Faculty Bibliography

BACKGROUND AND PURPOSE/OBJECTIVE:The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented demand and burden on emergency health care services in New York City. We aim to describe our experience providing acute stroke care at a comprehensive stroke center (CSC) and the impact of the pandemic on the quality of care for patients presenting with acute ischemic stroke (AIS). METHODS:We retrospectively analyzed data from a quality improvement registry of consecutive AIS patients at New York University Langone Health's CSC between 06/01/2019-05/15/2020. During the early stages of the pandemic, the acute stroke process was modified to incorporate COVID-19 screening, testing, and other precautionary measures. We compared stroke quality metrics including treatment times and discharge outcomes of AIS patients during the pandemic (03/012020-05/152020) compared with a historical pre-pandemic group (6/1/2019-2/29/2020). RESULTS:A total of 754 patients (pandemic-120; pre-pandemic-634) were admitted with a principal diagnosis of AIS; 198 (26.3%) received alteplase and/or mechanical thrombectomy. Despite longer median door to head CT times (16 vs 12 minutes; p = 0.05) and a trend towards longer door to groin puncture times (79.5 vs. 71 min, p = 0.06), the time to alteplase administration (36 vs 35 min; p = 0.83), door to reperfusion times (103 vs 97 min, p = 0.18) and defect-free care (95.2% vs 94.7%; p = 0.84) were similar in the pandemic and pre-pandemic groups. Successful recanalization rates (TICI≥2b) were also similar (82.6% vs. 86.7%, p = 0.48). After adjusting for stroke severity, age and a prior history of transient ischemic attack/stroke, pandemic patients had increased discharge mortality (adjusted OR 2.90 95% CI 1.77 - 7.17, p = 0.021) CONCLUSION: Despite unprecedented demands on emergency healthcare services, early multidisciplinary efforts to adapt the acute stroke treatment process resulted in keeping the stroke quality time metrics close to pre-pandemic levels. Future studies will be needed with a larger cohort comparing discharge and long-term outcomes between pre-pandemic and pandemic AIS patients.

Background: Substance use (SU) is common among ED patients, with 1 in 10 ED users having an alcohol or drug use disorder. ED patients also have high levels of social needs such as homelessness and food insecurity. Yet, little research has examined how such social determinants of health (SDOH) intersect with SU among ED patients. In this study, we compared the prevalence of several SDOH among ED patients who did and did not screen positive for unhealthy alcohol and drug use. Methods: We surveyed a random sample of ED patients at a NYC public hospital from Nov 2016-Sept 2017. Eligible patients were >=18 years old, medically/psychiatrically stable, not in prison/police custody, and spoke English or Spanish. RA shifts occurred during all days of the week and hours of the day. RAs administered a 20-40 minute survey with validated single-item screeners for unhealthy alcohol and drug use and questions on self-reported past year social needs from national surveys or prior studies. We compared prevalence of SDOH by SU screening status in bivariate analyses with chisquare tests. Results: About half of patients (52.0%) approached were ineligible, primarily because they were medically unfit, intoxicated, or in prison/police custody. 2,396 of 2,925 eligible patients participated (81.9%); 76 duplicate patient records were removed, leaving a final sample size of 2,321 patients. Nearly one-third (32.3%) screened positive for unhealthy alcohol use and 21.8% for any drug use. Regarding SDOH, rates among patients overall vs. those with unhealthy alcohol use vs. those with drug use were: 1) homelessness 13.8%, 18.7% (X2 p<0.01 for difference between those who did vs. did not screen positive), 25.8% (p<0.01); 2) housing instability 25.2%, 29.5% (p<0.01), 35.9% (p<0.01); 3) food insecurity 50.9%, 56.3% (p<0.01), 63.4% (p<0.01); 4) inability to meet essential expenses 40.8%, 45.9% (p<0.01), 52.7% (p<0.01); and 5) unemployment 43.3%, 45.1% (p=0.23), 55.1% (p<0.01). Conclusion: Rates of homelessness and other social needs were high among ED patients in this study, suggesting the importance of considering SDOH in emergency medicine practice. We add to prior literature by showing that these needs were even higher among patients who screened positive for SU. These findings are important, as patients' significant comorbid social needs may affect the success of ED-based efforts to address substance use