Publications by authors named "Danielle M McCarthy"

71 Publications

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021.

PLoS One 2021 10;16(3):e0248438. Epub 2021 Mar 10.

Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America.

Objectives: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care.

Methods: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables.

Results: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points).

Conclusion: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248438PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946184PMC
April 2021

In Reply to Hancock and Mattick.

Acad Med 2021 03;96(3):320

Associate professor and vice chair of research, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1097/ACM.0000000000003840DOI Listing
March 2021

Perceptions of Signs of Addiction Among Opioid Naive Patients Prescribed Opioids in the Emergency Department.

J Addict Med 2021 Feb 5. Epub 2021 Feb 5.

Department of Emergency Medicine, Northwestern University, Chicago, IL (PTS, PML, HSK, DMM); Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, Chicago, IL (KAC, LAO, LMC, MSW); Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX (DMC).

Objectives: Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction.

Methods: This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes.

Results: There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use.

Conclusions: Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention.
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http://dx.doi.org/10.1097/ADM.0000000000000806DOI Listing
February 2021

A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain.

Phys Ther 2021 Mar;101(3)

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Objective: Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain.

Methods: This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models.

Results: For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]).

Conclusion: In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored.

Impact: ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes.

Lay Summary: Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.
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http://dx.doi.org/10.1093/ptj/pzaa219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970627PMC
March 2021

Chest radiograph at admission predicts early intubation among inpatient COVID-19 patients.

Eur Radiol 2021 May 13;31(5):2825-2832. Epub 2020 Oct 13.

Department of Radiology, Division of Chest and Cardiovascular Imaging, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA.

Objective: The 2019 Coronavirus (COVID-19) results in a wide range of clinical severity and there remains a need for prognostic tools which identify patients at risk of rapid deterioration and who require critical care. Chest radiography (CXR) is routinely obtained at admission of COVID-19 patients. However, little is known regarding correlates between CXR severity and time to intubation. We hypothesize that the degree of opacification on CXR at time of admission independently predicts need and time to intubation.

Methods: In this retrospective cohort study, we reviewed COVID-19 patients who were admitted to an urban medical center during March 2020 that had a CXR performed on the day of admission. CXRs were divided into 12 lung zones and were assessed by two blinded thoracic radiologists. A COVID-19 opacification rating score (CORS) was generated by assigning one point for each lung zone in which an opacity was observed. Underlying comorbidities were abstracted and assessed for association.

Results: One hundred forty patients were included in this study and 47 (34%) patients required intubation during the admission. Patients with CORS ≥ 6 demonstrated significantly higher rates of early intubation within 48 h of admission and during the hospital stay (ORs 24 h, 19.8, p < 0.001; 48 h, 28.1, p < 0.001; intubation during hospital stay, 6.1, p < 0.0001). There was no significant correlation between CORS ≥ 6 and age, sex, BMI, or any underlying cardiac or pulmonary comorbidities.

Conclusions: CORS ≥ 6 at the time of admission predicts need for intubation, with significant increases in intubation at 24 and 48 h, independent of comorbidities.

Key Points: • Chest radiography at the time of admission independently predicts time to intubation within 48 h and during the hospital stay in COVID-19 patients. • More opacities on chest radiography are associated with several fold increases in early mechanical ventilation among COVID-19 patients. • Chest radiography is useful in identifying COVID-19 patients whom may rapidly deteriorate and help inform clinical management as well as hospital bed and ventilation allocation.
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http://dx.doi.org/10.1007/s00330-020-07354-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7553374PMC
May 2021

Academic Emergency Medicine Faculty Experiences with Racial and Sexual Orientation Discrimination.

West J Emerg Med 2020 Aug 21;21(5):1160-1169. Epub 2020 Aug 21.

Tufts University School of Medicine - Maine Medical Center, Department of Emergency Medicine, Portland, Maine.

Introduction: Despite the increasing diversity of individuals entering medicine, physicians from racial and sexual minority groups continue to experience bias and discrimination in the workplace. The objective of this study was to determine the current experiences and perceptions of discrimination on the basis of race and sexual orientation among academic emergency medicine (EM) faculty.

Methods: We conducted a cross-sectional survey of a convenience sample of EM faculty across six programs. Survey items included the Overt Gender Discrimination at Work (OGDW) Scale adapted for race and sexual orientation, and the frequency and source of experienced and observed discrimination. Group comparisons were made using t-tests or chi-square analyses, and relationships between race or sexual orientation, and we evaluated physicians' experiences using correlation analyses.

Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Non-White physicians reported higher mean racial OGDW scores than their White counterparts (13.4 vs 8.6; 95% confidence interval (CI) for difference, -7.7 - -2.9). Non-White EM faculty were also more likely to report having experienced discriminatory treatment based on race than were White EM faculty (48.0% vs 12.6%; CI for difference, 16.6% - 54.2%), although both groups were equally likely to report having observed race-based discrimination of another physician. EM faculty who identified as sexual minorities reported higher mean sexual minority OGDW scores than their heterosexual counterparts (11.1 vs 7.1; 95% CI for difference, -7.3 - -0.6). There were no significant differences between sexual minority and heterosexual faculty in their reports of experiencing or observing discrimination based on sexual orientation.

Conclusion: EM faculty from racial and sexual minority groups perceived more discrimination based on race or sexual orientation in their workplace than their majority counterparts. EM faculty regardless of race or sexual orientation were similar in their observations of discriminatory treatment of another physician based on race or sexual orientation.
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http://dx.doi.org/10.5811/westjem.2020.6.47123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7514380PMC
August 2020

Emergency Department Visits for Serious Diagnoses During the COVID-19 Pandemic.

Acad Emerg Med 2020 09 17;27(9):910-913. Epub 2020 Aug 17.

From the, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

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http://dx.doi.org/10.1111/acem.14099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436489PMC
September 2020

Development of a take-home naloxone program at an urban academic emergency department.

J Am Pharm Assoc (2003) 2020 Nov - Dec;60(6):e324-e331. Epub 2020 Jul 18.

Objective: To describe the development of an ED-based take-home naloxone (THN) program in which naloxone kits are dispensed directly to patients during ED discharge.

Practice Description: Our THN program was carried out at an urban academic hospital in downtown Chicago, IL. The THN kits consisted of 3 vials of 0.4-mg naloxone and 3 sterile syringes and needles for intramuscular delivery. Any member of the ED team (e.g., physician, pharmacist, or nurse) could recommend naloxone dispensing for a patient; however only the treating ED physician served as the prescriber for record. The ED pharmacist provided bedside education on recognizing opioid overdose and administering naloxone. The naloxone kit was dispensed to the patient at no cost.

Practice Innovation: This ED pharmacist-led naloxone dispensing model bypasses barriers to naloxone filling and ensures that patients walk out of the emergency department with naloxone in hand.

Evaluation Methods: We report key metrics from the first 16 months of program implementation, including the number of ED visits for opioid overdose and THN kits dispensed. We further describe the key facilitators and barriers to program development.

Results: Over 16 months, our emergency department had 669 unique visits for opioid overdose, and we dispensed 168 THN kits (10.5 per month). We are aware of at least 3 cases in which our THN kits were used to reverse opioid overdose. We faced key informational barriers to program development, such as a lack of knowledge regarding the allowability of ED medication dispensing, as well as financial barriers, such as the need to obtain a supply of naloxone. We also recognized the key facilitators of success, such as early engagement with hospital leadership.

Conclusion: Implementing a successful THN program is possible in the ED setting, and individual hospital emergency departments seeking to build their own program may benefit from our report.
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http://dx.doi.org/10.1016/j.japh.2020.06.017DOI Listing
July 2020

Emergency department operations in a large health system during COVID-19.

Am J Emerg Med 2021 Mar 2;41:241-243. Epub 2020 Jun 2.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario St., Suite #200, Chicago, IL 60611, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.05.097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264938PMC
March 2021

Incidentally discovered COVID-19 in low-suspicion patients-a threat to front line health care workers.

Emerg Radiol 2020 Dec 25;27(6):589-595. Epub 2020 May 25.

Department of Radiology, Division of Chest Imaging, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA.

Purpose: The COVID-19 pandemic has been responsible for thousands of deaths worldwide. Testing remains at a premium, and criteria for testing remains reserved for those with lower respiratory infection symptoms and/or a known high-risk exposure. The role of imaging in COVID-19 is rapidly evolving; however, few algorithms include imaging criteria, and it is unclear what should be done in low-suspicion patients with positive imaging findings.

Methods: From 03/01/2020-03/20/2020, a retrospective review of all patients with suspected COVID-19 on imaging was performed. Imaging was interpreted by a board-certified, fellowship-trained radiologist. Patients were excluded if COVID-19 infection was suspected at the time of presentation, was the reason for imaging, or if any lower respiratory symptoms were present.

Results: Eight patients with suspected COVID-19 infection on imaging were encountered. Seven patients received testing due to suspicious imaging findings with subsequent lab-confirmed COVID-19. No patients endorsed prior exposure to COVID-19 or recent international travel. COVID-19 was suggested in six patients incidentally on abdominal CT and two on chest radiography. At the time of presentation, no patients were febrile, and seven endorsed gastrointestinal symptoms. Five COVID-19 patients eventually developed respiratory symptoms and required intubation. Two patients expired during the admission.

Conclusions: Patients with imaging findings suspicious for COVID-19 warrant prompt reverse transcription polymerase chain reaction (RT-PCR) testing even in low clinical suspicion cases. The prevalence of disease in the population may be underestimated by the current paradigm of RT-PCR testing with the current clinical criteria of lower respiratory symptoms and exposure risk.
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http://dx.doi.org/10.1007/s10140-020-01792-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246084PMC
December 2020

Take-Home Naloxone Program Implementation: Lessons Learned From Seven Chicago-Area Hospitals.

Ann Emerg Med 2020 09 30;76(3):318-327. Epub 2020 Mar 30.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Electronic address:

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.
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http://dx.doi.org/10.1016/j.annemergmed.2020.02.013DOI Listing
September 2020

Patient-Reported Opioid Pill Consumption After an ED Visit: How Many Pills Are People Using?

Pain Med 2021 Feb;22(2):292-302

Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA.

Objectives: Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain.

Design: Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge.

Setting: Urban academic emergency department (>88,000 annual visits).

Subjects: Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary.

Methods: Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis.

Results: Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills.

Conclusions: In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.
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http://dx.doi.org/10.1093/pm/pnaa048DOI Listing
February 2021

#MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment.

West J Emerg Med 2020 Feb 21;21(2):252-260. Epub 2020 Feb 21.

Tufts University School of Medicine - Maine Medical Center, Department of Emergency Medicine, Portland, Maine.

Introduction: Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians' experiences with workplace gender discrimination and sexual harassment.

Methods: We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians' experiences using correlation analyses.

Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6-6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%-65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%-25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%-43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.

Conclusion: Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.
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http://dx.doi.org/10.5811/westjem.2019.11.44592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081862PMC
February 2020

Development of the Uncertainty Communication Checklist: A Patient-Centered Approach to Patient Discharge From the Emergency Department.

Acad Med 2020 07;95(7):1026-1034

K.L. Rising is associate professor and director of acute care transitions, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. R.E. Powell is associate professor, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, and senior researcher, Mathematica, Princeton, New Jersey. K.A. Cameron is research professor, Department of Medical Education and Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. D.H. Salzman is associate professor, Department of Emergency Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. D. Papanagnou is associate professor and vice chair for education, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. A.M.B. Doty is a research coordinator, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. L. Latimer is a research coordinator, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. K. Piserchia is a clinical research coordinator, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. W.C. McGaghie is professor, Department of Medical Education, Northwestern University, Feinberg School of Medicine, Chicago, Illinois. D.M. McCarthy is associate professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as it has potential to improve patient-centeredness of checklists related to assessment of clinical performance. Focus group patient participants from 2 clinical sites were included: Thomas Jefferson University Hospital, Philadelphia, PA, and Northwestern University Hospital, Chicago, Illinois.The authors developed a preliminary instrument based on existing checklists, clinical experience, literature review, and input from an expert panel comprising health care professionals and patient advocates. They then refined the instrument based on feedback from 2 waves of patient focus groups, resulting in a final 21-item checklist. The checklist items assess if uncertainty was addressed in each step of the discharge communication, including the following major categories: introduction, test results/ED summary, no/uncertain diagnosis, next steps/follow-up, home care, reasons to return, and general communication skills. Patient input influenced both what items were included and the wording of items in the final checklist. This patient-centered, systematic approach to checklist development is built upon the rigor of the Checklist Development Checklist and provides an illustration of how to integrate patient feedback into the design of assessment tools when appropriate.
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http://dx.doi.org/10.1097/ACM.0000000000003231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302334PMC
July 2020

Setting a Minimum Passing Standard for the Uncertainty Communication Checklist Through Patient and Physician Engagement.

J Grad Med Educ 2020 Feb;12(1):58-65

Background: Historically, medically trained experts have served as judges to establish a minimum passing standard (MPS) for mastery learning. As mastery learning expands from procedure-based skills to patient-centered domains, such as communication, there is an opportunity to incorporate patients as judges in setting the MPS.

Objective: We described our process of incorporating patients as judges to set the MPS and compared the MPS set by patients and emergency medicine residency program directors (PDs).

Methods: Patient and physician panels were convened to determine an MPS for a 21-item Uncertainty Communication Checklist. The MPS for both panels were independently calculated using the Mastery Angoff method. Mean scores on individual checklist items with corresponding 95% confidence intervals were also calculated for both panels and differences analyzed using a test.

Results: Of 240 eligible patients and 42 eligible PDs, 25 patients and 13 PDs (26% and 65% cooperation rates, respectively) completed MPS-setting procedures. The patient-generated MPS was 84.0% (range 45.2-96.2, SD 10.2) and the physician-generated MPS was 88.2% (range 79.7-98.1, SD 5.5). The overall MPS, calculated as an average of these 2 results, was 86.1% (range 45.2-98.1, SD 9.0), or 19 of 21 checklist items.

Conclusions: Patients are able to serve as judges to establish an MPS using the Mastery Angoff method for a task performed by resident physicians. The patient-established MPS was nearly identical to that generated by a panel of residency PDs, indicating similar expectations of proficiency for residents to achieve skill "mastery."
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http://dx.doi.org/10.4300/JGME-D-19-00483.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012525PMC
February 2020

Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial.

BMC Med Educ 2020 Feb 19;20(1):49. Epub 2020 Feb 19.

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

Background: Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.

Methods: The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit.

Discussion: Patients' understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake.

Trial Registration: The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.
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http://dx.doi.org/10.1186/s12909-020-1926-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7029572PMC
February 2020

Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers.

Acad Emerg Med 2020 05 5;27(5):403-418. Epub 2020 Feb 5.

Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL.

Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.
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http://dx.doi.org/10.1111/acem.13918DOI Listing
May 2020

Women's Night in Emergency Medicine Mentorship Program: A SWOT Analysis.

West J Emerg Med 2019 Dec 18;21(1):37-41. Epub 2019 Dec 18.

Northwestern University, Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois.

Introduction: Women in emergency medicine (EM) at all career stages report gender-specific obstacles to satisfaction and advancement. Programs that facilitate longitudinal mentoring, professional development, and networking may ameliorate these barriers.

Methods: We designed and implemented a program for female residents, faculty, and alumnae from our EM training program to enhance social support, leadership training and professional mentorship opportunities. An anonymous, online survey was sent to participants at the end of the academic year, using a SWOT (strengths, weaknesses, opportunities, and threats) format. The survey collected free-text responses designed to evaluate the program.

Results: Of 43 invited participants, 32 responded (74.4%). Eight themes emerged from the free-text responses and were grouped by SWOT domain. We identified four themes relating to the "strength" domain: 1) creating a dedicated space; 2) networking community; 3) building solidarity; and 4) providing forward guidance. Responses to the "weaknesses" and "threats" questions were combined due to overlapping codes and resulted in three themes: 5) barriers to participation; 6) the threat of poorly structured events lapsing into negativity; and 7) concerns about external optics. A final theme: 8) expansion of program scope was noted in the "opportunity" domain.

Conclusion: This program evaluation of the Women's Night curriculum demonstrates it was a positive addition to the formal curriculum, providing longitudinal professional development opportunities. Sharing the strengths of the program, along with identified weaknesses, threats, and opportunities for advancement allows other departments to learn from this experience and implement similar models that use existing intellectual and social capital.
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http://dx.doi.org/10.5811/westjem.2019.11.44433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948687PMC
December 2019

A Multifaceted Intervention to Improve Patient Knowledge and Safe Use of Opioids: Results of the ED EMC Randomized Controlled Trial.

Acad Emerg Med 2019 12 19;26(12):1311-1325. Epub 2019 Nov 19.

Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL.

Objectives: Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids.

Methods: This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC intervention, or 3) EMC  + short message service (SMS) text messaging. The ED EMC intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC  + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment.

Results: Among the 652 enrolled, 343 completed follow-up (57% women; mean ± SD age = 42 ± 14.0 years). Demonstrated safe opioid use occurred more often in the EMC group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC  + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC  + SMS group (β = 0.57, 95% CI = 0.09 to 1.06) than usual care.

Conclusions: The study found that the EMC tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.
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http://dx.doi.org/10.1111/acem.13860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901720PMC
December 2019

The Standardized Letter of Evaluation Narrative: Differences in Language Use by Gender.

West J Emerg Med 2019 Oct 17;20(6):948-956. Epub 2019 Oct 17.

Northwestern University Feinberg School of Medicine. Department of Emergency Medicine, Chicago, Illinois.

Introduction: Prior research demonstrates gender differences in language used in letters of recommendation. The emergency medicine (EM) Standardized Letter of Evaluation (SLOE) format limits word count and provides detailed instructions for writers. The objective of this study is to examine differences in language used to describe men and women applicants within the SLOE narrative.

Methods: All applicants to a four-year academic EM residency program within a single application year with a first rotation SLOE available were included in the sample. We used the Linguistic Inquiry and Word Count (LIWC) program to analyze word frequency within 16 categories. Descriptive statistics, chi-squared, and t-tests were used to describe the sample; gender differences in word frequency were tested for using Mann-Whitney U tests.

Results: Of 1117 applicants to the residency program, 822 (82%) first-rotation SLOEs were available; 64% were men, and 36% were women. We did not find a difference in baseline characteristics including age (mean 27 years), top 25 schools (22.5%), Alpha Omega Alpha Honor Medical Society rates (13%), and having earned advanced degrees (10%). The median word count per SLOE narrative for men was 171 and for women was 180 (p = 0.15). After adjusting for letter length, word frequency differences between genders were only present in two categories: social words (women: 23 words/letter; men: 21 words/letter, p = 0.02) and ability words (women: 2 words/letter; men: 1 word/letter, p = 0.04). We were unable to detect a statistical difference between men and women applicants in the remaining categories, including words representing communal traits, agentic traits, standout adjectives, grindstone traits, teaching words, and research words.

Conclusion: The small wording differences between genders noted in two categories were statistically significant, but of unclear real-world significance. Future work is planned to evaluate how the SLOE format may contribute to this relative lack of bias compared to other fields and formats.
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http://dx.doi.org/10.5811/westjem.2019.9.44307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6860384PMC
October 2019

Identifying Emergency Department Symptom-Based Diagnoses with the Unified Medical Language System.

West J Emerg Med 2019 Oct 24;20(6):910-917. Epub 2019 Oct 24.

Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania.

Introduction: Many patients who are discharged from the emergency department (ED) with a symptom-based discharge diagnosis (SBD) have post-discharge challenges related to lack of a definitive discharge diagnosis and follow-up plan. There is no well-defined method for identifying patients with a SBD without individual chart review. We describe a method for automated identification of SBDs from ICD-10 codes using the Unified Medical Language System (UMLS) Metathesaurus.

Methods: We mapped discharge diagnosis, with use of ICD-10 codes from a one-month period of ED discharges at an urban, academic ED to UMLS concepts and semantic types. Two physician reviewers independently manually identified all discharge diagnoses consistent with SBDs. We calculated inter-rater reliability for manual review and the sensitivity and specificity for our automated process for identifying SBDs against this "gold standard."

Results: We identified 3642 ED discharges with 1382 unique discharge diagnoses that corresponded to 875 unique ICD-10 codes and 10 UMLS semantic types. Over one third (37.5%, n = 1367) of ED discharges were assigned codes that mapped to the "Sign or Symptom" semantic type. Inter-rater reliability for manual review of SBDs was very good (0.87). Sensitivity and specificity of our automated process for identifying encounters with SBDs were 84.7% and 96.3%, respectively.

Conclusion: Use of our automated process to identify ICD-10 codes that classify into the UMLS "Sign or Symptom" semantic type identified the majority of patients with a SBD. While this method needs refinement to increase sensitivity of capture, it has potential to automate an otherwise highly time-consuming process. This novel use of informatics methods can facilitate future research specific to patients with SBDs.
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http://dx.doi.org/10.5811/westjem.2019.8.44230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6860381PMC
October 2019

A Quality Improvement Initiative Featuring Peer-Comparison Prescribing Feedback Reduces Emergency Department Opioid Prescribing.

Jt Comm J Qual Patient Saf 2019 10 2;45(10):669-679. Epub 2019 Sep 2.

Background: Opioid prescribing in the United States nearly tripled from 1999 to 2015, and opioid overdose deaths doubled in the same time frame. Emergency departments (EDs) may play a pivotal role in the opioid epidemic as a source of first-time opioid exposure; however, many prescribers are generally unaware of their prescribing behaviors relative to their peers.

Methods: All 117 ED prescribers at an urban academic medical center were provided with regular feedback on individual rates of opioid prescribing relative to their de-identified peers. To evaluate the effect of this intervention on the departmental rate of opioid prescribing, a statistical process control (SPC) chart was created to identify special cause variation, and an interrupted time series analysis was conducted to evaluate the immediate effect of the intervention and any change in the postintervention trend due to the intervention.

Results: The aggregate opioid prescribing rate in the preintervention period was 8.6% (95% confidence interval [CI]: 8.3%-8.9%), while the aggregate postintervention prescribing rate was 5.8% (95% CI: 5.5%-6.1%). The SPC chart revealed special cause variation in both the pre- and postintervention periods, with an overall downtrend of opioid prescribing rates across the evaluation period and flattening of rates in the final four blocks. Interrupted time series analysis demonstrated a significant immediate downward effect of the intervention and a nonsignificant additional decrease in postintervention trend.

Conclusion: Implementation of peer-comparison opioid prescribing feedback was associated with a significant immediate reduction in the rate of ED discharge opioid prescribing.
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http://dx.doi.org/10.1016/j.jcjq.2019.07.008DOI Listing
October 2019

Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study.

BMC Geriatr 2019 08 5;19(1):209. Epub 2019 Aug 5.

Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 211 E. Ontario St., Suite 200, Chicago, IL, 60611, USA.

Background: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit.

Methods: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes.

Results: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL.

Conclusions: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.
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http://dx.doi.org/10.1186/s12877-019-1228-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683497PMC
August 2019

Implementation fidelity of patient-centered prescription label to promote opioid safe use.

Pharmacoepidemiol Drug Saf 2019 09 9;28(9):1251-1257. Epub 2019 Jul 9.

Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, Illinois.

Purpose: Patient-centered labels may improve safe medication use, but implementation challenges limit use. We assessed implementation of a patient-centered "PRN" (as needed) label entitled "Take-Wait-Stop" (TWS) with three deconstructed steps replacing traditional wording.

Methods: As part of a larger investigation, patients received TWS prescriptions (eg, Take: 1 pill if you have pain; Wait: at least 4 h before taking again; Stop: do not take more than 6 pills in 24 h). Prescriptions labels recorded at follow-up were classified into three categories: (1) one-step wording (Take 1 pill every 4 h [without daily limits]), (2) two-step wording (Take 1 pill every 4 h; do not exceed 6 pills/day), and (3) three-step wording. There were three subtypes of three-step wording: (3a) three-step, not TWS (three deconstructed steps, not necessarily TWS wording), (3b) TWS format, employing three steps with leading verbs, but "with additions or replacements" (eg, replaced "do not take" with "do not exceed"), and (3c) verbatim TWS.

Results: Two hundred eleven participants completed follow-up. Mean age was 44.3 years (SD 14.3); 44% were male. One-step bottles represented 12% (n = 25) of the sample, whereas 26% (n = 55) had two-step wording. The majority (44%, n = 93) had three-deconstructed steps, not TWS (3a); 16% (n = 34) retained TWS structure, but not verbatim (3b). Only 2% (n = 4) displayed verbatim TWS wording (3c). All category three labels (utilizing deconstructed instructions) were considered adequate implementation (62%).

Conclusions: Exact intervention adherence was not achieved in the majority of cases, limiting impact. Nonetheless, community pharmacies were responsive to new instructions, but higher implementation reliability requires additional supports.
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http://dx.doi.org/10.1002/pds.4795DOI Listing
September 2019

Reply to Comment on Potentially Inappropriate Medication Prescriptions for Older Adults With Painful Conditions and Association With Return Emergency Department Visits.

J Am Geriatr Soc 2019 07 7;67(7):1532-1533. Epub 2019 May 7.

The Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1111/jgs.15973DOI Listing
July 2019

Who Is Keeping Their Unused Opioids and Why?

Pain Med 2020 01;21(1):84-91

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Objective: To better understand patients' reasoning for keeping unused opioid pills.

Methods: As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as "dispose," "keep," and "don't know." Baseline characteristics were compared between the "keep" and "dispose" groups. Verbatim responses categorized as "keep" were analyzed qualitatively using a team-based inductive approach with constant comparison across cases.

Results: One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills "just in case," with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills "just in case" without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids.

Conclusions: This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.
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http://dx.doi.org/10.1093/pm/pnz025DOI Listing
January 2020

Emergency Department-Based Palliative Interventions: A Novel Approach to Palliative Care in the Emergency Department.

J Palliat Med 2019 Jun 5;22(6):649-655. Epub 2019 Feb 5.

1 Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Patients with cancer and palliative care needs frequently use the emergency department (ED). ED-based palliative services may extend the reach of palliative care for these patients. To assess the feasibility and reach of an ED-based palliative intervention (EPI) program. A cross-sectional descriptive study of ED patients with active cancer from January 2017 to August 2017. Patients with palliative care needs were identified using an abbreviated 5-question version of the screen for palliative and end-of-life care needs in the ED (5-SPEED). Patients with palliative care needs were then automatically flagged for an EPI as determined by their identified need. The primary outcome was the prevalence of palliative care needs among patients with active cancer. Secondary outcomes were the rate of EPI services successfully delivered to ED patients with unmet palliative care needs, ED length of stay (LOS), and repeat ED visits within the next 10 days. Categorical variables were evaluated using chi-squared or Fischer's exact test as appropriate. Continuous variables were evaluated using analysis of variance. Of the 1278 patients with active cancer, 817 (63.9%) completed the 5-SPEED screen. Of the patients who completed the screen, 422 patients (51.7%) had one or more unmet palliative care needs and 167 (39.6%) received an EPI. There were no differences in ED LOS or 10-day repeat ED visit rates between patients who did or did not receive an EPI. This ED-based intervention successfully screened for palliative needs in cancer patients and improved access to specific palliative services without increasing ED LOS.
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http://dx.doi.org/10.1089/jpm.2018.0341DOI Listing
June 2019

Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits.

J Am Geriatr Soc 2019 04 27;67(4):719-725. Epub 2019 Jan 27.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Objectives: To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED.

Design: Retrospective cohort study.

Setting: Large urban academic ED from January 1, 2013, to December 31, 2015.

Participants: Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits).

Measurements: Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return.

Results: Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9-day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54-0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10-3.70).

Conclusions: These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient-centered outcomes. J Am Geriatr Soc 67:719-725, 2019.
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http://dx.doi.org/10.1111/jgs.15722DOI Listing
April 2019

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care.

Am J Emerg Med 2019 07 23;37(7):1322-1326. Epub 2018 Oct 23.

Department of Communication Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.

Objective: Physical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting.

Methods: This was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression.

Results: 74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48-2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50-8.83).

Conclusions: In this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.
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http://dx.doi.org/10.1016/j.ajem.2018.10.009DOI Listing
July 2019

Test-retest reliability of the Newest Vital Sign health literacy instrument: In-person and remote administration.

Patient Educ Couns 2019 04 22;102(4):749-752. Epub 2018 Nov 22.

Department of Emergency Medicine, Feinberg School of Medicine at Northwestern University, Chicago, IL, USA. Electronic address:

Objective: To determine the reliability of the Newest Vital Sign (NVS) administered via telephone by examining test-retest properties of the measure.

Methods: Data were obtained from a randomized controlled trial promoting opioid safe use. Participants were 18 or older and English-speaking. NVS assessment occurred in-person at baseline and in-person or via telephone at follow-up. Intraclass correlation coefficients (ICCs) were used to assess the test-retest reliability using raw NVS scores by mode of administration of the second NVS assessment. Kappa statistics were used to examine test-retest agreement based on categorized NVS score. Internal consistency was measured with Cronbach's alpha.

Results: Data from 216 patients (70 completing follow-up in-person and 146 via telephone) were included. Reliability was high (ICCs: in-person = 0.81, phone = 0.70). Agreement was lower for three category NVS score (Kappas: in-person = 0.58, 95% CI [0.39-0.77]; phone = 0.52, 95% CI [0.39-0.65]) compared to two category NVS (Kappas: in-person = 0.65, 95% CI [0.46-0.85]; phone = 0.64, 95% CI [0.51-0.78]). Correlations decreased as time between administrations increased. Internal consistency was moderately high (baseline NVS in-person (α = 0.76), follow-up NVS in-person (α = 0.76), and phone follow-up (α = 0.78).

Conclusion: The test-retest properties of the NVS are similar by mode of administration.

Practice Implications: This data suggests the NVS measure is reliably administered by telephone.
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http://dx.doi.org/10.1016/j.pec.2018.11.016DOI Listing
April 2019