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Introduction: Methamphetamine use is on the rise with increasing emergency department (ED) visits, behavioral health crises, and deaths associated with use and overdose. Emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and violence against staff, but little is known about the patient’s perspective. In this study our objective was to identify the motivations for initiation and continued methamphetamine use among people who use methamphetamine and their experiences in the ED to guide future ED-based approaches. Methods: This was a qualitative study of adults residing in the state of Washington in 2020, who used methamphetamine in the prior 30 days, met criteria for moderate- to high-risk use, reported recently receiving care in the ED, and had phone access. Twenty individuals were recruited to complete a brief survey and semistructured interview, which was recorded and transcribed prior to being coded. Modified grounded theory guided the analysis, and the interview guide and codebook were iteratively refined. Three investigators coded the interviews until consensus was reached. Data was collected until thematic saturation. Results: Participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. Many initially used methamphetamine to enhance social interactions, combat boredom, and escape difficult circumstances by numbing the senses. However, continued use regularly led to isolation, ED visits for the medical and psychological sequelae of methamphetamine use, and engagement in increasingly risky behaviors. Because of their overwhelmingly frustrating experiences in the past, interviewees anticipated difficult interactions with healthcare clinicians, leading to combativeness in the ED, avoidance of the ED at all costs, and downstream medical complications. Participants desired a non-judgmental conversation and linkage to outpatient social resources and addiction treatment. Conclusion: Methamphetamine use can lead patients to seek care in the ED, where they often feel stigmatized and are provided little assistance. Emergency clinicians should acknowledge addiction as a chronic condition, address acute medical and psychiatric symptoms adequately, and provide positive connections to addiction and medical resources. Future work should incorporate the perspectives of people who use methamphetamine into ED-based programs and interventions.

BackgroundQuestions regarding the extent to which post-traumatic stress disorder (PTSD) is comorbid with alcohol and drug use are particularly germane in an era when the American College of Surgeons Committee on Trauma (ACS-COT) is considering policy requiring screening, intervention and/or referral services for patients presenting with psychological sequalae of traumatic injury. Literature review revealed few multisite trauma-center-based investigations that have assessed the association between PTSD symptoms and alcohol and drug use comorbidities in injured patients.MethodsThis investigation was a secondary analysis of baseline data collected prior to randomization in a 25-site trauma center pragmatic clinical trial. All 635 patients included in the investigation had elevated PTSD symptom levels at the time of trauma center admission. Self-report questionnaire screening, laboratory toxicology results, and electronic health record data were combined to assess the frequencies of alcohol, stimulant (i.e., amphetamine and cocaine), opioid and marijuana use comorbidities for injured patients. Logistic regression was used to assess the associations between demographic and injury characteristics and alcohol and drug use comorbidity.ResultsThe frequency of patients with one or more alcohol or substance use comorbidity was between 62% and 79%. Over 50% of patients were positive for one or more alcohol or cannabis comorbidity. Approximately 26% of patients were positive for stimulants and 10% for opioid comorbidity.DiscussionThis multisite investigation suggests that between 62% and 79% of hospitalized injury survivors with elevated PTSD symptoms have one or more alcohol or drug use comorbidity. Orchestrated ACS-COT policy and trauma center service delivery development should incorporate the key finding that a substantial majority of patients with high levels of psychological distress (eg, elevated PTSD symptoms) may have alcohol and drug use comorbidities.Level of evidenceLevel II (epidemiological investigation of untreated controls from a multisite randomized clinical trial)Trial registration numberNCT02655354.

Introduction: Influenza vaccines are commonly provided through community health events and primary care appointments. However, acute unscheduled healthcare visits such as emergency department (ED) visits are increasingly viewed as important vaccination opportunities. Emergency departments may be well-positioned to complement broader public health efforts with integrated vaccination programs. Methods: We studied an ED-based influenza vaccination initiative in an urban hospital and examined patient-level factors associated with screening and vaccination uptake. Our analyses included patient visits to the ED from October 1, 2019-April 1, 2020. Results: The influenza screening and vaccination program proved feasible. Of the 20,878 ED visits that occurred within the study period, 3,565 (17.1%) included a screening for influenza vaccine eligibility; a small proportion (11.5%) of the patients seen had multiple screenings. Among the patients screened eligible for the vaccine, 916 ultimately received an influenza vaccination while in the ED (43.7% of eligible patients). There was significant variability in the characteristics of patients who were and were not screened and vaccinated. Age, gender, race, preferred language, and receipt of a flu vaccine in prior years were associated with screening and/or receiving a vaccine in the ED. Conclusion: Vaccination programs in the ED can boost community vaccination rates and play a role in both preventing and treating current and future vaccine-preventable public health crises, although efforts must be made to deliver services equitably.

ObjectivesThe goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.MethodsInjury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.ResultsA total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).ConclusionsThe intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.Level of evidenceLevel II, randomized clinical trial.Trial registration number NCT03569878.

BackgroundAccurate acute care medical utilization history is an important outcome for clinicians and investigators concerned with improving trauma center care. The objective of this study was to examine the accuracy of self-report emergency department (ED) utilization compared with utilization obtained from the Emergency Department Information Exchange (EDIE) in admitted trauma surgery patients with comorbid mental health and substance use problems.MethodsThis is a retrospective cohort study of 169 injured patients admitted to the University of Washington’s Harborview Level I Trauma Center. Patients had high levels of post-traumatic stress disorder and depressive symptoms, suicidal ideation and alcohol comorbidity. The investigation used EDIE, a novel health technology tool that collects information at the time a patient checks into any ED in Washington and other US states. Patterns of EDIE-documented visits were described, and the accuracy of injured patients’ self-report visits was compared with EDIE-recorded visits during the course of the 12 months prior to the index trauma center admission.ResultsOverall, 45% of the sample (n=76) inaccurately recalled their ED visits during the past year, with 36 participants (21%) reporting less ED visits than EDIE indicated and 40 (24%) reporting more ED visits than EDIE indicated. Patients with histories of alcohol use problems and major psychiatric illness were more likely to either under-report or over-report ED health service use.DiscussionNearly half of all patients were unable to accurately recall ED visits in the previous 12 months compared with EDIE, with almost one-quarter of patients demonstrating high levels of disagreement. The improved accuracy and ease of use when compared with self-report make EDIE an important tool for both clinical and pragmatic trial longitudinal outcome assessments. Orchestrated investigative and policy efforts could further examine the benefits of introducing EDIE and other information exchanges into routine acute care clinical workflows.Level of evidenceII/III.Trial registration numberClinicalTrials.gov NCT02274688.

BackgroundWe discuss barriers to recruitment, retention, and intervention delivery in a randomized controlled trial (RCT) of patients presenting with firearm injuries to a Level 1 trauma center. The intervention was adapted from the Critical Time Intervention and included a six-month period of support in the community after hospital discharge to address recovery goals. This study was one of the first RCTs of a hospital- and community-based intervention provided solely among patients with firearm injuries.Main textBarriers to recruitment included limited staffing, coupled with wide variability in length of stay and admission times, which made it difficult to predict the best time to recruit. At the same time, more acutely affected patients needed more time to stabilize in order to determine whether eligibility criteria were met. Barriers to retention included insufficient patient resources for stable housing, communication and transportation, as well as limited time for patients to meet with study staff to respond to follow-up surveys. These barriers similarly affected intervention delivery as patients who were recruited, but had fewer resources to help with recovery, had lower intervention engagement. These barriers fall within the broader context of system avoidance (e.g., avoiding institutions that keep formal records). Since the patient sample was racially diverse with the majority of patients having prior criminal justice system involvement, this may have precluded active participation from some patients, especially those from communities that have been subject to long and sustained history of trauma and racism. We discuss approaches to overcoming these barriers and the importance of such efforts to further implement and evaluate hospital-based violence intervention programs in the future.ConclusionDeveloping strategies to overcome barriers to data collection and ongoing participant contact are essential to gathering robust information to understand how well violence prevention programs work and providing the best care possible for people recovering from injuries.Trial registrationClinicalTrials.govNCT02630225. Registered 12/15/2015.

Opioid overdose is a major public health problem. Emergency physicians need information to better assess a patient's risk for overdose or opioid-related harms. The purpose of this study was to determine if patient-reported preference for specific pain medications was associated with a history of lifetime overdose among patients seeking care in the emergency department (ED). ED patients (18-60 years) completed a screening survey that included questions on overdose history, ED utilization, opioid misuse behaviors as measured by the Current Opioid Misuse Measure (COMM), and analgesic medication preferences for previous ED visits for pain with specific responses for preference for hydromorphone (Dilaudid®), morphine, ketorolac (Toradol®), \"no preference\" or \"never visited the ED for pain.\" We compared individuals who reported a lifetime history of overdose descriptively to those without a lifetime history of overdose. Logistic regression was used to determine factors associated with a history of overdose. We included 2,233 adults in the analysis (71.5% response rate of patients approached) with 532 reporting at least one lifetime overdose. In the univariate analysis, medication preference was significantly associated with overdose history (p < .001); more patients in the overdose group reported preferring morphine and hydromorphone and those without a history of overdose were more likely to have no preference or say they had never visited the ED for pain. In the logistic regression analysis, patients with higher odds of overdose included those of Caucasian race, participants with a higher COMM score, preference for ketorolac, morphine or hydromorphone. Those who were younger, female and reported never having visited the ED for pain had lower odds of reporting a lifetime overdose. Having \"any preference\" corresponded to 48% higher odds of lifetime overdose. Patients with a pain medication preference have higher odds of having a lifetime overdose compared to patients without a specific pain medication preference, even after accounting for level of opioid misuse. This patient-reported preference could cue emergency physicians to identifying high-risk patients for overdose and other substance-related harms.

Emerging infectious diseases often create concern and fear among the public. Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study was to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68 among a sample of adults seeking care at an emergency department (ED) in the United States. We included consenting adults who sought care in two different urban EDs in Seattle, WA in November 2014. Excluded were those who were not fluent in English, in police custody, had decreased level of consciousness, a psychiatric emergency, or required active resuscitation. Patients were approached to participate in an anonymous survey performed on a tablet computer. Information sought included demographics, medical comorbidities, risk factors for EVD and EV-68, and perceptions of disease likelihood, severity and worry for developing EVD, EV-68 or influenza along with subjective estimates of the number of people who have died of each virus over the year in the United States. A total of 262 (88.5% participation rate) patients participated in the survey. Overall, participants identified that they were more likely to get influenza compared to EVD (p<0.001) or EV-68 (p<0.001), but endorsed worry and concern about getting both EVD and EV-68 despite having little or no risk for these viral diseases. Nearly two-thirds (64%) of participants had at-least one risk factor for an influenza-related complication. Most participants (64%) believed they could get influenza in the next 12 months. Only 52% had received a seasonal influenza vaccine. Perception of risk for EVD, EV-68 and influenza is discordant with actual risk as well as self-reported use of preventive care. Influenza is a serious public health problem and the ED is an important healthcare location to educate patients.

Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.