IntroductionSeveral studies have shown that workplace violence in the emergency department (ED) is common. Residents may be among the most vulnerable staff, as they have the least experience with these volatile encounters. The goal for this study was to quantify and describe acts of violence against emergency medicine (EM) residents by patients and visitors and to identify perceived barriers to safety.MethodsThis cross-sectional survey study queried EM residents at multiple New York City hospitals. The primary outcome was the incidence of violence experienced by residents while working in the ED. The secondary outcomes were the subtypes of violence experienced by residents, as well as the perceived barriers to safety while at work.ResultsA majority of residents (66%, 78/119) reported experiencing at least one act of physical violence during an ED shift. Nearly all residents (97%, 115/119) experienced verbal harassment, 78% (93/119) had experienced verbal threats, and 52% (62/119) reported sexual harassment. Almost a quarter of residents felt safe “Occasionally,” “Seldom” or “Never” while at work. Patient-based factors most commonly cited as contributory to violence included substance use and psychiatric disease.ConclusionSelf-reported violence against EM residents appears to be a significant problem. Incidence of violence and patient risk factors are similar to what has been found previously for other ED staff. Understanding the prevalence of workplace violence as well as the related systems, environmental, and patient-based factors is essential for future prevention efforts.

Objectives More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele‐intake at the time of presentation would reduce LWBS rates and ED throughput measures. Methods We conducted a before‐and‐after study at an urban community hospital. The intervention was use of a tele‐intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele‐intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24‐hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6‐month tele‐intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. Results Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24‐hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele‐intake providers thought tele‐intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in‐person triage. Of the receiving physicians, most agreed with statements that tele‐intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). Conclusions Remote tele‐intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

Study Objectives: The United States is in the midst of an opioid epidemic. Of more than 42,000 opioid deaths in 2016, 40% were related to prescription medications. Emergency department (ED) visit prescriptions may provide the initial exposure for many patients who subsequently misuse or develop opioid use disorder (OUD). Physician prescribing patterns can vary extensively, however ED physicians are among the top 5 opioid prescribers in all medical specialties in almost all age groups. It is well documented that a larger quantity of tablets or prolonged prescription duration is associated with increased risk of chronic opioid use. Electronic health records (EHR) allow for implementation of active and passive interventions that may influence provider behavior, specifically the ability to set prescription preferences on the departmental level. We tested the hypothesis that decreasing the number of pills in our ED prescribing preference settings would decrease the duration of prescriptions and number of tablets for opioid medications prescribed by our providers.Methods: A pre-post study design was performed between 4/1/17 and 4/30/18 using all opioid prescriptions made through EPIC Corporation's 2015 ASAP EHR module in 2 EDs. Prior to the intervention, which occurred on 1/28/18, opioid prescriptions had the EHR default prescription settings, which varied in number of pills and durations. Using the CDC guidelines for opioid prescribing, all opioid entries were given defaults under 50 milligram morphine equivalents per day and supplies were only for 3-days. Opioid prescriptions, their dosages and total pills dispensed were abstracted using the institutional reporting software Qlik. Our outcome measures were rates of prescription attributes that were consistent with CDC guidelines. Chi-square and Mann Whitney test were used to determine statistical significance.Results: During the study period, there were 78,416 discharged patients, of whom 731 (0.093%) received opioid prescriptions. 503 (69%) of these prescriptions were for >3 days of therapy. Comparing the pre period to the post period there was a reduction in the median number of all opioid prescriptions per month (56 [IQR, 49.9-62.2] to 47 [IQR,[45][46][47][48][49], p ¼ 0.014). There was also a reduction in the proportion of prescriptions lasting >3 days (80% [95% CI, 76.5-83.1%] to 19.3% [95% CI, 13.2-27.1%], p<0.001), as well as a reduction in median number of pills dispensed (12 [IQR,[8][9][10][11][12][13][14][15][16] to 8 [IQR, 6-10], p<0.001).When isolating the 3 months pre and post intervention there was no difference in the median number of overall opioid prescriptions. However, there was a reduction in proportion of prescriptions lasting >3 days (70 .5% [95% CI, 62.6-77.4%] to 19.3% [95% CI, 13.2-27.1%], p<0.001), as well as the median number of pills dispensed (11 [IQR,.5] to 8 [IQR, 6-10] p<0.001).Conclusions: Modification of departmental EHR prescription preference settings can substantially alter prescribing patterns for opioid prescriptions in the ED. ...

ImportanceLong-term sequelae after symptomatic SARS-CoV-2 infection may impact well-being, yet existing data primarily focus on discrete symptoms and/or health care use.ObjectiveTo compare patient-reported outcomes of physical, mental, and social well-being among adults with symptomatic illness who received a positive vs negative test result for SARS-CoV-2 infection.Design, Setting, and ParticipantsThis cohort study was a planned interim analysis of an ongoing multicenter prospective longitudinal registry study (the Innovative Support for Patients With SARS-CoV-2 Infections Registry [INSPIRE]). Participants were enrolled from December 11, 2020, to September 10, 2021, and comprised adults (aged ≥18 years) with acute symptoms suggestive of SARS-CoV-2 infection at the time of receipt of a SARS-CoV-2 test approved by the US Food and Drug Administration. The analysis included the first 1000 participants who completed baseline and 3-month follow-up surveys consisting of questions from the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29; 7 subscales, including physical function, anxiety, depression, fatigue, social participation, sleep disturbance, and pain interference) and the PROMIS Short Form–Cognitive Function 8a scale, for which population-normed T scores were reported.ExposuresSARS-CoV-2 status (positive or negative test result) at enrollment.Main Outcomes and MeasuresMean PROMIS scores for participants with positive COVID-19 tests vs negative COVID-19 tests were compared descriptively and using multivariable regression analysis.ResultsAmong 1000 participants, 722 (72.2%) received a positive COVID-19 result and 278 (27.8%) received a negative result; 406 of 998 participants (40.7%) were aged 18 to 34 years, 644 of 972 (66.3%) were female, 833 of 984 (84.7%) were non-Hispanic, and 685 of 974 (70.3%) were White. A total of 282 of 712 participants (39.6%) in the COVID-19–positive group and 147 of 275 participants (53.5%) in the COVID-19–negative group reported persistently poor physical, mental, or social well-being at 3-month follow-up. After adjustment, improvements in well-being were statistically and clinically greater for participants in the COVID-19–positive group vs the COVID-19–negative group only for social participation (β = 3.32; 95% CI, 1.84-4.80; P &amp;lt; .001); changes in other well-being domains were not clinically different between groups. Improvements in well-being in the COVID-19–positive group were concentrated among participants aged 18 to 34 years (eg, social participation: β = 3.90; 95% CI, 1.75-6.05; P &amp;lt; .001) and those who presented for COVID-19 testing in an ambulatory setting (eg, social participation: β = 4.16; 95% CI, 2.12-6.20; P &amp;lt; .001).Conclusions and RelevanceIn this study, participants in both the COVID-19–positive and COVID-19–negative groups reported persistently poor physical, mental, or social well-being at 3-month follow-up. Although some individuals had clinically meaningful improvements over time, many reported moderate to severe impairments in well-being 3 months later. These results highlight the importance of including a control group of participants with negative COVID-19 results for comparison when examining the sequelae of COVID-19.

Several asynchronous automated electronic notification systems for laboratory results have been evaluated, most from >10 years ago. Further research on the effect of notifications on clinicians as well as the use of modern electronic health records and new methods of notification is warranted to determine their effects on workflow and clinical outcomes.

Background Reports on medium and long-term sequelae of SARS-CoV-2 infections largely lack quantification of incidence and relative risk. We describe the rationale and methods of the Innovative Support for Patients with SARS-CoV-2 Registry (INSPIRE) that combines patient-reported outcomes with data from digital health records to understand predictors and impacts of SARS-CoV-2 infection. Methods INSPIRE is a prospective, multicenter, longitudinal study of individuals with symptoms of SARS-CoV-2 infection in eight regions across the US. Adults are eligible for enrollment if they are fluent in English or Spanish, reported symptoms suggestive of acute SARS-CoV-2 infection, and if they are within 42 days of having a SARS-CoV-2 viral test (i.e., nucleic acid amplification test or antigen test), regardless of test results. Recruitment occurs in-person, by phone or email, and through online advertisement. A secure online platform is used to facilitate the collation of consent-related materials, digital health records, and responses to self-administered surveys. Participants are followed for up to 18 months, with patient-reported outcomes collected every three months via survey and linked to concurrent digital health data; follow-up includes no in-person involvement. Our planned enrollment is 4,800 participants, including 2,400 SARS-CoV-2 positive and 2,400 SARS-CoV-2 negative participants (as a concurrent comparison group). These data will allow assessment of longitudinal outcomes from SARS-CoV-2 infection and comparison of the relative risk of outcomes in individuals with and without infection. Patient-reported outcomes include self-reported health function and status, as well as clinical outcomes including health system encounters and new diagnoses. Results Participating sites obtained institutional review board approval. Enrollment and follow-up are ongoing. Conclusions This study will characterize medium and long-term sequelae of SARS-CoV-2 infection among a diverse population, predictors of sequelae, and their relative risk compared to persons with similar symptomatology but without SARS-CoV-2 infection. These data may inform clinical interventions for individuals with sequelae of SARS-CoV-2 infection.

The risk of cancer from computed tomography (CT) scan radiation is a rising concern in the medical field. Our objectives were to determine how many patients received more than ten CT scans in an academic emergency department (ED) over the course of 7 years and to quantify their radiation exposure and lifetime attributable risk of cancer. An electronic chart review was performed at our urban academic institution with an annual census of 110,000 patients. All patients who underwent a CT scan performed during ED management between the dates of January 2001 and December 2007 were identified. Specific predetermined data elements (e.g., subject demographics, type of CT scan) were extracted by two researchers blinded to hypothesis, using a preformatted data form. After identifying patients with more than ten CTs performed during the study period, radiation exposure was calculated based on accepted and reported radiation doses for the respective anatomic CTs, and lifetime attributable cancer risk was calculated based on the seventh report of the Biological Effects of Ionizing Radiation (BEIR VII) projections. Over the 7-year study period, 24,393 patients received 34,671 CT scans. The vast majority of patients (17,909) received a single CT. Twenty-six (0.1 %) patients received more than ten CTs totaling 374 scans with an average radiation exposure of 83.4 mSv. The maximum lifetime attributable risk for any individual in this cohort was 1.7 % above the baseline cancer risk. Among those undergoing CT imaging in our ED, high-exposure patients (greater than ten scans) constituted a significant minority, while more than one in four patients underwent more than one CT scan during the study period. While the presumed overall risk of radiation-induced cancer continues to be low, it is important for the emergency physician to use clinical knowledge as well as concern for the patient when utilizing radiographic imaging. Increasing attributable cancer risk may have important public health implications in the future, regardless of the low individual risk.

BACKGROUND Long-term symptoms following SARS-CoV-2 infection are a major concern, yet their prevalence is poorly understood. METHODS We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (COVID+) with adults who tested negative (COVID−), enrolled within 28 days of an FDA-approved SARS-CoV2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the CDC Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (i.e., fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email. RESULTS Among the first 1,000 participants, 722 were COVID + and 278 were COVID−. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID + group than the COVID − group. At 3-months, SARS-CoV-2 symptoms declined in both groups although were more prevalent in the COVID + group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID + and COVID − groups at 3 months. CONCLUSIONS Approximately half of COVID + participants, as compared with one-quarter of COVID − participants, had at least one SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish Long COVID.