How Long is too Long?

Background: The United States is experiencing a nationwide shortage of nurses. Emergency departments (EDs) are at the forefront of this crisis which is contributing to long wait times for patients. Existing literature shows a strong correlation between increased wait times and patients leaving without being seen (LWBS). This likely increases the incidence of adverse events (AE). Studies examining the impact of nursing coverage on the incidence of AE have been conducted primarily in inpatient settings. Our study aims to assess the relationship between nursing coverage and incidence of LWBS/AE in the ED. Methods: This is a retrospective cohort study from January 2019 to December 2023. The eligible participant population is adults presenting to Detroit Receiving Hospital (DRH), Harper University Hospital (HUH), or Sinai Grace Hospital (SGH) EDs and then LWBS. Data will be collected from the respective EMR databases, Detroit Medical Center nursing office (DMCNO), and Data to Intelligence. Results: Data from the DMCNO will be used to calculate the total number of nursing hours worked divided by the total number of patients in the ED in a given 24-hours. A logistic regression analysis will determine how variations in nurse staffing correlate with the incidence of LWBS/AE. Discussion: We hypothesize that the emergency nursing shortage will lead to an increase in the incidence of both LWBS and AE. Based on data obtained from this pilot study, we hope to compile a data registry from EDs nationwide to gain a better understanding of how alterations in nursing coverage impacts LWBS/AE

Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Departments

Study Objectives: Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based emergency department (HBED) settings and the translation of these protocols into free-standing emergency departments (FSED) has yet to be explored. This study compared the safety and efficacy of applying a rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs. Methods: This was a secondary analysis of a randomized trial of patients evaluated for possible AMI in 9 emergency departments (ED) from July 2020 through March 2021. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI versus standard care, which used a 0/3-hour protocol without reporting hs-cTnI values below the 99th percentile. The primary outcome was safe ED discharge, defined as discharge with no death or AMI within 30-days. Analysis included a mixed-effect model adjusting for demographic variables. Results: There was a statistically significant difference in safe discharges from FSEDs when comparing the standard care arm (86.2%) to the rapid rule-out protocol (95.1%). There was a statistically significant reduction in FSED length of stay with application of a rapid rule-out protocol at 3.43 hours vs. 3.97 hours using standard care. The percentage of patients who ruled-out with their initial hs-cTnI (\u3c4 ng/L) at FSEDs (74%) was also significantly larger when compared to HBEDs (54%). Conclusion: Implementation of a hs-cTnI rapid 0/1-hour protocol to evaluate for AMI in FSEDs is feasible and had greater impact on safe ED discharge and length of stay compared to HBEDs

Validation of the Termination of Resuscitation Rules in Detroit

Introduction: 326,000 patients suffer from an out of hospital cardiac arrest (OHCA) each year. The Termination of Resuscitation (TOR) criteria guides physicians in determining the futility of continuing CPR and transporting patients to the hospital. We examined compliance with current BLS TOR rules and assessed an alternate set of rules to derive improved TOR guidelines for OHCAs in Detroit. Methods: A retrospective study was conducted utilizing non-traumatic OHCA cases in Detroit from January 1, 2017 to December 31, 2019, which includes time before and after BLS TOR guidelines were implemented. Patients younger than 18 and arrests of traumatic origin or those with no resuscitation attempted were excluded. Results: Prior to TOR implementation, the overall survival rate was 5.8% while the transportation rate when TOR was met was 77%. Post-TOR implementation, the survival rate was 5.5% and the transportation rate was 34%. Post-hoc addition of age or EMS time to patient side increased transportation rates to 49% and 47%, respectively, and decreased false positive terminations from 0.88% to 0.84% and 0%, respectively. Conclusion: Since the implementation of the BLS TOR guidelines in Detroit, futile transportation rates have decreased without affecting overall survival. Addition of EMS time to patient side or patient age to the current TOR guidelines suggested improved performance. Although the additional criteria resulted in higher transportation rates, these factors may be useful for physicians to consider when deciding to transport patients who meet the current TOR criteria. However, further derivation and validation are necessary to create optimal TOR guidelines

Developing user personas to capture intersecting dimensions of disadvantage in marginalised older patients: a qualitative study.

BackgroundRemote and digital services must be equitable, but some patients have difficulty using these services. Designing measures to overcome digital disparities can be challenging for practices. Personas (fictional cases) are a potentially useful tool in this regard.AimTo develop and test a set of personas to reflect the lived experiences and challenges that disadvantaged older people face when navigating remote and digital primary care services.Design and settingA qualitative study of digital disparities in NHS community health services offering video appointments.MethodFollowing familiarisation visits and interviews with service providers, 17 older people with multiple markers of disadvantage (limited English, health conditions, poverty) were recruited and interviewed using narrative prompts. Data were analysed using an intersectionality lens, underpinned by sociological theory. Combining data across cases, we produced personas and refined these following focus groups involving health professionals, patients and advocates (n=12).ResultsDigital services created significant challenges for older patients with limited economic, social and linguistic resources and low digital-, health-, or system-literacy. Four contrasting personas were produced, capturing the variety and complexity of how dimensions of disadvantage intersected and influenced identity and actions. The personas illustrate important themes including experience of racism and discrimination, disorientation, discontinuity, limited presence, weak relationships, loss of agency and mistrust of services and providers.ConclusionPersonas can illuminate the multiple and intersecting dimensions of disadvantage in marginalised patient populations and may prove useful when designing or redesigning digital primary care services. Adopting an intersectional lens may help practices address digital disparities