Faculty Bibliography

BACKGROUND:Inadequate counseling at patient discharge from the emergency department can lead to adverse patient outcomes. Virtual discharge counseling can address gaps in discharge counseling and improve patients' understanding of instructions. METHODS:A previously established virtual discharge counseling program was scaled across three emergency departments and expanded to 13 diagnoses. Utilizing a standardized protocol and script, counselors performed virtual discharge counseling via a remote, secure teleconference platform in the patients' preferred language. RESULTS: < 0.001). Counseling times were the longest for COVID-19 and diabetes (18 min for each). CONCLUSION/CONCLUSIONS:We demonstrate the scalability of a virtual discharge counseling program. Our findings can assist in targeting virtual discharge counseling resources for limited English-proficiency patients and specific diagnoses that require longer counseling times.

BACKGROUND:Emergency departments (EDs) are critical touchpoints for overdose prevention efforts. In New York City (NYC), the Health Department's Relay initiative dispatches trained peer "Wellness Advocates" (WAs) to engage with patients in EDs after an overdose and for up to 90 days subsequently. Interest in peer-delivered interventions for patients at risk for overdose has grown nationally, but few studies have explored challenges and opportunities related to implementing such interventions in EDs. METHODS:We conducted in-depth interviews with Relay WAs, ED patients, and ED providers across 4 diverse NYC EDs. Sampling was purposeful and continued until theoretical saturation was reached. Interviews followed a semi-structured interview guide based on key domains from the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted by telephone or web conferencing; audio recordings were professionally transcribed. The study utilized rapid qualitative analysis using template summaries and summary matrices followed by line-by-line coding conducted independently by 3 researchers, then discussed and harmonized at group coding meetings. Coding was both inductive (using an a priori code list based on CFIR domains and study goals) and deductive (new codes allowed to emerge from transcripts). Dedoose software was used for data organization. RESULTS:We conducted 32 in-depth interviews (10 WAs, 12 patients, 10 ED providers). Four overarching themes emerged: 1) EDs are characterized by multiple competing demands (e.g., related to provider time and physical space), underscoring the utility of Relay and leading to some practical challenges for its delivery; 2) There is a strong role distinction of WAs as peers with lived experience; 3) ED providers value Relay, even though they have a limited understanding of its full scope and outcomes; 4) While the role of structural factors (e.g., homelessness and unstable housing) is recognized, responsibility is often placed on patients for controlling their own success. CONCLUSIONS:We identified four themes that shed new light on the implementation of peer-based overdose prevention programs in EDs. Our findings highlight unique ED inner and outer setting factors that may impact program implementation and effectiveness. The findings provide actionable information to inform implementation of similar programs nationally.

OBJECTIVE:Nerve agent attacks pose a serious threat worldwide and ensuring optimal readiness is essential to management. We review a mass casualty incident (MCI) drill in a busy urban New York City Emergency Department incorporating an antidote-dosing tool. METHODS:Emergency Management and Preparedness planned an MCI drill involving a nerve agent exposure and engaged the pharmacy department to participate on a more comprehensive level. The clinical pharmacist prepared a treatment tool with antidote dosing recommendations to distribute to team members participating in the drill. RESULTS:During the launch of the exercise, all clinicians involved reviewed the antidote-dosing tool with the pharmacy team members. Because of the ease of use, limited time was necessary to review the dosing tool before the start of the exercise. After the exercise, feedback regarding the use of the tool was very positive and participants appreciated the tool for use in a theoretical emergency that they have had limited experience managing. CONCLUSIONS:Optimizing team preparedness with accessible and practical dosing tools may be a helpful addition to emergency preparedness for chemical and biological events with the potential for many casualties.

BACKGROUND:During the COVID-19 pandemic, we identified a gap in adequate discharge counseling for COVID-19 patients in the Emergency Department. This was due to high patient volumes and lack of patient education regarding a novel disease. Medical students were also restricted from clinical areas due to safety concerns, compromising their clinical experience. We piloted a novel program in which medical students served as virtual discharge counselors for COVID-19 patients via teleconference. We aimed to demonstrate an impact on patient care by examining the patient bounce back rate as well as assessing medical student education and experience. METHODS:This program was piloted in a tertiary care Emergency Department. Medical student volunteers served as virtual discharge counselors. Students were trained in discharge counseling with a standardized protocol and a discharge script. Eligible patients for virtual discharge counseling were 18 years old or greater with a diagnosis of confirmed or suspected COVID-19 and no impediment precluding them from participating in a telemedicine encounter. Counseling was provided via secure teleconference in the patient's preferred language. Counseling included diagnosis, supportive care with medication dosing, quarantine instructions, return precautions, follow up, and time to ask questions. Duration of counseling was recorded and medical students were anonymously surveyed regarding their experience. RESULTS:Over an 18-week period, 45 patients were counseled for a median of 20 min. The 72-hr ED revisit rate was 0%, versus 4.2% in similarly-matched, not counseled COVID-19 patients. 90% of medical students believed this project increased their confidence when speaking with patients while 80% indicated this was their first telemedicine experience. CONCLUSION/CONCLUSIONS:Our pilot discharge program provided patients with an extensive discharge counseling experience that would not otherwise be possible in an urban ED setting and demonstrated benefit to patient care. Medical students received a safe clinical experience that improved their communication skills.

BACKGROUND:Patients presenting to emergency departments (EDs) after a nonfatal opioid-involved overdose are at high risk for future overdose and death. Responding to this risk, the New York City (NYC) Department of Health and Mental Hygiene operates the Relay initiative, which dispatches trained peer "Wellness Advocates" to meet patients in the ED after a suspected opioid-involved overdose and follow them for up to 90 days to provide support, education, referrals to treatment, and other resources using a harm reduction framework. METHODS:In this article, we describe the protocol for a multisite randomized controlled trial of Relay. Study participants are recruited from four NYC EDs and are randomized to receive the Relay intervention or site-directed care (the control arm). Outcomes are assessed through survey questionnaires conducted at 1-, 3-, and 6-months after the baseline visit, as well as through administrative health data. The primary outcome is the number of opioid-related adverse events, including any opioid-involved overdose or any other substance use-related ED visit, in the 12 months post-baseline. Secondary and exploratory outcomes will also be analyzed, as well as hypothesized mediators and moderators of Relay program effectiveness. CONCLUSION/CONCLUSIONS:We present the protocol for a multisite randomized controlled trial of a peer-delivered OD prevention intervention in EDs. We describe how the study was designed to minimize disruption to routine ED operations, and how the study was implemented and adapted during the COVID-19 pandemic. This trial is registered with ClinicalTrials.gov [NCT04317053].

Little research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.

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.

STUDY OBJECTIVE/OBJECTIVE:Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless. METHODS:We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline. RESULTS:Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use. CONCLUSION/CONCLUSIONS:In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.

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