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Open Access Publications from the University of California

Scholarly Works (5 results)

  • Article
  • Peer Reviewed
Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 16, Issue 5 (2015)

Emergency physicians are often required to evaluate and treat undifferentiated patients suffering acute hemodynamic compromise (AHC). It is helpful to apply a structured approach based on a differential diagnosis including all causes of AHC that can be identified and treated during a primary assessment. Tension pneumoperitoneum (TP) is an uncommon condition with the potential to be rapidly fatal. It is amenable to prompt diagnosis and stabilization in the emergency department. We present a case of a 16-year-old boy with TP to demonstrate how TP should be incorporated into a differential diagnosis when evaluating an undifferentiated patient with AHC.

    Cover page: Tension Pneumoperitoneum Caused by Obstipation
    • Article
    • Peer Reviewed
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 17, Issue 2 (2016)

    Introduction: Work interruptions during patient care have been correlated with error. Task-switching is identified by the Accreditation Council for Graduate Medical Education (ACGME) as a core competency for emergency medicine (EM). Simulation has been suggested as a means of assessing EM core competencies. We assumed that senior EM residents had better task-switching abilities than junior EM residents. We hypothesized that this difference could be measured by observing the execution of patient care tasks in the simulation environment when a patient with a ST-elevation myocardial infarction (STEMI) interrupted the ongoing management of a septic shock case.

    Methods: This was a multi-site, prospective, observational, cohort study. The study population consisted of a convenience sample of EM residents in their first three years of training. Each subject performed a standardized simulated encounter by evaluating and treating a patient in septic shock. At a predetermined point in every sepsis case, the subject was given a STEMI electrocardiogram (ECG) for a separate chest pain patient in triage and required to verbalize an interpretation and action. We scored learner performance using a dichotomous checklist of critical actions covering sepsis care, ECG interpretation and triaging of the STEMI patient.

    Results: Ninety-one subjects participated (30 postgraduate year [PGY]1s, 32 PGY2s, and 29 PGY3s). Of those, 87 properly managed the patient with septic shock (90.0% PGY1s, 100% PGY2, 96.6% PGY 3s; p=0.22). Of the 87 who successfully managed the septic shock, 80 correctly identified STEMI on the simulated STEMI patient (86.7% PGY1s, 96.9% PGY2s, 93.1% PGY3s; p=0.35). Of the 80 who successfully managed the septic shock patient and correctly identified the STEMI, 79 provided appropriate interventions for the STEMI patient (73.3% PGY1s, 93.8% PGY2s, 93.8% PGY3s; p=0.07).

    Conclusion: When management of a septic shock patient was interrupted with a STEMI ECG in a simulated environment we were unable to measure a significant difference in the ability of EM residents to successfully task-switch when compared across PGY levels of training. This study may help refine the use of simulation to assess EM resident competencies.

      Cover page: Can Simulation Measure Differences in Task-Switching Ability Between Junior and Senior Emergency Medicine Residents?
      • Article
      • Peer Reviewed
      Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 19, Issue 2 (2018)

      Introduction: This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit.

      Methods: We reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis.

      Results: Of the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively).

      Conclusion: Our study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.

        Cover page: Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2022)

        Study objective

        Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations.

        Methods

        This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them.

        Results

        Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks "all of the time" and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%).

        Conclusions

        Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.
          Cover page: Facemasks: Perceptions and use in an ED population during COVID-19
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2021)

          Study objective

          Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care.

          Methods

          This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt.

          Results

          Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED.

          Conclusion

          ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.
            Cover page: The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study
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