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Current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR. This was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations. We identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations. Among patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.

Point-of-care ultrasound (POCUS) is useful in the evaluation of early pregnancy by confirming intrauterine pregnancy and recognizing hemorrhage from ectopic pregnancy. We sought to determine whether transabdominal POCUS by itself or in conjunction with consultative radiology ultrasound (RADUS), reduces Emergency Department (ED) treatment time for patients with ectopic pregnancy requiring operative care, when compared to RADUS alone. A secondary objective was to determine whether the incorporation of POCUS reduces time to operative care for patients with ruptured ectopic pregnancy specifically, when compared to RADUS alone. We performed a retrospective review of patients admitted for operative management of ectopic pregnancy. We excluded patients with known ectopic pregnancy and/or imaging prior to arriving to the treatment area, found not to have an ectopic pregnancy, or did not undergo operative care. Descriptive statistics, classical and nonparametric statistical analysis, and linear regression were performed. There were 220 patients admitted with ectopic pregnancy, 111 met exclusion criteria, yielding 109 for analysis. Of 109, 36 received POCUS (23/36 also had RADUS), while 73 received RADUS only. Among the POCUS group 31/36 (86%) were classified as ruptured versus 47/73 (64%) in the RADUS group. The average ED treatment time in the POCUS group for all admitted ectopic pregnancies was 157.9 min (standard deviation [SD] 101.3) versus 206.3 min (SD 76.6) in the RADUS group (p = 0.0141). The median time to operating room (OR) for ruptured ectopic pregnancies was 203.0 min (interquartile range [IQR] 159.0) in the POCUS group versus 293.0 min (IQR 139.0) in the RADUS group (p = 0.0002). Regression analysis of the primary outcome was limited by multiple interactions and sample size. When controlling for race, positive shock index and ED visit time, POCUS was found to be associated with a significantly shorter time to OR among ruptured ectopic pregnancies compared to RADUS (p = 0.0052). Compared to RADUS alone, incorporation of POCUS was associated with significantly faster ED treatment time for all ectopic pregnancies and significantly faster time to OR for ruptured ectopic pregnancies, even when combined with RADUS. When controlling for clinical differences, time to OR was still faster for patients who underwent POCUS. The integration of POCUS should be considered to expedite care for patients with ectopic pregnancy requiring operative care.

Emergency department (ED) high utilizers are a costly group of patients due to their higher utilzation of acute care costs. At a safety-net hospital, we enrolled patients in a program which partnered with lawyers and community health advocates (CHAs) to navigate patients' social, medical and legal needs. Our aim was to decrease costs and utilization and address the patient's social determinants of heath (SDOH). We enrolled patients with 4 or more ED visits in the prior 6 months and gave them SDOH and medical questionnaires. Patients were followed for 6 months on a weekly, then bi-monthly basis. All utilization and cost data were obtained through an internal data warehouse and evaluated using a pre-post analysis and broken down into quartiles. ED, admission, and total costs did not differ significantly between the 12 months pre-enrollment and the 12 months post-enrollment. Outpatient costs did increase ($2182 increase, p < 0.005). ED visits declined significantly in the post-enrollment period (IRR = 0.84, p = 0.048), with the highest impact on those with <7 ED visits. Total admissions did not decline (IRR 0.84, p = 0.059). But, among those with 4 or 5 ED visits, admission costs and visits decreased. On average, six SDOH issues were identified. Of these, approximately 30.3% were mitigated with up to 17% requiring legal help. While outpatient costs did increase, total costs did not decrease in this program. This type of non-clinical intervention may be best served for patients who are less clinically complex but significant social needs. •Why is this topic important? ED high utilizers represent a costly group of individuals who are often high have social needs that prevent them from caring for themselves and address their medical needs.•What does this study attempt to show? Partnering with community health advocates and legal services can be beneficial to the system in reducing costs and to the patient in addressing their social needs.•What are the key findings? While ED, admission and total costs did not differ significantly overall, costs were lower in those who had less ED visits in the pre-enrollment period and many social needs were addressed but not fully mitigated or resolved.•How is patient care impacted? Hospitals can benefit from partnering with community health advocates and legal services in addressing many social needs that prevent patients from addressing their medical needs.

Opioid use disorder (OUD) is a national epidemic, and Black and Hispanic patients are less likely to receive treatment when compared to white patients. In this study, race was used as a proxy to assess potential effects of racism on the referral process for OUD treatment. Our primary aim was to examine whether Black or Hispanic patients experienced increased barriers to inpatient OUD detoxification (detox) placement at a community-integrated, substance use disorder support program based in an emergency department (ED). Our secondary aim was to determine if Black and Hispanic patients were more likely to have >3 referrals. This retrospective cohort study was conducted at a large urban safety-net hospital and included patients seen in the ED from July 2018 to September 2019 with ICD-10 codes for an opioid-related visit and who sought placement to inpatient detox. A generalized linear mixed model controlling for multiple visits, age, sex, insurance, time, day of week, and time of year was used to assess the association between race/ethnicity and hypothesized barriers to placement. The proportion of patients with >3 visits for referral to inpatient detox was compared between Black and Hispanic patients and white patients using a chi-squared test. We identified 1733 encounters from 782 unique patients seeking connection to inpatient detox for OUD. Of the 1733 encounters, 45% were among Black and Hispanic patients. Hispanic and Black men had significantly lower odds of having a barrier to inpatient OUD detox than white men (OR = 0.734, 95% CI 0.542–0.995). No significant difference was found for Hispanic and Black women (OR = 1.212, 95% CI 0.705–2.082). More Black and Hispanic patients experienced >3 referrals to inpatient detox compared to white patients (19.2% vs 12.9%, p = 0.016). This study suggests in the context of near-universal health insurance coverage, an ED-based OUD support program staffed by diverse community members can mitigate inequities in access to inpatient detox. However, the increased number of ED visits for OUD detox placement by Black and Hispanic patients suggests racial inequities in OUD treatment exist after linkage to care. Additional research should explore the causes, specifically structural and interpersonal racism, and determine solutions to address racial inequities in detox placement as well as maintenance in treatment programs. •Black and Hispanic men had lower odds of having a barrier to inpatient OUD detox.•ED-based support program staffed by diverse community members can mitigate inequities.•Black and Hispanic patients were more likely to have repeat visits.•Structural and interpersonal racism must be considered when assessing barriers.

Background Evidence-based and evidence-informed interventions designed to address gaps in the HIV care continuum have the potential to improve HIV care and treatment. However, inadequate organizational readiness can derail intervention uptake, prevent the integration of interventions, and contribute to suboptimal HIV treatment outcomes. This study sought to understand organizational readiness to implement bundled interventions for Black women with HIV and inform facilitators and barriers to implementation. Methods We conducted a mixed methods readiness assessment across 12 sites participating in the Black Women First (BWF) initiative to gauge preparedness to implement bundled interventions. Readiness was assessed using the organizational readiness for implementing change (ORIC) scale, and two open-ended questions examined facilitators and barriers. Associations between participant and organizational level factors were evaluated using linear models with clustering by site at baseline, 6- and 12-months. Pre-implementation interviews were conducted with staff virtually and transcripts were managed in NVivo. Directed content analysis was used to explore implementation barriers and facilitators. Findings Sites demonstrated high levels of organizational readiness at baseline; overall organizational readiness for implementing change (ORIC) (mean 56.4, median 59, interquartile range [IQR] 5) and subscales of the ORIC change efficacy (mean 32.4, median 35, IQR 4), change commitment (mean 24, median 25, IQR 1), which is consistent with willingness and capability to implement bundled interventions for Black women with HIV. Organizational readiness remained high at 6- and 12-month follow-up periods. Staff role was significantly associated with organizational readiness ( p  = 0.007), change efficacy ( p  = 0.006), and change commitment ( p  = 0.020) at 6 months. Qualitative analysis indicated strategic planning and assessment (e.g., team coordination and the development of workflows to support implementation); organizational change through network weaving across silos within the organization, and communications systems that engage external partners, as well as resources available for hiring and training, supported readiness. Collaborative leadership and organizational buy-in, staff motivation, and partnerships facilitated implementation processes. Conclusions Organizations in the BWF initiative have high levels of organizational readiness reflecting willingness and capability to implement bundled interventions for Black women with HIV. Future research should examine the relationship between readiness and clinical outcomes.

Despite the burdens that resident attrition places upon programs and fellow trainees, emergency medicine (EM) as a specialty has only begun to explore the issue. Our primary objectives were to quantify attrition in EM residency programs and elucidate the reasons behind it. Our secondary objectives were to describe demographic characteristics of residents undergoing attrition, personal factors associated with attrition, and methods of resident replacement. We conducted a national survey study of all EM program directors (PDs) during the 2018-2019 academic year. PDs were asked to identify all residents who had left their program prior to completion of training within the last four academic years (2015-2016 to 2018-2019), provide relevant demographic information, select perceived reasons for attrition, and report any resident replacements. Frequencies, percentages, proportions, and 95% confidence intervals were obtained for program- and resident-specific demographics. We performed Fisher's exact tests to compare reasons for attrition between age groups. Of 217 PDs successfully contacted, 118 completed the questionnaire (response rate of 54%). A third of programs (39 of 118) reported at least one resident attrition. A total of 52 residents underwent attrition. Attrition was most likely to occur prior to completion of two years of training. Gender and underrepresented minority status were not associated with attrition. Older residents were more likely to leave due to academic challenges. The most common reported reason for attrition was to switch specialties. Resident replacement was found in 42% of cases. One-third of programs were affected by resident attrition. Gender and underrepresented minority status were not associated with attrition.

AbstractStudy objectiveTo determine the prevalence of false negative point‐of‐care (POC) urine pregnancy tests among emergency department (ED) patients and among those with abdominal pain or vaginal bleeding. MethodsWe identified all female patients, ages 14–50 years without prior hysterectomy who had a negative POC urine pregnancy test (beta subunit of human chorionic gonadotropin [β‐hCG]) performed by trained clinical staff in the ED between September 1, 2017 and December 31, 2018, as well as a subgroup we defined a priori as “high risk” for early pregnancy complications based on a triage chief complaint (text) of abdominal pain or vaginal bleeding. We identified those with a positive urine β‐hCG, serum β‐hCG >5 mIU/mL, or a diagnosis of pregnancy within 3 months of the initial ED visit (index visit). We used structured chart review with American College of Obstetrics and Gynecology guidelines to determine pregnancy diagnosis and outcomes (ectopic, intrauterine, abnormal including spontaneous abortion, and unknown), the date of conception, and whether the pregnancy was present at the index visit. ResultsOf 10,924 visits with a negative urine pregnancy test result that were screened for a pregnancy outcome, 171 (1.6%, 95% confidence interval [CI] = 1.4, 1.8) had a pregnancy present at the index visit. Diagnoses were ectopic (n = 12, 7.0%), intrauterine (n = 71, 41.5%), abnormal (n = 77, 45.0%), and unknown (n = 11, 6.4%). Of the 2732 patients with high‐risk complaints, 97 (3.6%, 95% CI = 2.9, 4.3) had a pregnancy present at the index visit (relative risk of a pregnancy diagnosis 3.9, 95% CI = 2.9,5.3), including 10/12 ectopic (83%), 58/77 abnormal (75%), and 25/71 intrauterine pregnancies (35%). Serum β‐hCG ranged from 2 mIU/mL to above assay (median = 119.5, interquartile range = 957.5). ConclusionAlthough false negative urine pregnancy tests were uncommon, multiple pregnancy diagnoses were missed, including ectopic pregnancies. False negatives were more common among patients with abdominal pain or vaginal bleeding. Concurrent serum β‐hCG levels demonstrated a broad distribution.

Boston Medical Center (BMC), a safety-net hospital, treated a substantial portion of the Boston cohort that was sick with COVID-19. Unfortunately, these patients experienced high rates of morbidity and mortality given the significant health disparities that many of BMC's patients face. Boston Medical Center launched a palliative care extender program to help address the needs of critically ill ED patients under crisis conditions. In this program evaluation our goal was to assess outcomes between those who received palliative care in the emergency department (ED) vs those who received palliative care as an inpatient or were admitted to an intensive care unit (ICU). We used a matched retrospective cohort study design to assess the difference in outcomes between the two groups. A total of 82 patients received palliative care services in the ED, and 317 patients received palliative care services as an inpatient. After controlling for demographics, patients who received palliative care services in the ED were less likely to have a change in level of care (P<0.001) or be admitted to an ICU (P<0.001). Cases had an average length of stay of 5.2 days compared to controls who stayed 9.9 days (P<0.001). Within a busy ED environment, initiating palliative care discussions by ED staff can be challenging. This study demonstrates that consulting palliative care specialists early in the course of the patient's ED stay can benefit patients and families and improve resource utilization.

IntroductionDespite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer’s disease and related Dementias, regardless of age.Methods and analysisThe Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included.Ethics and disseminationThe Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov.Trial registration numberNCT04857060; ClinicalTrials.gov

There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol. This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017-December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients' clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia. Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69-0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96-2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use non-opiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns. The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization.