Faculty Bibliography

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.

IMPORTANCE:Agitation events are increasing in emergency departments (EDs), exacerbating safety risks for patients and clinicians. A wide range of clinical etiologies and behavioral patterns in the emergency setting make agitation prediction difficult in this setting. OBJECTIVE:To develop, train, and validate an agitation-specific prediction model based on a large, diverse set of past ED visit data. DESIGN, SETTING, AND PARTICIPANTS:This cohort study included electronic health record data collected from 9 ED sites within a large, urban health system in the Northeast US. All ED visits featuring patients aged 18 years or older from January 1, 2015, to December 31, 2022, were included in the analysis and modeling. Data analysis occurred between May 2023 and September 2024. EXPOSURES:Variables that served as potential exposures of interest, encompassing demographic information, patient history, initial vital signs, visit information, mode of arrival, and health services utilization. MAIN OUTCOMES AND MEASURES:The primary outcome of agitation was defined as the presence of an intramuscular chemical sedation and/or violent physical restraint order during an ED visit. A clinical model was developed to identify risk factors that predict agitation development during an ED visit prior to symptom onset. Model performance was measured using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (PR-AUC). RESULTS:The final cohort comprised 3 048 780 visits. The cohort had a mean (SD) age of 50.2 (20.4) years, with 54.7% visits among female patients. The final artificial intelligence model used 50 predictors for the primary outcome of predicting agitation events. The model achieved an AUROC of 0.94 (95% CI, 0.93-0.94) and a PR-AUC of 0.41 (95% CI, 0.40-0.42) in cross-validation, indicating good discriminative ability. Calibration of the model was evaluated and demonstrated robustness across the range of predicted probabilities. The top predictors in the final model included factors such as number of past ED visits, initial vital signs, medical history, chief concern, and number of previous sedation and restraint events. CONCLUSIONS AND RELEVANCE:Using a cross-sectional cohort of ED visits across 9 hospitals, the prediction model included factors for detecting risk of agitation that demonstrated high accuracy and applicability across diverse patient populations. These results suggest that clinical application of the model may enhance patient-centered care through preemptive deescalation and prevention of agitation.

INTRODUCTION/BACKGROUND:Despite expert recommendations to prioritise non-invasive and patient-centred approaches for behavioural crisis management, physical restraints are commonly used in the emergency department (ED). Patients describe the restraint process as coercive and dehumanising. The use of peer support workers, who are individuals with lived experience of mental illness and behavioural conditions, has shown positive patient outcomes when assisting individuals experiencing behavioural crises. However, there is limited evidence of the implementation of such an approach in the ED setting. The goal of this study is to evaluate if the implementation of a Peer support enhanced Agitation Crisis response Team (PACT) for behavioural crisis management in the ED is more effective than usual care to reduce restraint use and improve outcomes among patients presenting to the ED with behavioural crises. METHODS AND ANALYSIS/METHODS:We will first conduct a stakeholder-informed needs assessment to codesign the protocol and then train staff and peers in PACT intervention readiness. Next, a stepped-wedge, cluster-randomised controlled trial will be conducted over 3 years at five ED sites across a healthcare system in the Northeast USA. The PACT intervention will integrate peer delivery of trauma-informed care within a structured, interprofessional, team-based response protocol for behavioural crisis management. The primary outcome is the rate of physical restraint and/or sedation use. The secondary outcome is the level of patient agitation during the ED visit. Analyses of primary and secondary outcomes will be conducted using generalised linear mixed models. ETHICS AND DISSEMINATION/BACKGROUND:This protocol has been approved by the Yale University Human Investigation Committee (protocol number 2000037554). The study is deemed minimal risk and has been granted a waiver of consent for trial participants. However, verbal consent will be obtained for a subset of patients receiving follow-up data collection. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations, or through direct mail notifications. TRIAL REGISTRATION NUMBER/BACKGROUND:Clinicaltrials.gov: NCT06556069.

STUDY OBJECTIVE/OBJECTIVE:Although electronic behavioral alerts are placed as an alert flag in the electronic health record to notify staff of previous behavioral and/or violent incidents in emergency departments (EDs), they have the potential to reinforce negative perceptions of patients and contribute to bias. We provide characterization of ED electronic behavioral alerts using electronic health record data across a large, regional health care system. METHODS:We conducted a retrospective cross-sectional study of adult patients presenting to 10 adult EDs within a Northeastern United States health care system from 2013 to 2022. Electronic behavioral alerts were manually screened for safety concerns and then categorized by the type of concern. In our patient-level analyses, we included patient data at the time of the first ED visit where an electronic behavioral alert was triggered or, if a patient had no electronic behavioral alerts, the earliest visit in the study period. We performed a mixed-effects regression analysis to identify patient-level risk factors associated with safety-related electronic behavioral alert deployment. RESULTS:Of the 2,932,870 ED visits, 6,775 (0.2%) had associated electronic behavioral alerts across 789 unique patients and 1,364 unique electronic behavioral alerts. Of the encounters with electronic behavioral alerts, 5,945 (88%) were adjudicated as having a safety concern involving 653 patients. In our patient-level analysis, the median age for patients with safety-related electronic behavioral alerts was 44 years (interquartile range 33 to 55 years), 66% were men, and 37% were Black. Visits with safety-related electronic behavioral alerts had higher rates of discontinuance of care (7.8% vs 1.5% with no alert; P<.001) as defined by the patient-directed discharge, left-without-being-seen, or elopement-type dispositions. The most common topics in the electronic behavioral alerts were physical (41%) or verbal (36%) incidents with staff or other patients. In the mixed-effects logistic analysis, Black non-Hispanic patients (vs White non-Hispanic patients: adjusted odds ratio 2.60; 95% confidence interval [CI] 2.13 to 3.17), aged younger than 45 (vs aged 45-64 years: adjusted odds ratio 1.41; 95% CI 1.17 to 1.70), male (vs female: adjusted odds ratio 2.09; 95% CI 1.76 to 2.49), and publicly insured patients (Medicaid: adjusted odds ratio 6.18; 95% CI 4.58 to 8.36; Medicare: adjusted odds ratio 5.63; 95% CI 3.96 to 8.00 vs commercial) were associated with a higher risk of a patient having at least 1 safety-related electronic behavioral alert deployment during the study period. CONCLUSION/CONCLUSIONS:In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities.

INTRODUCTION:Police involvement in patient transport to emergency medical care has increased over time, yet studies assessing racial inequities in transport are limited. This study evaluated the relationship between race and police transport to the emergency department for adult patients. METHODS:This cross-sectional study evaluated adult (aged ≥18 years) visits at 13 different emergency departments across two regional hospital systems in the Southeastern and Northeastern U.S. from 2015 to 2022. Data were extracted from electronic health records. This analysis evaluated the association between race and transport by police transport using generalized linear multivariable mixed model with a binary logistic link for presence of police transport. Data were nested by patient and adjusted for site, demographics, and diagnostic visit characteristics. RESULTS:Of 4,291,809 adult emergency department visits, 25,901 (0.6%) involved transport by police. Of the 25,901 visits in police-involved encounters, 10,513 (40.6%) patients were Black, and 9,827 (37.9%) were White. The adjusted model showed that Black patients were at higher odds of transport by police than White patients (AOR=1.64; 95% CI=1.57-1.72). Male sex, younger age (18-35 years), history of behavioral health diagnosis, and emergency department psychiatric or substance use disorders were independently associated with increased odds of police transport. CONCLUSIONS:This analysis revealed racial inequities in police-involved transport to emergency medical care, highlighting an urgent need to evaluate drivers of inequities and the ways in which police transport influences clinical outcomes.

BACKGROUND/UNASSIGNED:Simulation-based procedural practice is crucial to emergency medicine skills training and maintenance. However, many commercial procedural models are either nonexistent or lacking in key elements. Simulationists often create their own novel models with minimal framework for designing, building, and validation. We propose two interlinked frameworks with the goal to systematically build and validate models for the desired educational outcomes. METHODS/UNASSIGNED:Simulation Academy Research Committee and members with novel model development expertise assembled as the MIDAS (Model Innovation, Development and Assessment for Simulation) working group. This working group focused on improving novel model creation and validation beginning with a preconference workshop at 2023 Society for Academic Emergency Medicine Annual Meeting. The MIDAS group sought to (1) assess the current state of novel model validation and (2) develop frameworks for the broader simulation community to create, improve, and validate procedural models. FINDINGS/UNASSIGNED:Workshop participants completed 17 surveys for a response rate of 100%. Many simulationists have created models but few have validated them. The most common barriers to validation were lack of standardized guidelines and familiarity with the validation process.We have combined principles from education and engineering fields into two interlinked frameworks. The first is centered on steps involved with model creation and refinement. The second is a framework for novel model validation processes. IMPLICATIONS/UNASSIGNED:These frameworks emphasize development of models through a deliberate, form-follows-function methodology, aimed at ensuring training quality through novel models. Following a blueprint of how to create, test, and improve models can save innovators time and energy, which in turn can yield greater and more plentiful innovation at lower time and financial cost. This guideline allows for more standardized approaches to model creation, thus improving future scholarship on novel models.

IMPORTANCE:Black patients are more likely than White patients to be restrained during behavioral crises in emergency departments (EDs). Although the perils of policing mental health for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the association between Black race and use of physical restraint in EDs. OBJECTIVE:To evaluate the degree to which police transport mediates the association between Black race and use of physical restraint in EDs. DESIGN, SETTING, AND PARTICIPANTS:This retrospective, cross-sectional study used electronic health record data from ED visits by adults (aged ≥18 years) to 3 hospitals in the southeastern US and 10 in the northeastern US between January 1, 2015, and December 31, 2022. Data were analyzed from September 1, 2022, to May 30, 2023. EXPOSURES:Race, ethnicity, and police transport to the hospital. MAIN OUTCOMES AND MEASURES:The primary outcome variable was the presence of an order for restraints during an ED visit. RESULTS:A total of 4 263 437 ED visits by 1 257 339 patients (55.5% of visits by female and 44.5% by male patients; 26.1% by patients 65 years or older) were included in the study. Black patients accounted for 27.5% of visits; Hispanic patients, 17.6%; White patients, 50.3%; and other or unknown race or ethnicity, 4.6%. In models adjusted for age, sex, site, previous behavioral or psychiatric history, and visit diagnoses, Black patients were at increased odds of experiencing restraint compared with White patients (adjusted odds ratio [AOR], 1.33 [95% CI, 1.28-1.37]). Within the mediation analysis, Black patients had higher odds of being brought to the hospital by police compared with all other patients (AOR, 1.38 [95% CI, 1.34-1.42]). Patients brought to the ED under police transport had increased odds of experiencing restraint compared with all other modes of transport (AOR, 5.51 [95% CI, 5.21-5.82]). The estimated proportion of use of restraints for Black patients mediated by police transport was 10.70% (95% CI, 9.26%-12.53%). CONCLUSIONS AND RELEVANCE:In this cross-sectional study of ED visits across 13 hospitals, police transport may have mediated the association between Black race and use of physical restraint. These findings suggest a need to further explore the mechanisms by which transport to emergency care may influence disparate restrictive interventions for patients experiencing behavioral emergencies.

INTRODUCTION/UNASSIGNED:Generation Z learners are entering emergency medicine (EM) residency training, bringing unique learning preferences that influence their engagement with residency education. To optimally teach and motivate this incoming generation of learners, EM educators must understand and adapt to the changing instructional landscape. METHODOLOGY/UNASSIGNED:The Simulation Leaders Advancing the Next Generation in Emergency Medicine (SLANG-EM) Workgroup was created to identify effective educational strategies for Generation Z learners entering EM. Members were faculty in the Society for Academic Emergency Medicine (SAEM) Simulation Academy, well versed in learning theory supporting simulation-based education (SBE) and actively involved in EM residency education. UNIQUE TREATMENT/ANALYSIS/UNASSIGNED:Through primary and secondary literature searches, the SLANG-EM Workgroup identified four distinctive learning preferences of Generation Z learners: (1) individualized and self-paced learning, (2) engaging and visual learning environments, (3) immediate and actionable feedback, and (4) combined personal and academic support. Workgroup members evaluated these learning preferences using a novel conceptual framework informed by the theoretical principles underpinning SBE, recommending instructional strategies for Generation Z EM residency learners across multiple educational environments. IMPLICATIONS FOR EDUCATORS/UNASSIGNED:Instructional strategies were described for the didactic, simulation, and clinical learning environments. In the didactic environment, identified instructional strategies included meaningful asynchronous education, interactive small-group learning, and improved multimedia design. In the simulation environment, educational innovations particularly suitable for Generation Z learners included learner-centered debriefing, rapid-cycle deliberate practice, and virtual simulation. In the clinical environment, described instructional strategies involved setting learner-centered goals and delivering facilitative feedback in the context of an educational alliance. Overall, these instructional strategies were clustered around themes of student-centered education and the educator as facilitator, which align well with Generation Z learning preferences. These findings were synthesized and presented as an advanced workshop, "Delivering Effective Education to the Next Generation," at the 2023 SAEM Annual Meeting.

BACKGROUND:The COVID-19 pandemic had a significant impact on both the clinical practice and the psychological states of frontline physicians in the emergency department. Trainees, at the beginning of their careers and thus still developing their practice styles and identities as physicians, were uniquely affected. OBJECTIVE:In this qualitative study, we sought to explore how the pandemic environment shaped the experiences of emergency medicine resident physicians. METHODS:This was a qualitative study. We conducted in-depth interviews with emergency medicine faculty, resident physicians, and staff at a single emergency department based at an urban academic institution in the northeastern United States. Interviews were audio recorded and transcribed, and transcripts were then analyzed in an iterative process by our coding team for recurring themes related to the resident experience. RESULTS:We reached data saturation with 27 individuals. Of those who were interviewed, 10 were resident physicians [6 senior residents (PGY-3 or PGY-4) and 4 junior residents (PGY-1 or PGY-2)]. Three major recurring themes regarding resident physician experience emerged during our analysis of the interviews: (1) novel educational experiences dampened by negative structural forces from the pandemic, (2) fracturing of social interactions and mitigation through ad-hoc support systems and community of practice, and (3) development of negative emotions and psychological trauma including fear, resentment, and moral injury causing lasting harm. CONCLUSIONS:Our results suggest that emergency medicine resident physicians training during the COVID-19 pandemic faced unique experiences concerning their education, social support systems, and emotional states. While the educational and social experiences were described as having both negative and positive impacts, the emotional experiences were largely negative. Residency program leadership may use these insights to improve resident preparation, wellness, and resilience in the face of future adverse events.