway management. Conclusion: In this case series the majority of patients (82.9%) did not require airway intervention, but a third of those requiring intervention (5.7% of total) had a surgical airway performed with two deaths and one anoxic brain injury. Clinicians must remain vigilant to identify signs of impending airway compromise in acute adult epiglottitis and be familiar with difficult and failed airway algorithms to prevent morbidity and mortality in these patients.

Clinical Characteristics Associated with Return Visits to the Emergency Department after COVID-19 Diagnosis

Introduction: Patients diagnosed with coronavirus disease 2019 (COVID-19) require significant healthcare resources. While published research has shown clinical characteristics associated with severe illness from COVID-19, there is limited data focused on the emergency department (ED) discharge population. Methods: We performed a retrospective chart review of all ED-discharged patients from Wake Forest Baptist Health and Wake Forest Baptist Health Davie Medical Center between April 25-August 9, 2020, who tested positive for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) from a nasopharyngeal swab using real-time reverse transcription polymerase chain reaction (rRT-PCR) tests. We compared the clinical characteristics of patients who were discharged and had return visits within 30 days to those patients who did not return to the ED within 30 days. Results: Our study included 235 adult patients who had an ED-performed SARS-CoV-2 rRT-PCR positive test and were subsequently discharged on their first ED visit. Of these patients, 57 (24.3%) had return visits to the ED within 30 days for symptoms related to COVID-19. Of these 57 patients, on return ED visits 27 were admitted to the hospital and 30 were not admitted. Of the 235 adult patients who were discharged, 11.5% (27) eventually required admission for COVID-19-related symptoms. With 24.3% patients having a return ED visit after a positive SARS-CoV-2 test and 11.5% requiring eventual admission, it is important to understand clinical characteristics associated with return ED visits. We performed multivariate logistic regression analysis of the clinical characteristics with independent association resulting in a return ED visit, which demonstrated the following: diabetes (odds ratio [OR] 2.990, 95% confidence interval [CI, 1.21-7.40, P = 0.0179); transaminitis (OR 8.973, 95% CI, 2.65-30.33, P = 0.004); increased pulse at triage (OR 1.04, 95% CI, 1.02-1.07, P = 0.0002); and myalgia (OR 4.43, 95% CI, 2.03-9.66, P = 0.0002). Conclusion: As EDs across the country continue to treat COVID-19 patients, it is important to understand the clinical factors associated with ED return visits related to SARS-CoV-2 infection. We identified key clinical characteristics associated with return ED visits for patients initially diagnosed with SARS-CoV-2 infection: diabetes mellitus; increased pulse at triage; transaminitis; and complaint of myalgias.

Food Insecurity in a Pediatric Emergency Department and the Feasibility of Universal Screening

Introduction: Children with food insecurity (FI) experience adverse health outcomes due to inadequate quantity or quality of food. Food insecurity may be high among families seeking emergency care. The Hunger Vital Sign (HVS) is a two-question validated tool used to screen families for FI. Our goal in this study was to assess prevalence of FI among emergency department (ED) patients, patient-level risk factors for FI, and the feasibility of screening. Methods: This was a cross-sectional analysis of FI in the ED. Parents or guardians of ED patients and adult patients (18 years or older) were approached for screening using the HVS during screening periods spanning weekdays/weekends and days/evenings. All ED patients were eligible, excluding siblings, repeat visits, critically ill patients, minors without a guardian, and families that healthcare staff asked us not to disturb. Families answered the HVS questions verbally or in writing, based on preference. Families with positive screens received information about food resources. We summarized patient and visit characteristics and defined medical complexity using a published algorithm. Multivariable logistic regression was used to assess FI risk factors. Results: In July-August 2019, 527 patients presented during screening periods: 439 agreed to screening, 18 declined, 19 met exclusions, and 51 were missed. On average the screening tool required five minutes (range 3-10 minutes) to complete. Most families (328; 75%) preferred to answer in writing rather than verbally. Overall, 77 participants (17.5%) screened positive for FI. In regression analyses, FI was associated with self-reported race/ethnicity (combined variable) of African American or Black (odds ratio [OR] 5.21, 95% confidence interval [CI], 2.13-12.77), Hispanic (OR 3.47, 95% CI, 1.48-8.15), or mixed/other (OR 3.81, 95% CI, 1.54-9.39), compared to non-Hispanic white. FI was also associated with public insurance type (OR 5.74, 95% CI, 2.52-13.07, reference: private insurance), and each year of increasing patient age (OR 1.05, 95% CI, 1.01-1.09). There were no associations between FI and medical complexity or preferred language. Conclusion: Food insecurity was common among our ED patients. Race and ethnicity, insurance status, and increasing patient age were associated with increased odds of FI. Efforts to include universal FI screening for ED patients with immediate connection to resources will enhance overall care quality and address important health needs.

A Dispatch Screening Tool to Identify Patients at High Risk for COVID-19 in the Prehospital Setting

Introduction: Emergency medical services (EMS) dispatchers have made efforts to determine whether patients are high risk for coronavirus disease 2019 (COVID-19) so that appropriate personal protective equipment (PPE) can be donned. A screening tool is valuable as the healthcare community balances protection of medical personnel and conservation of PPE. There is little existing literature on the efficacy of prehospital COVID-19 screening tools. The objective of this study was to determine the positive and negative predictive value of an emergency infectious disease surveillance tool for detecting COVID-19 patients and the impact of positive screening on PPE usage. Methods: This study was a retrospective chart review of prehospital care reports and hospital electronic health records. We abstracted records for all 911 calls to an urban EMS from March 1–July 31, 2020 that had a documented positive screen for COVID-19 and/or had a positive COVID-19 test. The dispatch screen solicited information regarding travel, sick contacts, and high-risk symptoms. We reviewed charts to determine dispatch-screening results, the outcome of patients’ COVID-19 testing, and documentation of crew fidelity to PPE guidelines. Results: The sample size was 263. The rate of positive COVID-19 tests for all-comers in the state of Massachusetts was 2.0%. The dispatch screen had a sensitivity of 74.9% (confidence interval [CI], 69.21-80.03) and a specificity of 67.7% (CI, 66.91-68.50). The positive predictive value was 4.5% (CI, 4.17-4.80), and the negative predictive value was 99.3% (CI, 99.09-99.40). The most common symptom that triggered a positive screen was shortness of breath (51.5% of calls). The most common high-risk population identified was skilled nursing facility patients (19.5%), but most positive tests did not belong to a high-risk population (58.1%). The EMS personnel were documented as wearing full PPE for the patient in 55.7% of encounters, not wearing PPE in 8.0% of encounters, and not documented in 27.9% of encounters. Conclusion: This dispatch-screening questionnaire has a high negative predictive value but moderate sensitivity and therefore should be used with some caution to guide EMS crews in their PPE usage. Clinical judgment is still essential and may supersede screening status.

Surgical Treatment of Pediatric Dog-bite Wounds: A 5-year Retrospective Review

Introduction: Dog bites are a significant health concern in the pediatric population. Few studies published to date have stratified the injuries caused by dog bites based on surgical severity to elucidate the contributing risk factors. Methods: We used an electronic hospital database to identify all patients ≤17 years of age treated for dog bites from 2013–2018. Data related to patient demographics, injury type, intervention, dog breed, and payer source were collected. We extracted socioeconomic data from the American Community Survey. Data related to dog breed was obtained from public records on dog licenses. We calculated descriptive statistics as well as relative risk of dog bite by breed. Results: Of 1,252 injuries identified in 967 pediatric patients, 17.1% required consultation with a surgical specialist for repair. Bites affecting the head/neck region were most common (61.7%) and most likely to require operating room intervention (P = 0.002). The relative risk of a patient being bitten in a low-income area was 2.24, compared with 0.46 in a high-income area. Among cases where the breed of dog responsible for the bite was known, the dog breed most commonly associated with severe bites was the pit bull (relative risk vs German shepherd 8.53, relative risk vs unknown, 3.28). Conclusion: The majority of injuries did not require repair and were sufficiently handled by an emergency physician. Repair by a surgical specialist was required <20% of the time, usually for bites affecting the head/neck region. Disparities in the frequency and characteristics of dog bites across socioeconomic levels and dog breeds suggest that public education efforts may decrease the incidence of pediatric dog bites.