Faculty Bibliography

BACKGROUND:Endotracheal intubation in the emergency department (ED) is a critical and time-sensitive procedure requiring both technical skills and cognitive-based reasoning. Evidence on supervised resident-attending dyads with differing years of seniority on decision making during clinical encounters with endotracheal intubations is nascent. OBJECTIVE:To investigate the intersection of postgraduate years in clinical practice between resident and attending supervisor dyads and its associations for clinician choice of laryngoscopy technique and paralytic agent during ED intubations. METHODS:We conducted a retrospective analysis of intubations performed at a multi-site, urban, academic emergency medicine training program, analyzing institutional airway registry data from 2013 to 2023. Using a standardized predictor that accounted for similarity in years of clinical experience within a dyad between a resident and their supervising attending, we performed adjusted mixed-effects logistic regression examining the association of this dyad on two primary outcomes in endotracheal intubation decision making. Our primary outcome measures were the selection of a laryngoscopy technique (either DL or VL), and of a paralytic agent (either short-acting or long-acting) analyzed as categorical variables with a linear mixed effects model, using a binomial response distribution. RESULTS:We examined 2969 intubations for choice of laryngoscopy technique (n = 1117, 37.6 %) and paralytic agent (n = 967, 32.6 %). Higher adjusted odds (aOR) were associated with resident choice of DL over VL when years of experience between residents and supervising attendings were more concordant (aOR 3.05, 95 % CI: 1.1-8.2). Choice of paralytic agent was not associated with differing years of experience. CONCLUSION/CONCLUSIONS:Concordant years of experience between residents and their attendings were associated with technical skill-based laryngoscopy technique choice but not for cognitive-based reasoning in paralytic agent choice among ED intubations, suggesting supervising attending's years in clinical practice may influence decision making during time-sensitive procedures.

Introduction: Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process. Methods: We screened the medical records for patients presenting to the ED of an urban public hospital between 2016–2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics. Results: A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition. Conclusion: In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Assessment of acute coronary syndrome (ACS) has pressured rapid diagnostic evaluation through point of care troponins (POCT-Tns). However, POCT-Tns have demonstrated inconsistent accuracy compared to laboratory (LABT)-Tn. A POCT-Tn used inappropriately to "rule-out" ACS can lead to premature diagnostic closure. We aimed to minimize indiscriminate POCT-Tn testing, while balancing test turnaround time (TAT), institutional cost, and impact on patient time to disposition (TTD). METHODS:A quality improvement (QI) initiative from 2018 to 2022 included educational interventions and electronic health record (EHR) adaptations. We evaluated test characteristics, trended test frequency, TATs, cost, and TTD. We used statistical process control charts to evaluate changes in test frequency over time. We used the Mann-Whitney U and Wilcoxon Signed-Rank Sum test to analyze changes in TAT, TTD, and cost. RESULTS:POCT-Tn had high discordance with LAB-Tn (9.7%) and low sensitivity (52.5%). SPCs showed a significant decrease in POCT-Tn tests performed over time. LABT-Tn TATs were longer than POCT-Tn (54 vs 21 min; P < .001). Total Tn testing costs decreased by $668 827.83 annually. Compared to pre-initiative, arrival to disposition was 20 min longer for patients receiving a LABT-Tn (P < .001) and 37 min shorter for patients receiving a POCT with reflex to LABT-Tn (P < .001). CONCLUSION/CONCLUSIONS:POCT-Tn test characteristics may place patients at risk for missed ACS. A combined approach using education and EHR adaptations decreased use of indiscriminate POCT-Tn tests, decreased health care costs, and resulted in clinically appropriate changes in disposition times for this large cohort of ED patients.

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.

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.

INTRODUCTION/BACKGROUND:It is difficult to determine illness severity for coronavirus disease 2019 (COVID-19) patients, especially among stable-appearing emergency department (ED) patients. We evaluated patient outcomes among ED patients with a documented ambulatory oxygen saturation measurement. METHODS:This was a retrospective chart review of ED patients seen at New York University Langone Health during the peak of the COVID-19 pandemic in New York City. We identified ED patients who had a documented ambulatory oxygen saturation. We studied the outcomes of high oxygen requirement (defined as >4 liters per minute) and mechanical ventilation among admitted patients and bounceback admissions among discharged patients. We also performed logistic regression and compared the performance of different ambulatory oxygen saturation cutoffs in predicting these outcomes. RESULTS:Between March 15-April 14, 2020, 6194 patients presented with fever, cough, or shortness of breath at our EDs. Of these patients, 648 (11%) had a documented ambulatory oxygen saturation, of which 165 (24%) were admitted. Notably, admitted and discharged patients had similar initial vital signs. However, the average ambulatory oxygen saturation among admitted patients was significantly lower at 89% compared to 96% among discharged patients (p<0.01). Among admitted patients with an ambulatory oxygen saturation, 30% had high oxygen requirements and 8% required mechanical ventilation. These rates were predicted by low ambulatory oxygen saturation (p<0.01). Among discharged patients, 50 (10%) had a subsequent ED visit resulting in admission. Although bounceback admissions were predicted by ambulatory oxygen saturation at the first ED visit (p<0.01), our analysis of cutoffs suggested that this association may not be clinically useful. CONCLUSION/CONCLUSIONS:Measuring ambulatory oxygen saturation can help ED clinicians identify patients who may require high levels of oxygen or mechanical ventilation during admission. However, it is less useful for identifying which patients may deteriorate clinically in the days after ED discharge and require subsequent hospitalization.

New York City (NYC) has emerged as the global epicenter for the COVID-19 pandemic. The NYC Public Health System (NYC Health +Hospitals, NYC H + H) was key to the city's response because its vulnerable patient population was disproportionately affected by the disease. As cases rose in the city, NYC H+H carried out plans to greatly expand critical care capacity. Primary ICU spaces were identified and upgraded as needed, while new ICU spaces were created in emergency departments (EDs), procedural areas, and other inpatient units. Patients were transferred between hospitals in order to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and military deployments. Supplies to deliver critical care were monitored closely and obtained as needed to prevent interruptions. An ED action team was formed to ensure that the experience of frontline providers was informing network level decisions. The steps taken by NYC H+H greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally ac-cepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospital received multiple injured patients within minutes; lessons learned included the need for a formal-ized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for multiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in orga-nizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally accepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospi-tal received multiple injured patients within minutes; lessons learned included the need for a formalized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for hmultiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in organizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.