Northwestern University Feinberg School of Medicine

Department of Emergency Medicine

Research Publications

Following is information on recent faculty publications. For more information on our research, see the Emergency Medicine section on Northwestern Scholars.

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Corporate Philanthropy Toward Community Health Improvement in Manufacturing Communities.

McHugh M, Farley D, Maechling CR, Dunlop DD, French DD, Holl JL

J Community Health. 2017 Dec 7. doi: 10.1007/s10900-017-0452-2. [Epub ahead of print]

Virtually all large employers engage in corporate philanthropy, but little is known about the extent to which it is directed toward improving community health. We conducted in-depth interviews with leaders of corporate philanthropy from 13 of the largest manufacturing companies in the US to understand how giving decisions were made, the extent to which funding was directed towards improving community health, and whether companies coordinate with local public health agencies. We found that corporate giving was sizable and directed towards communities in which the manufacturers have a large presence. Giving was aligned with the social determinants of health (i.e., aimed at improving economic stability, the neighborhood and physical environment, education, food security and nutrition, the community and social context, and the health care system). However, improving public health was not often cited as a goal of corporate giving, and coordination with public health agencies was limited. Our results suggest that there may be opportunities for public health agencies to help guide corporate philanthropy, particularly by sharing community-level data and offering their measurement and evaluation expertise.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

Lin MP, Probst MA, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Butler K, Runyon MS, Wang H, Courtney DM, Muckley B, Hobgood CD, Hall CL, Kline JA

Patient Educ Couns. 2017 Nov 22. pii: S0738-3991(17)30635-3. doi: 10.1016/j.pec.2017.11.012. [Epub ahead of print]

OBJECTIVE:

We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging.

METHODS:

Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning.

RESULTS:

We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%).

CONCLUSION:

The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing.

PRACTICE IMPLICATIONS:

Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

Opioid vs Nonopioid Acute Pain Management in the Emergency Department.

Kyriacou DN

JAMA. 2017 Nov 7;318(17):1655-1656. doi: 10.1001/jama.2017.16725.

Impact of Discharge Anticoagulation Education by Emergency Department Pharmacists at a Tertiary Academic Medical Center.

Zdyb EG, Courtney DM, Malik S, Schmidt MJ, Lyden AE

J Emerg Med. 2017 Dec;53(6):896-903. doi: 10.1016/j.jemermed.2017.06.008. Epub 2017 Sep 21.

BACKGROUND:

Although pharmacists commonly provide patient education and help manage high-risk anticoagulant medications in inpatient and outpatient settings, the evidence for these interventions in the emergency department (ED) is less established, especially in the era of direct-acting oral anticoagulants. In 2013, a formal program was initiated whereby patients discharged with a new prescription for any anticoagulant receive education from an ED pharmacist when on-site. In addition, they received follow-up phone calls from an ED pharmacist within 72 hours of discharge.

OBJECTIVE:

We sought to identify the impact of pharmacist education, defined as the need for intervention on callback, versus physician and nursing-driven discharge measures on patient understanding and appropriate use of anticoagulant medications.

METHODS:

A single-center retrospective analysis included patients discharged from the ED between May 2013 and May 2016 with a new anticoagulant prescription. Electronic callback records were reviewed to assess patients' adherence and understanding of discharge instructions as well as for an anticoagulant-related hospital readmission within 90 days.

RESULTS:

One hundred seventy-four patients were evaluated in a per protocol analysis. Patients who did not receive pharmacist education prior to discharge required an increased need for intervention during callback versus those who did (36.4% vs. 12.9%, p = 0.0005) related to adherence, inappropriate administration, and continued use of interacting medications or supplements, among other concerns. In addition, patients who had not received pharmacist counseling were more likely to be readmitted to a hospital or return to the ED within 90 days after their initial visit for an anticoagulation-related problem versus patients who had (12.12% vs. 1.85%, p = 0.0069).

CONCLUSION:

Discharge education by ED pharmacists leads to improved patient understanding and appropriate use of anticoagulants.

What Did You Google? Describing Online Health Information Search Patterns of ED patients and Their Relationship with Final Diagnoses.

McCarthy DM, Scott GN, Courtney DM, Czerniak A, Aldeen AZ, Gravenor S, Dresden SM

West J Emerg Med. 2017 Aug;18(5):928-936. doi: 10.5811/westjem.2017.5.34108. Epub 2017 Jul 14.

INTRODUCTION:

Emergency department (ED) patients' Internet search terms prior to arrival have not been well characterized. The objective of this analysis was to characterize the Internet search terms patients used prior to ED arrival and their relationship to final diagnoses.

METHODS:

We collected data via survey; participants listed Internet search terms used. Terms were classified into categories: symptom, specific diagnosis, treatment options, anatomy questions, processes of care/physicians, or "other." We categorized each discharge diagnosis as either symptom-based or formal diagnosis. The relationship between the search term and final diagnosis was assigned to one of four categories of search/diagnosis combinations (symptom search/symptom diagnosis, symptom search/formal diagnosis, diagnosis search/symptom diagnosis, diagnosis search/formal diagnosis), representing different "trajectories."

RESULTS:

We approached 889 patients; 723 (81.3%) participated. Of these, 177 (24.5%) used the Internet prior to ED presentation; however, seven had incomplete data (N=170). Mean age was 47 years (standard deviation 18.2); 58.6% were female and 65.7% white. We found that 61.7% searched symptoms and 40.6% searched a specific diagnosis. Most patients received discharge diagnoses of equal specificity as their search terms (34% flat trajectory-symptoms and 34% flat trajectory-diagnosis). Ten percent searched for a diagnosis by name but received a symptom-based discharge diagnosis with less specificity. In contrast, 22% searched for a symptom and received a detailed diagnosis. Among those who searched for a diagnosis by name (n=69) only 29% received the diagnosis that they had searched.

CONCLUSION:

The majority of patients used symptoms as the basis of their pre-ED presentation Internet search. When patients did search for specific diagnoses, only a minority searched for the diagnosis they eventually received.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois.

Feinglass J, Cooper AJ, Rydland K, Powell ES, McHugh M, Kang R, Dresden SM

West J Emerg Med. 2017 Aug;18(5):811-820. doi: 10.5811/westjem.2017.5.34007. Epub 2017 Jul 17.

INTRODUCTION:

This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88 socioeconomically diverse areas of Illinois.

METHODS:

We used annual American Community Survey estimates for 2012-2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation.

RESULTS:

The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs.

CONCLUSION:

ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis.

Musa J, Achenbach CJ, O'Dwyer LC, Evans CT, McHugh M, Hou L, Simon MA, Murphy RL, Jordan N

PLoS One. 2017 Sep 5;12(9):e0183924. doi: 10.1371/journal.pone.0183924. eCollection 2017.

BACKGROUND:

Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally.

OBJECTIVES:

The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer.

METHODS:

We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I2 was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot.

RESULTS:

Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk.

CONCLUSION:

Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women's participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

Trends in Adult Cancer-Related Emergency Department Utilization: An Analysis of Data From the Nationwide Emergency Department Sample.

Rivera DR, Gallicchio L, Brown J, Liu B, Kyriacou DN, Shelburne N

JAMA Oncol. 2017 Oct 12;3(10):e172450. doi: 10.1001/jamaoncol.2017.2450. Epub 2017 Oct 12.

Importance:

The emergency department (ED) is used to manage cancer-related complications among the 15.5 million people living with cancer in the United States. However, ED utilization patterns by the population of US adults with cancer have not been previously evaluated or described in published literature.

Objective:

To estimate the proportion of US ED visits made by adults with a cancer diagnosis, understand the clinical presentation of adult patients with cancer in the ED, and examine factors related to inpatient admission within this population.

Design, Setting, and Participants:

Nationally representative data comprised of 7 survey cycles (January 2006-December 2012) from the Nationwide Emergency Department Sample were analyzed. Identification of adult (age ≥18 years) cancer-related visits was based on Clinical Classifications Software diagnoses documented during the ED visit. Weighted frequencies and proportions of ED visits among adult patients with cancer by demographic, geographic, and clinical characteristics were calculated. Weighted multivariable logistic regression was used to examine the associations between inpatient admission and key demographic and clinical variables for adult cancer-related ED visits.

Main Outcomes and Measures:

Adult cancer-related ED utilization patterns; identification of primary reason for ED visit; patient-related factors associated with inpatient admission from the ED.

Results:

Among an estimated 696 million weighted adult ED visits from January 2006 to December 2012, 29.5 million (4.2%) were made by a patient with a cancer diagnosis. The most common cancers associated with an ED visit were breast, prostate, and lung cancer, and most common primary reasons for visit were pneumonia (4.5%), nonspecific chest pain (3.7%), and urinary tract infection (3.2%). Adult cancer-related ED visits resulted in inpatient admissions more frequently (59.7%) than non-cancer-related visits (16.3%) (P < .001). Septicemia (odds ratio [OR], 91.2; 95% CI, 81.2-102.3) and intestinal obstruction (OR, 10.94; 95% CI, 10.6-11.4) were associated with the highest odds of inpatient admission.

Conclusions and Relevance:

Consistent with national prevalence statistics among adults, breast, prostate, and lung cancer were the most common cancer diagnoses presenting to the ED. Pneumonia was the most common reason for adult cancer-related ED visits with an associated high inpatient admission rate. This analysis highlights cancer-specific ED clinical presentations and the opportunity to inform patient and system-directed prevention and management strategies.

Emergency Department Provider Perspectives on Benzodiazepine-Opioid Coprescribing: A Qualitative Study.

Kim HS, McCarthy DM, Hoppe JA, Mark Courtney D, Lambert BL

Acad Emerg Med. 2017 Aug 9. doi: 10.1111/acem.13273. [Epub ahead of print]

OBJECTIVE:

Benzodiazepines and opioids are prescribed simultaneously (i.e., "coprescribed") in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid coprescribing occurs and providers' reasons for coprescribing.

METHODS:

We conducted focus groups with emergency department (ED) providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semistructured interviews to elicit perspectives on benzodiazepine-opioid coprescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid coprescribing.

RESULTS:

Participants acknowledged coprescribing rarely and reluctantly and often provided specific discharge instructions when coprescribing. The decision to coprescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g., low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to coprescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of coprescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial.

CONCLUSIONS:

In this qualitative study of ED providers, we found that benzodiazepine-opioid coprescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to coprescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.

Antibiotic Prescribing for Adults Hospitalized in the Etiology of Pneumonia in the Community Study.

Tomczyk S, Jain S, Bramley AM, Self WH, Anderson EJ, Trabue C, Courtney DM, Grijalva CG, Waterer GW, Edwards KM, Wunderink RG, Hicks LA

Open Forum Infect Dis. 2017 Jun 20;4(2):ofx088. doi: 10.1093/ofid/ofx088. eCollection 2017 Spring.

BACKGROUND:

Community-acquired pneumonia (CAP) 2007 guidelines from the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) recommend a respiratory fluoroquinolone or beta-lactam plus macrolide as first-line antibiotics for adults hospitalized with CAP. Few studies have assessed guideline-concordant antibiotic use for patients hospitalized with CAP after the 2007 IDSA/ATS guidelines. We examine antibiotics prescribed and associated factors in adults hospitalized with CAP.

METHODS:

From January 2010 to June 2012, adults hospitalized with clinical and radiographic CAP were enrolled in a prospective Etiology of Pneumonia in the Community study across 5 US hospitals. Patients were interviewed using a standardized questionnaire, and medical charts were reviewed. Antibiotics prescribed were classified according to defined nonrecommended CAP antibiotics. We assessed factors associated with nonrecommended CAP antibiotics using logistic regression.

RESULTS:

Among enrollees, 1843 of 1874 (98%) ward and 440 of 446 (99%) ICU patients received ≥1 antibiotic ≤24 hours after admission. Ward patients were prescribed a respiratory fluoroquinolone alone (n = 613; 33%), or beta-lactam plus macrolide (n = 365; 19%), beta-lactam alone (n = 240; 13%), among other antibiotics, including vancomycin (n = 235; 13%) or piperacillin/tazobactam (n = 157; 8%) ≤24 hours after admission. Ward patients with known risk for healthcare-associated pneumonia (HCAP), recent outpatient antibiotic use, and in-hospital antibiotic use <6 hours after admission were significantly more likely to receive nonrecommended CAP antibiotics.

CONCLUSIONS:

Although more than half of ward patients received antibiotics concordant with IDSA/ATS guidelines, a number received nonrecommended CAP antibiotics, including vancomycin and piperacillin/tazobactam; risk factors for HCAP, recent outpatient antibiotic, and rapid inpatient antibiotic use contributed to this. This hypothesis-generating descriptive epidemiology analysis could help inform antibiotic stewardship efforts, reinforces the need to harmonize guidelines for CAP and HCAP, and highlights the need for improved diagnostics to better equip clinicians.

Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department.

Weston V, Jain SK, Gottlieb M, Aldeen A, Gravenor S, Schmidt MJ, Malik S

West J Emerg Med. 2017 Jun;18(4):577-584. doi: 10.5811/westjem.2017.1.33243. Epub 2017 Apr 17.

INTRODUCTION:

Emergency department (ED) crowding is associated with detrimental effects on ED quality of care. Triage liaison providers (TLP) have been used to mitigate the effects of crowding. Prior studies have evaluated attending physicians and advanced practice providers as TLPs, with limited data evaluating resident physicians as TLPs. This study compares operational performance outcomes between resident and attending physicians as TLPs.

METHODS:

This retrospective cohort study compared aggregate operational performance at an urban, academic ED during pre- and post-TLP periods. The primary outcome was defined as cost-effectiveness based upon return on investment (ROI). Secondary outcomes were defined as differences in median ED length of stay (LOS), median door-to-provider (DTP) time, proportion of left without being seen (LWBS), and proportion of "very good" overall patient satisfaction scores.

RESULTS:

Annual profit generated for physician-based collections through LWBS capture (after deducting respective salary costs) equated to a gain (ROI: 54%) for resident TLPs and a loss (ROI: -31%) for attending TLPs. Accounting for hospital-based collections made both profitable, with gains for resident TLPs (ROI: 317%) and for attending TLPs (ROI: 86%). Median DTP time for resident TLPs was significantly lower (p<0.0001) than attending or historical control. Proportion of "very good" patient satisfaction scores and LWBS was improved for both resident and attending TLPs over historical control. Overall median LOS was not significantly different.

CONCLUSION:

Resident and attending TLPs improved DTP time, patient satisfaction, and LWBS rates. Both resident and attending TLPs are cost effective, with residents having a more favorable financial profile.

Oseltamivir Use Among Children and Adults Hospitalized With Community-Acquired Pneumonia.

Oboho IK, Bramley A, Finelli L, Fry A, Ampofo K, Arnold SR, Self WH, Williams DJ, Courtney DM, Zhu Y, Anderson EJ, Grijalva CG, McCullers JA, Wunderink RG, Pavia AT, Edwards KM, Jain S

Open Forum Infect Dis. 2016 Dec 27;4(1):ofw254. doi: 10.1093/ofid/ofw254. eCollection 2017 Winter.

BACKGROUND:

Data on oseltamivir treatment among hospitalized community-acquired pneumonia (CAP) patients are limited.

METHODS:

Patients hospitalized with CAP at 6 hospitals during the 2010-2012 influenza seasons were included. We assessed factors associated with oseltamivir treatment using logistic regression.

RESULTS:

Oseltamivir treatment was provided to 89 of 1627 (5%) children (<18 years) and 143 of 1051 (14%) adults. Among those with positive clinician-ordered influenza tests, 39 of 61 (64%) children and 37 of 48 (77%) adults received oseltamivir. Among children, oseltamivir treatment was associated with hospital A (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.36-4.88), clinician-ordered testing performed (aOR, 2.44; 95% CI, 1.47-5.19), intensive care unit (ICU) admission (aOR, 2.09; 95% CI, 1.27-3.45), and age ≥2 years (aOR, 1.43; 95% CI, 1.16-1.76). Among adults, oseltamivir treatment was associated with clinician-ordered testing performed (aOR, 8.38; 95% CI, 4.64-15.12), hospitals D and E (aOR, 3.46-5.11; 95% CI, 1.75-11.01), Hispanic ethnicity (aOR, 2.06; 95% CI, 1.18-3.59), and ICU admission (aOR, 2.05; 95% CI, 1.34-3.13).

CONCLUSIONS:

Among patients hospitalized with CAP during influenza season, oseltamivir treatment was moderate overall and associated with clinician-ordered testing, severe illness, and specific hospitals. Increased clinician education is needed to include influenza in the differential diagnosis for hospitalized CAP patients and to test and treat patients empirically if influenza is suspected.

Electronic medication complete communication strategy for opioid prescriptions in the emergency department: Rationale and design for a three-arm provider randomized trial.

McCarthy DM, Courtney DM, Lank PM, Cameron KA, Russell AM, Curtis LM, Kim KA, Walton SM, Montague E, Lyden AL, Gravenor SJ, Wolf MS

Contemp Clin Trials. 2017 Aug;59:22-29. doi: 10.1016/j.cct.2017.05.003. Epub 2017 May 4.

BACKGROUND:

Thousands of people die annually from prescription opioid overdoses; however there are few strategies to ensure patients receive medication risk information at the time of prescribing.

OBJECTIVES:

To compare the effectiveness of the Emergency Department (ED) Electronic Medication Complete Communication (EMC2) Opioid Strategy (with and without text messaging) to promote safe medication use and improved patient knowledge as compared to usual care.

METHODS:

The ED EMC2 Opioid Strategy consists of 5 automated components to promote safe medication use: 1) physician reminder to counsel, 2) inbox message sent on to the patient's primary care physician, 3) pharmacist message on the prescription to counsel, 4) MedSheet supporting prescription information, and 5) patient-centered Take-Wait-Stop wording of prescription instructions. This strategy will be assessed both with and without the addition of text messages via a three-arm randomized trial. The study will take place at an urban academic ED (annual volume>85,000) in Chicago, IL. Patients being discharged with a new prescription for hydrocodone-acetaminophen will be enrolled and randomized (based on their prescribing physician). The primary outcome of the study is medication safe use as measured by a demonstrated dosing task. Additionally actual safe use, patient knowledge and provider counseling will be measured. Implementation fidelity as well as costs will be reported.

CONCLUSIONS:

The ED EMC2 Opioid Strategy embeds a risk communication strategy into the electronic health record and promotes medication counseling with minimal workflow disruption. This trial will evaluate the strategy's effectiveness and implementation fidelity as compared to usual care.

TRIAL REGISTRATION:

This trial is registered on clinicaltrials.gov with identifier NCT02431793.

Unresponsive Male.

Kim HS, Ingalsbe GS, Lank PM

Ann Emerg Med. 2017 May;69(5):552-561. doi: 10.1016/j.annemergmed.2016.03.022.

Is there a clinically meaningful difference in patient reported dyspnea in acute heart failure? An analysis from URGENT Dyspnea.

Pang PS, Lane KA, Tavares M, Storrow AB, Shen C, Peacock WF, Nowak R, Mebazaa A, Laribi S, Hollander JE, Gheorghiade M, Collins SP

Heart Lung. 2017 Jul - Aug;46(4):300-307. doi: 10.1016/j.hrtlng.2017.03.003. Epub 2017 Apr 19.

BACKGROUND:

Dyspnea is the most common presenting symptom in patients with acute heart failure (AHF), but is difficult to quantify as a research measure. The URGENT Dyspnea study compared 3 scales: (1) 10 cm VAS, (2) 5-point Likert, and (3) a 7-point Likert (both VAS and 5-point Likert were recorded in the upright and supine positions). However, the minimal clinically important difference (MCID) to patients has not been well established.

METHODS:

We performed a secondary analysis from URGENT Dyspnea, an observational, multi-center study of AHF patients enrolled within 1 h of first physician assessment in the ED. Using the anchor-based method to determine the MCID, a one-category change in the 7-point Likert was used as the criterion standard ('minimally improved or worse'). The main outcome measures were the change in visual analog scale (VAS) and 5-point Likert scale from baseline to 6-h assessment relative to a 1-category change response in the 7-point Likert scale ('minimally worse', 'no change', or 'minimally better').

RESULTS:

Of the 776 patients enrolled, 491 had a final diagnosis of AHF with responses at both time points. A 10.5 mm (SD 1.6 mm) change in VAS was the MCID for improvement in the upright position, and 14.5 mm (SD 2.0 mm) in the supine position. However, there was no MCID for worsening, as few patients reported worse dyspnea. There was also no significant MCID for the 5-point Likert scale.

CONCLUSION:

A 10.5 mm change is the MCID for improvement in dyspnea over 6 h in ED patients with AHF.

Use of Online Health Information by Geriatric and Adult Emergency Department Patients: Access, Understanding, and Trust.

Scott G, McCarthy DM, Aldeen AZ, Czerniak A, Courtney DM, Dresden SM

Acad Emerg Med. 2017 Jul;24(7):796-802. doi: 10.1111/acem.13207. Epub 2017 May 29.

OBJECTIVE:

The objective was to characterize geriatric patients' use of online health information (OHI) relative to younger adults and assess their comfort ith OHI compared to health information (HI) from their physician.

METHODS:

This was a prospective cross-sectional survey study of adult emergency department (ED) patients. The survey assessed patients' self-reported use of OHI in the past year and immediately prior to ED visit and analyzed differences across four age groups: 18-39, 40-64, 65-74, and 75+. Patients' ability to access, understand, and trust OHI was assessed using a 7-point Likert scale and compared to parallel questions regarding HI obtained from their doctor. Patient use of OHI was compared across age groups. Comfort with OHI and HI obtained from a doctor was compared across age groups using the Kruskal-Wallis test. Comparisons between sources of HI were made within age groups using the Wilcoxon signed-rank test.

RESULTS:

Of 889 patients who were approached for study inclusion, 723 patients (81.3%) completed the survey. The majority of patients had used OHI in the past year in all age groups, but older patients were less likely to have used OHI: age 18-39, 90.3%; 40-64, 85.3%; 65-74, 76.4%; and 75+, 50.7% (p < 0.001). The youngest patients were most likely to have used OHI prior to coming to the ED, 47.1%, 28.3%, 17.1%, and 8.0% (p < 0.001). Older patients were more likely to have an established doctor-18-39, 79.4%; 40-64, 91.1%; 65-74, 97.5%; and 75+ 97.4% (p < 0.001)-and were more likely to have contacted their doctor prior to their ED visit: 36.7, 40.2, 46.7, and 53.5% (p = 0.02). The oldest patients were most likely to find HI more accessible from their doctor than the Internet, while the youngest patients found HI more accessible on the Internet than from their doctor. Regardless of age, patients noted that information from their physician was both easier to understand and more trustworthy than information found on the Internet.

CONCLUSION:

Although many older patients used OHI, they were less likely than younger adults to use the Internet immediately prior to an ED visit. Despite often using OHI, patients of all age groups found healthcare information from their doctor easier to understand and more trustworthy than information from the Internet. As health systems work to efficiently provide information to patients, addressing these perceived deficiencies may be necessary to build effective OHI programs.

Procalcitonin as a Marker of Etiology in Adults Hospitalized With Community-Acquired Pneumonia.

Self WH, Balk RA, Grijalva CG, Williams DJ, Zhu Y, Anderson EJ, Waterer GW, Courtney DM, Bramley AM, Trabue C, Fakhran S, Blaschke AJ, Jain S, Edwards KM, Wunderink RG

Clin Infect Dis. 2017 Jul 15;65(2):183-190. doi: 10.1093/cid/cix317.

Background:

Recent trials suggest procalcitonin-based guidelines can reduce antibiotic use for respiratory infections. However, the accuracy of procalcitonin to discriminate between viral and bacterial pneumonia requires further dissection.

Methods:

We evaluated the association between serum procalcitonin concentration at hospital admission with pathogens detected in a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia. Systematic pathogen testing included cultures, serology, urine antigen tests, and molecular detection. Accuracy of procalcitonin to discriminate between viral and bacterial pathogens was calculated.

Results:

Among 1735 patients, pathogens were identified in 645 (37%), including 169 (10%) with typical bacteria, 67 (4%) with atypical bacteria, and 409 (24%) with viruses only. Median procalcitonin concentration was lower with viral pathogens (0.09 ng/mL; interquartile range [IQR], <0.05-0.54 ng/mL) than atypical bacteria (0.20 ng/mL; IQR, <0.05-0.87 ng/mL; P = .05), and typical bacteria (2.5 ng/mL; IQR, 0.29-12.2 ng/mL; P < .01). Procalcitonin discriminated bacterial pathogens, including typical and atypical bacteria, from viral pathogens with an area under the receiver operating characteristic (ROC) curve of 0.73 (95% confidence interval [CI], .69-.77). A procalcitonin threshold of 0.1 ng/mL resulted in 80.9% (95% CI, 75.3%-85.7%) sensitivity and 51.6% (95% CI, 46.6%-56.5%) specificity for identification of any bacterial pathogen. Procalcitonin discriminated between typical bacteria and the combined group of viruses and atypical bacteria with an area under the ROC curve of 0.79 (95% CI, .75-.82).

Conclusions:

No procalcitonin threshold perfectly discriminated between viral and bacterial pathogens, but higher procalcitonin strongly correlated with increased probability of bacterial pathogens, particularly typical bacteria.

Corrigendum to "The electronic medication complete communication (EMC2) study: Rationale and methods for a randomized controlled trial of a strategy to promote medication safety in ambulatory care" [Contemp. Clin. Trials (2016) 72-77].

Bailey SC, Paasche-Orlow MK, Adams WG, Brokenshire SA, Hedlund LA, Hickson RP, Oramasionwu CU, Moore AL, McCarthy DM, Curtis LM, Kwasny MJ, Wolf MS

Contemp Clin Trials. 2017 Jun;57:99. doi: 10.1016/j.cct.2017.03.002. Epub 2017 Mar 17.

Nuts and bolts of running a pulmonary embolism response team: results from an organizational survey of the National PERT™ Consortium members.

Barnes G, Giri J, Courtney DM, Naydenov S, Wood T, Rosovsky R, Rosenfield K, Kabrhel C, National PERT™ Consortium Research Committee

Hosp Pract (1995). 2017 Aug;45(3):76-80. doi: 10.1080/21548331.2017.1309954. Epub 2017 Mar 31.

OBJECTIVES:

Pulmonary embolism response teams (PERT) are developing rapidly to operationalize multi-disciplinary care for acute pulmonary embolism patients. Our objective is to describe the core components of PERT necessary for newly developing programs.

METHODS:

An online organizational survey of active National PERT™ Consortium members was performed between April and June 2016. Analysis, including descriptive statistics and Kruskal-Wallis tests, was performed on centers self-reporting a fully operational PERT program.

RESULTS:

The survey response rate was 80%. Of the 31 institutions that responded (71% academic), 19 had fully functioning PERT programs. These programs were run by steering committees (17/19, 89%) more often than individual physicians (2/19, 11%). Most PERT programs involved 3-5 different specialties (14/19, 74%), which did not vary based on hospital size or academic affiliation. Of programs using multidisciplinary discussions, these occurred via phone or conference call (12/18, 67%), with a minority of these utilizing 'virtual meeting' software (2/12, 17%). Guidelines for appropriate activations were provided at 16/19 (84%) hospitals. Most PERT programs offered around-the-clock catheter-based or surgical care (17/19, 89%). Outpatient follow up usually occurred in personal physician clinics (15/19, 79%) or dedicated PERT clinics (9/19, 47%), which were only available at academic institutions.

CONCLUSIONS:

PERT programs can be implemented, with similar structures, at small and large, community and academic medical centers. While all PERT programs incorporate team-based multi-disciplinary care into their core structure, several different models exist with varying personnel and resource utilization. Understanding how different PERT programs impact clinical care remains to be investigated.

Serial Procalcitonin Predicts Mortality in Severe Sepsis Patients: Results From the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) Study.

Schuetz P, Birkhahn R, Sherwin R, Jones AE, Singer A, Kline JA, Runyon MS, Self WH, Courtney DM, Nowak RM, Gaieski DF, Ebmeyer S, Johannes S, Wiemer JC, Schwabe A, Shapiro NI

Crit Care Med. 2017 May;45(5):781-789. doi: 10.1097/CCM.0000000000002321.

OBJECTIVES:

To prospectively validate that the inability to decrease procalcitonin levels by more than 80% between baseline and day 4 is associated with increased 28-day all-cause mortality in a large sepsis patient population recruited across the United States.

DESIGN:

Blinded, prospective multicenter observational clinical trial following an Food and Drug Administration-approved protocol.

SETTING:

Thirteen U.S.-based emergency departments and ICUs.

PATIENTS:

Consecutive patients meeting criteria for severe sepsis or septic shock who were admitted to the ICU from the emergency department, other wards, or directly from out of hospital were included.

INTERVENTIONS:

Procalcitonin was measured daily over the first 5 days.

MEASUREMENTS AND MAIN RESULTS:

The primary analysis of interest was the relationship between a procalcitonin decrease of more than 80% from baseline to day 4 and 28-day mortality using Cox proportional hazards regression. Among 858 enrolled patients, 646 patients were alive and in the hospital on day 4 and included in the main intention-to-diagnose analysis. The 28-day all-cause mortality was two-fold higher when procalcitonin did not show a decrease of more than 80% from baseline to day 4 (20% vs 10%; p = 0.001). This was confirmed as an independent predictor in Cox regression analysis (hazard ratio, 1.97 [95% CI, 1.18-3.30; p < 0.009]) after adjusting for demographics, Acute Physiology and Chronic Health Evaluation II, ICU residence on day 4, sepsis syndrome severity, antibiotic administration time, and other relevant confounders.

CONCLUSIONS:

Results of this large, prospective multicenter U.S. study indicate that inability to decrease procalcitonin by more than 80% is a significant independent predictor of mortality and may aid in sepsis care.