Medicine and Health Sciences Commons^™

Patient Safety Escape Room: A Graduate Medical Education Simulation For Event Reporting., Gretchen Diemer, Rebecca Jaffe, Dimitrios Papanagnou, Xiao Chi Zhang, Jillian Zavodnick

Department of Emergency Medicine Faculty Papers

Introduction: Although residents are on the front lines of patient care, they enter few formal patient safety reports on the adverse events and near misses they witness. Demonstrating the rationale and mechanics of reporting may improve this.

Methods: We designed and implemented an escape room patient safety simulation to incorporate active learning, gamification, and adult learning theory into intern patient safety onboarding. Interns from all sponsoring institution programs participated, identifying, mitigating, and reporting a range of patient safety hazards. Props and faculty time were the major resources required.

Results: One hundred twenty interns participated in this simulation in June 2018. …

Clinical Significance Of Obstructive Sleep Apnea In Patients With Acute Coronary Syndrome In Relation To Diabetes Status., Xiao Wang, Jingyao Fan, Yunhui Du, Changsheng Ma, Xin-Liang Ma, Shaoping Nie, Yongxiang Wei

Department of Emergency Medicine Faculty Papers

Objective: The prognostic significance of obstructive sleep apnea (OSA) in patients with acute coronary syndrome (ACS) according to diabetes mellitus (DM) status remains unclear. We aimed to elucidate the association of OSA with subsequent cardiovascular events in patients with ACS with or without DM.

Research design and methods: In this prospective cohort study, consecutive eligible patients with ACS underwent cardiorespiratory polygraphy between June 2015 and May 2017. OSA was defined as an Apnea Hypopnea Index ≥15 events/hour. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for …

Update To The Vitamin C, Thiamine And Steroids In Sepsis (Victas) Protocol: Statistical Analysis Plan For A Prospective, Multicenter, Double-Blind, Adaptive Sample Size, Randomized, Placebo-Controlled, Clinical Trial., Christopher J. Lindsell, Anna Mcglothlin, Samuel Nwosu, Todd W. Rice, Alex Hall, Gordon R. Bernard, Laurence W. Busse, E. Wesley Ely, Alpha A. Fowler, David F. Gaieski, Jeremiah S. Hinson, Michael H. Hooper, James C. Jackson, Gabor D. Kelen, Mark Levine, Greg S. Martin, Richard E. Rothman, Jonathan E. Sevransky, Kert Viele, David W. Wright, David N. Hager

Department of Emergency Medicine Faculty Papers

BACKGROUND: Observational research suggests that combined therapy with Vitamin C, thiamine and hydrocortisone may reduce mortality in patients with septic shock.

METHODS AND DESIGN: The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a multicenter, double-blind, adaptive sample size, randomized, placebo-controlled trial designed to test the efficacy of combination therapy with vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) given every 6 h for up to 16 doses in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. The primary outcome is ventilator- and vasopressor-free days with mortality as the key secondary outcome. …

Characterizing Non-Heroin Opioid Overdoses Using Electronic Health Records., Amelia J Averitt, B. H. Slovis, Abdul A Tariq, David K Vawdrey, Adler J Perotte

Department of Emergency Medicine Faculty Papers

Introduction: The opioid epidemic is a modern public health emergency. Common interventions to alleviate the opioid epidemic aim to discourage excessive prescription of opioids. However, these methods often take place over large municipal areas (state-level) and may fail to address the diversity that exists within each opioid case (individual-level). An intervention to combat the opioid epidemic that takes place at the individual-level would be preferable.

Methods: This research leverages computational tools and methods to characterize the opioid epidemic at the individual-level using the electronic health record data from a large, academic medical center. To better understand the …

Identifying Emergency Department Symptom-Based Diagnoses With The Unified Medical Language System., Benjamin H. Slovis, Danielle M. Mccarthy, Garrison Nord, Amanda Doty, Katherine Piserchia, Kristin L. Rising

Department of Emergency Medicine Faculty Papers

INTRODUCTION: Many patients who are discharged from the emergency department (ED) with a symptom-based discharge diagnosis (SBD) have post-discharge challenges related to lack of a definitive discharge diagnosis and follow-up plan. There is no well-defined method for identifying patients with a SBD without individual chart review. We describe a method for automated identification of SBDs from ICD-10 codes using the Unified Medical Language System (UMLS) Metathesaurus.

METHODS: We mapped discharge diagnosis, with use of ICD-10 codes from a one-month period of ED discharges at an urban, academic ED to UMLS concepts and semantic types. Two physician reviewers independently manually identified …

Heat Shock Factor 1-Mediated Transcription Activation Of Omi/Htra2 Induces Myocardial Mitochondrial Apoptosis In The Aging Heart., Dan Liu, Linguo Wu, Ye Wu, Xin Wei, Wen Wang, Suli Zhang, Ming Yi, Jing Li, Huirong Liu, Xin-Liang Ma

Department of Emergency Medicine Faculty Papers

BACKGROUND: Increased cardiac apoptosis is a hallmark of the elderly, which in turn increases the risk for developing cardiac disease. The overexpression of Omi/HtrA2 mRNA and protein contributes to apoptosis in the aged heart. Heat shock factor 1 (HSF1) is a transcription factor that binds to the promoter of Omi/HtrA2 in the aging myocardium. However, whether HSF1 participates in cardiomyocyte apoptosis via transcriptional regulation of Omi/HtrA2 remains unclear. The present study was designed to investigate whether HSF1 plays a role in Omi/HtrA2 transcriptional regulation and myocardial apoptosis.

METHODS AND RESULTS: Assessment of the hearts of mice of different ages was …

The Case For Revamping New Faculty Orientation: Integrating Case-Based Learning Into Faculty Onboarding., Mansoor Siddiqui, Dimitrios Papanagnou, Samantha Bruno, Karen Novielli

Department of Emergency Medicine Faculty Papers

Introduction: New faculty orientation (NFO) for onboarding faculty members is replete with critical information and resources. Most NFO sessions are facilitated through lecture-based slide presentations. We employed a case-based learning (CBL) format to promote learner engagement through active use of the content being taught. We hypothesized that a CBL format would lead to improved learner satisfaction.

Methods: An inventory of topics presented at NFO was generated by reviewing previous orientation sessions. Cases and discussion questions were developed to link to specific content areas from previously delivered lectures. Participants were assigned cases with discussion questions, followed by a large-group debriefing. In …

Chemical Disaster Preparedness For Hospitals And Emergency Departments, Gregory K. Wanner, Do, Sukhi Atti, Md, Edward Jasper, Md

Department of Emergency Medicine Faculty Papers

Preparing to evaluate and treat victims of a chemical exposure incident is one aspect of hospital disaster preparedness. Past chemical disasters, including terrorist attacks and industrial or transit accidents, have highlighted the need for hospital planning, preparation, and training. Emergency department and hospital staff members must be familiar with their facility-specific protocols and be trained for their individual roles during these incidents. This article provides a brief review of the requirements and guidelines related to chemical disaster response from a healthcare perspective. Resources for training and the evaluation of chemically contaminated patients are discussed. Decontamination procedures, including pre-hospital and hospital-based …

Surgical Stress And Cancer Progression: The Twisted Tango., Zhiwei Chen, Peidong Zhang, Ya Xu, Jiahui Yan, Zixuan Liu, Wayne Bond Lau, Bonnie Lau, Ying Li, Xia Zhao, Yuquan Wei, Shengtao Zhou

Department of Emergency Medicine Faculty Papers

Surgical resection is an important avenue for cancer treatment, which, in most cases, can effectively alleviate the patient symptoms. However, accumulating evidence has documented that surgical resection potentially enhances metastatic seeding of tumor cells. In this review, we revisit the literature on surgical stress, and outline the mechanisms by which surgical stress, including ischemia/reperfusion injury, activation of sympathetic nervous system, inflammation, systemically hypercoagulable state, immune suppression and effects of anesthetic agents, promotes tumor metastasis. We also propose preventive strategies or resolution of tumor metastasis caused by surgical stress.

Patient Experience And Challenges In Group Concept Mapping For Clinical Research., Geoffrey D. Mills, Marianna Lanoue, Alexzandra T. Gentsch, Amanda M.B. Doty, Amy Cunningham, Garrison Nord, Kristin L. Rising

Department of Emergency Medicine Faculty Papers

BACKGROUND AND OBJECTIVE: Group concept mapping (GCM) is a research method that engages stakeholders in generating, structuring and representing ideas around a specific topic or question. GCM has been used with patients to answer questions related to health and disease but little is known about the patient experience as a participant in the process. This paper explores the patient experience participating in GCM as assessed with direct observation and surveys of participants.

METHODS: This is a secondary analysis performed within a larger study in which 3 GCM iterations were performed to engage patients in identifying patient-important outcomes for diabetes care. …

Identification Of Emergency Care-Sensitive Conditions And Characteristics Of Emergency Department Utilization., Anita A. Vashi, Tracy Urech, Brendan Carr, Liberty Greene, Theodore Warsavage, Renee Hsia, Steven M. Asch

Department of Emergency Medicine Faculty Papers

Importance: Monitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care.

Objectives: To identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization.

Design, Setting, and Participants: A modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis …

Quality Assurance In Telehealth: Adherence To Evidence-Based Indicators., Daniel Halpren-Ruder, Anna Marie Chang, Judd E. Hollander, Anuh Shah

Department of Emergency Medicine Faculty Papers

Background: Value enhancing telehealth (TH) lacks a robust body of formal clinically focused quality assessment studies. Innovations such as telehealth must always demonstrate that it preserves or hopefully advances quality. Introduction: We sought to determine whether adherence to the evidence-based Choosing Wisely (CW) recommendations (antibiotic stewardship) for acute sinusitis differs for encounters through direct-to-consumer (DTC) telemedicine verses "in-person" care in an emergency department (ED) or an urgent care (UC) center.

Materials and Methods: Study design was a retrospective review. Patients with a symptom complex consistent with acute sinusitis treated through DTC were matched with ED and UC patients, based upon …

Electrocardiogram And Cardiac Testing Among Patients In The Emergency Department With Seizure Versus Syncope., Jennifer L. White, Judd E. Hollander, Jesse M. Pines, Peter M. Mullins, Anna Marie Chang

Department of Emergency Medicine Faculty Papers

OBJECTIVE: Cardiogenic syncope can present as a seizure. The distinction between seizure disorder and cardiogenic syncope can only be made if one considers the diagnosis. Our main objective was to identify whether patients presenting with a chief complaint (reason for visit) as seizure or syncope received an electrocardiogram in the emergency department across all age groups.

METHODS: We conducted a secondary analysis of data collected in the 2010 to 2014 National Hospital Ambulatory Medical Care Survey comparing patients presenting with a chief complaint of syncope versus seizure to determine likelihood of getting an evaluation for possible life threatening cardiovascular disease. …

Antibody-Based Ticagrelor Reversal Agent In Healthy Volunteers., Deepak L. Bhatt, Charles V. Pollack, Jeffrey I. Weitz, Lisa K. Jennings, Sherry Xu, Susan E. Arnold, Bret R. Umstead, Michael C. Mays, John S. Lee

Department of Emergency Medicine Faculty Papers

BACKGROUND: Ticagrelor is an oral P2Y₁₂ inhibitor that is used with aspirin to reduce the risk of ischemic events among patients with acute coronary syndromes or previous myocardial infarction. Spontaneous major bleeding and bleeding associated with urgent invasive procedures are concerns with ticagrelor, as with other antiplatelet drugs. The antiplatelet effects of ticagrelor cannot be reversed with platelet transfusion. A rapid-acting reversal agent would be useful.

METHODS: In this randomized, double-blind, placebo-controlled, phase 1 trial, we evaluated intravenous PB2452, a monoclonal antibody fragment that binds ticagrelor with high affinity, as a ticagrelor reversal agent. We assessed platelet function in …

Patients With Refractory Out-Of-Cardiac Arrest And Sustained Ventricular Fibrillation As Candidates For Extracorporeal Cardiopulmonary Resuscitation - Prospective Multi-Center Observational Study., Takahiro Nakashima, Teruo Noguchi, Yoshio Tahara, Kunihiro Nishimura, Soshiro Ogata, Satoshi Yasuda, Daisuke Onozuka, Naoto Morimura, Ken Nagao, David F. Gaieski, Yasufumi Asai, Hiroyuki Yokota, Satoshi Nara, Mamoru Hase, Takahiro Atsumi, Tetsuya Sakamoto

Department of Emergency Medicine Faculty Papers

BACKGROUND: We investigated whether patients with out-of-hospital cardiac arrest (OHCA) and sustained ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) or conversion to pulseless electrical activity/asystole (PEA/asystole) benefit more from extracorporeal cardiopulmonary resuscitation (ECPR). Methods and Results: We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan, which was a prospective, multicenter, observational study with 22 institutions in the ECPR group and 17 institutions in the conventional CPR (CCPR) group. Patients were divided into 4 groups by cardiac rhythm and CPR group. The primary endpoint was favorable neurological outcome, defined as Cerebral Performance Category 1 …

An Evaluation Of Risk Attitudes And Risk Tolerance In Emergency Medicine Residents., Carlos Rodriguez, Nishad A Rahman, Kory London, Robin Naples, Simran Buttar, Xiao Chi Zhang, Hyunjoo Lee, Joshua Rudner, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Introduction Previous studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool. Methods First-, second-, and third-year residents of Thomas Jefferson University Hospital's EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health …

Coronary Angiography After Cardiac Arrest - The Right Timing Or The Right Patients?, Benjamin S. Abella, David F. Gaieski

Department of Emergency Medicine Faculty Papers

No abstract provided.

The Vitamin C, Thiamine And Steroids In Sepsis (Victas) Protocol: A Prospective, Multi-Center, Double-Blind, Adaptive Sample Size, Randomized, Placebo-Controlled, Clinical Trial., David N. Hager, Michael H. Hooper, Gordon R. Bernard, Laurence W. Busse, E. Wesley Ely, Alpha A. Fowler, David F. Gaieski, Alex Hall, Jeremiah S. Hinson, James C. Jackson, Gabor D. Kelen, Mark Levine, Christopher J. Lindsell, Richard E. Malone, Anna Mcglothlin, Richard E. Rothman, Kert Viele, David W. Wright, Jonathan E. Sevransky, Greg S. Martin

Department of Emergency Medicine Faculty Papers

BACKGROUND: Sepsis accounts for 30% to 50% of all in-hospital deaths in the United States. Other than antibiotics and source control, management strategies are largely supportive with fluid resuscitation and respiratory, renal, and circulatory support. Intravenous vitamin C in conjunction with thiamine and hydrocortisone has recently been suggested to improve outcomes in patients with sepsis in a single-center before-and-after study. However, before this therapeutic strategy is adopted, a rigorous assessment of its efficacy is needed.

METHODS: The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial. It will enroll …

A Curious Critic's Guide On Writing A Five-Star Student Evaluation: Five Lessons Learned From Food Blogging., Xiao Chi Zhang, Meryl Abrams, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Timely feedback is critical in promoting learner self-reflection. When provided effectively, feedback can assist learners with the acquisition of new skills and knowledge in the ever-changing and complex landscape of healthcare. While the literature is replete on methods to provide feedback, faculty and supervisors receive little, if any, training on writing constructive feedback. Abbreviated comments (i.e., 'good job' or 'read more') provide little information on specific behaviors learners can change. As an avid food enthusiast and restaurant reviewer, I, too, am met with the challenge of writing a meaningful, constructive review (or evaluation) of a dining experience. To better assist …

Finding The 'Qr' To Patient Safety: Applying Gamification To Incorporate Patient Safety Priorities Through A Simulated 'Escape Room' Experience., Xiao Chi Zhang, Gretchen Diemer, Hyunjoo Lee, Rebecca Jaffe, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Medical errors are the eighth leading cause of mortality in the United States and contribute to over one million preventable injuries. In an effort to prevent medical errors, reporting systems serve as invaluable tools to detect patient safety events and quality problems longitudinally. Historically, trainees (i.e., students and residents) rarely submit incident reports for encountered patient safety threats. The authors propose an immersive learning experience utilizing gamification theory and leveraging the increasingly popular ‘escape room’ to help resident trainees identify reportable patient safety priorities. All 130 incoming intern physicians at the Thomas Jefferson University (Jefferson) were enrolled in the Patient …

Eliciting Patient-Important Outcomes Through Group Brainstorming: When Is Saturation Reached?, Marianna Lanoue, Alexzandra Gentsch, Amy Cunningham, Geoffrey Mills, Amanda M.B. Doty, Judd E. Hollander, Brendan G. Carr, Larry Loebell, Gail Weingarten, Kristin L. Rising

Department of Emergency Medicine Faculty Papers

PURPOSE: Group brainstorming is a technique for the elicitation of patient input that has many potential uses, however no data demonstrate concept saturation. In this study we explore concept saturation in group brainstorming performed in a single session as compared to two or three sessions.

METHODS: Fifty-two predominately African American adults patients with moderately to poorly controlled Diabetes Mellitus participated in three separate group brainstorming sessions as part of a PCORI-funded group concept mapping study examining comparing methods for the elicitation of patient important outcomes (PIOs). Brainstorming was unstructured, in response to a prompt designed to elicit PIOs in diabetes …

Assessing The Use Of Social Media In Physician Assistant Education., Gregory K. Wanner, Andrew W. Phillips, Dimitrios Papanagnou, Md

Department of Emergency Medicine Faculty Papers

Objectives: This study aims to assess physician assistant (PA) students' experiences with social media (SM) as a part of their medical education.

Methods: The study is split into two phases: Phase 1- A cross-sectional survey emailed to all PA students at four PA school campuses to assess students' prior SM experiences (226 responses, 71.1% response rate); and Phase 2- Inclusion of SM educational resources, via Twitter, within lectures performed at two PA schools. A phase-2 survey assessed students' opinions of educational SM (50 responses, 59.5% response rate) and SM usage was tracked.

Results: The phase-1 survey respondents indicated that 97.3% …

Association Of Obstructive Sleep Apnea With Cardiovascular Outcomes In Patients With Acute Coronary Syndrome., Jingyao Fan, Xiao Wang, Xin-Liang Ma, Virend K. Somers, Shaoping Nie, Yongxiang Wei

Department of Emergency Medicine Faculty Papers

Background The prognostic significance of obstructive sleep apnea ( OSA ) in patients with acute coronary syndrome ( ACS ) in the contemporary era is unclear. We performed a large, prospective cohort study and did a landmark analysis to delineate the association of OSA with subsequent cardiovascular events after ACS onset. Methods and Results Between June 2015 and May 2017, consecutive eligible patients admitted for ACS underwent cardiorespiratory polygraphy during hospitalization. OSA was defined as an apnea-hypopnea index ≥15 events·h-1. The primary end point was major adverse cardiovascular and cerebrovascular event ( MACCE ), including cardiovascular death, myocardial infarction, stroke, …

The Power Of The Group: Comparison Of Interviews And Group Concept Mapping For Identifying Patient-Important Outcomes Of Care., Kristin L. Rising, Marianna Lanoue, Alexzandra Gentsch, Amanda Doty, Amy Cunningham, Brendan G. Carr, Judd E. Hollander, Lori Latimer, Larry Loebell, Gail Weingarten, Neva White, Geoffrey Mills

Department of Emergency Medicine Faculty Papers

BACKGROUND: Data are limited regarding how to effectively and efficiently identify patient priorities for research or clinical care. Our goal was to compare the comprehensiveness and efficiency of group concept mapping (GCM), a group participatory method, to interviews for identifying patient goals when seeking care.

METHODS: We engaged patients with moderately- to poorly-controlled diabetes mellitus in either GCM or an individual interview. The primary outcome was the comprehensiveness of GCM brainstorming (the first stage of GCM) as compared to interviews for eliciting patient-important outcomes (PIOs) related to seeking care. Secondary outcomes included 1) comprehensiveness of GCM brainstorming and interviews compared …