Publications by authors named "R Bart Sangal"

82 Publications

Radiation Induced Liver Injury: Collateral Damage Radiologically Simulating Interval Metastasis in Carcinoma Esophagus; a Diagnostic Dilemma Resolved Through Liver Biopsy.

Int J Surg Pathol 2022 Apr 26:10668969221095181. Epub 2022 Apr 26.

Department of Histopathology and cytopathology, BLK-MAX Hospital, New Delhi, India.

F-18-fluorodeoxyglucose positron emission tomography (18-FDG PET/CT) is increasingly being used in patients with cancer, both for baseline staging and for evaluation of treatment response. However, in patients with incidental irradiation of the liver during radiotherapy, particularly for lower gastrointestinal tract cancers, increased focal F-18-fluorodeoxyglucose positron emission tomography avidity may be the result of collateral radiation induced liver damage rather than metastases. Awareness of this pathologic entity and correlation with with other imaging, clinical and laboratory findings including liver biopsy is vital to avoid misinterpretation and overstaging of the carcinoma in these patients. We encountered such a scenario in an elderly female patient with distal esophageal squamous cell carcinoma patient, who developed F-18-fluorodeoxyglucose positron emission tomography avid left lobe liver lesion post neoadjuvant radiotherapy, simulating interval metastasis. A liver biopsy ruled out malignancy and helped to clinch the correct diagnosis of radiation induced liver injury.
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http://dx.doi.org/10.1177/10668969221095181DOI Listing
April 2022

Implementation of an Electronic Health Record Integrated Clinical Pathway Improves Adherence to COVID-19 Hospital Care Guidelines.

Am J Med Qual 2022 Apr 12. Epub 2022 Apr 12.

Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.

Background: During the COVID-19 pandemic, frequently changing guidelines presented challenges to emergency department (ED) clinicians. The authors implemented an electronic health record (EHR)-integrated clinical pathway that could be accessed by clinicians within existing workflows when caring for patients under investigation (PUI) for COVID-19. The objective was to examine the association between clinical pathway utilization and adherence to institutional best practice treatment recommendations for COVID-19.

Methods: The authors conducted an observational analysis of all ED patients seen in a health system inclusive of seven EDs between March 18, 2020, and April 20, 2021. They implemented the pathway as an interactive flow chart that allowed clinicians to place orders while viewing the most up-to-date institutional guidance. Primary outcomes were proportion of admitted PUIs receiving dexamethasone and aspirin in the ED, and secondary outcome was time to delivering treatment.

Results: A total of 13 269 patients were admitted PUIs. The pathway was used by 40.6% of ED clinicians. When clinicians used the pathway, patients were more likely to be prescribed aspirin (OR, 7.15; 95% CI, 6.2-8.26) and dexamethasone (10.4; 8.85-12.2). For secondary outcomes, clinicians using the pathway had statistically significant (P < 0.0001) improvement in timeliness of ordering medications and admission to the hospital. Aspirin, dexamethasone, and admission order time were improved by 103.89, 94.34, and 121.94 minutes, respectively.

Conclusions: The use of an EHR-integrated clinical pathway improved clinician adherence to changing COVID-19 treatment guidelines and timeliness to associated medication administration. As pathways continue to be implemented, their effects on improving patient outcomes and decreasing disparities in patient care should be further examined.
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http://dx.doi.org/10.1097/JMQ.0000000000000036DOI Listing
April 2022

Universal SARS-CoV-2 Testing of Emergency Department Admissions Increases Emergency Department Length of Stay.

Ann Emerg Med 2022 02 8;79(2):182-186. Epub 2021 Sep 8.

Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.

Study Objective: Our institution experienced a change in SARS-CoV-2 testing policy as well as substantial changes in local COVID-19 prevalence, allowing for a unique examination of the relationship between SARS-CoV-2 testing and emergency department (ED) length of stay.

Methods: This was an observational interrupted time series of all patients admitted to an academic health system between March 15, 2020, and September 30, 2020. Given testing limitations from March 15 to April 24, all patients receiving SARS-CoV-2 tests were symptomatic. On April 24, testing was expanded to all ED admissions. The primary and secondary outcomes were ED length of stay and number needed to test to obtain a positive, respectively.

Results: A total of 70,856 patients were cared for in the EDs during the 7-month period. The testing change increased admission length of stay by 1.89 hours (95% confidence interval 1.39 to 2.38). The number needed to test was 2.5 patients and was highest yield on April 1, 2020, when the state positivity rate was 39.7%; however, the number needed to test exceeded 170 patients by Sept 1, 2020, at which point the state positivity rate was 0.5%.

Conclusion: Although universal SARS-CoV-2 testing of ED admissions may meaningfully support mitigation and containment efforts, the clinical cost of testing all admissions amid low community positivity is notable. In our system, universal ED SARS-CoV-2 testing was associated with a 24% increase in admission length of stay alongside the detection of only 1 positive case every other day. Given the known harms and risks of ED boarding and crowding, solutions must be developed to support regular operational flow while balancing infection prevention needs.
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http://dx.doi.org/10.1016/j.annemergmed.2021.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424016PMC
February 2022

Leadership communication, stress, and burnout among frontline emergency department staff amid the COVID-19 pandemic: A mixed methods approach.

Healthc (Amst) 2021 Dec 13;9(4):100577. Epub 2021 Aug 13.

Yale University School of Management, New Haven, CT, USA.

Background: Organizations have a key role to play in supporting healthcare workers (HCWs) and mitigating stress during COVID-19. We aimed to understand whether perceptions of support and communication by local leadership were associated with reduced reports of stress and burnout among frontline HCWs.

Methods: We conducted cross-sectional surveys embedded within emergency department (ED) workflow during the first wave of COVID-19 from April 9, 2020 to June 15th, 2020 within three EDs of a multisite health system in the Northeast United States. All ED HCWs were administered electronic surveys during shift via text message. We simultaneously conducted 64 qualitative interviews to better characterize and validate survey responses. Primary survey outcomes were levels of work stress and burnout.

Results: Over 10 week study, 327 of 431 (76%) frontline HCWs responded to at least one round of the survey. More useful communication mediated through higher perception of support was significantly associated with lower work stress (B = -0.33, p < 0.001) and burnout (B = -7.84, p < 0.001). A one-point increase on the communication Likert scale was associated with a 9% reduction in stress and a 19% reduction in burnout. Three themes related to effective crisis communication during COVID-19 emerged in interviews: (1) information consolidation prior to dissemination, (2) consistency of communication, and (3) bi-directional communication.

Conclusion: This work suggests that effective local leadership communication, characterized by information consolidation, consistency, and bi-directionality, leads to higher perceptions of support and lower stress and burnout among ED frontline workers. As the pandemic continues, these results present an evidence-based framework for leaders to support frontline HCWs through effective crisis communication.
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http://dx.doi.org/10.1016/j.hjdsi.2021.100577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361146PMC
December 2021

Simulating approaches to emergency department pandemic physician staffing during COVID-19.

Am J Disaster Med 2021 Spring;16(2):85-93

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut. ORCID: https://orcid.org/0000-0001-8319-7643.

Objective: During pandemics, emergency departments (EDs) are challenged by the need to replace quarantined ED staff and avoid staffing EDs with nonemergency medicine (EM) trained physicians. We sought to design and examine three feasible ED staffing models intended to safely schedule EM physicians to staff three EDs within a health system during a prolonged infectious disease outbreak.

Methods: We conducted simulation analyses examining the strengths and limitations of three ED clinician staffing models: two-team and three-team fixed cohort, and three-team unfixed cohort. Each model was assessed with and without immunity, and by varying infection rates. We assumed a 12-week pandemic disaster requiring a 2-week quarantine.

Main Outcome: The outcome, time to staffing shortage, was defined as depletion of available physicians in both 8- and 12-hour shift duration scenarios.

Results: All staffing models initially showed linear physician attrition with higher infection rates resulting in faster staffing shortages. The three-team fixed cohort model without immunity was not viable beyond 11 weeks. The three-team unfixed cohort model without immunity avoided staffing shortage for the duration of the pandemic up to an infection rate of 50 percent. The two-team model without immunity also avoided staffing shortage up to 30 percent infection rate. When accounting for immunity, all models behaved similarly initially but returned to adequate staffing during week 5 of the pandemic.

Conclusions: Simulation analyses reveal fundamental tradeoffs that are critical to designing feasible pandemic disaster staffing models. Emergency physicians should test similar models based on local assumptions and capacity to ensure adequate staffing preparedness for prolonged pandemics.
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http://dx.doi.org/10.5055/ajdm.2021.0391DOI Listing
August 2021
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