Bridging Language Gaps in Emergency Care: Expanding Qualified Bilingual Staff and Evaluating Interpreter Modalities.

Objective This review was conducted to identify and synthesise the evidence around the use of telephone and video interpreter services compared with in-person services in healthcare. Methods A systematic search of articles published in the English language was conducted using PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Database of Abstracts of Reviews of Effects (DARE), Joanna Briggs, Google Scholar and Google. Search terms included 'interpreter', 'patient satisfaction', 'consumer satisfaction' and 'client satisfaction'. Any study that did not compare in-person interpreter services with either telephone or video interpreter services was excluded from analysis. Studies were screened for inclusion or exclusion by two reviewers, using criteria established a priori. Data were extracted via a custom form and synthesised. Results The database search yielded 196 studies, eight of which were included in the present review. The search using an Internet search engine did not identify any relevant studies. Of the studies included, five used telephone and three used video interpreter services. All studies, except one, compared levels of satisfaction regarding in-person interpretation and telephone or video interpretation. One study compared satisfaction of two versions of video interpretation. There is evidence of higher satisfaction with hospital-trained interpreters compared with ad hoc (friend or family) or telephone interpreters. There is no difference in satisfaction between in-person interpreting, telephone interpreting or interpretation provided by the treating bilingual physician. Video interpreting has the same satisfaction as in-person interpreting, regardless of whether the patient and the physician are in the same room. Higher levels of satisfaction were reported for trained telephone interpreters than for in-person interpreters or an external telephone interpreter service. Conclusions Current evidence does not suggest there is one particular mode of interpreting that is superior to all others. This review is limited in its translational capacity given that most studies were from the US and in a Spanish-speaking cohort. What is known about the topic? Access to interpreters has been shown to positively affect patients who are not proficient in speaking the local language of the health service. What does this paper add? This paper adds to the literature by providing a comprehensive summary of patient satisfaction when engaging several different types of language interpreting services used in healthcare. What are the implications for practitioners? This review provides clear information for health services on the use of language interpreter services and patient satisfaction. The current body of evidence does not indicate a superior interpreting method when patient satisfaction is concerned.

385 Emergency Department Staff Attitudes and Satisfaction With Live-Feed Video Interpreting for Limited English Proficient Patients: Pre- and Post- Training

Over 50 million U.S. adults 65 years and older account for >20 million emergency departments (ED) visits each year. Increasing ED use by older adults is projected to exceed the capacity of U.S. EDs. The traditional ED model of care is ill-equipped to address the many complex care needs of older adults.

Is it time to implement clinical decision rules for upper GI bleeding? Barriers, facilitators, and the need for a collaborative approach

Utility of mobile technology in medical interpretation: A literature review of current practices

Introduction: Emergency Department (ED) Physicians typically consult with a specialist after pertinent results are gathered. In the case of acute stroke, delays in neurologist consultation equate to valuable time lost for treatment. When Telestroke went live in June 2015 at our 148-bed regional medical center, the physician norm was challenged because Telestroke protocol stipulates activation of the system before the CT scan. Despite education about the importance of calling early, ED physicians continued to activate Telestroke after gathering results. Hypothesis: Implementation of timely, structured feedback to ED physicians will change ED physician culture to reduce Door-to-Telestroke Activation (DTA) times. Methods: In February 2017, monthly feedback was initiated with ED physicians. Graphs showing current performance related to activation times were discussed, goals were reviewed, small improvements were acknowledged, and physicians were encouraged to share their successes. Using a prospective observational study design and a REDCap database, data from June 2015 to February 2017 were compared to data from March 2017 to July 2018. Results: From June 10, 2015 to July 18, 2018 Telestroke was activated 246 times in the ED. After the feedback initiation, the median DTA of 20 m (n=145) was significantly lower than the baseline median of 32 m (n=101, p<0.0001) and the percentage of activations prior to the CT scan rose significantly from 20% to 46% (p=0.0003). Also, Door-to-Needle (DTN) time decreased to a median of 48 m (n=27), compared to the baseline of 56 m (n=19, p=0.15) and the percentage of ischemic stroke patients treated with IV Alteplase increased to 17.7% from 13.4%. Median Door-to-CT (DTCT) remained unchanged at 17 m both pre and post intervention, demonstrating consistent ED processes. Conclusions: Timely ED physician feedback led to faster Door-to-Telestroke Activation times. While statistically insignificant, post intervention DTN times rose from a baseline of 63% (n=19) to 81% (n=27, p=0.29) which met the primary Target: Stroke Phase II goal to treat 75% of patients within 60 minutes. Faster activation resulted in faster treatment and ultimately improved chances of a better outcome.

Introduction: Emergency departments (EDs) are overcrowded and patient acuity and volumes are ever-increasing. While changes to the flow of ED patient input and output are outside the control of frontline ED teams, the efficiency of ED throughput can be optimized. One widely studied intervention is the implementation of a physician liaison role to assist in managing overall ED flow. The Physician Float (PF) acts as a triage liaison, second physician for resuscitations, ED procedural sedation physician, and fields ED referral calls. This is a first-iteration proof-of-concept trial to plan, implement and evaluate if the PF role could decrease ED length of stay (LOS) by a goal of 30 minutes, over a four-week period, without adverse changes to left without being seen (LWBS) and bounce-back rates. Methods: The PF role was implemented as a scheduled emergency physician shift in the fall of 2017. Ongoing iterations of this role implementation are being reviewed for re-implementation. The primary outcome measure was ED LOS; secondary outcomes included time-to-physician initial assessment (PIA), EMS offload rates, and LWBS and 72-hour bounce-back rates. Qualitative data including patient concerns and physician feedback were also collected. Data were collected after the trial from a centralized, de-identified ED information system database with time-stamp quantifiers and compared to the following four-week time period where the shift is a regular ED physician shift at the same time. The ED physician and nursing team planned and implemented the PF role, then results were evaluated and shared with the wider ED staff in departmental grand rounds and quality council presentation formats, and recommendations were gathered from to adjust and strengthen future iterations of PF role implementation. Results: Descriptive statistics and Mann-Whitney and Median tests were calculated. On average there were 185 daily ED visits in the trial and comparison periods. Median ED LOS decreased by 12 minutes in the PF trial period (p<0.05). Furthermore, there was a 12 minute decreased ED LOS for all discharged patients (p<0.05). PIA time decreased by 13 minutes for patients that were admitted. The average percentage of EMS offloads within 60 min improved from 75% to 80.7% for admitted patients. LWBS and 72-hour bounce-back rates were unchanged. No additional patient concerns arose related to or during the trial. Physician feedback on the PF role was mainly positive. Conclusion: The defined role of a PF in an ED can decrease ED LOS, albeit not achieving the desired 30-minute reduction on the first iteration, this trial supported proof-of-concept for implementation of a PF role in a tertiary care centre ED. Further iterations are needed to evaluate the scalability and sustainability of this role.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (<10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (>10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2<90%), hypotension (sBP<90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.

Objective: Compare non-mydriatic ocular fundus photography read by ED physicians to their direct ophthalmoscopy. Background In the first phase of the FOTO-ED Study, 12.6% of 350 ED patients with complaints/conditions warranting ocular fundus examination had findings, such as papilledema, that should have altered their management/disposition. Disturbingly, only 14% of these 350 patients had direct ophthalmoscopy performed, and nearly all of the relevant findings were missed and identified solely by fundus photography reviewed by neuro-ophthalmologists. Design/Methods: Patients presenting to our ED with headache, focal neurologic defect, visual change, or diastolic blood pressure ≥120 were prospectively enrolled. Fundus photography was performed by a nurse practitioner or medical student using a non-mydriatic fundus camera (Kowa nonmyd-alpha-D). ED physicians were notified that photographs were available on the electronic medical record, but were not required to review the photographs. Results: 354 patients were included from among 473 assessed for eligibility (exclusions:82 ineligible, 33 refused participation, 3 other reasons). Photographs of 239 (68%) were reviewed by ED physicians. 34 patients (10%) had relevant findings identified by neuro-ophthalmologist review (6 disc edema, 6 grade III/IV HTN retinopathy, 6 isolated hemorrhages, 15 optic disc pallor, and 1 retinal vascular occlusion). 14 of those 34 relevant findings (41%) were identified by the ED physicians, eight (24%) occurred in patients whose photographs were not reviewed by ED physicians, and the remaining were reviewed but recorded as likely normal/normal. The ED physicians reported that the photographs were helpful for 125 patients (35%). Conclusions: Non-mydriatic fundus photographs were used more frequently than direct ophthalmoscopy by ED physicians, and were more sensitive to relevant abnormalities. Ocular fundus photography was more often helpful in ED patient evaluations, even when normal. We plan to investigate whether training in the interpretation of fundus photographs improves ED physician performance and facilitates appropriate ED management. Supported by: In part by an unrestricted departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York, and by NIH/NEI core grant P30-EY06360 (Department of Ophthalmology). Dr. Bruce receives research support from the NIH/NEI (K23-EY019341). Dr. Newman is a recipient of the Research to Prevent Blindness Lew R. Wasserman Merit Award. Disclosure: Dr. Bruce has nothing to disclose. Dr. Thulasi has nothing to disclose. Dr. Fraser has nothing to disclose. Dr. Keadey has nothing to disclose. Dr. Ward has nothing to disclose. Dr. Heilpern has nothing to disclose. Dr. Wright has received (royalty or license fee or contractual rights) payments from Emory University. Dr. Wright holds stock and/or stock options in Zenda Technologies. Dr. Newman has received personal compensation for activities with Biogen Idec. Dr. Biousse has nothing to disclose.

Coding for Emergency Department Visits

Unsolicited Letters With News, Notes, and Comments From Our Readers Always Welcomed

Opioid analgesics, when taken as prescribed, are effective therapeutic options that provide pain relief for moderate to severe pain. The use of opioids in the treatment of pain has been increasing in the U.S. at an alarming rate, possibly contributing to the simultaneous rise in opioid abuse. Emergency departments play a major role in managing patients who present in pain, with approximately 10% of all opioid analgesic prescriptions written in hospital emergency departments. It is estimated that dental pain patients represent between 0.3-4% of the overall patient emergency department workload. Yet, the literature suggests that many of these physicians may not have sufficient training in handling dentofacial emergencies. The goal of this study was to systematically review the available literature on the topics of: 1) emergency department physicians’ training related to treating dental pain patients, and 2) the frequency in which they prescribe opioid medications to these patients. Methods: A systematic literature review was conducted among publications from 1985-2014 in the databases PubMed, Ovid, and Science Citation Index. The following search terms were used in this systematic literature review in order to identify the available literature of interest: “opioid and dental and emergency departments,” “dental pain and drug abuse,” “ER physicians and dental pain,” “ER physicians and drug abuse,” and “dental pain and emergency departments.” Publications in any language or country were considered, as well as editorials and commentaries. Findings: A total of 769 publications were identified. Seventeen publications met the criteria for inclusion. Eight studies commented on the emergency department physicians’ perceived “lack of training” in handling dentofacial emergencies and found that the majority of this group did not feel comfortable in managing dental patients. Nine studies assessed the frequency in which physicians prescribe pain medications to dental patients. Within these 9 studies, 5 specifically reported that between 29.6% and 81% of dental patients treated, received an “opioid” or a “narcotic” upon discharge. The remaining 4 studies in this group instead used non-specific terms that included “prescription medications,” “analgesics,” “pain medicine,” and “pharmacotherapy” to describe their findings and did not particularly report opioid prescribing trends. Of those publications rejected, 9 addressed the topic of dental pain patients presenting to non-dental providers, but did not include data that met the criteria related to emergency department prescribing frequency or physician training. Conclusions: This review of the literature suggests that emergency department physicians’ training level in treating dentofacial pain is less than ideal. It also confirms that individuals presenting to emergency departments with dental pain are a subset of the population of patients who are prescribed opioids as an analgesic. Coupling these results with the increased use of opioids in this country, dentists are in a key position to collaborate with emergency department physicians to help positively affect change. To further justify this approach, research agendas must carefully monitor prescribing patterns for dentofacial pain in the emergency department that are specific to opioid use, carefully excluding other non-narcotic analgesics. Should comparable outcomes of data related to the same topic in other non-dental settings exist, additional areas in medicine that may benefit from this partnership may also be identified. Moving forward, this interprofessional team approach may include a presence in medical school and residency program curricula so that alternative treatment options for addressing dental pain patients can be presented that consider the increased prescribing trends of opioids.

We aimed to assess whether the MEESSI-AHF score for 30-day mortality stratification in acute heart failure (AHF) patients presenting to the emergency department (ED) is equally accurate in men and women. As a secondary objective, we explored whether sex influences decision-making in aspects that largely depend on severity as estimated by MEESSI-AHF. We analyzed patients diagnosed with AHF in 56 Spanish ED that were consecutively included in the EAHFE registry during eight different time points between 2007 and 2022 for whom sex and MEESSI-AHF score were available. Patients were classified into the four MEESSI-AHF risk groups (low, intermediate, high, and very high) and by sex (men/women) as stated in the administrative records. We compared 30-day mortality in men and women (to independently assess the reliability of MEESSI-AHF in men and women, as MEESSI-AHF was derived to estimate the risk of death at 30days); ED physicians' decisions regarding hospitalization and extended (> 24h) ED observation in patients discharged home after ED care; and for hospital physicians' decisions regarding prolonged hospitalization (> 7days) in hospitalized patients. We supposed that ED and hospital physicians' decisions should not differ between men and women in the same MEESSI-AHF risk category. These associations were tested using logistic regression and interaction analyses. The same analyses were repeated treating the MEESSI-AHF score as a continuous variable, modeled with restricted cubic splines. We included 13,042 patients (median age 83years; 56% women). MEESSI-AHF accurately stratified 30-day mortality overall (2.9%, 9.6%, 18.2%, and 39.7% across risk groups; with a c-statistic of 0.78; p < 0.001), with no differences according to patient's sex (c-statistics of 0.77 for men and 0.78 for women, p > 0.05). We did not find sex interaction for the relationship between MEESSI-AHF score and 30-day mortality in categorical or continuous analyses (all p > 0.05). Hospital admission decisions (76%) and extended ED observation among discharged patients (9%), both made by ED physicians, as well as prolonged hospitalization (47%) determined by hospital physicians, increased with higher MEESSI-AHF risk (all p < 0.05). No sex interaction was observed in either categorical or continuous analyses (all p > 0.05).The MEESSI-AHF scale, as originally derived, provides equally reliable estimations of risk in men and women. Clinical decisions taken by ED and hospital physicians in patients with AHF did not differ in men and women with the same risk.

High-sensitivity cardiac troponin T (hs-cTnT) protocols for the evaluation of chest pain in the emergency department (ED) may reduce unnecessary resource use and overcrowding. To determine whether the implementation of a novel hs-cTnT protocol, which incorporated troponin values drawn at 0, 1, and 3 hours after ED presentation and the modified HEART score (history, electrocardiogram, age, risk factors), was associated with improvements in resource use while maintaining safety. This retrospective cohort study from Parkland Health and Hospital System, a large safety net hospital in Dallas, Texas, included data on 31 543 unique ED encounters in which patients underwent electrocardiographic and troponin testing from January 1, 2017, to October 16, 2018. The hs-cTnT protocol was implemented in December 2017. Resource use outcomes included trends in ED dwell time, troponin to disposition decision time (the difference between the first troponin draw time and the time an order was placed for inpatient admission, admission to observation, or discharge), and final patient disposition. Safety outcomes included readmission for myocardial infarction and death. In 31 543 encounters, mean (SD) patient age was 54 (14.4) years and 14 675 patients (48%) were female. Department dwell time decreased by a mean of -1.09 (95% CI, -2.81 to 0.64) minutes per month in the preintervention period. The decline was steeper after the intervention (-4.69 [95% CI, -9.05 to -0.33] minutes per month) (P for interaction = .007). The troponin to disposition time was increasing in the preintervention period by 1.72 (95% CI, 1.08 to 2.36) minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, -1.25 to 1.99 minutes per month; P value for interaction = .007]). The proportion of patients discharged from the ED increased after the intervention (48% vs 54%, P < .001). Thirty-day major adverse cardiac event rates were low and did not differ before and after the intervention. Implementation of a novel protocol incorporating serial hs-cTnT measurements over 3 hours with the Modified HEART Score was associated with reduction in ED dwell times and attenuation of temporal increases in time from troponin measurement to disposition. This or similar protocols to rule out myocardial infarction have the potential to reduce ED overcrowding and improve health care quality while maintaining safety.