Publications by authors named "Lewis R Goldfrank"

53 Publications

Emergency Medicine's Role in the Crossroads of Social Revolution and the COVID-19 Pandemic.

Acad Emerg Med 2020 12 10;27(12):1350-1352. Epub 2020 Nov 10.

and the, Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA.

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http://dx.doi.org/10.1111/acem.14155DOI Listing
December 2020

Reflections on Mortality and Uncertainty in Emergency Medicine.

JAMA Intern Med 2020 Jan;180(1):88-90

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY.

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http://dx.doi.org/10.1001/jamainternmed.2019.4858DOI Listing
January 2020

Unintentional use of the word "accident"?

Clin Toxicol (Phila) 2019 01 13;57(1):73-74. Epub 2018 Jul 13.

c The Ronald O. Perelman Department of Emergency Medicine , New York University , New York , NY , USA.

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http://dx.doi.org/10.1080/15563650.2018.1489050DOI Listing
January 2019

Material Needs of Emergency Department Patients: A Systematic Review.

Acad Emerg Med 2018 03 5;25(3):330-359. Epub 2018 Feb 5.

Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY.

Background: Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.

Methods: We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.

Results: Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.

Conclusions: Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.
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http://dx.doi.org/10.1111/acem.13370DOI Listing
March 2018

Vulnerability of Older Adults in Disasters: Emergency Department Utilization by Geriatric Patients After Hurricane Sandy.

Disaster Med Public Health Prep 2018 04 2;12(2):184-193. Epub 2017 Aug 2.

1Ronald O. Perelman Department of Emergency Medicine,New York University School of Medicine,New York,New York.

Objective: Older adults are a potentially medically vulnerable population with increased mortality rates during and after disasters. To evaluate the impact of a natural disaster on this population, we performed a temporal and geospatial analysis of emergency department (ED) use by adults aged 65 years and older in New York City (NYC) following Hurricane Sandy's landfall.

Methods: We used an all-payer claims database to analyze demographics, insurance status, geographic distribution, and health conditions for post-disaster ED visits among older adults. We compared ED patterns of use in the weeks before and after Hurricane Sandy throughout NYC and the most afflicted evacuation zones.

Results: We found significant increases in ED utilization by older adults (and disproportionately higher in those aged ≥85 years) in the 3 weeks after Hurricane Sandy, especially in NYC evacuation zone one. Primary diagnoses with notable increases included dialysis, electrolyte disorders, and prescription refills. Secondary diagnoses highlighted homelessness and care access issues.

Conclusions: Older adults display heightened risk for worse health outcomes with increased ED visits after a disaster. Our findings suggest the need for dedicated resources and planning for older adults following a natural disaster by ensuring access to medical facilities, prescriptions, dialysis, and safe housing and by optimizing health care delivery needs to reduce the burden of chronic disease. (Disaster Med Public Health Preparedness. 2018;12:184-193).
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http://dx.doi.org/10.1017/dmp.2017.44DOI Listing
April 2018

Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care.

Ann Emerg Med 2018 Mar 29;71(3):314-325.e1. Epub 2017 Jun 29.

Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO. Electronic address:

We provide recommendations for stocking of antidotes used in emergency departments (EDs). An expert panel representing diverse perspectives (clinical pharmacology, medical toxicology, critical care medicine, hematology/oncology, hospital pharmacy, emergency medicine, emergency medical services, pediatric emergency medicine, pediatric critical care medicine, poison centers, hospital administration, and public health) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for both the quantity of antidote that should be stocked and the acceptable timeframe for its delivery. The panel recommended consideration of 45 antidotes; 44 were recommended for stocking, of which 23 should be immediately available. In most hospitals, this timeframe requires that the antidote be stocked in a location that allows immediate availability. Another 14 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine its specific need for antidote stocking. Antidote administration is an important part of emergency care. These expert recommendations provide a tool for hospitals that offer emergency care to provide appropriate care of poisoned patients.
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http://dx.doi.org/10.1016/j.annemergmed.2017.05.021DOI Listing
March 2018

Capacity? Informed Consent; Informed Discharge? Uncertainty!

Ann Emerg Med 2017 11 26;70(5):704-706. Epub 2017 Jun 26.

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY.

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http://dx.doi.org/10.1016/j.annemergmed.2017.05.009DOI Listing
November 2017

Letter in response to "Efficiency of acidemia correction on intermittent versus continuous hemodialysis in acute methanol poisoning".

Clin Toxicol (Phila) 2017 04;55(4):305

a The Ronald O. Perelman Department of Emergency Medicine , NYU School of Medicine , New York , NY , USA.

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http://dx.doi.org/10.1080/15563650.2017.1285032DOI Listing
April 2017

Acute post-disaster medical needs of patients with diabetes: emergency department use in New York City by diabetic adults after Hurricane Sandy.

BMJ Open Diabetes Res Care 2016 26;4(1):e000248. Epub 2016 Jul 26.

Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York, New York , USA.

Objective: To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy.

Research Design And Methods: Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012.

Results: In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions.

Conclusions: We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks.
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http://dx.doi.org/10.1136/bmjdrc-2016-000248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964212PMC
August 2016

Freestanding Emergency Critical Care During the Aftermath of Hurricane Sandy: Implications for Disaster Preparedness and Response.

Disaster Med Public Health Prep 2016 06 13;10(3):496-502. Epub 2016 May 13.

5Icahn School of Medicine at Mount Sinai,New York,New York.

Objective: To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy.

Methods: We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated.

Results: Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively.

Conclusions: An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).
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http://dx.doi.org/10.1017/dmp.2016.84DOI Listing
June 2016

Observation Services Linked With an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster.

Disaster Med Public Health Prep 2016 06 18;10(3):405-10. Epub 2016 Apr 18.

1Ronald O. Perelman Department of Emergency Medicine,NYU School of Medicine,New York,New York.

Objective: The emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster.

Methods: We conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics.

Results: Of 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume.

Conclusions: A diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;10:405-410).
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http://dx.doi.org/10.1017/dmp.2016.49DOI Listing
June 2016

Emergency Department Visits for Homelessness or Inadequate Housing in New York City before and after Hurricane Sandy.

J Urban Health 2016 Apr;93(2):331-44

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA.

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.
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http://dx.doi.org/10.1007/s11524-016-0035-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835349PMC
April 2016

Geographic Distribution of Disaster-Specific Emergency Department Use After Hurricane Sandy in New York City.

Disaster Med Public Health Prep 2016 06 9;10(3):351-61. Epub 2016 Feb 9.

1Ronald O. Perelman Department of Emergency Medicine,New York University School of Medicine,New York,New York.

Objective: We aimed to characterize the geographic distribution of post-Hurricane Sandy emergency department use in administrative flood evacuation zones of New York City.

Methods: Using emergency claims data, we identified significant deviations in emergency department use after Hurricane Sandy. Using time-series analysis, we analyzed the frequency of visits for specific conditions and comorbidities to identify medically vulnerable populations who developed acute postdisaster medical needs.

Results: We found statistically significant decreases in overall post-Sandy emergency department use in New York City but increased utilization in the most vulnerable evacuation zone. In addition to dialysis- and ventilator-dependent patients, we identified that patients who were elderly or homeless or who had diabetes, dementia, cardiac conditions, limitations in mobility, or drug dependence were more likely to visit emergency departments after Hurricane Sandy. Furthermore, patients were more likely to develop drug-resistant infections, require isolation, and present for hypothermia, environmental exposures, or administrative reasons.

Conclusions: Our study identified high-risk populations who developed acute medical and social needs in specific geographic areas after Hurricane Sandy. Our findings can inform coherent and targeted responses to disasters. Early identification of medically vulnerable populations can help to map "hot spots" requiring additional medical and social attention and prioritize resources for areas most impacted by disasters. (Disaster Med Public Health Preparedness. 2016;10:351-361).
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http://dx.doi.org/10.1017/dmp.2015.190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7112993PMC
June 2016

Prehospital Indicators for Disaster Preparedness and Response: New York City Emergency Medical Services in Hurricane Sandy.

Disaster Med Public Health Prep 2016 06 7;10(3):333-43. Epub 2016 Jan 7.

1Ronald O. Perelman Department of Emergency Medicine,NYU School of Medicine,New York,New York.

Objective: We aimed to evaluate emergency medical services (EMS) data as disaster metrics and to assess stress in surrounding hospitals and a municipal network after the closure of Bellevue Hospital during Hurricane Sandy in 2012.

Methods: We retrospectively reviewed EMS activity and call types within New York City's 911 computer-assisted dispatch database from January 1, 2011, to December 31, 2013. We evaluated EMS ambulance transports to individual hospitals during Bellevue's closure and incremental recovery from urgent care capacity, to freestanding emergency department (ED) capability, freestanding ED with 911-receiving designation, and return of inpatient services.

Results: A total of 2,877,087 patient transports were available for analysis; a total of 707,593 involved Manhattan hospitals. The 911 ambulance transports disproportionately increased at the 3 closest hospitals by 63.6%, 60.7%, and 37.2%. When Bellevue closed, transports to specific hospitals increased by 45% or more for the following call types: blunt traumatic injury, drugs and alcohol, cardiac conditions, difficulty breathing, "pedestrian struck," unconsciousness, altered mental status, and emotionally disturbed persons.

Conclusions: EMS data identified hospitals with disproportionately increased patient loads after Hurricane Sandy. Loss of Bellevue, a public, safety net medical center, produced statistically significant increases in specific types of medical and trauma transports at surrounding hospitals. Focused redeployment of human, economic, and social capital across hospital systems may be required to expedite regional health care systems recovery. (Disaster Med Public Health Preparedness. 2016;10:333-343).
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http://dx.doi.org/10.1017/dmp.2015.175DOI Listing
June 2016

Lesson From the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program.

Ann Emerg Med 2016 Apr 25;67(4):531-537.e39. Epub 2015 Nov 25.

Bellevue Hospital Center, New York, NY; Department of Emergency Medicine, NYU School of Medicine, New York, NY. Electronic address:

Study Objective: In 2006, the Institute of Medicine emphasized substantial potential to expand organ donation opportunities through uncontrolled donation after circulatory determination of death (uDCDD). We pilot an out-of-hospital uDCDD kidney program for New York City in partnership with communities that it was intended to benefit. We evaluate protocol process and outcomes while identifying barriers to success and means for improvement.

Methods: We conducted a prospective, participatory action research study in Manhattan from December 2010 to May 2011. Daily from 4 to 12 pm, our organ preservation unit monitored emergency medical services (EMS) frequencies for cardiac arrests occurring in private locations. After EMS providers independently ordered termination of resuscitation, organ preservation unit staff determined clinical eligibility and donor status. Authorized parties, persons authorized to make organ donation decisions, were approached about in vivo preservation. The study population included organ preservation unit staff, authorized parties, passersby, and other New York City agency personnel. Organ preservation unit staff independently documented shift activities with daily operations notes and teleconference summaries that we analyzed with mixed qualitative and quantitative methods.

Results: The organ preservation unit entered 9 private locations; all the deceased lacked previous registration, although 4 met clinical screening eligibility. No kidneys were recovered. We collected 837 notes from 35 organ preservation unit staff. Despite frequently recounting protocol breaches, most responses from passersby including New York City agencies were favorable. No authorized parties were offended by preservation requests, yielding a Bayesian posterior median 98% (95% credible interval 76% to 100%).

Conclusion: In summary, the New York City out-of-hospital uDCDD program was not feasible. There were frequent protocol breaches and confusion in determining clinical eligibility. In the small sample of authorized persons we encountered during the immediate grieving period, negative reactions were infrequent.
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http://dx.doi.org/10.1016/j.annemergmed.2015.09.017DOI Listing
April 2016

Redistribution of Emergency Department Patients After Disaster-Related Closures of a Public Versus Private Hospital in New York City.

Disaster Med Public Health Prep 2015 Jun 17;9(3):256-64. Epub 2015 Mar 17.

3Leonard Davis Institute of Health Economics,University of Pennsylvania.

Sudden hospital closures displace patients from usual sources of care and force them to access facilities that lack their prior medical records. For patients with complex needs and for nearby hospitals already strained by high volume, disaster-related hospital closures induce a public health emergency. Our objective was to analyze responses of patients from public versus private emergency departments after closure of their usual hospital after Hurricane Sandy. Using a statewide database of emergency visits, we followed patients with an established pattern of accessing 1 of 2 hospitals that closed after Hurricane Sandy: Bellevue Hospital Center and NYU Langone Medical Center. We determined how these patients redistributed for emergency care after the storm. We found that proximity strongly predicted patient redistribution to nearby open hospitals. However, for patients from the closed public hospital, this redistribution was also influenced by hospital ownership, because patients redistributed to other public hospitals at rates higher than expected by proximity alone. This differential response to hospital closures demonstrates significant differences in how public and private patients respond to changes in health care access during disasters. Public health response must consider these differences to meet the needs of all patients affected by disasters and other public health emergencies.
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http://dx.doi.org/10.1017/dmp.2015.11DOI Listing
June 2015

Including frequent emergency department users with severe alcohol use disorders in research: assessing capacity.

Ann Emerg Med 2015 Feb 23;65(2):172-7.e1. Epub 2014 Oct 23.

Department of Population Health, Division of Medical Ethics, New York University School of Medicine, New York, NY.

Study Objective: Frequent emergency department (ED) users with severe alcohol use disorders are often excluded from research, in part because assessing capacity to provide consent is challenging. We aim to assess the feasibility of using the University of California, San Diego Brief Assessment of Capacity to Consent, a 5-minute, easy-to-use, validated instrument, to screen for capacity to consent for research in frequent ED users with severe alcohol use disorders.

Methods: We prospectively enrolled a convenience sample of 20 adults to assess their capacity to provide consent for participation in 30-minute mixed-methods interviews using the 10-question University of California, San Diego Brief Assessment of Capacity to Consent. Participants were identified through an administrative database, had greater than 4 annual ED visits for 2 years, and had severe alcohol use disorders. The study was conducted with institutional review board approval from March to July 2013 in an urban, public, university ED receiving approximately 120,000 visits per year. Blood alcohol concentration and demographic data were extracted from the medical record.

Results: We completed assessments for 19 of 20 participants. One was removed because of agitation. Sixteen of 19 participants passed each question and were deemed capable of providing informed consent. Interventions to improve understanding (prompting and material review) were required for 15 of 19 participants. The mean duration to describe the study and perform the assessment was 10.4 minutes (SD 3 minutes). The mean blood alcohol concentration was 211.5 mg/dL (SD 137.4 mg/dL). The 3 patients unable to demonstrate capacity had blood alcohol concentrations of 226 and 348 mg/dL, with 1 not obtained.

Conclusion: This pilot study supports the feasibility of using the University of California, San Diego Brief Assessment of Capacity to Consent to assess capacity of frequent ED users with severe alcohol use disorders to participate in research. Blood alcohol concentration was not correlated with capacity.
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http://dx.doi.org/10.1016/j.annemergmed.2014.09.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530610PMC
February 2015

Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study.

Ann Emerg Med 2015 Feb 26;65(2):178-86.e6. Epub 2014 Jun 26.

Department of Emergency Medicine, New York University School of Medicine, New York, NY; Department of Humanities and Social Sciences and Interdepartmental Research Studies, New York University Steinhardt School of Culture, Education, and Human Development, New York, NY.

Study Objective: We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism.

Methods: We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail.

Results: Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma.

Conclusion: Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.
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http://dx.doi.org/10.1016/j.annemergmed.2014.05.025DOI Listing
February 2015

Rebuilding Emergency Care After Hurricane Sandy.

Disaster Med Public Health Prep 2014 Apr 9:1-4. Epub 2014 Apr 9.

Department of Emergency Medicine and Office of the Commissioner, New York State Department of Health, Albany, New York.

A freestanding, 911-receiving emergency department was implemented at Bellevue Hospital Center during the recovery efforts after Hurricane Sandy to compensate for the increased volume experienced at nearby hospitals. Because inpatient services at several hospitals remained closed for months, emergency volume increased significantly. Thus, in collaboration with the New York State Department of Health and other partners, the Health and Hospitals Corporation and Bellevue Hospital Center opened a freestanding emergency department without on-site inpatient care. The successful operation of this facility hinged on key partnerships with emergency medical services and nearby hospitals. Also essential was the establishment of an emergency critical care ward and a system to monitor emergency department utilization at affected hospitals. The results of this experience, we believe, can provide a model for future efforts to rebuild emergency care capacity after a natural disaster such as Hurricane Sandy. (Disaster Med Public Health Preparedness. 2014;0:1-4).
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http://dx.doi.org/10.1017/dmp.2014.19DOI Listing
April 2014

Reasons for emergency department use: do frequent users differ?

Am J Manag Care 2014 Nov 1;20(11):e506-14. Epub 2014 Nov 1.

Department of Emergency Medicine, Bellevue Hospital Center Room A-345, First Ave and 27th St, New York, NY 10016. E-mail:

Objectives: To examine patients' reasons for using the emergency department (ED) for low-acuity health complaints, and determine whether reasons differed for frequent ED users versus nonfrequent ED users.

Study Design: Prospective cross-sectional survey.

Methods: Patients presenting to an urban public hospital for low-acuity health complaints were surveyed about their reasons for visiting the ED rather than a private doctor's office or clinic. Patients with 3 or more visits to the study hospital ED over the past year were classified as frequent ED users. Multivariable logistic regression was used to determine if frequent ED users gave different reasons for ED use than nonfrequent ED users, while controlling for differences in other baseline patient characteristics.

Results: 940 patients, including 163 frequent ED users, completed the study questionnaire. Commonly cited reasons for using the ED were that coming to the ED was easier than making a clinic appointment (82.3% agreed); the problem could not wait (78.8%); they didn't know how to make a clinic appointment (66.7%); they felt the ED provided better care (56.7%); and they believed the clinic would cost more (54.8%). After controlling for other patient characteristics, there were no significant differences found in reasons for ED use given by frequent versus nonfrequent ED users.

Conclusions: Frequent ED users gave similar reasons for using the ED for low-acuity health complaints compared with nonfrequent ED users. Access, convenience, cost, and quality concerns, as well as feeling that ED care was needed, were all commonly cited as reasons for using the ED.
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November 2014

Uncontrolled organ donation after circulatory determination of death: US policy failures and call to action.

Ann Emerg Med 2014 Apr 20;63(4):392-400. Epub 2013 Nov 20.

Department of Emergency Medicine, Bellevue Hospital Center, NYU School of Medicine, New York, NY. Electronic address:

In the United States, more than 115,000 patients are wait-listed for organ transplants despite that there are 12,000 patients each year who die or become too ill for transplantation. One reason for the organ shortage is that candidates for donation must die in the hospital, not the emergency department (ED), either from neurologic or circulatory-respiratory death under controlled circumstances. Evidence from Spain and France suggests that a substantial number of deaths from cardiac arrest may qualify for organ donation using uncontrolled donation after circulatory determination of death (uDCDD) protocols that rapidly initiate organ preservation in out-of-hospital and ED settings. Despite its potential, uDCDD has been criticized by panels of experts that included neurologists, intensivists, attorneys, and ethicists who suggest that organ preservation strategies that reestablish oxygenated circulation to the brain retroactively negate previous death determination based on circulatory-respiratory criteria and hence violate the dead donor rule. In this article, we assert that in uDCDD, all efforts at saving lives are exhausted before organ donation is considered, and death is determined according to "irreversible cessation of circulatory and respiratory functions" evidenced by "persistent cessation of functions during an appropriate period of observation and/or trial of therapy." Therefore, postmortem in vivo organ preservation with chest compressions, mechanical ventilation, and extracorporeal membrane oxygenation is legally and ethically appropriate. As frontline providers for patients presenting with unexpected cardiac arrest, emergency medicine practitioners need be included in the uDCDD debate to advocate for patients and honor the wishes of the deceased.
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http://dx.doi.org/10.1016/j.annemergmed.2013.10.014DOI Listing
April 2014

Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users.

Am J Public Health 2013 Dec 22;103 Suppl 2:S221-4. Epub 2013 Oct 22.

Ryan P. McCormack, Lily F. Hoffman, Stephen P. Wall, and Lewis R. Goldfrank are with the Department of Emergency Medicine, New York University School of Medicine, New York, NY.

We introduced case management and homeless outreach to chronically homeless, alcohol-dependent, frequent emergency department (ED) visitors using existing resources. We assessed the difference in differences of ED visits 6 months pre- and postintervention using a prospective, nonequivalent control group trial. Secondary outcomes included changes in hospitalizations and housing. The differences in differences between intervention and prospective patients and retrospective controls were -12.1 (95% CI = -22.1, -2.0) and -12.8 (95% CI = -26.1, 0.6) for ED visits and -8.5 (95% CI = -22.8, 5.8) and -19.0 (95% CI = -34.3, -3.6) for inpatient days, respectively. Eighteen participants accepted shelter; no controls were housed. Through intervention, ED use decreased and housing was achieved.
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http://dx.doi.org/10.2105/AJPH.2013.301373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969119PMC
December 2013

Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders.

Lancet 2013 Sep 19;382(9896):995-7. Epub 2013 Apr 19.

Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA.

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http://dx.doi.org/10.1016/S0140-6736(12)62206-5DOI Listing
September 2013

Attack rates assessment of the 2009 pandemic H1N1 influenza A in children and their contacts: a systematic review and meta-analysis.

PLoS One 2012 30;7(11):e50228. Epub 2012 Nov 30.

Department of Family and Community Medicine, New York Medical College, Valhalla, New York, United States of America.

Background: The recent H1N1 influenza A pandemic was marked by multiple reports of illness and hospitalization in children, suggesting that children may have played a major role in the propagation of the virus. A comprehensive detailed analysis of the attack rates among children as compared with their contacts in various settings is of great importance for understanding their unique role in influenza pandemics.

Methodology/principal Findings: We searched MEDLINE (PubMed) and Embase for published studies reporting outbreak investigations with direct measurements of attack rates of the 2009 pandemic H1N1 influenza A among children, and quantified how these compare with those of their contacts. We identified 50 articles suitable for review, which reported school, household, travel and social events. The selected reports and our meta-analysis indicated that children had significantly higher attack rates as compared to adults, and that this phenomenon was observed for both virologically confirmed and clinical cases, in various settings and locations around the world. The review also provided insight into some characteristics of transmission between children and their contacts in the various settings.

Conclusion/significance: The consistently higher attack rates of the 2009 pandemic H1N1 influenza A among children, as compared to adults, as well as the magnitude of the difference is important for understanding the contribution of children to disease burden, for implementation of mitigation strategies directed towards children, as well as more precise mathematical modeling and simulation of future influenza pandemics.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0050228PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523802PMC
March 2013

An intervention connecting low-acuity emergency department patients with primary care: effect on future primary care linkage.

Ann Emerg Med 2013 Mar 20;61(3):312-321.e7. Epub 2012 Dec 20.

Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine and the US Department of Veterans Affairs, New Haven, CT, USA.

Study Objective: Our objective is to determine whether a point-of-care intervention that navigates willing, low-acuity patients from the emergency department (ED) to a Primary Care Clinic will increase future primary care follow-up.

Methods: We conducted a quasi-experimental trial at an urban safety net hospital. Adults presenting to the ED for select low-acuity problems were eligible. Patients were excluded if arriving by emergency medical services, if febrile, or if the triage nurse believed they required ED care. We enrolled 965 patients. Navigators escorted a subset of willing participants to the Primary Care Clinic (in the same hospital complex), where they were assigned a personal physician, were given an overview of clinic services, and received same-day clinic care. The primary outcome was Primary Care Clinic follow-up within 1 year of the index ED visit among patients having no previous primary care provider.

Results: In the bivariate intention-to-treat analysis, 50.3% of intervention group patients versus 36.9% of control group patients with no previous primary care provider had at least 1 Primary Care Clinic follow-up visit in the year after the intervention. In the multivariable analysis, the absolute difference in having at least 1 Primary Care Clinic follow-up for the intervention group compared with the control group was 9.3% (95% confidence interval 2.2% to 16.3%). There was no significant difference in the number of future ED visits.

Conclusion: A point-of-care intervention offering low-acuity ED patients the opportunity to alternatively be treated at the hospital's Primary Care Clinic resulted in increased future primary care follow-up compared with standard ED referral practices.
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http://dx.doi.org/10.1016/j.annemergmed.2012.10.021DOI Listing
March 2013

A rationale in support of uncontrolled donation after circulatory determination of death.

Hastings Cent Rep 2013 Jan-Feb;43(1):19-26. Epub 2012 Dec 18.

In the United States, when people die unexpectedly, they are usually not considered as organ donors because of the difficulty of keeping organs viable when death occurs outside the hospital, in "uncontrolled" circumstances. New protocols to permit donation in these cases have renewed the debate about how we decide whether a person has died- and whether the moral imperative to help those in need of transplant should affect the determination of death.
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http://dx.doi.org/10.1002/hast.113DOI Listing
February 2013

Death on the waiting list: a failure in public health.

Ann Emerg Med 2012 Oct 13;60(4):492-4. Epub 2012 Jun 13.

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http://dx.doi.org/10.1016/j.annemergmed.2012.05.015DOI Listing
October 2012

Training physician investigators in medicine and public health research.

Am J Public Health 2012 Jul 17;102(7):e39-45. Epub 2012 May 17.

Department of Population Health, New York University (NYU) School of Medicine, New York, New York 10016, USA.

Objectives: We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health.

Methods: We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations.

Results: Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12).

Conclusions: A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health.
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http://dx.doi.org/10.2105/AJPH.2011.300486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3478019PMC
July 2012

Developing a consensus framework and risk profile for agents of opportunity in academic medical centers: implications for public health preparedness.

Disaster Med Public Health Prep 2010 Dec;4(4):318-25

New York Presbyterian Hospital/Weill-Cornell Medical Center, NY 10065, USA.

Agents of opportunity (AO) in academic medical centers (AMC) are defined as unregulated or lightly regulated substances used for medical research or patient care that can be used as "dual purpose" substances by terrorists to inflict damage upon populations. Most of these agents are used routinely throughout AMC either during research or for general clinical practice. To date, the lack of careful regulations for AOs creates uncertain security conditions and increased malicious potential. Using a consensus-based approach, we collected information and opinions from staff working in an AMC and 4 AMC-affiliated hospitals concerning identification of AO, AO attributes, and AMC risk and preparedness, focusing on AO security and dissemination mechanisms and likely hospital response. The goal was to develop a risk profile and framework for AO in the institution. Agents of opportunity in 4 classes were identified and an AO profile was developed, comprising 16 attributes denoting information critical to preparedness for AO misuse. Agents of opportunity found in AMC present a unique and vital gap in public health preparedness. Findings of this project may provide a foundation for a discussion and consensus efforts to determine a nationally accepted risk profile framework for AO. This foundation may further lead to the implementation of appropriate regulatory policies to improve public health preparedness. Agents of opportunity modeling of dissemination properties should be developed to better predict AO risk.
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http://dx.doi.org/10.1001/dmp.2010.37DOI Listing
December 2010