The Application of Margin in Life Theory in Regard to Attrition and Remediation Among Emergency Medicine Residents

Medical residency is a time of high stress, long hours, high case loads, fatigue, and lack of free time. Burnout rates among residents have been reported to be between 25-76%. Scant literature exists in regard to resident stress and its impact on learning and attrition during residency. The theory of margin posits that a healthy margin is necessary for adults to learn. Healthy margin exists when a person’s ratio of burdens over resources creates a surplus of energy. This study sought to determine if there was a difference between emergency medicine (EM) residents’ margin in life scores and remediation, at risk for remediation, and those considering leaving their emergency medicine residency training. Volunteer EM residents (n = 279) completed the Margin in Life Scale for Emergency Medicine (MILS EM) questionnaire, which measures six life areas: Health/Body, Religion/Spirituality, Self-Confidence, Interdependence, Parenting, and EM Work. Residents self-reported if they were considering leaving EM training and program directors provided remediation, at risk for remediation, and attrition rates. The mean MILS EM score among the 273 included EM residents was .64, which is within the recommended healthy range of .30 to .80. Additionally, all mean subscale scores fell within the healthy range. Only 13% of residents were reported as being on remediation, MILS EM (M=.63) with no statistically significant differences between those on remediation versus those not. Only 6% of residents were reported as being in jeopardy of remediation, MILS EM (M=.63) versus those not at risk (M=.64). Finally, only 5% of EM residents self-reported considering leaving EM training and no residents left their training program. Women scored lower on the MILS EM, and the life areas Health/Body (p Results of this study suggest that EM residents appear to have sufficient margin overall and in each of the life areas. Few were on or at risk for remediation and even fewer reported they were considering leaving EM residency training. As females scored lower in some of the life areas, further investigation is needed to determine if there are characteristics in the work environment that affect women differently than men

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

Introduction: Older, chronically ill patients with limited health literacy are often under-engagedin managing their health and turn to the emergency department (ED) for healthcare needs. Wetested the impact of an ED-initiated coaching intervention on patient engagement and follow-updoctor visits in this high-risk population. We also explored patients’ care-seeking decisions. Methods: We conducted a mixed-methods study including a randomized controlled trial andindepth interviews in two EDs in northern Florida. Participants were chronically ill older EDpatients with limited health literacy and Medicare as a payer source. Patients were assignedto an evidencebased coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitativeinterviews (n=9) explored patients’ reasons for ED use. We assessed average between-groupdifferences in patient engagement over time with the Patient Activation Measure (PAM) tool,using logistic regression and a difference-in-difference approach. Between-group differences infollow-up doctor visits were determined. We analyzed qualitative data using open coding andthematic analysis. Results: PAM scores fell in both groups after the ED visit but fell signi ficantly more in “usualcare” (average decline -4.64) than “intervention” participants (average decline -2.77) (β=1.87,p=0.043). There were no between-group differences in doctor visits. Patients described wellinformedreasons for ED visits including onset and severity of symptoms, lack of timely provideraccess, and immediate and comprehensive ED care. Conclusion: The coaching intervention significantly reduced declines in pati ent engagementobserved after usual post-ED care. Patients reported well-informed reasons for ED use andwill likely continue to make ED visits unless strategies, such as ED-initiated coaching, areimplemented to help vulnerable patients better manage their health and healthcare

Low HDL cholesterol is associated with increased atherogenic lipoproteins and insulin resistance in women classified with metabolic syndrome

Both metabolic syndrome (MetS) and elevated LDL cholesterol (LDL-C) increase the risk for cardiovascular disease (CVD). We hypothesized that low HDL cholesterol (HDL-C) would further increase CVD risk in women having both conditions. To assess this, we recruited 89 women with MetS (25-72 y) and LDL-C ≥ 2.6 mmol/L. To determine whether plasma HDL-C concentrations were associated with dietary components, circulating atherogenic particles, and other risk factors for CVD, we divided the subjects into two groups: high HDL-C (H-HDL) (≥ 1.3 mmol/L, n = 32) and low HDL-C (L-HDL) (< 1.3 mmol/L, n = 57). Plasma lipids, insulin, adiponectin, apolipoproteins, oxidized LDL, Lipoprotein(a), and lipoprotein size and subfractions were measured, and 3-d dietary records were used to assess macronutrient intake. Women with L-HDL had higher sugar intake and glycemic load (P < 0.05), higher plasma insulin (P < 0.01), lower adiponectin (P < 0.05), and higher numbers of atherogenic lipoproteins such as large VLDL (P < 0.01) and small LDL (P < 0.001) than the H-HDL group. Women with L-HDL also had larger VLDL and both smaller LDL and HDL particle diameters (P < 0.001). HDL-C was positively correlated with LDL size (r = 0.691, P < 0.0001) and HDL size (r = 0.606, P < 0.001), and inversely correlated with VLDL size (r = -0.327, P < 0.01). We concluded that L-HDL could be used as a marker for increased numbers of circulating atherogenic lipoproteins as well as increased insulin resistance in women who are already at risk for CVD

Poisonings with Suicidal Intent Aged 0-21 Years Reported to Poison Centers 2003-12

Introduction: Few studies explore the clinical features of youth suicide by poisoning. The use of both social and clinical features of self-poisoning with suicidal intent could be helpful in enhancing existing and creating new prevention strategies. We sought to characterize self-poisonings with suicide intent in ages 0 to 21 years reported to three regional poison control centers from 2003-2012.Methods: This study was a blinded retrospective review of intentional self-poisonings by those age 21 or younger captured by the Poison Information Control Network. Age, sex, substance(s) used, medical outcome, management site, clinical effects, and therapies were described using counts and percentages and analyzed using chi-square tests. We analyzed the medical outcome ranging from no effect to death using the Wilcoxon rank-sum test. Serious medical outcome was defined as death or major outcome.Results: We analyzed a total of 29,737 cases. The majority were females (20,945;70.5%), of whom 274 (1.3%) were pregnant. Most cases were 15-18 year olds (15,520;52.2%). Many experienced no effects (9,068;30.5%) or minor medical outcomes (8,612;29%). Males had more serious medical outcomes (p&lt;0.0001), but females were more likely to be admitted to a critical care unit (p&lt;0.0001). There were 17 deaths (0.06%), most in males (10; p=0.008). Of the 52 substances reported in the death cases, 12 (23.1%) were analgesics. In eight (47.1%) of the deaths, over two substances were used. Overall, drowsiness/lethargy (7,097;19.3%) and single-dose charcoal (8,815;16.3%) were frequently reported. Nearly 20% were admitted to critical care units (5,727;19.3%) and 28.7% went to psychiatric facilities (8,523). Of those admitted to hospitals (8,203), nearly 70% (5,727) required critical care units. Almost half &lt;10 years old were evaluated and released (43;47.2%). Of the 114 reported substances for this population, 22.8% involved psychotropic medications, 15.8% analgesics, and 14% Attention Deficit-Hyperactive Disorder (ADHD) medications. Analgesics (13,539;33.6%) were the most common medication category used by all age groups. Typically only one substance (20,549;69.1%) was used.Conclusion: Undiagnosed ADHD may be a potential underlying cause for self-harming behaviors in the very young. Gender-specific suicide prevention strategies may be more effective at identifying those at risk than traditional measures alone. Further study into admitting practices by emergency physicians is needed to understand the difference in critical care admission rates based on gender. Once identified to be at-risk for suicidal behavior, access to analgesics and psychotropics should be monitored by care-givers especially in those between the ages of 15-18. [West J Emerg Med.–0

HDL Cholesterol Efflux is Impaired in Older Patients with Early Sepsis

BackgroundProper functioning of high-density lipoprotein (HDL) is necessary for protection against sepsis. However, previous work has demonstrated that HDL becomes oxidized and dysfunctional (Dys-HDL) during sepsis. Older (aged &gt;65 years) patients are at particularly high risk of sepsis and poor outcomes from sepsis.Study objectiveThe aim of the study was to compare functional properties of HDL (cholesterol efflux capacity and paraoxonase enzyme 1 [PON-1] activity) and Dys-HDL between older (aged &gt;65 years) sepsis patients and older healthy volunteers.MethodsThis was a subanalysis of a prospective study in which patients with sepsis were prospectively enrolled from the emergency department within the first 24 h. Serum and plasma samples were drawn from septic patients and age- and sex-matched control subjects. Percent cholesterol efflux, HDL inflammatory index, and PON1 activity were measured. Data were analyzed using Student t test or Wilcoxon rank-sum test.ResultsTen sepsis and 10 healthy controls were analyzed. Mean age of sepsis patients (80 ± 2 years [SD]) and control subjects (77 ± 2 years) was similar (P = 0.31). Mean systolic blood pressures were significantly different in sepsis patients (113 ± 8 mmHg) compared with controls (133 ± 6 mmHg) (P = 0.049). Median SOFA scores for sepsis patients were 5.5 (interquartile range [IQR] 4-9). Mean percent cholesterol efflux was significantly reduced in sepsis (24.1 ± 1.2%) compared with controls (31.5 ± 1.0%) (P &lt; 0.001). HDL inflammatory index was also significantly elevated in septic patients (1.63, IQR 1.3-2.34) compared with controls (0.62, IQR 0.56-0.67) (P &lt; 0.001). However, PON1 activity was not significantly different between septic patients (70.3 ± 16.3 nmol/min/mL) and control subjects (88.8 ± 18.3 nmol/min/mL).ConclusionsCholesterol efflux capacity seems to be significantly impaired in sepsis patients who also exhibited a higher index of Dys-HDL. The findings suggest that HDL function may be impaired in older individuals with sepsis

Using an Online Vaccination Registry to Confirm Tetanus Status in Children with Tetanus-prone Wounds

Introduction: Tetanus vaccination status is an important consideration for emergency physicians managing patients with tetanus-prone wounds. Physicians must identify at-risk patients, but vaccination histories are often unknown and commonly lack documentation. The study objective was to determine the potential impact of an online immunization registry (Florida SHOTS – State Health Online Tracking System) on the appropriate administration of tetanus prophylaxis for pediatric patients managed in the emergency department (ED).Methods: We conducted a retrospective review of all patients less than 18 years old who received ED tetanus prophylaxis at two separate sites between January 2011–May 2015. The Florida SHOTS database was accessed to determine vaccination status for each patient in the study group at the time of the encounter. We compared vaccination status for each patient, as documented in the electronic health record (EHR), with Florida SHOTS data to determine whether tetanus prophylaxis was indicated. The proportion of patients receiving tetanus prophylaxis in the ED, who were subsequently identified as up to date with tetanus vaccination per Florida SHOTS, was determined.Results: We identified 743 patients who received ED tetanus prophylaxis. Forty-three (6%) were listed as “up to date” on the EHR and 656 (93%) were listed as “not up to date.” In comparison, 209 (30%) of the study group were identified as “up to date” via Florida SHOTS, and 477 (70%) were not. We accessed the Florida SHOTS record retrospectively to determine whether the vaccine was required. It was determined that 174 (25%) of the patients received tetanus prophylaxis unnecessarily as they were already up to date per Florida SHOTS documentation.Conclusions: Twenty-five percent of patients vaccinated for tetanus in the ED could have been spared if Florida SHOTS data had been used by providers at the time of the encounter. Access to Florida SHOTS provides valuable information regarding vaccination status that impacts patient care and resource utilization in the ED

Impact of an Abbreviated Cardiac Enzyme Protocol to Aid Rapid Discharge of Patients with Cocaine-associated Chest Pain in the Clinical Decision Unit

INTRODUCTION: In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9–12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. METHODS: We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. RESULTS: There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0–5.1%; 95% CI, 0–3.6%). CONCLUSION: Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain