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2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and Needs

Yore, Mackensie; Fockele, Callan Elswick; Duber, Herbert C; Doran, Kelly M; Cooper, Richelle J; Lin, Michelle P; Campbell, Steffani; Eswaran, Vidya; Chang, Betty; Hong, Haeyeon; Gbenedio, Kessiena; Stanford, Kimberly A; Gavin, Nicholas
INTRODUCTION/BACKGROUND:Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown. METHODS:Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies. RESULTS:Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability. CONCLUSION/CONCLUSIONS:Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.
PMCID:10047739
PMID: 36976611
ISSN: 1936-9018
CID: 5454082

Comparing the Timeliness of Treatment in Younger vs. Older Patients with ST-Segment Elevation Myocardial Infarction: A Multi-Center Cohort Study

Bloos, Sean M; Kaur, Karampreet; Lang, Kendrick; Gavin, Nicholas; Mills, Angela M; Baugh, Christopher W; Patterson, Brian W; Podolsky, Seth R; Salazar, Gilberto; Mumma, Bryn E; Tanski, Mary; Hadley, Kelsea; Roumie, Christianne; McNaughton, Candace D; Yiadom, Maame Yaa A B
BACKGROUND:ST-segment elevation myocardial infarction (STEMI) predominantly affects older adults. Lower incidence among younger patients may challenge diagnosis. OBJECTIVES/OBJECTIVE:We hypothesize that among patients ≤ 50 years old, emergent percutaneous coronary intervention (PCI) for STEMI is delayed when compared with patients aged > 50 years. METHODS:This 3-year, 10-center retrospective cohort study included emergency department (ED) STEMI patients ≥ 18 years of age treated with emergent PCI. We excluded patients with an electrocardiogram (ECG) completed prior to ED arrival or a nondiagnostic initial ECG. Our primary outcome was door-to-balloon (D2B) time. We compared characteristics and outcomes among younger vs. older STEMI patients, and among age subgroups. RESULTS:There were 576 ED STEMI PCI patients, of whom 100 were ≤ 50 years old and 476 were > 50 years old. Median age was 44 years in the younger cohort (interquartile range [IQR] 41-47) vs. 62 years (IQR 57-70) among older patients. Median D2B time for the younger cohort was 76.5 min (IQR 67.5-102.5) vs. 81.0 min (IQR 65.0-105.5) in the older cohort (p = 0.91). This outcome did not change when ages 40 or 45 years were used to demarcate younger vs. older. The younger cohort had a higher prevalence of nonwhite races (38% vs. 21%; p < 0.001) and those currently smoking (36% vs. 23%; p = 0.005). The very young (≤30 years; 6/576) and very old (>80 years; 45/576) had 5.51 and 2.2 greater odds of delays. CONCLUSION/CONCLUSIONS:We found no statistically significant difference in D2B times between patients ≤ 50 years old and those > 50 years old. Nonwhite patients and those who smoke were disproportionately represented within the younger population. The very young and very old had higher odds of D2B times > 90 min.
PMID: 33676790
ISSN: 0736-4679
CID: 4914412

Novel Use of Telepalliative Care in a New York City Emergency Department During the COVID-19 Pandemic

Flores, Stefan; Abrukin, Liliya; Jiang, Lynn; Titone, Lauren; Firew, Tsion; Lee, Jihae; Gavin, Nicholas; Romney, Marie-Laure; Nakagawa, Shunichi; Chang, Bernard P
BACKGROUND:Coronavirus-2 (COVID-19) is a global pandemic. As of August 21, mortality from COVID-19 has reached almost 200,000 people, with the United States leading the globe in levels of morbidity and mortality. Large volumes of high-acuity patients, particularly those of advanced age and with chronic comorbidities, have significantly increased the need for palliative care resources beyond usual capacity. More specifically, COVID-19 has changed the way we approach patient and family member interactions. DISCUSSION/CONCLUSIONS:Concern for nosocomial spread of this infection has resulted in strict visitation restrictions that have left many patients to face this illness, make difficult decisions, and even die, alone in the hospital. To meet the needs of COVID patients, services such as Emergency Medicine and Palliative Care have responded rapidly by adopting novel ways of practicing medicine. We describe the use of telepalliative medicine (TM) implemented in an emergency department (ED) setting to allow family members the ability to interact with their loved ones during critical illness, and even during the end of life. Use of this technology has helped facilitate goals of care discussions, in addition to providing contact and closure for both patients and their loved ones. CONCLUSION/CONCLUSIONS:We describe our rapid and ongoing implementation of TM consultation for our ED patients and discuss lessons learned and recommendations for others considering similar care models.
PMID: 32962902
ISSN: 0736-4679
CID: 4605702

Early Intervention of Palliative Care in the Emergency Department During the COVID-19 Pandemic

Lee, Jihae; Abrukin, Liliya; Flores, Stefan; Gavin, Nicholas; Romney, Marie-Laure; Blinderman, Craig D; Nakagawa, Shunichi
PMID: 32501486
ISSN: 2168-6114
CID: 4469472

COVID-19: New York City pandemic notes from the first 30 days [Letter]

Flores, Stefan; Gavin, Nicholas; Romney, Marie-Laure; Tedeschi, Christopher; Olsen, Erica; Heravian, Anisa; Abrukin, Liliya; Kessler, David; Mills, Angela M; Chang, Bernard P
PMID: 32354529
ISSN: 1532-8171
CID: 4412792

Clinical Pathway for Management of Suspected or Positive Novel Coronavirus-19 Patients With ST-Segment Elevation Myocardial Infarction

Ranard, Lauren S; Ahmad, Yousif; Masoumi, Amirali; Chuich, Taylor; Romney, Marie-Laure S; Gavin, Nicholas; Sayan, Osman R; Kirtane, Ajay J; Rabbani, LeRoy E
Novel coronavirus-19 disease (COVID-19) is an escalating, highly infectious global pandemic that is quickly overwhelming healthcare systems. This has implications on standard cardiac care for ST-elevation myocardial infarctions (STEMIs). In the setting of anticipated resource scarcity in the future, we are forced to reconsider fibrinolytic therapy in our management algorithms. We encourage clinicians to maintain a high level of suspicion for STEMI mimics, such as myopericarditis which is a known, not infrequent, complication of COVID-19 disease. Herein, we present a pathway developed by a multidisciplinary panel of stakeholders at NewYork-Presbyterian/Columbia University Irving Medical Center for the management of STEMI in suspected or confirmed COVID-19 patients.
PMID: 32356955
ISSN: 1535-2811
CID: 4412922

Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series

Argenziano, Michael G; Bruce, Samuel L; Slater, Cody L; Tiao, Jonathan R; Baldwin, Matthew R; Barr, R Graham; Chang, Bernard P; Chau, Katherine H; Choi, Justin J; Gavin, Nicholas; Goyal, Parag; Mills, Angela M; Patel, Ashmi A; Romney, Marie-Laure S; Safford, Monika M; Schluger, Neil W; Sengupta, Soumitra; Sobieszczyk, Magdalena E; Zucker, Jason E; Asadourian, Paul A; Bell, Fletcher M; Boyd, Rebekah; Cohen, Matthew F; Colquhoun, MacAlistair I; Colville, Lucy A; de Jonge, Joseph H; Dershowitz, Lyle B; Dey, Shirin A; Eiseman, Katherine A; Girvin, Zachary P; Goni, Daniella T; Harb, Amro A; Herzik, Nicholas; Householder, Sarah; Karaaslan, Lara E; Lee, Heather; Lieberman, Evan; Ling, Andrew; Lu, Ree; Shou, Arthur Y; Sisti, Alexander C; Snow, Zachary E; Sperring, Colin P; Xiong, Yuqing; Zhou, Henry W; Natarajan, Karthik; Hripcsak, George; Chen, Ruijun
OBJECTIVE:To characterize patients with coronavirus disease 2019 (covid-19) in a large New York City medical center and describe their clinical course across the emergency department, hospital wards, and intensive care units. DESIGN:Retrospective manual medical record review. SETTING:NewYork-Presbyterian/Columbia University Irving Medical Center, a quaternary care academic medical center in New York City. PARTICIPANTS:The first 1000 consecutive patients with a positive result on the reverse transcriptase polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to the emergency department or were admitted to hospital between 1 March and 5 April 2020. Patient data were manually abstracted from electronic medical records. MAIN OUTCOME MEASURES:Characterization of patients, including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition. RESULTS:Of the first 1000 patients, 150 presented to the emergency department, 614 were admitted to hospital (not intensive care units), and 236 were admitted or transferred to intensive care units. The most common presenting symptoms were cough (732/1000), fever (728/1000), and dyspnea (631/1000). Patients in hospital, particularly those treated in intensive care units, often had baseline comorbidities including hypertension, diabetes, and obesity. Patients admitted to intensive care units were older, predominantly male (158/236, 66.9%), and had long lengths of stay (median 23 days, interquartile range 12-32 days); 78.0% (184/236) developed acute kidney injury and 35.2% (83/236) needed dialysis. Only 4.4% (6/136) of patients who required mechanical ventilation were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at three to four days, and at nine days. As of 30 April, 90 patients remained in hospital and 211 had died in hospital. CONCLUSIONS:Patients admitted to hospital with covid-19 at this medical center faced major morbidity and mortality, with high rates of acute kidney injury and inpatient dialysis, prolonged intubations, and a bimodal distribution of time to intubation from symptom onset.
PMID: 32471884
ISSN: 1756-1833
CID: 4468392

Characterization and clinical course of 1000 Patients with COVID-19 in New York: retrospective case series

Argenziano, Michael G; Bruce, Samuel L; Slater, Cody L; Tiao, Jonathan R; Baldwin, Matthew R; Barr, R Graham; Chang, Bernard P; Chau, Katherine H; Choi, Justin J; Gavin, Nicholas; Goyal, Parag; Mills, Angela M; Patel, Ashmi A; Romney, Marie-Laure S; Safford, Monika M; Schluger, Neil W; Sengupta, Soumitra; Sobieszczyk, Magdalena E; Zucker, Jason E; Asadourian, Paul A; Bell, Fletcher M; Boyd, Rebekah; Cohen, Matthew F; Colquhoun, MacAlistair I; Colville, Lucy A; de Jonge, Joseph H; Dershowitz, Lyle B; Dey, Shirin A; Eiseman, Katherine A; Girvin, Zachary P; Goni, Daniella T; Harb, Amro A; Herzik, Nicholas; Householder, Sarah; Karaaslan, Lara E; Lee, Heather; Lieberman, Evan; Ling, Andrew; Lu, Ree; Shou, Arthur Y; Sisti, Alexander C; Snow, Zachary E; Sperring, Colin P; Xiong, Yuqing; Zhou, Henry W; Natarajan, Karthik; Hripcsak, George; Chen, Ruijun
OBJECTIVE:To characterize patients with coronavirus disease 2019 (COVID-19) in a large New York City (NYC) medical center and describe their clinical course across the emergency department (ED), inpatient wards, and intensive care units (ICUs). DESIGN/METHODS:Retrospective manual medical record review. SETTING/METHODS:NewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC), a quaternary care academic medical center in NYC. PARTICIPANTS/METHODS:The first 1000 consecutive patients with laboratory-confirmed COVID-19. METHODS:We identified the first 1000 consecutive patients with a positive RT-SARS-CoV-2 PCR test who first presented to the ED or were hospitalized at NYP/CUIMC between March 1 and April 5, 2020. Patient data was manually abstracted from the electronic medical record. MAIN OUTCOME MEASURES/METHODS:We describe patient characteristics including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition. RESULTS:Among the first 1000 patients, 150 were ED patients, 614 were admitted without requiring ICU-level care, and 236 were admitted or transferred to the ICU. The most common presenting symptoms were cough (73.2%), fever (72.8%), and dyspnea (63.1%). Hospitalized patients, and ICU patients in particular, most commonly had baseline comorbidities including of hypertension, diabetes, and obesity. ICU patients were older, predominantly male (66.9%), and long lengths of stay (median 23 days; IQR 12 to 32 days); 78.0% developed AKI and 35.2% required dialysis. Notably, for patients who required mechanical ventilation, only 4.4% were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at 3-4 and 9 days. As of April 30, 90 patients remained hospitalized and 211 had died in the hospital. CONCLUSIONS:Hospitalized patients with COVID-19 illness at this medical center faced significant morbidity and mortality, with high rates of AKI, dialysis, and a bimodal distribution in time to intubation from symptom onset.
PMID: 32511507
ISSN: n/a
CID: 4477852

Design and implementation of a clinical decision support tool for primary palliative Care for Emergency Medicine (PRIM-ER)

Tan, Audrey; Durbin, Mark; Chung, Frank R; Rubin, Ada L; Cuthel, Allison M; McQuilkin, Jordan A; Modrek, Aram S; Jamin, Catherine; Gavin, Nicholas; Mann, Devin; Swartz, Jordan L; Austrian, Jonathan S; Testa, Paul A; Hill, Jacob D; Grudzen, Corita R
BACKGROUND:The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. METHODS:A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. RESULTS:The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. CONCLUSIONS:CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.
PMCID:6988238
PMID: 31992301
ISSN: 1472-6947
CID: 4294142

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers

De Marchis, Emilia H; Hessler, Danielle; Fichtenberg, Caroline; Adler, Nancy; Byhoff, Elena; Cohen, Alicia J; Doran, Kelly M; Ettinger de Cuba, Stephanie; Fleegler, Eric W; Lewis, Cara C; Lindau, Stacy Tessler; Tung, Elizabeth L; Huebschmann, Amy G; Prather, Aric A; Raven, Maria; Gavin, Nicholas; Jepson, Susan; Johnson, Wendy; Ochoa, Eduardo; Olson, Ardis L; Sandel, Megan; Sheward, Richard S; Gottlieb, Laura M
INTRODUCTION/BACKGROUND:Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening. METHODS:This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019. RESULTS:Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07). CONCLUSIONS:A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier. SUPPLEMENT INFORMATION/UNASSIGNED:This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
PMID: 31753277
ISSN: 1873-2607
CID: 4211982