Faculty Bibliography

BACKGROUND:Agitation is a common clinical presentation associated with up to 2.6% of emergency department (ED) visits per year. The science of identifying, predicting, and managing agitation has rapidly progressed over the past decade, leading to broad recommendations about initial approaches and management strategies. OBJECTIVE:The purpose of this clinical review is to review existing literature on the etiology, recognition, and management of agitation to help clinicians and staff who care for these patients. METHODS:A narrative review was performed of articles published from 1984 to 2026. DISCUSSION/CONCLUSIONS:Standardized approaches to agitation management are discussed, highlighting both existing literature and research gaps. There is broad agreement on 5 main objectives of the approach to the agitated patient in the ED: address safety issues for the patient and ED staff, an expedited clinical assessment, identifying a presumptive etiology of agitation in order to guide treatment, verbal de-escalation as an initial management strategy, and judicious medication administration. CONCLUSIONS:This review shows that practices like verbal de-escalation, therapeutically-indicated medication administration, and multidisciplinary teamwork are imperative to improving care and reducing mistrust, longer hospital stays, use of restraints, and physical assaults on ED staff and ultimately, workplace violence. In particular, verbal de-escalation should be a first-line treatment. There is agreement that the etiology of agitation should guide management, but less agreement on particular drug combinations if medication is needed. Recommendations are given but further research is necessary.

OBJECTIVE:To assess the association between child protective services (CPS) involvement and the risk and timing of intramuscular (IM) medication or physical restraint use in pediatric patients presenting to the emergency department (ED) with behavioral health concerns. METHODS:An electronic health record dataset spanning January 2021 to October 2023 was retrospectively analyzed. Individual cumulative incidence plots and Cox regression models were created to model the risk and risk rate of receiving either IM medication or being physically restrained by different levels of CPS involvement. Cox regression models were adjusted for age, legal sex, and race and ethnicity. RESULTS:We analyzed 6257 behavioral health encounters. Children in CPS custody had the highest cumulative incidence of receiving IM medication or being physically restrained compared to children with a new CPS report filed or children without any CPS involvement after 72 hours (IM medication: 17%, 6%, 5% respectively, p < 0.001, physical restraints: 8%, 4%, 3% respectively, p < 0.001). Compared to children without CPS involvement, children in CPS custody had a significantly higher risk rate of receiving IM medications (adjusted hazard ratio (aHR) 1.79, 95% Confidence Interval (CI) 1.01-3.18, p = 0.046), and physical restraints (aHR 2.71, 95% CI 1.35-5.43 p = 0.005). CONCLUSION/CONCLUSIONS:Children in CPS custody had a higher risk of receiving IM medication and being physically restrained during behavioral health encounters in a pediatric ED. Further work should focus on understanding the causal mechanisms and designing interventions that maximize optimal health outcomes for vulnerable children experiencing behavioral health emergencies.

STUDY OBJECTIVE/OBJECTIVE:To identify high-priority research questions related to emergency care of children with mental and behavioral health conditions and develop a consensus-based research agenda. METHODS:We recruited expert partners to participate in a modified Delphi method to develop a consensus-based research agenda. The Pediatric Emergency Care Applied Research Network Mental Health Working Group formulated initial research priorities, informed by literature review. Expert partners modified, added to, and rated proposed research priorities on a 9-point scale across 3 survey rounds. Ratings assessed overall priority, followed by need and urgency, research impact, and family centeredness. Top tier priorities had a median of at least 7 for all 3 domains and a median over 7 in at least 2 domains. RESULTS:The 23 expert partners included 4 parents/caregivers and 1 young adult with lived experience, 9 physicians with various training backgrounds, 3 nurses, 3 social workers, 2 out-of-hospital clinicians, and 1 program officer. Of 76 initial research priorities, 41 were dropped and 16 were newly proposed; the expert panel reached consensus on 51 research priorities. Thirty-one top tier research priorities encompassed aspects of out-of-hospital care (eg, training, novel response models), general emergency care and boarding (eg, brief interventions), management of acute agitation (eg, effectiveness of de-escalation methods and medications), suicide prevention (eg, effectiveness of safety planning), and optimal postdischarge follow-up care. CONCLUSION/CONCLUSIONS:This consensus-based research agenda, which integrates diverse perspectives, informs the need for research to improve identification and management of children at risk of harming themselves or others in the out-of-hospital and emergency department settings.

BACKGROUND/UNASSIGNED:Law enforcement is a common yet complicated presence in the emergency department (ED). Studies have found emergency medicine (EM) attending physicians have varied interactions with and attitudes toward law enforcement. EM resident physicians are in a uniquely formative professional period. However, the experiences and perspectives of EM resident physicians have not been previously explored in depth. METHODS/UNASSIGNED:We recruited EM resident physicians from three geopolitically distinct urban academic EDs in the United States to participate in semi-structured interviews regarding their experiences with law enforcement in the ED. We analyzed the transcripts thematically, looking for unifying concepts across institutions and latent meaning. A codebook was created and iteratively refined based on review of transcripts, after which salient themes were developed through ongoing discussions with the research team. RESULTS/UNASSIGNED:Twenty-four resident physicians across three sites participated. Three salient themes emerged from our study: ambiguity of authority between emergency physicians and law enforcement, concerns about the impact of law enforcement presence on patients, and disruptions to the ED team workflow. First, as trainees learning professional norms in the ED, participants reported difficulty navigating situations in which law enforcement attempted to assert authority over patient care. Second, participants perceived negative impacts of law enforcement presence on patients in custody and non-incarcerated patients of color receiving care in the ED. Finally, participants described frequent disruptions to the ED team workflow due to the presence of law enforcement. Participants relied on hospital security, rather than law enforcement, to ensure the safety of patients and staff. CONCLUSION/UNASSIGNED:Emergency resident physicians described ambiguous boundaries and complex interactions among law enforcement, patients, and themselves in the ED. Although our study found several concerning impacts of law enforcement in the ED, these represent opportunities to clarify roles and responsibilities in the emergency physician-law enforcement relationship and improve patient care. Further research is needed, including eliciting perspectives of law enforcement and patients, particularly those with substance use disorders, trauma, and serious mental illness.

OBJECTIVES/UNASSIGNED:To examine how structural factors, such as child protective services (CPS) involvement, prehospital interactions with police or emergency medical services (EMS), and clinical factors, such as autism diagnosis, contribute to physical restraint use among pediatric patients presenting to the emergency department (ED) for behavioral health concerns. METHODS/UNASSIGNED:In this retrospective cohort study, we reviewed pediatric ED encounters from January 1, 2021, to October 31, 2023, at a tertiary care children's hospital. Multivariable logistic regression was used to assess associations among autism diagnosis, CPS involvement, and arrival mode (police/EMS) and physical restraint use, adjusted for demographic variables. RESULTS/UNASSIGNED:Among 6288 behavioral health encounters, physical restraints were used in 124 (1.97%; 95% CI, 1.69, 2.58) encounters. Children arriving by police or EMS were 3 times more likely to be restrained than those arriving by car or walk-in (adjusted odds ratio, aOR = 3.07, 95% CI, 2.01-4.69). Children with CPS involvement were almost twice as likely to be restrained (aOR = 1.91; 95% CI, 1.26-2.88). Children diagnosed with autism were 7 times more likely to be restrained (aOR = 7.25, 95% CI, 3.61-14.55). Black children were more likely to be restrained than White children (aOR = 1.78, 95% CI, 1.12-2.84). CONCLUSION/UNASSIGNED:CPS involvement, transport by police or EMS, autism diagnosis, and Black race were independently associated with increased physical restraint use in pediatric ED patients. These findings emphasize the role of both structural and child-level factors in contributing to physical restraint in emergency behavioral health care, highlighting the need for a multifactorial approach to reduce restraint use.

BACKGROUND:Emergency medicine (EM) and internal medicine (IM) physicians care for patients in settings where prompt recognition of and effective communication about acute decompensation and the potential for imminent death is crucial to providing goal-concordant care. Competence in these tasks requires dedicated training and facilitated practice in serious illness communication (SIC). Existing simulation-based SIC curricula typically utilize cases in which the diagnosis and prognosis are already established in a medically stable patient, representing a missed opportunity for learners. To fill this gap, the authors aimed to explore IM and EM resident perceptions of a novel, entirely virtual SIC curriculum, Managing Acute Decompensation in Life-limiting Illness (MADLI), that required participants to assess and manage a clinically decompensating seriously ill patient while simultaneously incorporating newly learned SIC skills. METHODS:Sixteen participants were recruited from the EM and IM residency programs at a large, tertiary, academic medical center. Using a "flipped classroom" approach, residents asynchronously viewed a 20-minute didactic video introducing evidence-based communication frameworks. In small peer groups led by a trained faculty facilitator, they then participated in a 60-minute simulated clinical encounter involving an acutely decompensating patient and their surrogate decision maker, played by an SIC-trained actor. Lastly, residents participated in a 30- to 60-minute semi-structured group interview. Qualitative thematic analysis was performed to identify overarching themes that resulted from the interview data. RESULTS:Qualitative analysis of group interview transcripts yielded 3 major themes that reflect the trainee experience with the MADLI curriculum: (I) simulation unmasked moral challenges; (II) simulation facilitated safe practice and identification of knowledge gaps for SIC skills; and (III) task switching and case realism were virtual SIC curricular elements that promoted learner engagement and effective learning. Additionally, integrating medical management and SIC tasks was perceived as novel, challenging, and realistic. Residents who completed the MADLI curriculum viewed it as an effective modality to teach SIC. CONCLUSIONS:Simulation-based curricula for EM and IM residents that combine medical management, prognostication, and complex SIC into a single virtual, simulated patient encounter can address critical gaps in resident education related to the management of seriously ill patients at high risk of imminent death. Incorporating a trained actor and task-switching enhanced realism and learner engagement, highlighting the value of this model as a feasible approach to advancing IM and EM resident SIC skills.

BACKGROUND:Female physicians often report lower self-confidence in their procedural and clinical competency compared to male physicians. There is limited data regarding self-reported confidence of female versus male trainees and any relation to objective competency in central venous catheter insertion. OBJECTIVE:To analyze differences between male and female trainees in self-confidence and skill-based outcomes in placing central venous catheters. DESIGN/METHODS:Using data from a central venous catheter simulation training program at a large tertiary medical center, we performed linear regressions to analyze confidence difference pre- and post-training, number of restarts, and number of cannulation attempts while controlling for baseline demographic characteristics of the sample. PARTICIPANTS/METHODS:PGY-1 physician residents in all residency specialties who insert central venous catheters in the clinical setting at a tertiary academic center with a sample size of 281 residents. MAIN MEASURES/METHODS:Confidence difference pre- and post-training measured on a Likert scale 1-5, number of restarts (novel global assessment variable), and number of cannulation attempts during the competency evaluation. KEY RESULTS/RESULTS:Female trainees had both lower pre-program confidence (1.35 versus 1.74 out of 5, p < 0.001) and lower post-program confidence (3.77 versus 4.12 out of 5, p = 0.0021) as compared to male trainees. There was no statistically significant difference in number of restarts (95% CI - 0.073 to 0.368, p = 0.185) or cannulation attempts (95% CI - 0.039 to 0.342, p = 0.117) between sexes in linear regressions controlled for age, specialty designation, prior central venous catheter training, prior ultrasound guided vessel cannulation training, and pre-training confidence level. CONCLUSIONS:Female trainees rated their confidence significantly lower than their male counterparts both before and after the training program, despite no significant difference in skill-based outcomes. We discuss potential implications for trainees acquiring procedural skills during residency and for physician educators as they design training programs and delegate procedural opportunities.

OBJECTIVES/UNASSIGNED:Patients with a history of incarceration experience bias from health care team members, barriers to privacy, and a multitude of health care disparities. We aimed to assess care processes delivered in emergency departments (EDs) for people with histories of incarceration. METHODS/UNASSIGNED:We utilized a fine-tuned large language model to identify patient incarceration status from 480,374 notes from the ED setting. We compared socio-demographic characteristics, comorbidities, and care processes, including disposition, restraint use, and sedation, between individuals with and without a history of incarceration. We then conducted multivariable logistic regression to assess the independent correlation of incarceration history and management in the ED while adjusting for demographic characteristics, health behaviors, presentation, and past medical history. RESULTS/UNASSIGNED:We found 1734 unique patient encounters with a history of incarceration from a total of 177,987 encounters. Patients with history of incarceration were more likely to be male, Black, Hispanic, or other race/ethnicity, currently unemployed or disabled, and had smoking and substance use histories, compared with those without. This cohort demonstrated higher odds of elopement (OR: 3.59 [95% CI: 2.41-5.12]), leaving against medical advice (OR: 2.39 [95% CI: 1.46-3.67]), and being subjected to sedation (OR: 3.89 [95% CI: 3.19-4.70]) and restraint use (OR: 3.76 [95% CI: 3.06-4.57]). After adjusting for covariates, the association between incarceration and elopement remained significant (adjusted odds ratio: 1.65 [95% CI: 1.08-2.43]), while associations with other dispositions, restraint use, and sedation did not persist. CONCLUSION/UNASSIGNED:This study identified differences in patient characteristics and care processes in the ED for patients with histories of incarceration and demonstrated the potential of using natural language processing in measuring care processes in populations that are largely hidden, but highly prevalent and subject to discrimination, in the health care system.

BACKGROUND:Stressful work environments and burnout in emergency medicine (EM) physicians adversely impact patient care quality. The future EM workforce will need to prioritize clinician well-being to ensure optimal patient care. METHODS:This prospective, randomized, controlled study aimed to determine whether an adaptive simulation intervention, COVID-19 Responsive Intervention: Systems Improvement Simulations (CRI:SIS), decreased physiologic stress as measured by heart rate variability (HRV) in front-line EM physicians during the COVID-19 pandemic. HRV was measured with smart shirts and self-reported State-Trait Anxiety Inventory (STAI) were collected at baseline and during four 8-hour clinical shifts for all participants. The intervention group (n = 40) received a 3-hour virtual educational simulation intervention consisting of four simulation scenarios (CRI:SIS). The control group (n = 41) received no simulation intervention. RESULTS:There were no significant differences in demographics between groups. HRV data collected from 81 physicians across a total of 324 clinical shifts showed an increase in HRV (decrease in physiologic stress) in shifts immediately following CRI:SIS in the intervention group as measured by a root mean square standard deviation (RMSSD) difference of 11.55 ms (95% CI, -19.90 to -3.20; P = 0.007) compared to the control group. Post-intervention STAI did not significantly differ between intervention and control. CONCLUSION/CONCLUSIONS:An adaptive simulation-based educational intervention led to decreased physiologic stress (increased HRV) among emergency physicians who received a simulation education intervention. Reduced physiologic stress generated by adaptive simulation interventions may improve both patient safety and clinician well-being.

BACKGROUND:A growing body of research has found there to be disproportionate physical restraint and chemical sedation use for historically marginalized populations in the emergency department (ED). This association has been examined with regard to patient race, ethnicity, sex, and age. Preliminary research has highlighted the ways in which unhoused status may also relate to the use of physical restraint and chemical sedation in the ED. Given the adverse health outcomes associated with these methods in the ED, further research is needed to explore the relationship between patient housing status and physical restraint/chemical sedation use in more depth. METHODS:We conducted a cross-sectional study of all ED visits among patients aged 18 years of age and older presenting to eight hospitals within a regional healthcare network in New England between January 1, 2013, and December 31, 2021. Descriptive statistics and mixed effects logistic regression models nesting by patient were used to characterize the relationship between housing status and likelihood of restraint and/or sedation use. FINDINGS/RESULTS:Restraint orders were found in 3,160 (5.7%) visits by unhoused patients, compared to 44,155 (1.5%) for housed patients. Unhoused status was significantly associated with restraint/sedation use (adjusted odds ratio =  1.45, 95% CI 1.36-1.54). CONCLUSION/CONCLUSIONS:Our study identified a significant association between housing status and ED restraint and sedation use after adjusting for demographic factors and chief complaints. This finding has important implications pertaining to the care of unhoused patients in the ED and for examination of structural factors like housing status and their impact on psychiatric emergency care.