Publications by authors named "Bernard Chang"

172 Publications

Virtual powers of observation: A telemedicine approach for the suspected COVID-19 patient.

J Emerg Manag 2021 Special Issue on COVID-19;18(7):45-48

Department of Emergency Medicine, Columbia University Irving Medical Center, New York.

Study Objectives: Prior to COVID-19, telemedicine and its applications to the emergency department (ED) had made significant inroads toward remote evaluation and care. During the local peak of the COVID-19 pandemic in New York City (NYC), there was a dramatic increase in telemedicine based patient encounters for suspected COVID-19 symptoms. In response, pathways were developed to promote a standardized telemedicine approach to remote evaluation and assessment of suspected COVID-19 patients.

Methods: A pathway was developed and implemented at two academic EDs in NYC, which collectively had approximately 8,300 telemedicine visits for suspected COVID-19 from March 2020 to June 2020. A protocol was developed by an expert consensus panel of four board-certified emergency physicians and two pediatric emergency physicians, all with telemedicine training/administrative roles.

Results: The pathway was initiated for any telehealth patient with suspected COVID-19 symptoms (cough, fever, shortness of breath, and bodyaches). A standardized history solicited known or suspected risk factors for worse prognosis, including age > 50, cardiovascular or lung disease, obesity, immunosuppression, and living alone, as well as a focused assessment of symptom severity and exercise tolerance. An exam at rest included visual counting of breaths along with instruction on palpation of radial pulse. Saturation was included if pulse oximetry was available. If exam at rest was reassuring, providers were instructed to repeat the respiratory assessment on exertion by having the patient walk in place briskly for 1 minute. Patients with severe illness defined by resting or exertional respiratory rate greater than 30 and/or oxygen saturation less than 90 percent were instructed to go to the ED. Patients with moderate illness defined by exertional metrics of respiratory rate less than 22, oxygen saturation greater than 94 percent, and heart rate less than 125 were discharged from the virtual urgent care visit with a repeat telehealth follow-up call at either 12 or 24 hours depending on the number of risk factors. Patients without risk factors and with reassuring respiratory assessment were discharged from the telemedicine encounter with reassurance and standard discharge precautions for escalation of care.

Conclusion: Designing and disseminating a standardized pathway helped to provide a framework to approach patients suspected of COVID-19 over telemedicine. Future work focusing on patient outcome data will help guide and refine any standardized telehealth approach to the COVID-19-suspected patient.
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http://dx.doi.org/10.5055/jem.200044DOI Listing
November 2021

Associations between emergency department crowding and perceptions of interpersonal care in patients presenting with suspected acute coronary syndrome.

Emerg Med J 2021 Aug 16. Epub 2021 Aug 16.

Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA

Background: Emergency department (ED) crowding is associated with numerous healthcare issues, but little is known about its effect on psychosocial aspects of patient-provider interactions or . We examined whether ED crowding was associated with perceptions of interpersonal care in patients evaluated for acute coronary syndrome (ACS).

Methods: Patients presenting to a quaternary academic medical centre ED in New York City for evaluation of suspected ACS were enrolled between November 2013 and December 2016. ED crowding was measured using the ED Work Index (EDWIN), which incorporates patient volume, triage category, physician staffing and bed availability. Patients completed the 18-item Interpersonal Processes of Care (IPC) survey, which assesses communication, patient-centred decision-making and interpersonal style. Regression analyses examined associations between EDWIN and IPC scores, adjusting for demographics, comorbidities and depression.

Results: Among 933 included patients, 11% experienced ED overcrowding (EDWIN score >2) at admission, 11% experienced ED overcrowding throughout the ED stay and 30% reported suboptimal interpersonal care (defined as per-item IPC score <5). Higher admission EDWIN score was associated with modestly lower IPC score in both unadjusted (β=-1.70, 95% CI -3.15 to -0.24, p=0.02) and adjusted models (β = -1.77, 95% CI -3.31 to -0.24, p=0.02). EDWIN score averaged over the entire ED stay was not significantly associated with IPC score (unadjusted β=-1.30, 95% CI -3.19 to 0.59, p=0.18; adjusted β=-1.24, 95% CI -3.21 to 0.74, p=0.22).

Conclusion: Increased crowding at the time of ED admission was associated with poorer perceptions of interpersonal care among patients with suspected ACS.
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http://dx.doi.org/10.1136/emermed-2020-210493DOI Listing
August 2021

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine.

Acad Emerg Med 2021 Jul 10. Epub 2021 Jul 10.

Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA.

Introduction: Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

Methods: Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

Results: Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

Conclusion: The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.
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http://dx.doi.org/10.1111/acem.14330DOI Listing
July 2021

Letter to the editor: The critical eye of science should know no borders.

Authors:
Bernard P Chang

Schizophr Res 2021 Jul 2. Epub 2021 Jul 2.

Columbia University Medical Center, Emergency Medicine, Columbia University Medical Center, 628 West 168th St., New York, NY, United States. Electronic address:

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http://dx.doi.org/10.1016/j.schres.2021.06.039DOI Listing
July 2021

COVID-19 Vaccine Uptake and Intent Among Emergency Healthcare Workers: A Cross-Sectional Survey.

J Occup Environ Med 2021 10;63(10):852-856

University of Pittsburgh, Department of Emergency Medicine, School of Medicine, Pittsburgh, Pennsylvania (Dr Pacella-LaBarbara, Ms Park, Dr Patterson, Dr Doshi, and Dr Guyette); Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut (Dr Wong); Columbia University Irving Medical Center, Department of Emergency Medicine, New York, New York (Dr Chang); Stanford University, Department of Emergency Medicine, Palo Alto, Stanford, California (Dr Suffoletto).

Objective: Vaccine hesitancy limits population protection from SARS-CoV (coronavirus disease [COVID-19]). Vaccine hesitancy among healthcare workers (HCW) could put patients and coworkers at risk.

Methods: We surveyed 475 emergency department and emergency medical service workers from January to February 2021 to determine vaccine intent/uptake, perceived COVID-19 vulnerability, and factors associated with vaccine intent/uptake.

Results: Although 79% of HCWs received or had plans to receive the COVID-19 vaccine, 21% had no intent/were unvaccinated; intent/uptake was lower among females (odds ratio [OR] = 0.34) and those with a history of COVID-19 infection (OR = 0.55), and higher among those with advanced degrees (OR = 3.53) and high perceived COVID-19 vulnerability (OR = 1.99).

Conclusions: This study provides a timely assessment of vaccination status among frontline HCWs and highlights subgroups who may be at high risk of exposure and transmission.
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http://dx.doi.org/10.1097/JOM.0000000000002298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8478093PMC
October 2021

The Value of Measuring Diabetes Burnout.

Curr Diab Rep 2021 06 16;21(8):25. Epub 2021 Jun 16.

College of Medicine, Humanities and Public Health Sciences, Penn State University, Hershey, PA, USA.

Purpose Of Review: Diabetes represents a chronic illness with significant physical and psychological morbidities. This review aims to summarize current conceptualizations of diabetes burnout in individuals with diabetes and describe its associated adverse outcomes in this population while proposing possible mechanisms of action and targets of intervention.

Recent Findings: "Diabetes burnout" may result in adverse long-term outcomes including poor treatment compliance, diabetes complications, and depression. Diabetes burnout may impact not only individuals, but also providers, and caregivers and family members of affected individuals. Diabetes burnout may results from sustained cognitive stresses of chronic treatment adherence, assessment of realistic treatment goals, and treatment challenges. Early screening and interdisciplinary approaches for patient-centered diabetes care are critical for sustained diabetes social support. Future work exploring these approaches may identify early support and targeted interventions for the long-term support of individuals with diabetes.
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http://dx.doi.org/10.1007/s11892-021-01392-6DOI Listing
June 2021

Risk of stroke and myocardial infarction after influenza-like illness in New York State.

BMC Public Health 2021 05 5;21(1):864. Epub 2021 May 5.

Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA.

Background: Influenza may be associated with increased stroke and myocardial infarction (MI) risk. We hypothesized that risk of stroke and MI after influenza-like illness (ILI) would be higher in patients in New York State. We additionally assessed whether this relationship differed across a series of sociodemographic factors.

Methods: A case-crossover analysis of the 2012-2014 New York Statewide Planning and Research Cooperative System (SPARCS) was used to estimate odds of ischemic stroke and MI after ILI. Each patient's case window (the time period preceding event) was compared to their control windows (same dates from the previous 2 years) in conditional logistic regression models used to estimate odds ratios and 95% confidence intervals (OR, 95% CI). We varied the case windows from 15 to 365 days preceding event as compared to control windows constructed using the same dates from the previous 2 years. Analyses were stratified by sex, race, and urban-rural status based on residential zip code.

Results: A total of 33,742 patients were identified as having ischemic stroke and 53,094 had MI. ILI events in the 15 days prior were associated with a 39% increase in odds of ischemic stroke (95% CI 1.09-1.77), increasing to an almost 70% increase in odds when looking at ILI events over the last year (95% CI 1.56, 1.83). In contrast, the effect of ILI hospitalization on MI was strongest in the 15 days prior (OR = 1.24, 95% CI 1.06-1.44). The risk of ischemic stroke after ILI was higher among individuals living in rural areas in the 90 days prior to stroke and among men in the year prior to event. In contrast, the association between ILI and MI varied only across race with whites having significantly higher ILI associated MI.

Conclusion: This study highlights risk period differences for acute cardiovascular events after ILI, indicating possible differences in mechanism behind the risk of stroke after ILI compared to the risk of MI. High risk populations for stroke after ILI include men and people living in rural areas, while whites are at high risk for MI after ILI. Future studies are needed to identify ways to mitigate these risks.
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http://dx.doi.org/10.1186/s12889-021-10916-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097921PMC
May 2021

An international survey of healthcare workers use of personal protective equipment during the early stages of the COVID-19 pandemic.

J Am Coll Emerg Physicians Open 2021 Apr 26;2(2):e12392. Epub 2021 Mar 26.

Center for Policy and Research in Emergency Medicine Oregon Health and Science University Department of Emergency Medicine Portland Oregon USA.

Objective: Little is known regarding the specific ways personal protective equipment (PPE) has been used and reused during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate the patterns of PPE use and the impact of PPE availability on the attitudes and well-being of an international population of healthcare workers.

Methods: This was an online, cross-sectional survey of healthcare workers. The survey was disseminated internationally using social media, specialty society list-serves, and email augmented by snowball sampling to healthcare workers who provided direct care to patients with suspected or confirmed COVID-19. The survey was conducted between April 13 and May 1, 2020. The primary outcome was self-reported PPE use during aerosol-generating medical procedures. Other outcomes included PPE use during care for respiratory patients in general, PPE reuse, PPE decontamination, and healthcare worker impressions related to their work and the pandemic.

Results: A total of 2227 healthcare workers from 23 countries completed the survey. The N95 was the most common respirator among the 1451 respondents who performed aerosol-generating procedures (n = 1050, 72.3%). Overall, 1783 (80.1%) of providers reported general reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain. The most commonly reused item of PPE was the N95 respirator, with the majority of respondents who reused PPE reporting N95 reuse (n = 1157, 64.9%). Of the 1050 individuals who wore an N95 mask while performing an aerosol-generating medical procedure, 756 (72%) reported re-using an N95, and 344 (45.5%) reported reuse for >3 days. Qualitative results identified several common themes, including (1) lack of availability of PPE, (2) fear and anxiety as a result of inadequate PPE, (3) potential exposure to family members, and (4) concerns regarding workload and pay.

Conclusions: This international survey of healthcare workers found that N95 respirators were commonly used to care for patients with respiratory symptoms with and without aerosol-generating medical procedures. Healthcare workers reported an unprecedented need to reuse PPE that was designed for single-use, specifically the N95 respirator. The reuse of PPE increased the perceived risk for COVID-19 infection and harmed mental health.
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http://dx.doi.org/10.1002/emp2.12392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002904PMC
April 2021

Safety and Hospital Costs Averted Using a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Strokes: The RAVEN Clinic.

Neurohospitalist 2021 Apr 5;11(2):107-113. Epub 2020 Nov 5.

Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.

Study Objective: Patients presenting to emergency departments (ED) with transient ischemic attack and minor strokes (TIAMS) are often admitted for evaluation, though experience in other countries have suggested that an expedited outpatient care models may be a safe alternative. We hypothesized that a rapid access clinic for select TIAMS was feasible and would avert hospitalization costs.

Methods: This retrospective analysis included patients presenting to our institution's ED with TIAMS and NIHSS ≤5 in calendar year 2017. We referred low-risk patients with TIAMS to a Rapid Access Vascular Evaluation-Neurology (RAVEN) clinic within 24 hours of ED discharge. We identified admitted patients who met RAVEN criteria at ED presentation. Rates of follow-up to the RAVEN clinic were recorded. Financial data collected included total hospital costs and time spent in the ED, as well hospital length of stay for admitted patients with low-risk TIAMS.

Results: In 2017, 149 patients were referred to RAVEN clinic and 50 patients were admitted. Of the RAVEN patients 99 (94%) appeared as scheduled. None had clinical changes between ED discharge and clinical evaluation. One patient required hospitalization at the RAVEN evaluation. When compared to RAVEN patients, admitted patients had significantly higher $7,719 (SD 354) total hospital costs and were hospitalized for 2 days on average. Overall, the RAVEN strategy averted approximately $764,000 in hospitalization costs and 208 hospital bed-days in accounting year 2017.

Conclusions: For select patients presenting with TIAMS without disabling deficits, a rapid outpatient evaluation may be feasible while averting significant total hospital costs and preserving inpatient hospital beds.
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http://dx.doi.org/10.1177/1941874420972236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958688PMC
April 2021

COVUS: An Algorithm to Maximize the Use of Point-of-Care Ultrasound in the Emergency Management of COVID-19.

J Emerg Med 2021 07 9;61(1):61-66. Epub 2021 Feb 9.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York.

Background: Patients with coronavirus disease 2019 (COVID-19) present with diagnostic challenges because COVID-19 can cause varied end-organ failures that mimic respiratory distress of pulmonary origin. Early identification of concurrent complications can significantly alter patient management and course. Point-of-care ultrasound (POCUS) can be particularly useful in helping to differentiate concomitant complications with COVID-19. While lung POCUS findings related to COVID-19 have been published, little guidance exists on how ultrasound can be incorporated into a more comprehensive evaluation of patients under investigation for COVID-19.

Objectives: We devised a pathway called COVUS that incorporates POCUS into the initial evaluation of patients under investigation for COVID-19 to guide diagnosis and management.

Discussion: The pathway was derived based on a review of literature, consensus from the ultrasound faculty, as well as feedback from the entire faculty group at one academic institution with high volumes of patients with COVID-19. The scanning protocol uses a cardiac-first (rather than lung-first) approach to identify potential concomitant organ failure that may immediately alter management.

Conclusions: COVUS aims to maximize identification of the most immediately life-threatening complications while minimizing time at bedside and provider risk of exposure to COVID-19.
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http://dx.doi.org/10.1016/j.jemermed.2021.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871761PMC
July 2021

Objective short sleep duration and 24-hour blood pressure.

Int J Cardiol Hypertens 2020 Dec 29;7:100062. Epub 2020 Oct 29.

Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.

Background: Short sleep duration is a contributor to cardiovascular disease (CVD) events and mortality. Short sleep duration is associated with an increased risk of high clinic blood pressure (BP). BP measured outside the clinic using 24-h ambulatory blood pressure monitoring (ABPM) is a better predictor of an individual's CVD risk. We examined the association between objectively-assessed sleep duration and 24-h ambulatory blood pressure (ABP).

Methods: A total of 893 working adults underwent sleep and ABPM. Participants were fitted with an ABPM device, and measures were taken at 28-30 min intervals. Objective sleep duration, and times of wakefulness and sleep during the 24-h ABPM period were derived from wrist-worn actigraphy. Linear regression, adjusted for age, sex, race/ethnicity, body mass index, smoking status, and diabetes were conducted on the relationship between sleep duration and the ABP measures.

Results: Mean age of participants (final n = 729, 59.5% female, 11.9% Hispanic) was 45.2 ± 10.4 y. Mean actigraphy-derived sleep duration was 6.8 ± 1.2 h. Sleep duration <6 h was associated with a 1.73 mmHg higher 24-h systolic BP (p = 0.031) and 2.17 mmHg higher 24-h diastolic BP (p < 0.001). Shorter sleep duration was not associated with mean awake or asleep systolic BP (p = 0.89 and p = 0.92) or mean awake or asleep diastolic BP (p = 0.30 and p = 0.74).

Conclusions: To our knowledge, this is the largest study conducted which assessed sleep duration objectively while measuring 24-h ABP. Shorter sleep duration is associated with higher 24-h BP and potentially cardiovascular risk.
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http://dx.doi.org/10.1016/j.ijchy.2020.100062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803013PMC
December 2020

Beyond the bedside: Clinicians as guardians of public health, medicine and science.

Am J Emerg Med 2021 07 25;45:571-572. Epub 2020 Dec 25.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, United States of America.

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http://dx.doi.org/10.1016/j.ajem.2020.12.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833099PMC
July 2021

Hemorrhagic Stroke Risk in Armed Forces Veterans: The Role of Post-Traumatic Stress Disorder and Its Treatment.

Stroke 2021 01 10;52(1):130-131. Epub 2020 Dec 10.

Department of Emergency Medicine (B.P.C.), Columbia University Irving Medical Center, New York, NY.

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http://dx.doi.org/10.1161/STROKEAHA.120.032669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770039PMC
January 2021

A research blueprint for keeping our healthcare workers healthy in the age of pandemics and the crises to come.

Gen Hosp Psychiatry 2021 Jan-Feb;68:35-37. Epub 2020 Dec 1.

Center of Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States of America.

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http://dx.doi.org/10.1016/j.genhosppsych.2020.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706591PMC
February 2021

Impact of prior trauma exposure on the development of PTSD symptoms after suspected acute coronary syndrome.

Gen Hosp Psychiatry 2021 Jan-Feb;68:7-11. Epub 2020 Nov 14.

Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, 622 W. 168th St, NY, New York, USA. Electronic address:

Objective: To determine the association between PTSD symptoms due to prior trauma and prior trauma type with PTSD symptoms after suspected acute coronary syndrome (ACS).

Method: A consecutive sample of patients presenting to the emergency department (ED) for suspected ACS were surveyed. Logistic regression was used to estimate the odds of elevated ACS-related PTSD symptoms [PCL-S ≥ 33] at 1-month associated with PTSD symptoms due to prior trauma and prior trauma type at the time of suspected ACS, adjusting for demographics, comorbidities, depression, and etiology of ACS symptoms.

Results: Of 984 patients, 81.6% reported ≥1 prior trauma type and 22.5% reported PTSD symptoms due to prior trauma at the time of suspected ACS. One month later, 18.0% had ACS-related PTSD symptoms. Patients with versus without PTSD symptoms due to prior trauma at the time of the suspected ACS had increased odds of ACS-related PTSD symptoms one month later (42.1% vs 9.9%; aOR 4.49, 95% CI:3.05-6.60; p < .001). Prior life-threatening illness was the only trauma type significantly associated with ACS-related PTSD symptoms (aOR 1.57, 95% CI:1.03-2.39; p = .04).

Conclusions: PTSD symptoms from prior trauma and history of life-threatening medical illness at the time of suspected ACS increased risk of ACS-related PTSD symptoms one month later.
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http://dx.doi.org/10.1016/j.genhosppsych.2020.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855440PMC
November 2021

The opportunities and challenges of machine learning in the acute care setting for precision prevention of posttraumatic stress sequelae.

Exp Neurol 2021 02 4;336:113526. Epub 2020 Nov 4.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, United States of America.

Personalized medicine is among the most exciting innovations in recent clinical research, offering the opportunity for tailored screening and management at the individual level. Biomarker-enriched clinical trials have shown increased efficiency and informativeness in cancer research due to the selective exclusion of patients unlikely to benefit. In acute stress situations, clinically significant decisions are often made in time-sensitive manners and providers may be pressed to make decisions based on abbreviated clinical assessments. Up to 30% of trauma survivors admitted to the Emergency Department (ED) will develop long-lasting posttraumatic stress psychopathologies. The long-term impact of those survivors with posttraumatic stress sequelae are significant, impacting both long-term psychological and physiological recovery. An accurate prognostic model of who will develop posttraumatic stress symptoms does not exist yet. Additionally, no scalable and cost-effective method that can be easily integrated into routine care exists, even though especially the acute care setting provides a critical window of opportunity for prevention in the so-called golden hours when preventive measures are most effective. In this review, we aim to discuss emerging machine learning (ML) applications that are promising for precisely risk stratification and targeted treatments in the acute care setting. The aim of this narrative review is to present examples of digital health innovations and to discuss the potential of these new approaches for treatment selection and prevention of posttraumatic sequelae in the acute care setting. The application of artificial intelligence-based solutions have already had great success in other areas and are rapidly approaching the field of psychological care as well. New ways of algorithm-based risk predicting, and the use of digital phenotypes provide a high potential for predicting future risk of PTSD in acute care settings and to go new steps in precision psychiatry.
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http://dx.doi.org/10.1016/j.expneurol.2020.113526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856033PMC
February 2021

Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers' infection and psychological distress during the COVID-19 pandemic in the USA.

BMJ Open 2020 10 21;10(10):e042752. Epub 2020 Oct 21.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA.

Objective: The COVID-19 pandemic has been associated with significant occupational stressors and challenges for front-line healthcare workers (HCWs), including COVID-19 exposure risk. Our study sought to assess factors contributing to HCW infection and psychological distress during the COVID-19 pandemic in the USA.

Design: We conducted a cross sectional survey of HCWs (physicians, nurses, emergency medical technicians (EMTs), non-clinical staff) during May 2020. Participants completed a 42-item survey assessing disease transmission risk (clinical role, work environment, availability of personal protective equipment) and mental health (anxiety, depression and burn-out).

Setting: The questionnaire was disseminated over various social media platforms. 3083 respondents from 48 states, the District of Columbia and US territories accessed the survey.

Participants: Using a convenience sample of HCWs who worked during the pandemic, 3083 respondents accessed the survey and 2040 participants completed at least 80% of the survey.

Primary Outcome: Prevalence of self-reported COVID-19 infection, in addition to burn-out, depression and anxiety symptoms.

Results: Participants were largely from the Northeast and Southern USA, with attending physicians (31.12%), nurses (26.80%), EMTs (13.04%) with emergency medicine department (38.30%) being the most common department and specialty represented. Twenty-nine per cent of respondents met the criteria for being a probable case due to reported COVID-19 symptoms or a positive test. HCWs in the emergency department (31.64%) were more likely to contract COVID-19 compared with HCWs in the ICU (23.17%) and inpatient settings (25.53%). HCWs that contracted COVID-19 also reported higher levels of depressive symptoms (mean diff.=0.31; 95% CI 0.16 to 0.47), anxiety symptoms (mean diff.=0.34; 95% CI 0.17 to 0.52) and burn-out (mean diff.=0.54; 95% CI 0.36 to 0.71).

Conclusion: HCWs have experienced significant physical and psychological risk while working during the COVID-19 pandemic. These findings highlight the urgent need for increased support for provider physical and mental health well-being.
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http://dx.doi.org/10.1136/bmjopen-2020-042752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580061PMC
October 2020

Novel Use of Telepalliative Care in a New York City Emergency Department During the COVID-19 Pandemic.

J Emerg Med 2020 11 4;59(5):714-716. Epub 2020 Aug 4.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York.

Background: Coronavirus-2 (COVID-19) is a global pandemic. As of August 21, mortality from COVID-19 has reached almost 200,000 people, with the United States leading the globe in levels of morbidity and mortality. Large volumes of high-acuity patients, particularly those of advanced age and with chronic comorbidities, have significantly increased the need for palliative care resources beyond usual capacity. More specifically, COVID-19 has changed the way we approach patient and family member interactions.

Discussion: Concern for nosocomial spread of this infection has resulted in strict visitation restrictions that have left many patients to face this illness, make difficult decisions, and even die, alone in the hospital. To meet the needs of COVID patients, services such as Emergency Medicine and Palliative Care have responded rapidly by adopting novel ways of practicing medicine. We describe the use of telepalliative medicine (TM) implemented in an emergency department (ED) setting to allow family members the ability to interact with their loved ones during critical illness, and even during the end of life. Use of this technology has helped facilitate goals of care discussions, in addition to providing contact and closure for both patients and their loved ones.

Conclusion: We describe our rapid and ongoing implementation of TM consultation for our ED patients and discuss lessons learned and recommendations for others considering similar care models.
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http://dx.doi.org/10.1016/j.jemermed.2020.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402363PMC
November 2020

Well-being and burnout: One size does not fit all.

J Am Coll Emerg Physicians Open 2020 May 22. Epub 2020 May 22.

LSU Health Sciences Center New Orleans Louisiana.

Well-being and burnout are concepts that have become well described throughout emergency medicine. In the past, both well-being and burnout have been defined and addressed as a singular phenomenon, similar for all physicians, regardless of career stage. However, unique stressors may exist for physicians, as a function of their work environment and stage. In this concepts article we present clinician well-being as a dynamic and continuous process, subject to unique factors along the professional lifespan. Specific individual and system-level factors are discussed, ranging from demographic variables, to evolving administrative and professional responsibilities depending on the career stage of a clinician. This detailed description of stressors spanning an emergency physician's professional career may help create more targeted physician well-being and burnout interventions.
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http://dx.doi.org/10.1002/emp2.12077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280727PMC
May 2020

Management of Agitation During the COVID-19 Pandemic.

West J Emerg Med 2020 May 22;21(4):795-800. Epub 2020 May 22.

University of Pittsburgh School of Law and School of Medicine, Department of Psychiatry, Pittsburgh, Pennsylvania.

The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.
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http://dx.doi.org/10.5811/westjem.2020.5.47789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390577PMC
May 2020

Changes to the ACGME Common Program Requirements and Their Potential Impact on Emergency Medicine Core Faculty Protected Time.

AEM Educ Train 2020 Jul 19;4(3):244-253. Epub 2020 Jan 19.

San Antonio Military Medical Center Uniformed Services University of the Health Sciences San Antonio TX.

The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM.
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http://dx.doi.org/10.1002/aet2.10421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369497PMC
July 2020

Battle Scars and Resilience at the Health Care Frontline.

Acad Emerg Med 2020 09 1;27(9):934-935. Epub 2020 Aug 1.

Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA.

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http://dx.doi.org/10.1111/acem.14079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405499PMC
September 2020

Digital approaches for mental health in the age of covid-19.

BMJ 2020 06 29;369:m2541. Epub 2020 Jun 29.

Department of Psychology, Harvard University, Boston, MA, USA.

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http://dx.doi.org/10.1136/bmj.m2541DOI Listing
June 2020

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic.

Gen Hosp Psychiatry 2020 Sep - Oct;66:1-8. Epub 2020 Jun 16.

Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States of America.

Objective: The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic.

Methods: This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657).

Results: Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest.

Conclusions: NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.
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http://dx.doi.org/10.1016/j.genhosppsych.2020.06.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297159PMC
September 2020

Healing the Healer: Protecting Emergency Health Care Workers' Mental Health During COVID-19.

Ann Emerg Med 2020 10 3;76(4):379-384. Epub 2020 May 3.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY.

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http://dx.doi.org/10.1016/j.annemergmed.2020.04.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196406PMC
October 2020

Characterization and clinical course of 1000 Patients with COVID-19 in New York: retrospective case series.

medRxiv 2020 Apr 22. Epub 2020 Apr 22.

Objective: To characterize patients with coronavirus disease 2019 (COVID-19) in a large New York City (NYC) medical center and describe their clinical course across the emergency department (ED), inpatient wards, and intensive care units (ICUs).

Design: Retrospective manual medical record review.

Setting: NewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC), a quaternary care academic medical center in NYC.

Participants: The first 1000 consecutive patients with laboratory-confirmed COVID-19.

Methods: We identified the first 1000 consecutive patients with a positive RT-SARS-CoV-2 PCR test who first presented to the ED or were hospitalized at NYP/CUIMC between March 1 and April 5, 2020. Patient data was manually abstracted from the electronic medical record.

Main Outcome Measures: We describe patient characteristics including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition.

Results: Among the first 1000 patients, 150 were ED patients, 614 were admitted without requiring ICU-level care, and 236 were admitted or transferred to the ICU. The most common presenting symptoms were cough (73.2%), fever (72.8%), and dyspnea (63.1%). Hospitalized patients, and ICU patients in particular, most commonly had baseline comorbidities including of hypertension, diabetes, and obesity. ICU patients were older, predominantly male (66.9%), and long lengths of stay (median 23 days; IQR 12 to 32 days); 78.0% developed AKI and 35.2% required dialysis. Notably, for patients who required mechanical ventilation, only 4.4% were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at 3-4 and 9 days. As of April 30, 90 patients remained hospitalized and 211 had died in the hospital.

Conclusions: Hospitalized patients with COVID-19 illness at this medical center faced significant morbidity and mortality, with high rates of AKI, dialysis, and a bimodal distribution in time to intubation from symptom onset.
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http://dx.doi.org/10.1101/2020.04.20.20072116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273275PMC
April 2020

Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series.

BMJ 2020 05 29;369:m1996. Epub 2020 May 29.

Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.

Objective: To characterize patients with coronavirus disease 2019 (covid-19) in a large New York City medical center and describe their clinical course across the emergency department, hospital wards, and intensive care units.

Design: Retrospective manual medical record review.

Setting: NewYork-Presbyterian/Columbia University Irving Medical Center, a quaternary care academic medical center in New York City.

Participants: The first 1000 consecutive patients with a positive result on the reverse transcriptase polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to the emergency department or were admitted to hospital between 1 March and 5 April 2020. Patient data were manually abstracted from electronic medical records.

Main Outcome Measures: Characterization of patients, including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition.

Results: Of the first 1000 patients, 150 presented to the emergency department, 614 were admitted to hospital (not intensive care units), and 236 were admitted or transferred to intensive care units. The most common presenting symptoms were cough (732/1000), fever (728/1000), and dyspnea (631/1000). Patients in hospital, particularly those treated in intensive care units, often had baseline comorbidities including hypertension, diabetes, and obesity. Patients admitted to intensive care units were older, predominantly male (158/236, 66.9%), and had long lengths of stay (median 23 days, interquartile range 12-32 days); 78.0% (184/236) developed acute kidney injury and 35.2% (83/236) needed dialysis. Only 4.4% (6/136) of patients who required mechanical ventilation were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at three to four days, and at nine days. As of 30 April, 90 patients remained in hospital and 211 had died in hospital.

Conclusions: Patients admitted to hospital with covid-19 at this medical center faced major morbidity and mortality, with high rates of acute kidney injury and inpatient dialysis, prolonged intubations, and a bimodal distribution of time to intubation from symptom onset.
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http://dx.doi.org/10.1136/bmj.m1996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256651PMC
May 2020

Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients.

Acad Emerg Med 2020 07 23;27(7):566-569. Epub 2020 Jun 23.

From the, Department of Emergency Medicine, NYP Weill Cornell Medical Center, New York, NY, USA.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.
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http://dx.doi.org/10.1111/acem.14035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283629PMC
July 2020

COVID-19: New York City pandemic notes from the first 30 days.

Am J Emerg Med 2020 07 21;38(7):1534-1535. Epub 2020 Apr 21.

622 West 168th Street, Department of Emergency Medicine, Columbia University Medical Center, VC 2nd Floor Suite 260, New York, NY 10032, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.04.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7172877PMC
July 2020
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