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Papers by james adams

Research paper thumbnail of Supporting the Health Care Workforce During the COVID-19 Global Epidemic

JAMA

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally.... more Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally. Worldwide, more than 100 000 cases of coronavirus disease 2019 (COVID-19, the disease caused by SARS-CoV-2) and more than 3500 deaths have been reported. COVID-19 is thought to have higher mortality than seasonal influenza, even as wide variation is reported. While the World Health Organization (WHO) estimates global mortality at 3.4%, South Korea has noted mortality of about 0.6%. 1-3 Vaccine development and research into medical treatment for COVID-19 are under way, but are many months away. Meanwhile, the pressure on the global health care workforce continues to intensify. This pressure takes 2 forms. The first is the potentially overwhelming burden of illnesses that stresses health system capacity and the second is the adverse effects on health care workers, including the risk of infection. In China, an estimated 3000 health care workers have been infected and at least 22 have died. Transmission to family members is widely reported. Despite recognition that transmission occurs mostly via symptomatic individuals, there are reports of asymptomatic individuals who transmitted the disease to multiple family members. 4 These reports underscore the need for prevention of cross-infection. Evidence related to transmissibility and mortality inform the clinical community of the importance of vigilance, preparation, active management, and protection. Adherence to the Centers for Disease Control and Prevention's (CDC) recommended guidelines advances safety. 5 SARS-CoV-2 is spread by droplet and contact. It is not principally an airborne virus. Therefore, ensuring routine droplet barrier precautions, environmental hygiene, and overall sound infection prevention practice is indicated. To ensure minimal risk of infection when treating patients with COVID-19, the CDC recommends the use of personal protective equipment including a gown, gloves, and either an N95 respirator plus a face shield/ goggles or a powered, air-purifying respirator (PAPR). However, airborne precautions are not used in daily, routine care of patients with general respiratory illness. The widespread use of recommended barrier precautions (such as masks, gloves, gowns, and eye wear) in the care of all patients with respiratory symptoms must be of highest priority. In emergency departments, outpatient offices, homes, and other settings, there will be undiagnosed but infected patients, many with clinically mild cases or atypical presentations. There is limited availability of N95 masks, respiratory isolation rooms, and PAPR, particularly in outpatient offices, to feasibly evaluate every patient with respiratory illness and such measures are not routinely necessary.

Research paper thumbnail of Supporting the Health Care Workforce During the COVID-19 Global Epidemic

Supporting the Health Care Workforce During the COVID-19 Global Epidemic, 2020

Supporting the Health Care Workforce During the COVID-19 Global Epidemic

Research paper thumbnail of Ensuring the Quality of Quality Metrics for Emergency Care

JAMA, Jan 16, 2016

Every year in the United States there are more than 136 million total visits to emergency departm... more Every year in the United States there are more than 136 million total visits to emergency departments (EDs).1 Approximately 20% of adult patients who seek ED care will be hospitalized, and the rest will be treated and discharged, usually to home. However, a proportion of patients who are discharged from the ED will soon return for additional ED care, usually related to the problem treated at the previous visit or on occasion for new symptoms. Depending on location, payer mix, and acuity of illness, rates of return visits to the ED range from 7.5% to 22.4% between 3 days and 30 days.2,3 Return visits to the ED are not a newly recognized phenomenon; they have been documented and discussed for at least the last 3 decades.4,5 Moreover, return visits to the ED have been of persistent concern because of the perception that patients who experience ED revisits are at higher risk for poor health outcomes or may have been misdiagnosed or incorrectly or inadequately treated during their initial ED visit.6 The important question in the era of electronically enabled reporting is whether the return visit rate can be used as a marker of ED quality. The simple answer, long suspected and now clearly proven in the report by Sabbatini and colleagues7 in this issue of JAMA, is no. In this study, the authors used data from the Healthcare Cost and Utilization Project to evaluate clinical outcomes and costs for adult patients who were hospitalized during a return visit to the ED at 424 acute care hospitals in Florida and New York in 2013. Among the 9 million ED visits, 1.7 million patients (19.5%) were hospitalized during their index ED visit, whereas among the 7.3 million discharged from the ED, 8.2% (nearly 600 000) returned for additional ED care within 7 days. By 2 weeks after the index visit, 11.5% had a return visit to the ED, and by 30 days, 16.6% (1.2 million) had returned for additional ED treatment.7 These numbers demand attention. If important misdiagnoses or inadequate treatment was the primary cause of return visits to the ED, it would be expected that the patients would be worse off upon return. Notably, patients who returned to the ED were not worse off. Among the patients who revisited the ED within 7 days after their ED index visit, 14.4% were admitted to the hospital compared with the approximately 20% of patients who were admitted during an initial ED visit and the approximately 55% of patients who were readmitted if they presented to the ED within 30 days after an inpatient hospital stay. The group of patients who were admitted during a return visit to the ED within 7 days of their index visit had lower in-hospital mortality compared with patients who were admitted during their index ED visit (1.85% vs 2.48%, respectively), lower rates of ICU admission (23.3% vs 29.0%), and lower mean costs ($10 169 vs $10 799), although slightly longer mean hospital length of stay (5.16 days vs 4.97 days).7 The findings were similar for patients who were hospitalized during return ED visits at 14 days and 30 days after their index ED visit. These findings suggest that misdiagnoses that harm patients who are discharged from the ED are not the key driver of repeat visits to the ED. Still, patients who have been treated and are discharged from the ED are sometimes misdiagnosed, do sometimes experience harm, and, rarely, even die.6 However, the aggregated ED revisit data do not reveal these adverse events. To find cases of inadequate diagnosis or treatment, ED directors for decades have undertaken individual case review of patients who return to the ED after an initial visit. Reviewing cases reveals many factors other than clinical mistakes. Some revisits to the ED represent the frequent, repeated use by patients who have intractable social and mental health conditions. Other patients return to the ED because they are unable to access a primary care physician or specialist physician as advised at their initial ED visit. Return visits are influenced by the demographics of patients served by the ED and structural characteristics of the local health care and social systems. When asked why they return to the ED, many patients report that they had continued concerns, had continued pain or distressing symptoms, and found the ED a convenient, reliable source of care.8 Moreover, return visits to the ED sometimes also signal, paradoxically, that the initial care was acceptable. For example, some patients are deliberately instructed to return to the ED because of planned wound check, ongoing abscess treatment, or need for suture removal. Other patients receive a prudent trial of outpatient care for conditions, such as acute gastroenteritis, abdominal pain, febrile illness, skin infections, or kidney stones, even though some will not recover as hoped and must return. Often a careful trial of outpatient treatment, if it can be safely achieved, is warranted even though this approach will not always work. How, then, can administrators and…

Research paper thumbnail of Ambulatory Care Sensitive Hospitalizations Through the Emergency Department by Payer: Comparing 2003 and 2009

The Journal of emergency medicine, Jan 15, 2015

Ambulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preven... more Ambulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preventable with timely and effective outpatient care. Approximately 75% of all ACSHs occur through the emergency department (ED). ACSHs through the ED (ED ACSHs) have significant implications for costs and ED crowding. This study compares rates of ED ACSHs for 2003 and 2009 among patients 18 to 64 years of age with private insurance, Medicaid, or no insurance. Nationally representative estimates of ED ACSHs, defined by the Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs), were generated from the 2003 and 2009 Nationwide Inpatient Samples. Census data were used to calculate direct age- and sex-standardized ACSH rates by non-Medicare payers for both years. Between 2003 and 2009, the overall rate of ED ACSHs decreased from 7.6 (95% confidence interval [CI] 7.57-7.75) to 7.3 (95% CI 7.2-7.4) per 1000 18- to 64-year-old non-Medicare patients. ED ASCH rates dec...

Research paper thumbnail of American Medical Association

(AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium)... more (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium) and the National Committee for Quality Assurance (NCQA) pursuant to government sponsorship under subcontract 6205-05-054 with Mathematica Policy Research, Inc. under contract 500-00-0033 with Centers for Medicare & Medicaid Services. These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed

Research paper thumbnail of American College of Emergency Physicians: physician impairment

Annals of emergency medicine, 1995

Research paper thumbnail of Ethical issues in geriatric emergency medicine

Emergency medicine clinics of North America, 1990

The emergence of ethics, geriatrics, and emergency medicine as areas of specialized interest has ... more The emergence of ethics, geriatrics, and emergency medicine as areas of specialized interest has proceeded rapidly over the past two decades. Each of these fields continues to grow in response to patient needs, but it is clear that scientific knowledge alone cannot provide the physician with all the guidance necessary to ensure the provision of optimal care. Patient care cannot consist only of making diagnoses, prescribing medications, and performing technical procedures. Particularly in the care of the elderly, the emergency physician must be able to recognize ethical issues and to respond to them in the manner that will provide the greatest benefit to the patient. With the application of such skills, the emergency treatment of the elderly promises more benefit for elderly patients and their families and less doubt and anguish for emergency practitioners.

Research paper thumbnail of ED operational factors associated with patient satisfaction

The American journal of emergency medicine, 2015

used by drug-seeking patients in the emergency department? West J Emerg Med 2012;13(5):416–21. [3... more used by drug-seeking patients in the emergency department? West J Emerg Med 2012;13(5):416–21. [3] Grover CA, Garmel GM. How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain? Perm J 2012;16(4):32–6. [4] Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med 2010;56(1):19–23.e1-3 [Epub 2010 Jan 4]. [5] Volkow ND, McLellan TA, Cotto JH, KarithanomM,Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA 2011;305(13):1299–301. [6] Kunins H, Farley T, Dowell D. Guidelines for opioid prescription: why emergency physicians need support. In the balance on www.annals.org; 2013. [7] Heins J, Heins A, Grammas M, Costello M, Huang K, Mishra S. Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. J Emerg Nurs 2006;32(3):219–24. [8] Office of Diversion Control. State prescription drug monitoring programs; 2011 [Retrieved September 24, 2014, from http://www.deadiversion.usdoj.gov/faq/rx_ monitor.htm].

Research paper thumbnail of Talk-time in the emergency department: duration of patient-provider conversations during an emergency department visit

The Journal of emergency medicine, 2014

Analyses of patient flow through the emergency department (ED) typically focus on metrics such as... more Analyses of patient flow through the emergency department (ED) typically focus on metrics such as wait time, total length of stay (LOS), or boarding time. Less is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of their in-room visit is also spent waiting. Our aim was to assess the proportion of time that a patient spent in conversation with providers during an ED visit. Seventy-four audio-taped encounters of patients with low-acuity diagnoses were analyzed. Recorded ED visits were edited to remove downtime. The proportion of time the patient spent in conversation with providers (talk-time) was calculated as follows: (talk-time = [edited audio time/{LOS - door-to-doctor time}]). Participants were 46% male; mean age was 41 years (standard deviation 15.7 years). Median LOS was 126 min (interquartile range [IQR] 96 to 163 min), median time in a patient care area was 76 min (IQR 55 to 122 min). Median time in conversation w...

Research paper thumbnail of ED Overcrowding-Meeting Many Needs

Pediatric Emergency Care, 2004

... KATHY N. SHAW, MD, MSCE. Question 1. ... An electronic tracking system will make it easier to... more ... KATHY N. SHAW, MD, MSCE. Question 1. ... An electronic tracking system will make it easier to collect these data, but registration and billing information systems can be used also. The hard part is getting help to analyze the data and keep it current. ...

Research paper thumbnail of The Emergency Severity Index (version 3) 5-Level Triage System Scores Predict ED Resource Consumption

Journal of Emergency Nursing, 2004

The Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument th... more The Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument that is gaining in popularity. A unique component of the ESI algorithm is prediction of resource consumption. Our objective was to validate the ESI version 3 triage algorithm in a clinical setting for the following outcome measures: actual resource consumption and patient length of stay in the emergency department and hospital. We conducted a retrospective, descriptive study of 403 ED patients who presented to a large academic medical center. The following dependent variables were abstracted from the ED record: number of ED resources used and emergency department and hospital length of stay. The relationship between ESI level and each of the dependent variables was determined. Mean resource use decreased monotonically as a function of ESI level 1 (5), 2 (3.89), 3 (3.3), 4 (1.2) and 5 (0.2). The ED average length of stay (minutes) per ESI level was as follows: 1 (195), 2 (255), 3 (304), 4 (193), and 5 (98). ESI triage level did not predict hospital length of stay. The ESI algorithm accurately predicted ED resource intensity and gives administrators the opportunity to benchmark ED length of stay according to triage acuity level.

Research paper thumbnail of Validating a model of patient satisfaction with emergency care

Annals of Emergency Medicine, 2001

We sought to validate a previously developed model of emergency department patient satisfaction i... more We sought to validate a previously developed model of emergency department patient satisfaction in a general population using a standard mailed format. The study aims to export the findings of a comprehensive ED quality-of-care study to an easily measured patient population. A double-sided, single-page survey was mailed to all patients discharged home from 4 teaching hospital EDs during a 1-month period. Determinants of patient satisfaction were analyzed with a previously developed multivariate, ordinal logistic-regression model. The mail survey response rate was 22.9% (2,373/10,381). The survey validates the importance of previously identified determinants of patient satisfaction, including age, help not received when needed, poor explanation of problem, not told about wait time, not told when to resume normal activity, poor explanation of test results, and not told when to return to the ED (P <.01). Greater age predicted higher patient satisfaction, whereas all other variables correlated with lower patient satisfaction. In contrast with prior findings, black race was not a significant predictor of satisfaction in the mail survey population. Low ratings of overall care are strongly correlated with reduced willingness to return (P <.0001). A patient satisfaction model was previously developed from a comprehensive research survey of ED care. We demonstrate the generalizability of this model to a mail survey population and replicate the finding that satisfaction strongly predicts willingness to return. The response rate of this study is typical of commercial patient-satisfaction surveys. The validated model suggests that ED patient satisfaction improvement efforts should focus on a limited number of modifiable and easily measured factors.

Research paper thumbnail of Increased Blood Pressure in the Emergency Department: Pain, Anxiety, or Undiagnosed Hypertension?

Annals of Emergency Medicine, 2008

Study objective: We determine the proportion of patients with increased emergency department (ED)... more Study objective: We determine the proportion of patients with increased emergency department (ED) blood pressure and no history of hypertension who have persistently increased blood pressure at home, describe characteristics associated with sustained blood pressure increase, and examine the relationship between pain and anxiety and the change in blood pressure after ED discharge. Methods: This was a prospective cohort study. Patients with no history of hypertension and 2 blood pressure measurements of at least 140/90 mm Hg who were treated in an urban ED were enrolled, provided with home blood pressure monitors, and asked to take their blood pressure twice a day for 1 week. Outcome measures were increased mean home blood pressure (140/90 mm Hg or greater), and correlations between ED anxiety (Spielberger State Anxiety Scale) or pain (10-point scale) and the change in blood pressure after discharge. Potential relevant predictors were recorded and a multivariate model was constructed to assess the relationship between these predictors and increased home blood pressure. Results: 189 patients were enrolled and 156 returned the monitors and completed the protocol. Increased mean home blood pressure was present in 79 of 156 (51%) patients and was associated with older age and being black. Of patients with ED blood pressures meeting criteria for stage I hypertension, 6% had home blood pressures meeting stage II hypertension, 36% stage I, and 52% prehypertension, and 6% had normal blood pressure For patients with ED blood pressures meeting stage II criteria, the corresponding percentages were 28%, 31%, 33%, and 8%, respectively. The difference between home and ED systolic blood pressures was not associated with anxiety (rϭ-.03; Pϭ.69) and showed a slight association with pain in the opposite direction from what was expected (rϭ.18; Pϭ.03). Conclusion: Patients without diagnosed hypertension and increased ED blood pressures often have persistently increased home blood pressures, which does not appear to be related to pain or anxiety in the ED.

Research paper thumbnail of Communication about Opioid versus Non-Opioid Analgesics in the Emergency Department

Annals of Emergency Medicine, 2013

The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioi... more The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioid analgesics in the Emergency Department (ED) setting. Secondary analysis of prospectively collected audio recordings of ED patient visits. Urban, academic medical center (>85,000 annual patient visits). Patient participants aged >18 years with one of four low acuity diagnoses: ankle sprain, back pain, head injury, and laceration. ED clinician participants included resident and attending physicians, nursing staff, and ED technicians. The MCI is a five-point index that assigns points for communicating the following: medication name (1), purpose (1), duration (1), adverse effects (1), number of tablets (0.5), and frequency of use (0.5). Recording transcripts were scored with the MCI, and total scores were compared between drug classes. The 41 patients received 56 prescriptions (27 nonopioids, 29 opioids). Nonopioid median MCI score was 3 and opioid score was 4.5 (p = 0.0008). Patients were counseled equally about name (nonopioid 100 percent, opioid 96.6 percent, p = 0.34) and purpose (88.9 percent, 89.7 percent, p = 0.93). However, patients receiving opioids were counseled more frequently about duration of use (nonopioid 40.7 percent, opioid 69.0 percent, p = 0.03) and adverse effects (18.5 percent, 93.1 percent, p < 0.001). In multivariable analysis, opioids (β = 0.54, p = 0.04), number of medications prescribed (β = -0.49, p = 0.05), and time spent in the ED (β = 0.007, p = 0.006) were all predictors of total MCI score. The extent of counseling about analgesic medications in the ED differs by drug class. When counseling patients about all analgesic medications, providers should address not only medication name and purpose but also the less frequently covered topics of medication dosing, timing, and adverse effects.

Research paper thumbnail of 174: Effect of a Process Improvement Intervention on Inpatient Telemetry Utilization Initiated In the Emergency Department

Annals of Emergency Medicine, 2010

Research paper thumbnail of Determinants of Patient Satisfaction and Willingness to Return With Emergency Care

Annals of Emergency Medicine, 2000

To identify emergency department process of care measures that are significantly associated with ... more To identify emergency department process of care measures that are significantly associated with satisfaction and willingness to return. Patient satisfaction and willingness to return at 5 urban, teaching hospital EDs were assessed. Baseline questionnaire, chart review, and 10-day follow-up telephone interviews were performed, and 38 process of care measures and 30 patient characteristic were collected for each respondent. Overall satisfaction was modeled with ordinal logistic regression. Willingness to return was modeled with logistic regression. During a 1-month study period, 2,899 (84% of eligible) on-site questionnaires were completed. Telephone interviews were completed by 2,333 patients (80% of patients who completed a questionnaire). Patient-reported problems that were highly correlated with satisfaction included help not received when needed (odds ratio [OR] 0.345; 95% confidence interval [CI] 0.261 to 0.456), poor explanation of causes of problem (OR 0.434; 95% CI 0.345 to 0.546), not told about potential wait time (OR 0.479; 95% CI 0.399 to 0.577), not told when to resume normal activities (OR 0.691; 95% CI 0.531 to 0.901), poor explanation of test results (OR 0.647; 95% CI 0.495 to 0.845), and not told when to return to the ED (OR 0.656; 95% CI 0. 494 to 0.871). Other process of care measures correlated with satisfaction include nonacute triage status (OR 0.701, 95% CI 0.578 to 0.851) and number of treatments in the ED (OR 1.164 per treatment; 95% CI 1.073 to 1.263). Patient characteristics that significantly predicted less satisfaction included younger age and black race. Determinants of willingness to return include poor explanation of causes of problem (OR 0.328; 95% CI 0.217 to 0.495), unable to leave a message for family (OR 0.391; 95% CI 0.226 to 0. 677), not told about potential wait time (OR 0.561; 95% CI 0.381 to 0.825), poor explanation of test results (OR 0.541; 95% CI 0.347 to 0.846), and help not received when needed (OR 0.537; 95% CI 0.340 to 0.846). Patients with a chief complaint of hand laceration were less willing to return compared with a reference population of patients with abdominal pain. Willingness to return is strongly predicted by overall satisfaction (OR 2.601; 95% CI 2.292 to 2.951). These data identify specific process of care measures that are determinants of patient satisfaction and willingness to return. Efforts to increase patient satisfaction and willingness to return should focus on improving ED performance on these identified process measures.

Research paper thumbnail of 225: The Effect of Wait Times and Emergency Department Length of Stay on Patient Perception of Medical Team Communication

Annals of Emergency Medicine, 2008

Annals of Emergency Medicine, Volume 52, Issue 4, Pages S111-S112, October 2008, Authors:SM Donla... more Annals of Emergency Medicine, Volume 52, Issue 4, Pages S111-S112, October 2008, Authors:SM Donlan; A. Venkatesh; PS Pang; LM Mercer; P. Tanabe; D. Courtney; K. Engel; J. Duval-Arnould; MA Gisondi; G. Makoul; JG Adams. ...

Research paper thumbnail of The Endangered Safety Net Establishing a Measure of Control

Academic Emergency Medicine, 2001

Research paper thumbnail of Derivation of a Triage Algorithm for Chest Radiography of Community-acquired Pneumonia Patients in the Emergency Department

Academic Emergency Medicine, 2008

Background: Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED)... more Background: Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED) patient visits in the United States each year. Objectives: To derive an algorithm for the ED triage setting that facilitates rapid and accurate ordering of chest radiography (CXR) for CAP. Methods: The authors conducted an ED-based retrospective matched case-control study using 100 radiographic confirmed CAP cases and 100 radiographic confirmed influenzalike illness (ILI) controls. Sensitivities and specificities of characteristics assessed in the triage setting were measured to discriminate CAP from ILI. The authors then used classification tree analysis to derive an algorithm that maximizes sensitivity and specificity for detecting patients with CAP in the ED triage setting. Results: Temperature greater than 100.4°F (likelihood ratio = 4.39, 95% confidence interval [CI] = 2.04 to 9.45), heart rate greater than 110 beats ⁄ minute (likelihood ratio = 3.59, 95% CI = 1.82 to 7.10), and pulse oximetry less than 96% (likelihood ratio = 2.36, 95% CI = 1.32 to 4.20) were the strongest predictors of CAP. However, no single characteristic was adequately sensitive and specific to accurately discriminate CAP from ILI. A three-step algorithm (using optimum cut points for elevated temperature, tachycardia, and hypoxemia on room air pulse oximetry) was derived that is 70.8% sensitive (95% CI = 60.7% to 79.7%) and 79.1% specific (95% CI = 69.3% to 86.9%). Conclusions: No single characteristic adequately discriminates CAP from ILI, but a derived clinical algorithm may detect most radiographic confirmed CAP patients in the triage setting. Prospective assessment of this algorithm will be needed to determine its effects on the care of ED patients with suspected pneumonia.

Research paper thumbnail of Errors in Emergency Medicine A Call to Action

Academic Emergency Medicine, 2000

Research paper thumbnail of Supporting the Health Care Workforce During the COVID-19 Global Epidemic

JAMA

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally.... more Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally. Worldwide, more than 100 000 cases of coronavirus disease 2019 (COVID-19, the disease caused by SARS-CoV-2) and more than 3500 deaths have been reported. COVID-19 is thought to have higher mortality than seasonal influenza, even as wide variation is reported. While the World Health Organization (WHO) estimates global mortality at 3.4%, South Korea has noted mortality of about 0.6%. 1-3 Vaccine development and research into medical treatment for COVID-19 are under way, but are many months away. Meanwhile, the pressure on the global health care workforce continues to intensify. This pressure takes 2 forms. The first is the potentially overwhelming burden of illnesses that stresses health system capacity and the second is the adverse effects on health care workers, including the risk of infection. In China, an estimated 3000 health care workers have been infected and at least 22 have died. Transmission to family members is widely reported. Despite recognition that transmission occurs mostly via symptomatic individuals, there are reports of asymptomatic individuals who transmitted the disease to multiple family members. 4 These reports underscore the need for prevention of cross-infection. Evidence related to transmissibility and mortality inform the clinical community of the importance of vigilance, preparation, active management, and protection. Adherence to the Centers for Disease Control and Prevention's (CDC) recommended guidelines advances safety. 5 SARS-CoV-2 is spread by droplet and contact. It is not principally an airborne virus. Therefore, ensuring routine droplet barrier precautions, environmental hygiene, and overall sound infection prevention practice is indicated. To ensure minimal risk of infection when treating patients with COVID-19, the CDC recommends the use of personal protective equipment including a gown, gloves, and either an N95 respirator plus a face shield/ goggles or a powered, air-purifying respirator (PAPR). However, airborne precautions are not used in daily, routine care of patients with general respiratory illness. The widespread use of recommended barrier precautions (such as masks, gloves, gowns, and eye wear) in the care of all patients with respiratory symptoms must be of highest priority. In emergency departments, outpatient offices, homes, and other settings, there will be undiagnosed but infected patients, many with clinically mild cases or atypical presentations. There is limited availability of N95 masks, respiratory isolation rooms, and PAPR, particularly in outpatient offices, to feasibly evaluate every patient with respiratory illness and such measures are not routinely necessary.

Research paper thumbnail of Supporting the Health Care Workforce During the COVID-19 Global Epidemic

Supporting the Health Care Workforce During the COVID-19 Global Epidemic, 2020

Supporting the Health Care Workforce During the COVID-19 Global Epidemic

Research paper thumbnail of Ensuring the Quality of Quality Metrics for Emergency Care

JAMA, Jan 16, 2016

Every year in the United States there are more than 136 million total visits to emergency departm... more Every year in the United States there are more than 136 million total visits to emergency departments (EDs).1 Approximately 20% of adult patients who seek ED care will be hospitalized, and the rest will be treated and discharged, usually to home. However, a proportion of patients who are discharged from the ED will soon return for additional ED care, usually related to the problem treated at the previous visit or on occasion for new symptoms. Depending on location, payer mix, and acuity of illness, rates of return visits to the ED range from 7.5% to 22.4% between 3 days and 30 days.2,3 Return visits to the ED are not a newly recognized phenomenon; they have been documented and discussed for at least the last 3 decades.4,5 Moreover, return visits to the ED have been of persistent concern because of the perception that patients who experience ED revisits are at higher risk for poor health outcomes or may have been misdiagnosed or incorrectly or inadequately treated during their initial ED visit.6 The important question in the era of electronically enabled reporting is whether the return visit rate can be used as a marker of ED quality. The simple answer, long suspected and now clearly proven in the report by Sabbatini and colleagues7 in this issue of JAMA, is no. In this study, the authors used data from the Healthcare Cost and Utilization Project to evaluate clinical outcomes and costs for adult patients who were hospitalized during a return visit to the ED at 424 acute care hospitals in Florida and New York in 2013. Among the 9 million ED visits, 1.7 million patients (19.5%) were hospitalized during their index ED visit, whereas among the 7.3 million discharged from the ED, 8.2% (nearly 600 000) returned for additional ED care within 7 days. By 2 weeks after the index visit, 11.5% had a return visit to the ED, and by 30 days, 16.6% (1.2 million) had returned for additional ED treatment.7 These numbers demand attention. If important misdiagnoses or inadequate treatment was the primary cause of return visits to the ED, it would be expected that the patients would be worse off upon return. Notably, patients who returned to the ED were not worse off. Among the patients who revisited the ED within 7 days after their ED index visit, 14.4% were admitted to the hospital compared with the approximately 20% of patients who were admitted during an initial ED visit and the approximately 55% of patients who were readmitted if they presented to the ED within 30 days after an inpatient hospital stay. The group of patients who were admitted during a return visit to the ED within 7 days of their index visit had lower in-hospital mortality compared with patients who were admitted during their index ED visit (1.85% vs 2.48%, respectively), lower rates of ICU admission (23.3% vs 29.0%), and lower mean costs ($10 169 vs $10 799), although slightly longer mean hospital length of stay (5.16 days vs 4.97 days).7 The findings were similar for patients who were hospitalized during return ED visits at 14 days and 30 days after their index ED visit. These findings suggest that misdiagnoses that harm patients who are discharged from the ED are not the key driver of repeat visits to the ED. Still, patients who have been treated and are discharged from the ED are sometimes misdiagnosed, do sometimes experience harm, and, rarely, even die.6 However, the aggregated ED revisit data do not reveal these adverse events. To find cases of inadequate diagnosis or treatment, ED directors for decades have undertaken individual case review of patients who return to the ED after an initial visit. Reviewing cases reveals many factors other than clinical mistakes. Some revisits to the ED represent the frequent, repeated use by patients who have intractable social and mental health conditions. Other patients return to the ED because they are unable to access a primary care physician or specialist physician as advised at their initial ED visit. Return visits are influenced by the demographics of patients served by the ED and structural characteristics of the local health care and social systems. When asked why they return to the ED, many patients report that they had continued concerns, had continued pain or distressing symptoms, and found the ED a convenient, reliable source of care.8 Moreover, return visits to the ED sometimes also signal, paradoxically, that the initial care was acceptable. For example, some patients are deliberately instructed to return to the ED because of planned wound check, ongoing abscess treatment, or need for suture removal. Other patients receive a prudent trial of outpatient care for conditions, such as acute gastroenteritis, abdominal pain, febrile illness, skin infections, or kidney stones, even though some will not recover as hoped and must return. Often a careful trial of outpatient treatment, if it can be safely achieved, is warranted even though this approach will not always work. How, then, can administrators and…

Research paper thumbnail of Ambulatory Care Sensitive Hospitalizations Through the Emergency Department by Payer: Comparing 2003 and 2009

The Journal of emergency medicine, Jan 15, 2015

Ambulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preven... more Ambulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preventable with timely and effective outpatient care. Approximately 75% of all ACSHs occur through the emergency department (ED). ACSHs through the ED (ED ACSHs) have significant implications for costs and ED crowding. This study compares rates of ED ACSHs for 2003 and 2009 among patients 18 to 64 years of age with private insurance, Medicaid, or no insurance. Nationally representative estimates of ED ACSHs, defined by the Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs), were generated from the 2003 and 2009 Nationwide Inpatient Samples. Census data were used to calculate direct age- and sex-standardized ACSH rates by non-Medicare payers for both years. Between 2003 and 2009, the overall rate of ED ACSHs decreased from 7.6 (95% confidence interval [CI] 7.57-7.75) to 7.3 (95% CI 7.2-7.4) per 1000 18- to 64-year-old non-Medicare patients. ED ASCH rates dec...

Research paper thumbnail of American Medical Association

(AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium)... more (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium) and the National Committee for Quality Assurance (NCQA) pursuant to government sponsorship under subcontract 6205-05-054 with Mathematica Policy Research, Inc. under contract 500-00-0033 with Centers for Medicare & Medicaid Services. These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed

Research paper thumbnail of American College of Emergency Physicians: physician impairment

Annals of emergency medicine, 1995

Research paper thumbnail of Ethical issues in geriatric emergency medicine

Emergency medicine clinics of North America, 1990

The emergence of ethics, geriatrics, and emergency medicine as areas of specialized interest has ... more The emergence of ethics, geriatrics, and emergency medicine as areas of specialized interest has proceeded rapidly over the past two decades. Each of these fields continues to grow in response to patient needs, but it is clear that scientific knowledge alone cannot provide the physician with all the guidance necessary to ensure the provision of optimal care. Patient care cannot consist only of making diagnoses, prescribing medications, and performing technical procedures. Particularly in the care of the elderly, the emergency physician must be able to recognize ethical issues and to respond to them in the manner that will provide the greatest benefit to the patient. With the application of such skills, the emergency treatment of the elderly promises more benefit for elderly patients and their families and less doubt and anguish for emergency practitioners.

Research paper thumbnail of ED operational factors associated with patient satisfaction

The American journal of emergency medicine, 2015

used by drug-seeking patients in the emergency department? West J Emerg Med 2012;13(5):416–21. [3... more used by drug-seeking patients in the emergency department? West J Emerg Med 2012;13(5):416–21. [3] Grover CA, Garmel GM. How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain? Perm J 2012;16(4):32–6. [4] Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med 2010;56(1):19–23.e1-3 [Epub 2010 Jan 4]. [5] Volkow ND, McLellan TA, Cotto JH, KarithanomM,Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA 2011;305(13):1299–301. [6] Kunins H, Farley T, Dowell D. Guidelines for opioid prescription: why emergency physicians need support. In the balance on www.annals.org; 2013. [7] Heins J, Heins A, Grammas M, Costello M, Huang K, Mishra S. Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. J Emerg Nurs 2006;32(3):219–24. [8] Office of Diversion Control. State prescription drug monitoring programs; 2011 [Retrieved September 24, 2014, from http://www.deadiversion.usdoj.gov/faq/rx_ monitor.htm].

Research paper thumbnail of Talk-time in the emergency department: duration of patient-provider conversations during an emergency department visit

The Journal of emergency medicine, 2014

Analyses of patient flow through the emergency department (ED) typically focus on metrics such as... more Analyses of patient flow through the emergency department (ED) typically focus on metrics such as wait time, total length of stay (LOS), or boarding time. Less is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of their in-room visit is also spent waiting. Our aim was to assess the proportion of time that a patient spent in conversation with providers during an ED visit. Seventy-four audio-taped encounters of patients with low-acuity diagnoses were analyzed. Recorded ED visits were edited to remove downtime. The proportion of time the patient spent in conversation with providers (talk-time) was calculated as follows: (talk-time = [edited audio time/{LOS - door-to-doctor time}]). Participants were 46% male; mean age was 41 years (standard deviation 15.7 years). Median LOS was 126 min (interquartile range [IQR] 96 to 163 min), median time in a patient care area was 76 min (IQR 55 to 122 min). Median time in conversation w...

Research paper thumbnail of ED Overcrowding-Meeting Many Needs

Pediatric Emergency Care, 2004

... KATHY N. SHAW, MD, MSCE. Question 1. ... An electronic tracking system will make it easier to... more ... KATHY N. SHAW, MD, MSCE. Question 1. ... An electronic tracking system will make it easier to collect these data, but registration and billing information systems can be used also. The hard part is getting help to analyze the data and keep it current. ...

Research paper thumbnail of The Emergency Severity Index (version 3) 5-Level Triage System Scores Predict ED Resource Consumption

Journal of Emergency Nursing, 2004

The Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument th... more The Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument that is gaining in popularity. A unique component of the ESI algorithm is prediction of resource consumption. Our objective was to validate the ESI version 3 triage algorithm in a clinical setting for the following outcome measures: actual resource consumption and patient length of stay in the emergency department and hospital. We conducted a retrospective, descriptive study of 403 ED patients who presented to a large academic medical center. The following dependent variables were abstracted from the ED record: number of ED resources used and emergency department and hospital length of stay. The relationship between ESI level and each of the dependent variables was determined. Mean resource use decreased monotonically as a function of ESI level 1 (5), 2 (3.89), 3 (3.3), 4 (1.2) and 5 (0.2). The ED average length of stay (minutes) per ESI level was as follows: 1 (195), 2 (255), 3 (304), 4 (193), and 5 (98). ESI triage level did not predict hospital length of stay. The ESI algorithm accurately predicted ED resource intensity and gives administrators the opportunity to benchmark ED length of stay according to triage acuity level.

Research paper thumbnail of Validating a model of patient satisfaction with emergency care

Annals of Emergency Medicine, 2001

We sought to validate a previously developed model of emergency department patient satisfaction i... more We sought to validate a previously developed model of emergency department patient satisfaction in a general population using a standard mailed format. The study aims to export the findings of a comprehensive ED quality-of-care study to an easily measured patient population. A double-sided, single-page survey was mailed to all patients discharged home from 4 teaching hospital EDs during a 1-month period. Determinants of patient satisfaction were analyzed with a previously developed multivariate, ordinal logistic-regression model. The mail survey response rate was 22.9% (2,373/10,381). The survey validates the importance of previously identified determinants of patient satisfaction, including age, help not received when needed, poor explanation of problem, not told about wait time, not told when to resume normal activity, poor explanation of test results, and not told when to return to the ED (P <.01). Greater age predicted higher patient satisfaction, whereas all other variables correlated with lower patient satisfaction. In contrast with prior findings, black race was not a significant predictor of satisfaction in the mail survey population. Low ratings of overall care are strongly correlated with reduced willingness to return (P <.0001). A patient satisfaction model was previously developed from a comprehensive research survey of ED care. We demonstrate the generalizability of this model to a mail survey population and replicate the finding that satisfaction strongly predicts willingness to return. The response rate of this study is typical of commercial patient-satisfaction surveys. The validated model suggests that ED patient satisfaction improvement efforts should focus on a limited number of modifiable and easily measured factors.

Research paper thumbnail of Increased Blood Pressure in the Emergency Department: Pain, Anxiety, or Undiagnosed Hypertension?

Annals of Emergency Medicine, 2008

Study objective: We determine the proportion of patients with increased emergency department (ED)... more Study objective: We determine the proportion of patients with increased emergency department (ED) blood pressure and no history of hypertension who have persistently increased blood pressure at home, describe characteristics associated with sustained blood pressure increase, and examine the relationship between pain and anxiety and the change in blood pressure after ED discharge. Methods: This was a prospective cohort study. Patients with no history of hypertension and 2 blood pressure measurements of at least 140/90 mm Hg who were treated in an urban ED were enrolled, provided with home blood pressure monitors, and asked to take their blood pressure twice a day for 1 week. Outcome measures were increased mean home blood pressure (140/90 mm Hg or greater), and correlations between ED anxiety (Spielberger State Anxiety Scale) or pain (10-point scale) and the change in blood pressure after discharge. Potential relevant predictors were recorded and a multivariate model was constructed to assess the relationship between these predictors and increased home blood pressure. Results: 189 patients were enrolled and 156 returned the monitors and completed the protocol. Increased mean home blood pressure was present in 79 of 156 (51%) patients and was associated with older age and being black. Of patients with ED blood pressures meeting criteria for stage I hypertension, 6% had home blood pressures meeting stage II hypertension, 36% stage I, and 52% prehypertension, and 6% had normal blood pressure For patients with ED blood pressures meeting stage II criteria, the corresponding percentages were 28%, 31%, 33%, and 8%, respectively. The difference between home and ED systolic blood pressures was not associated with anxiety (rϭ-.03; Pϭ.69) and showed a slight association with pain in the opposite direction from what was expected (rϭ.18; Pϭ.03). Conclusion: Patients without diagnosed hypertension and increased ED blood pressures often have persistently increased home blood pressures, which does not appear to be related to pain or anxiety in the ED.

Research paper thumbnail of Communication about Opioid versus Non-Opioid Analgesics in the Emergency Department

Annals of Emergency Medicine, 2013

The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioi... more The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioid analgesics in the Emergency Department (ED) setting. Secondary analysis of prospectively collected audio recordings of ED patient visits. Urban, academic medical center (>85,000 annual patient visits). Patient participants aged >18 years with one of four low acuity diagnoses: ankle sprain, back pain, head injury, and laceration. ED clinician participants included resident and attending physicians, nursing staff, and ED technicians. The MCI is a five-point index that assigns points for communicating the following: medication name (1), purpose (1), duration (1), adverse effects (1), number of tablets (0.5), and frequency of use (0.5). Recording transcripts were scored with the MCI, and total scores were compared between drug classes. The 41 patients received 56 prescriptions (27 nonopioids, 29 opioids). Nonopioid median MCI score was 3 and opioid score was 4.5 (p = 0.0008). Patients were counseled equally about name (nonopioid 100 percent, opioid 96.6 percent, p = 0.34) and purpose (88.9 percent, 89.7 percent, p = 0.93). However, patients receiving opioids were counseled more frequently about duration of use (nonopioid 40.7 percent, opioid 69.0 percent, p = 0.03) and adverse effects (18.5 percent, 93.1 percent, p < 0.001). In multivariable analysis, opioids (β = 0.54, p = 0.04), number of medications prescribed (β = -0.49, p = 0.05), and time spent in the ED (β = 0.007, p = 0.006) were all predictors of total MCI score. The extent of counseling about analgesic medications in the ED differs by drug class. When counseling patients about all analgesic medications, providers should address not only medication name and purpose but also the less frequently covered topics of medication dosing, timing, and adverse effects.

Research paper thumbnail of 174: Effect of a Process Improvement Intervention on Inpatient Telemetry Utilization Initiated In the Emergency Department

Annals of Emergency Medicine, 2010

Research paper thumbnail of Determinants of Patient Satisfaction and Willingness to Return With Emergency Care

Annals of Emergency Medicine, 2000

To identify emergency department process of care measures that are significantly associated with ... more To identify emergency department process of care measures that are significantly associated with satisfaction and willingness to return. Patient satisfaction and willingness to return at 5 urban, teaching hospital EDs were assessed. Baseline questionnaire, chart review, and 10-day follow-up telephone interviews were performed, and 38 process of care measures and 30 patient characteristic were collected for each respondent. Overall satisfaction was modeled with ordinal logistic regression. Willingness to return was modeled with logistic regression. During a 1-month study period, 2,899 (84% of eligible) on-site questionnaires were completed. Telephone interviews were completed by 2,333 patients (80% of patients who completed a questionnaire). Patient-reported problems that were highly correlated with satisfaction included help not received when needed (odds ratio [OR] 0.345; 95% confidence interval [CI] 0.261 to 0.456), poor explanation of causes of problem (OR 0.434; 95% CI 0.345 to 0.546), not told about potential wait time (OR 0.479; 95% CI 0.399 to 0.577), not told when to resume normal activities (OR 0.691; 95% CI 0.531 to 0.901), poor explanation of test results (OR 0.647; 95% CI 0.495 to 0.845), and not told when to return to the ED (OR 0.656; 95% CI 0. 494 to 0.871). Other process of care measures correlated with satisfaction include nonacute triage status (OR 0.701, 95% CI 0.578 to 0.851) and number of treatments in the ED (OR 1.164 per treatment; 95% CI 1.073 to 1.263). Patient characteristics that significantly predicted less satisfaction included younger age and black race. Determinants of willingness to return include poor explanation of causes of problem (OR 0.328; 95% CI 0.217 to 0.495), unable to leave a message for family (OR 0.391; 95% CI 0.226 to 0. 677), not told about potential wait time (OR 0.561; 95% CI 0.381 to 0.825), poor explanation of test results (OR 0.541; 95% CI 0.347 to 0.846), and help not received when needed (OR 0.537; 95% CI 0.340 to 0.846). Patients with a chief complaint of hand laceration were less willing to return compared with a reference population of patients with abdominal pain. Willingness to return is strongly predicted by overall satisfaction (OR 2.601; 95% CI 2.292 to 2.951). These data identify specific process of care measures that are determinants of patient satisfaction and willingness to return. Efforts to increase patient satisfaction and willingness to return should focus on improving ED performance on these identified process measures.

Research paper thumbnail of 225: The Effect of Wait Times and Emergency Department Length of Stay on Patient Perception of Medical Team Communication

Annals of Emergency Medicine, 2008

Annals of Emergency Medicine, Volume 52, Issue 4, Pages S111-S112, October 2008, Authors:SM Donla... more Annals of Emergency Medicine, Volume 52, Issue 4, Pages S111-S112, October 2008, Authors:SM Donlan; A. Venkatesh; PS Pang; LM Mercer; P. Tanabe; D. Courtney; K. Engel; J. Duval-Arnould; MA Gisondi; G. Makoul; JG Adams. ...

Research paper thumbnail of The Endangered Safety Net Establishing a Measure of Control

Academic Emergency Medicine, 2001

Research paper thumbnail of Derivation of a Triage Algorithm for Chest Radiography of Community-acquired Pneumonia Patients in the Emergency Department

Academic Emergency Medicine, 2008

Background: Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED)... more Background: Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED) patient visits in the United States each year. Objectives: To derive an algorithm for the ED triage setting that facilitates rapid and accurate ordering of chest radiography (CXR) for CAP. Methods: The authors conducted an ED-based retrospective matched case-control study using 100 radiographic confirmed CAP cases and 100 radiographic confirmed influenzalike illness (ILI) controls. Sensitivities and specificities of characteristics assessed in the triage setting were measured to discriminate CAP from ILI. The authors then used classification tree analysis to derive an algorithm that maximizes sensitivity and specificity for detecting patients with CAP in the ED triage setting. Results: Temperature greater than 100.4°F (likelihood ratio = 4.39, 95% confidence interval [CI] = 2.04 to 9.45), heart rate greater than 110 beats ⁄ minute (likelihood ratio = 3.59, 95% CI = 1.82 to 7.10), and pulse oximetry less than 96% (likelihood ratio = 2.36, 95% CI = 1.32 to 4.20) were the strongest predictors of CAP. However, no single characteristic was adequately sensitive and specific to accurately discriminate CAP from ILI. A three-step algorithm (using optimum cut points for elevated temperature, tachycardia, and hypoxemia on room air pulse oximetry) was derived that is 70.8% sensitive (95% CI = 60.7% to 79.7%) and 79.1% specific (95% CI = 69.3% to 86.9%). Conclusions: No single characteristic adequately discriminates CAP from ILI, but a derived clinical algorithm may detect most radiographic confirmed CAP patients in the triage setting. Prospective assessment of this algorithm will be needed to determine its effects on the care of ED patients with suspected pneumonia.

Research paper thumbnail of Errors in Emergency Medicine A Call to Action

Academic Emergency Medicine, 2000