Yanina A. Purim-Shem-Tov

SEROPREVALENCE STUDY USING ORAL RAPID HIV TESTING IN A LARGE URBAN EMERGENCY DEPARTMENT

BACKGROUND The Centers for Disease Control (CDC) recommends universal human immunodeficiency virus (HIV) testing for patients aged 13-64 years in health care settings where the seroprevalence is>0.1%. Rapid HIV testing has several advantages; however, recent studies have raised concerns about false positives in populations with low seroprevalence. STUDY OBJECTIVES To determine the seroprevalence of HIV in our Emergency Department (ED) population, understand patient preferences toward rapid testing in the ED, and evaluate the performance of a rapid oral HIV test. METHODS A serosurvey offered oral rapid HIV 1/2 testing (OraQuick ADVANCE, Bethlehem, PA) to a convenience sample of 1348 ED patients beginning August 2008. Subjects declining participation were asked to complete an opt-out survey. RESULTS 1000 patients were tested. Twelve had positive results (1.2%), including one who had newly diagnosed HIV infection; 988 patients tested negative. Of these, 335 (33.3%) had never been tested; 640 had prior history of a negative HIV test. No false-positive rapid HIV results were detected; 98.7% received the results of their preliminary HIV test, including 100% of those who tested positive. Most subjects who declined testing cited either a recent negative HIV test (160/348) or low perceived risk (65/348). A minority cited a concern regarding their privacy (11/348) or that the test might delay their treatment (7/348). CONCLUSIONS The seroprevalence estimate of 1.2% was above the rate recommended by the CDC for routine universal opt-out testing in our study population. The acceptance rate of rapid HIV testing and the percentage of patients receiving results approximated other recent reports.

Adverse outcomes in hospitalized patients who develop ST-elevation myocardial infarction.

BACKGROUND There has been considerable emphasis on the care of patients with ST-elevation myocardial infarction (STEMI) with the wide implementation of protocols to quickly identify and triage them from the emergency department (ED) to a cardiac catheterization laboratory for percutaneous coronary intervention. However, a small but important number of patients with STEMI develop ST-elevation while hospitalized for another medical problem. METHODS A single-center, retrospective chart review was performed on 172 consecutive patients with STEMI who underwent emergency percutaneous coronary intervention. One hundred thirty-seven patients presenting to the ED with STEMI and 35 patients who developed STEMI while hospitalized were compared. RESULTS Hospitalized patients with STEMI had delayed reperfusion, longer hospitalization, greater rates of stent thrombosis, and greater 30-day and 1-year mortality compared with these in patients presenting with STEMI to the ED. CONCLUSIONS Optimized clinical pathways for prevention, early diagnosis, and expedited reperfusion of inpatients with STEMI are urgently needed.

The Rush University advanced trauma training program, a novel approach for military trauma training

Nearly 90% of combat deaths occur on the battlefield before the casualty reaches a treatment facility. It has been shown that early intervention in trauma patients improves morbidity and mortality. Hence, the training of military health care providers in lifesaving measures is imperative to saving lives on the battlefield. To date, few courses exist to provide skills in combat-zone trauma stabilization and treatment. Even fewer offer training in the identification and treatment of post-traumatic stress disorders and traumatic brain injury. We set out to develop a multidisciplinary, comprehensive course to include didactic lectures as well as hands-on training and observational modules. Ten courses have been delivered to date. Thus far, feedback from military personnel and course participants has revealed the positive impact of the training program. In this manuscript, we present the layout of the program and its contents.

Medicaid beneficiaries who continue to use the ED: a focus on the Illinois Medical Home Network

OBJECTIVES Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities. METHODS We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data. RESULTS Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients. CONCLUSIONS This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

Impact of a novel interventional platform and hospital design on the door-to-balloon time in patients presenting with ST-segment elevation myocardial infarction.

INTRODUCTION Reducing door-to-balloon (DTB) time in ST-segment elevation myocardial infarction improves outcomes. Several hospital factors can delay DTB times and lead to increased morbidity and mortality. The effects of hospital design and an interventional platform (IP) on patient care, particularly on the DTB time, are unknown. METHODS We performed a retrospective analysis of consecutive patients presenting to the emergency department of a medical center from September 2010 to February 2014 who met criteria for a ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention. Patients were divided into 2 groups based on whether they presented before or after the opening of the IP in our new hospital on January 6, 2012. Total DTB time and separate systematic intervals were tabulated. RESULTS Fifty-two patients met our inclusion criteria, 21 pre-IP and 31 post-IP. Both groups had overall similar baseline characteristics. The mean DTB time significantly improved by 11.7 minutes after the opening of the IP (P = 0.016), and all cases had a DTB time 90 minutes or less as compared with 90.4% prior. Eighty-nine percent of the overall improvement in DTB happened before the patient reached the catheterization table. Important factors were the new emergency department (ED) design that facilitates rapid patient triage and the direct connection between the ED and cath lab. CONCLUSIONS This study showed that the new hospital design had significant effects on immediate patient care by improving the DTB time at our institution. Further study regarding the long-term impact of hospital designs on patient care is needed.

SUCCESSFUL COLLABORATIVE MODEL FOR STEMI CARE BETWEEN A STEMI REFERRAL AND A STEMI RECEIVING CENTER

BACKGROUND Patients with ST-segment elevation myocardial infarction (STEMI) greatly benefit from a rapid door-to-balloon (D2B) time. For hospitals without a catheterization laboratory, it is imperative to establish partnerships with a STEMI receiving center (SRC). STEMI systems of care have been established to facilitate these relationships to improve rapid reperfusion. We describe the experience and benefits of such a relationship. METHODS A partnership between our 2 institutions was established in April 2011. Saint Anthony Hospital (SAH) of Chicago is an inner city hospital with interventional cardiologists on staff, but no catheterization laboratory. Before the partnership, STEMI patients were transferred 8 miles to a percutaneous coronary intervention (PCI) hospital on the citys north side. Rush University Medical Center (RUMC) is an academic medical center with 24/7/365 PCI capability. SAH decided that a transfer relationship with a closer SRC would benefit patient care. The following steps were taken: both hospitals signed a STEMI transfer agreement for STEMI transfers regardless of insurance status; an education process occurred at both hospitals; agreement that transferred patients would follow-up at the STEMI referring hospital (SAH); a contract with a single ambulance provider was signed; a simple STEMI protocol was adopted. RESULTS In 2010, SAH saw 20 patients with STEMI. Average time from patient arrival to leaving the emergency department (ED) [Door-in-Door-out (DIDO)] was 83 minutes, these times were not tracked carefully; approximate transfer time to SRC was 25 minutes; Door1-2-Balloon (D12B) time was not recorded. Since the new protocol, 44 patients transferred to RUMC for PCI to date. Median (inclusive minimum, maximum) time from ED arrival (D1) at referral hospital to SRC (D2) was 52 minutes (56, 192) for all PCI cases; 11 patients transferred did not have PCI; 1 patient expired upon arrival; and median time to first PCI device (D12B) was 86 minutes (53-167). DISCUSSION Streamlining STEMI patient care to reduce D2B is a major priority. We have demonstrated that establishing a transfer program between a STEMI-Referral Hospital (SRH) and SRC can markedly improve time to reperfusion. This approach has resulted in D12B that match or exceeds the D2B for nontransfer patients at most STEMI-receiving hospitals.

Social support, social undermining, and acute clinical pain in women: Mediational pathways of negative cognitive appraisal and emotion:

Women may be disproportionately vulnerable to acute pain, potentially due to their social landscape. We examined whether positive and negative social processes (social support and social undermining) are associated with acute pain and if the processes are linked to pain via negative cognitive appraisal and emotion (pain catastrophizing, hyperarousal, anger). Psychosocial variables were assessed in inner-city women (N = 375) presenting to an Emergency Department with acute pain. The latent cognitive-emotion variable fully mediated social undermining and support effects on pain, with undermining showing greater impact. Pain may be alleviated by limiting negative social interactions, mitigating risks of alternative pharmacological interventions.

Race, psychosocial vulnerability and social support differences in inner-city women's symptoms of posttraumatic stress disorder

ABSTRACT Background/Objectives: Inner-city Black women may be more susceptible to posttraumatic stress disorder (PTSD) than White women, although mechanisms underlying this association are unclear. Living in urban neighborhoods distinguished by higher chronic stress may contribute to racial differences in womens cognitive, affective, and social vulnerabilities, leading to greater trauma-related distress including PTSD. Yet social support could buffer the negative effects of psychosocial vulnerabilities on womens health. Methods/Design: Mediation and moderated mediation models were tested with 371 inner-city women, including psychosocial vulnerability (i.e., catastrophizing, anger, social undermining) mediating the pathway between race and PTSD, and social support moderating psychosocial vulnerability and PTSD. Results: Despite comparable rates of trauma, Black women reported higher vulnerability and PTSD symptoms, and lower support compared to White Hispanic and non-Hispanic women. Psychosocial vulnerability mediated the pathway between race and PTSD, and social support moderated vulnerability, reducing negative effects on PTSD. When examining associations by race, the moderation effect remained significant for Black women only. Conclusions: Altogether these psychosocial vulnerabilities represent one potential mechanism explaining Black womens greater risk of PTSD, although cumulative psychosocial vulnerability may be buffered by social support. Despite higher support, inner-city White womens psychosocial vulnerability may actually outweigh supports benefits for reducing trauma-related distress.

Medicaid beneficiaries who continue to use the ED: A focus on the Illinois medical home network

☆ Prior presentations: N/A. ☆☆ Funding sources/disclosures: N/A. ⁎ Corresponding author. Department of Preventive Me Center, 1700 West Van Buren, Suite 470, Chicago, IL. Tel.: E-mail addresses: Crystal_Glover@rush.edu (C.M. Glov Yanina_Purim-Shem-Tov@rush.edu (Y.A. Purim-Shem-To (T.J. Johnson), Shital_C_Shah@rush.edu (S.C. Shah). 1 Tel.: +1 312 947 0229. 2 Tel.: +1 312 942 7107. 3 Tel.: +1 312 942 7926. http://dx.doi.org/10.1016/j.ajem.2015.10.011 0735-6757/© 2015 Elsevier Inc. All rights reserved. Article history: Received 16 April 2015 Received in revised form 8 October 2015 Accepted 11 October 2015 Objectives: Frequent, nonurgent emergency department use continues to plague theAmerican health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities. Methods: We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data. Results: Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients. Conclusions: This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

Qualitative patient interviews conducted within the ED: purpose and problems.

A wealth of literature [1,2] addresses the multifaceted problem posed by frequent, nonurgent emergency department (ED) use to the health care system (eg, costs) as well as patients (eg, disease management). As Medicaid patients visit the ED more than those privately insured [3], numerous interventions [2,4,5] aim to decrease ED use among Medicaid patients. The State of Illinois developed the Medical Home Network (MHN) [6] in 2012 to address frequent, nonurgent ED use by Medicaid recipients living in Chicago. A recent retrospective analysis [7] found that MHN patients visited the ED more and arrived to the ED with lower acuity in comparison to non-MHN patients. Hence, more research and continued intervention development are needed to address the reduction of ED use among Medicaid patients. What providers and researchers know regarding frequent, nonurgent ED use among Medicaid recipients is largely based upon quantitative data sources [8] includingmedical records from the perspectives of providers and insurers [9]. The patient perspective remains limited; however, it is an important source of data for developing interventions [9]. Qualitative methods such as individual interviews provide in-depth examinations of the patient perspective [10]. While conducting qualitative research within an ED is less common than quantitative studies [10], it can produce important findings [10] used to modify and create interventions to reduce ED use. Regardless of patient population, most qualitative research regarding EDuse has been conducted outside of the ED.We conducted a qualitative study within a large, urban ED at an academicmedical center in Chicago. Participants were 50MHNpatients seeking carewithin the ED for a nonurgent issue. After completing the informed consent process, participants took part in 1-time, individual interviews lasting 1 hour or less during their downtime in the ED. Interviews occurred inside of private rooms. Participants were interviewed Monday through Sunday during the morning, afternoon, and evening. The goal of the interviews was to identify and understand MHN patient-identified facilitators of ED use. When conducting qualitative research within the ED, researchers must develop a partnership with an ED physician before conducting the study. The ED physician (1) informs the qualitative study design,