“I don’t know, I don’t know,” the patient mumbled. He kept shrugging and shaking his head, avoiding eye contact with the resident who was interviewing him. He was slumped in his chair. “It just hurts all over,” he said again, as he gestured towards the right side of his body. He made a big sweeping motion with his arm to show us. Was he indicating his leg? His abdomen? Whenever he motioned, he showed us a different body part.

The emergency department was noisy as usual, with nurses and therapists squeezing behind us to get by. The rooms were full, so the man we were interviewing was parked in a chair in the middle of the hallway. A first-year resident, a nurse, and I, a medical student, formed a wall around this man. He looked small in his baggy jeans and sweatshirt, and he seemed even smaller from my view looking above him. I wanted to kneel to see him at eye level, but the resident I was shadowing was standing, so I continued to stand too.

The resident persisted in his unfalteringly chipper voice, “Well, for me to help you, Sir, we must know exactly what happened. Do you know if you hit your head when you fell? Try to remember.” The patient repeated that he did not know what happened, and then asked when he could get some food. I was getting increasingly uncomfortable. The resident kept trying to rephrase the same questions to get more information about this patient’s reported fall, but I knew he was going to get the same response from this man despite his sincere efforts. The man just wanted food. I thought, could we just give him one of the sandwiches from the emergency department fridge and be done with it? It was agonizing to continue questioning him in the busy hallway.

The resident had finally given up trying to get a history from this man, so I followed him back to the nursing station where he stuttered out to the attending physician that he thought we should order an x-ray or a CT scan to make sure there was nothing serious going on. The attending asked, “How far do you want to go with this? Does this patient’s story match up with what is going on here?” I felt embarrassed observing this encounter to begin with, and now the attending physician’s evaluation of the resident’s decision-making was making me feel embarrassed for the resident. “Well, uh, you know, I just do not want to let my, uh, biases get in the way of my medical decision-making. You know what I mean?” I knew what he meant. Not once did anyone mention the word ‘homeless’ in conversation to describe the man in the sweatshirt for fear of sounding biased, but we all knew that he was clearly struggling.

The next morning, the weather was cold and rainy with freezing temperatures. I wore my earmuffs on the walk to the hospital that morning, wishing my walk was not so far, when I passed by someone in a sleeping bag under a bus stop, unfortunately not an uncommon sight in Washington, DC. He was wrapped up tightly in his sleeping bag; I could not see any part of his body. The sleeping bag was soaking wet. Water dripped down to join the puddles on the wet sidewalk where this person’s feet were propping up the sleeping bag. I shivered thinking about how cold it must be, to be wrapped up in a wet sleeping bag in this weather. I thought back to the patient in the emergency room the previous evening, thinking about how cold he must have been outside. His sweatshirt had been big, but not warm enough to withstand the cold and rain. I considered what it must be like to be a patient who must undergo a barrage of invasive questions and tests to get a meal or to have a dry bed to sleep in.

The Housing First approach to homelessness advocates the need to provide individuals with permanent housing primarily, rather than using a stepwise approach with an end goal of securing housing. This approach has been proven to save money for communities, decrease interactions with law enforcement, and decrease the amount of time unhoused people spend in the hospital. In DC, where I study, local organizations, such as Pathways to Housing DC, use the Housing First model to help people who are experiencing chronic homelessness. Pathways to Housing DC assists its clients with finding stable housing first, and then each client is matched with a support team that can provide client-centered wraparound services including but not limited to psychiatric care and addiction counseling. This model of providing permanent housing first has received bipartisan support and has shown itself to be the most successful way to keep people housed and on a path to recovery. For example, Pathways to Housing DC has proudly been able to keep at least 89% of its clients, who were previously considered ‘treatment-resistant,’ permanently housed.

Please — if you work in an emergency department, make yourself familiar with the housing policies of your local community. With a concerted effort, it is possible to bring homelessness to functional zero in our community.

When the Emergency Department is Home was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

Today, we find ourselves in an era of escalating international and domestic tension. International conflicts like the ongoing Russian invasion of Ukraine, and domestic conflicts such as civil unrest have the potential to create situations that bring hazardous materials to the doorsteps of emergency departments (EDs). From chemical weapons and even nuclear weapon threats in Ukraine to significant riot control agent uses in the United States, and the ongoing possibility of accidental hazardous material (hazmat) incidents, ED patient decontamination strategies are becoming increasingly important. When patients present to an ED after being exposed to hazardous chemicals, biological agents, or even radiological threats, proper decontamination can be one of the most important actions taken by staff. Immediate decontamination and casualty management can single-handedly keep an ED open by preventing accidental widespread contamination of patients and personnel inside.

As seen historically, failure to properly decontaminate patients can be disastrous. In 1995, domestic terrorists released Sarin gas, a nerve agent, within the Tokyo subway system. Patients were rapidly transported from the scene without field decontamination. When they arrived at St. Luke’s hospital, only the most seriously ill were decontaminated. The hospital had no pre-planned decontamination areas, and the only personal protective equipment (PPE) staff wore were surgical gloves and masks, which are inadequate to protect against Sarin. As a result, approximately one-quarter of the ED staff showed signs of nerve agent exposure from secondary contamination. Exposures without proper decontamination can cause significant ED disruption even if they are not immediately life-threatening. Riot control agents like tear gas can lead to large numbers of ED patients covered in irritative, but not deadly, substances after usage in cases of civil unrest, which unfortunately has been significantly more common in the last decade.

Competency in field mass decontamination is standard for hazmat responders in the US and should ideally occur at the scene. However, decontamination capabilities are equally important in the hospital setting, as many patients are transported separately from emergency medical services. Most EDs have pre-planned procedures and trained staff to receive potentially contaminated patients but some still rely solely on local hazmat teams or fire departments to provide this service. In the wake of a disaster, when first responders are responding to the scene of incidents, EDs should be able to rapidly implement mass decontamination on their own. The best way to do this successfully is with ongoing training and preparedness. The Occupational Safety and Health Administration (OSHA) mandates those responsible for these tasks to have initial and yearly training. Federally funded training is available at the Center for Domestic Preparedness, but hospitals may need to go beyond once-yearly training to have sufficient proficiency.

In a time of rising hazmat threats, EDs need to be significantly more prepared to decontaminate patients if necessary. Hospitals should train regularly, and staff should have significant proficiency, not just minimum competency, in decontamination techniques. Universally, there needs to be an understanding that even a low index of suspicion may be appropriate to activate mass decontamination protocols to protect healthcare workers alongside the public. Allowing contaminated patients to enter the ED prior to decontamination could exacerbate an already catastrophic situation.

Patient Decontamination; A Last Line Defense Keeping EDs Open During Disasters was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

A New Therapy

The FDA authorization of Pfizer’s Paxlovid (nirmatrelvir/ritonavir) antiviral therapy for mild-to-moderate symptomatic COVID-19 represents the introduction of the newest and potentially the most potent pharmaceutical intervention to mitigate COVID-19 disease severity. Other pharmaceutical interventions utilized throughout the COVID-19 pandemic have failed to prevent a deluge of hospital admissions, many of which led to prolonged hospital stays, severely limiting both ICU and general medicine floor capacities. Monoclonal antibodies (mAbs) remain a promising therapy that could prevent hospital admission outright or reduce the length of stay, but many of these options do not appear to withstand viral evolution with the proliferation of the Omicron variant. In addition, the remaining Omicron-responsive mAbs remain extremely constrained by supply and the challenges with delivering IV infusions. Now recently authorized, the NIH recommends Paxlovid as the preferred treatment for high-risk, non-hospitalized patients over the still Omicron-responsive mAbs based on the EPIC-HR trial.

Creating a Plan

Simultaneously, reported COVID-19 cases have taken a sharp downturn while the distribution of Paxlovid continues to ramp up. As of now (March 2022), Paxlovid is available at every approved DC pharmacy, as well as in other states, though in limited quantities. By the end of June 2022, Pfizer estimates that 10 million doses will have been delivered throughout the United States, with 10 million additional doses available by the end of 2022, enough for 6% of the U.S. population. Given that the Paxlovid supply will soon be far greater, healthcare systems must act during this relative lull in COVID-19 cases to consider how Paxlovid will be most efficiently distributed should the level of cases rise.

Any institutional plan to administer Paxlovid on a mass scale must incorporate early diagnosis and prioritization of high-risk groups. The EPIC-HR trial investigated the efficacy of Paxlovid within 5 days of symptom onset. The trial also showed the most benefit in groups such as those who were SARS-CoV-2 seronegative and 65 years or older. Central to the effective use of this new antiviral therapy will be the promotion of COVID-19 testing as a social norm as public health restrictions and mask mandates are rolled back. Local public health messaging must emphasize that a “return to normal” is driven mostly by the availability of pharmaceutical interventions (vaccines, antivirals, and mAbs) in addition to low baseline rates and high rates of vaccination. This emphasis ensures that the public continues to test and seek treatment expeditiously in the event of a positive result.

Test Early, Prescribe Early

While a robust primary care system may be best suited to test for COVID-19 and determine Paxlovid eligibility and benefit, emergency departments will inevitably see undiagnosed cases of mild to moderate COVID-19 in high-risk individuals, particularly during future surges where immediate access to outpatient healthcare may be strained. As such, emergency departments may be stewards in the proliferation of this new therapy requiring standardization of their criteria for high-risk individuals and broadening of these criteria if the supply of Paxlovid allows. Patients not meeting criteria for severe COVID-19 illness could be tested, prescribed Paxlovid to be taken outpatient, and discharged within a few hours without taking up emergency department beds.

Paxlovid remains a promising therapy due to its potential to alter the disease course of COVID-19, the unlikelihood of viral evolution if used judiciously, and its lack of controversy as compared to other pharmaceutical options (i.e., vaccines). It should be noted Paxlovid arrives at a time when SARS-CoV-2 has evolved to be seemingly less virulent, and the general population has immunity through vaccination or prior infection. In January, the Omicron wave is suspected of having infected 40% of the U.S. population. As a result, patients who are high-risk may not follow the same disease time course as clinicians have seen to date.

Impact of Paxlovid

Paxlovid may mitigate COVID-19’s burden on hospital admissions in high-risk populations, clearing up space in overwhelmed and overburdened emergency departments. A reduction in testing could be problematic to the use of Paxlovid during times of low caseloads. If used appropriately in conjunction with a priority on early and accessible testing, Paxlovid may represent a life-saving tool to complement vaccine-derived immunity in high-risk groups. This has beneficial implications for the ability of emergency departments to function, beyond the obvious benefit to mortality caused by COVID-19.

Considering Paxlovid’s Role in the Emergency Department Setting was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

Emma Wellington

Imagine a healthcare system where prices are transparent, insurance plans do not rapidly change, and free resources are accessible to anyone in need. While this idea may seem far-fetched, there are organizations working to reduce the burden of hidden costs and non-transparent healthcare billing. Digital tools may be a solution to navigating the billing of fee-for-service and ACO (Accountable Care Organization) care for Medicaid and Medicare users. In addition to federal programs, creating platforms for private insurance that tackle the lack of cost consistency could transform the healthcare experience for many. By reviewing the gaps in billing for Medicaid, Medicare, Private Insurers, and High-Risk payors, researchers can determine areas that would benefit from app development and create a comprehensive solution.

Medicaid

Medicaid has experienced a massive shift in coverage since the beginning of the COVID-19 pandemic, and these changes add to the pre-existing confusion that plagues patients. The Institute for Family Health implemented a patient portal that connected MyChart with MedlinePlus Connect, offering patients hyperlinks that took them from complex medical terminology to language that was more accessible. By monitoring the use of these hyperlinks, researchers found that Medicaid patients utilized this resource frequently, signaling the crucial importance of tools such as these and room for growth with app development.

The lack of consistency between Medicaid fee-for-service and Medicaid managed care organization plans is another key issue for patients with Medicaid. Researchers reveal that identical telehealth visits carried out in the same state may vary in coverage depending on whether the patient is visiting a Medicaid fee-for-service or managed care organization. Without developing platforms that increase billing transparency, we continue to send patients through a confusing and frustrating maze of billing. The process of selecting care needs to be streamlined in a way that provides patients with prices that they can choose from, like those found in FH Healthcare Cost Estimator.

Medicare

Digital health measures implemented by Medicare have also transformed rapidly since the beginning of the pandemic, thereby decreasing the simplicity of billing. Before the COVID-19 pandemic, Medicare targeted their telehealth efforts to patients within rural areas, reaching demographic populations at an elevated risk for experiencing barriers to care. This structure changed on March 17, 2020, due to the COVID-19 pandemic, and this past year Medicare Advantage began to broaden their telehealth services accordingly. Due to the pandemic, it is no longer necessary for patients to meet their virtual providers at “originating sites”. Instead, home visits are the standard and make telehealth utilization simpler.

While telehealth operated in “originating sites” for fee-for-service organizations before the pandemic called for vast expansion, digital modes of treatment were less common for ACOs (accountable care organizations), regardless of Medicare’s previous attempts to increase telemedicine. Not only were ACO telemedicine visits uncommon overall, but this resource was more frequently used by non-ACO providers. Researchers hypothesize that this could be a direct result of the cost sharing risk of the organization. For example, if ACOs are taking part in one-sided risk structures, then the cost savings of telemedicine are not a large incentive when overspending suffers no penalty. Further, adding lack of reimbursement, due to strict requirements, combined with the low occurrence of established ACOs in rural communities appeared to make telehealth visits before COVID-19 more hassle than benefit for providers.

Private Insurance

Although the growth of digital health is frequently associated with changes in Medicare and Medicaid coverage, there is also a space within the medical field to learn about how private insurance coverage is related to digital healthcare. According to one report by Regence on BlueCross BlueShield, it is possible to save $100 per visit in a telehealth appointment compared to seeing a physician in their office, when clinically appropriate. In a comparison between the 25th and 75th percentile of income for adult patients, anywhere from $14-$39 can be saved through decreased car mileage, travel time, and wait time. When compounded with a decreased $75 cost for out-of-pocket (OOP) prices from the physician’s office, there is the potential for significant cost benefit. Other insurance companies, such as Aetna, also offer low-cost telehealth solutions due to the COVID-19 pandemic. Teladoc® visits are offered for a maximum of $45 when a patient is covered by any of their full insurance plans. The insurance company also provides a toll-free, 24-hour hotline for nurse consultations, showing how digital care billing can truly be transparent and accessible.

Information on private insurance coverage is available on individual company websites, but there is not enough academic literature on this topic. This lack of data signals a gap in knowledge surrounding different private insurance plans in relation to digital health and is a scary reality that represents the variability between plans and the confusion that digital health can cause both providers and their patients. Insurance plans vary, billing codes are ever-changing, and certain coverage laws fluctuate by state. For example, telehealth parity laws only cover 31 states and Washington, D.C. while teleradiology is covered by all 50. Alas, coverage for services rendered is unique to the private insurance provider, as well as their state, and are constantly in flux.

Uninsured/Hard-to-Reach Populations

A payor population that is commonly overlooked in healthcare is the uninsured. Uninsured patients are a hard-to-reach population that may benefit from digital healthcare. Unfortunately, digital health may have a negligible effect if not properly utilized, and patients can be further separated from their care due to the digital divide. One issue that needs to be overcome is the lack of “online health-management tools” that are used by uninsured populations. Researchers predict that older populations using these online tools are the same patients that are able to receive preventive services in the first place, emphasizing that it is critical to brainstorm ways to increase access to free online tools for patients who are not regularly seen by a provider.

When implementing a digital health solution, providers must focus on how to overcome barriers to access for the use of online tools in high-risk populations. A platform is needed to provide educational materials to the uninsured. While FH Healthcare Cost Estimator is a start to teaching app users the basics of insurance and health definitions, providers should also use applications to distribute educational sources regarding diagnostic information. The remaining barrier is finding how to do so in a means that reaches more than just those patients already receiving care.

Conclusion

Healthcare is not one-size-fits-all, but there is the potential that one app could solve questions of billing, keep patients up to date on policy changes and options, and increase access to healthcare materials. By creating applications for hard-to-reach populations and teaching those patients how best to utilize these resources, providers have the potential to determine gaps in digital outreach and how to address them.

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How digital health expansion has shined a light in the opaque system of healthcare was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

People experiencing homelessness represent a disproportionately high share of US (United States) Emergency Department (ED) visits. Since 2015, homelessness, like other social and structural determinants of health, has been considered a diagnosable condition in the International Classifications of Diagnosis (ICD) codebook. US EDs have long assumed the role of a safety net for the most vulnerable in society and many people experiencing homelessness may not have an alternative avenue to obtain medical care. However, it takes more than a single ED physician or one ED encounter to provide the comprehensive support needed by most people experiencing homelessness. It is one thing for a physician to treat a rash, administer a breathing treatment, or refill medication, but an integrated system is required to address the larger issues of housing instability, access to care, food insecurity, violence, mental health disease and risky substance use. How do EDs avoid applying Band-Aids to wounds that require more definitive care?

By working closely with social services, the ED has the potential to help our unhoused patients at a level that is not merely superficial. This requires a different priority-set than applied to most ED patients. For the typical ED patient with secure housing, the main purpose of the visit is to address the chief complaint; linkage with social services is a distant secondary goal. For patients with housing insecurity, the priorities are often reversed. Linking unhoused patients with local social services and addressing barriers to health created by their lack of safe housing is often the most important part of the care provided. In places such as Washington, DC, optimal ED care may mean reaching out to Community Connections, a community organization that provides residential services, and primary health care coordination for marginalized and disenfranchised people who are coping with mental illness, addiction, and the aftermath of trauma and abuse. It may mean seeking out a patient’s Assertive Community Treatment (“ACT”) team to make sure that someone checks on the patients for follow-up mental health treatment. Sometimes, the most important part of an ED medical interaction is simply providing a sandwich and a warm place to be for a few hours.

Tackling challenging social determinants of health requires rethinking how we finance healthcare care. Many states have begun allowing Medicaid funds to pay for programs that address essential needs but have traditionally been considered out of the scope of healthcare services. In January 2021, the Centers for Medicare and Medicaid Services (CMMS) established guidelines for how funds can be allocated for such programs. Each state institutes its own criteria for how individuals qualify, though experiencing homelessness or being at risk of experiencing homelessness is inclusionary for all states. Pilot programs are currently underway across the country, and as data emerges, we will be able to further refine and streamline this approach.

While it is unrealistic to think that EDs will ever be able to address all social needs in addition to providing 24/7 acute unscheduled medical care, the ED does aim to meet the patients’ needs as they present. Better integration with partners and services that provide affordable housing, substance use treatment, transportation, legal assistance, and mental health services is critically needed for unhoused patients. EDs require further legislative and leadership support for locally responsive, collaborative, innovative approaches to address entrenched social inequities that play out in the healthcare system.

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David Bronstein is a first year medical student at the George Washington University School of Medicine and Health Sciences interested in the intersections of clinical care delivery, health policy, and public health. He attended the University of California, Davis, for his undergraduate education and received a Master of Public Health in Health Policy from the Mailman School of Public Health at Columbia University prior to attending medical school.

Addressing Homelessness through the ED was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

A useful biomarker is a measurable substance whose presence can improve risk stratification, minimize the use of unnecessary procedures, and more quickly direct the patient to appropriate management. The most effective biomarkers, such as troponin for myocardial infarction, are routinely incorporated into the standard work-ups of patients with undifferentiated chest pain in the ED. Unfortunately, there is no troponin equivalent for patients who present to the ED with potentially serious causes of abdominal pain such as appendicitis or intra-abdominal abscess.

Messenger RNA (mRNA) represents a novel class of biomarkers. Specific diseases may be associated with a detectable mRNA fingerprint that could improve our diagnostic capabilities. A growing sector of diagnostics already utilizes RNA to produce actionable clinical information. For instance, Oncotype Dx is an FDA-approved test used to evaluate the risk of recurrence in patients with a particular type of early-stage breast cancer[1]. Differential RNA expression is also associated with the activation of circulating neutrophils[2]. Likely, the RNAs code for proteins that have important functions in innate immunity and are associated with host responses to bacterial biofilms, which are involved in the pathogenesis of diseases such as acute appendicitis. By examining specific changes in these mRNA biomarkers, we may improve clinical decision-making and rule-out or rule-in the presence of an internal infection.

Studies are ongoing at George Washington University to evaluate the clinical utility of mRNA biomarker to diagnose acute appendicitis and other intra-abdominal infections. The application of this technology to address gaps in diagnostics is an exciting development in medicine. According to Genetics professor Dr. Tim McCaffrey, “RNA-based diagnostics represent a largely untapped resource for diagnostics that are extremely flexible and can be quantified very precisely. We see opportunities for improved physician guidance in almost every medical specialty.” Emergency Medicine professor Dr. Andrew Meltzer adds that “Abdominal pain is the most common presenting complaint in the ED and RNA research is focused on improving diagnostic testing modalities to provide early risk stratification and diagnosis.”

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Reference List

1. Kwa M, Makris A, Esteva FJ. Clinical utility of gene-expression signatures in early stage breast cancer. Nat Rev Clin Oncol. 2017;14(10):595–610. doi: 10.1038/nrclinonc.2017.74 [doi].

2. Chawla LS, Toma I, Davison D, et al. Acute appendicitis: Transcript profiling of blood identifies promising biomarkers and potential underlying processes. BMC Med Genomics. 2016;9(1):40-y. doi: 10.1186/s12920–016–0200-y [doi].

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Tristan Jordan is a second year medical student at The George Washington University School of Medicine and Health Sciences, with an interest in translational medicine and global health. He has previously worked as a research fellow at the National Institute of Allergy and Infectious Diseases.

In Pursuit of a Clinically Useful Biomarker for Abdominal Pain, is mRNA the Answer? was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

Emma Wellington

From the moment that we are born, we learn to lean on our communities. There is an innate human desire to hear stories from others, to gain insights, and listen to advice. Community is a basic need, and language is how we, as humans, make it happen. In the past, we depended on letters and house phones. Cell phones have become pivotal in the modern world, and human interaction, once complex and diverse, have been confined to the illuminating glow of electronic screens. The use of technology has great potential, both to bring us together and drive us apart. By replacing the old phrase “I heard it through the Grapevine” with “I saw it on social media,” digital developments have created a deeper divide between those who have access to technology and those who continue to rely solely on word of mouth. It is human nature to talk, but as Dr. Lisa Fitzpatrick of Grapevine Health — a digital literacy organization — states, we need to start listening.

Listening to those facing healthcare inequities begins with the addressing the digital divide. The digital divide is a term used to describe how some members of a community have preferential access to digital health tools [1]. The digital divide is evident in several groups, specifically the elderly, rural populations, ethnic and racial minorities, and patients with chronic health conditions [3]. In order to combat the digital divide, one must understand the complex characteristics of these populations and efforts that can be made to improve their quality of healthcare. Many patients are members of more than one of these two groups at risk for experiencing digital disparities.

Digital Divide in Elderly Communities

The digital divide affects many communities, but one that is frequently overlooked is the elderly population. The term for the phenomenon of the digital divide faced by the elderly is the “gray divide,” and it is growing more prominent due to the COVID-19 pandemic [2]. While COVID-19 has shown to both increase the general incidence of mental illness and psychiatric disorders [2, 7, 8], as well as created a more challenging environment for those who have already been diagnosed [2,9]. These outcomes are more pervasive among the elderly [2,10].

As the medical field has recently turned to the use of digital health to access hard-to-reach populations, we are still at a loss on how to contact the elderly. Both low- and high-income elderly populations demonstrate highly negative feelings towards technology usage and incorporating it into their lives and healthcare [2,13]. Therefore, community programs teaching technology usage skills may benefit elderly populations and decrease the gray divide [2]. However, while these programs may be useful, it is also important for healthcare professionals to recognize the intertwined nature of these communities

as they relate to the digital divide. Without facing all aspects of the digital divide that relate to a patient, who may be taking on roles from many communities, we risk losing the ability to create access for all.

Digital Divide in Rural Communities

Rural communities are another known hard-to-reach population, and the isolation caused by COVID-19 has created a widened gap for medical professionals due to the digital divide [3]. One area of interest for researchers is rural Wisconsin [3]. In these communities, older patients with limited access to technology focus on developing “informal social safety nets” in person [3]. This phenomenon was also found to be true for adult populations with barriers to receiving healthcare [3]. While it is possible, to a degree, to maintain “informal social safety nets” through socially distanced programs, these efforts do not eliminate the greater need for digital health outreach to combat the growing divide [3]. One possible solution is to establish community centers [2] in low-income rural communities aimed at reducing the digital divide. These centers can decrease sole dependency on these “informal safety nets” and provide an alternative means to access health information and social support. Furthermore, by creating a network between community centers and local hospitals, multiple stakeholders would be involved in patient care, allowing providers to offer personalized patient treatment aimed at best supporting patients.

Digital Divide in BIPOC Communities

Racial and ethnic minorities are further suppressed by the digital divide. In one analysis, while black and white populations had nonsignificant differences in youth technology usage, this relationship changed in adulthood [4]. African Americans were less likely to use healthcare technology when compared to whites as they aged [4]. Additionally, when looking at older Hispanic and African American populations, it was found that when compared to whites, there was a decrease in use of health-related phone calls and websites [4]. Hispanic populations in underserved communities, also were reported to show inconsistencies in patient ability to perform web skills [14,15]. It is possible that these differences may be due to language barriers [4,14] that increase the likelihood for English-based technology to be inaccessible for non-English speakers [4].

It is possible that we may be able to decrease the digital divide for racial and ethnic minorities by increasing access to digital health. In one study, researchers found that evidence-based digital health programs for parents have the potential to combat the harmful effects of chronic stress on adolescents due to racism [4,16]. Parents who were assigned to digital intervention groups enrolled more frequently in the program and had higher retention rates compared to the control group, suggesting that digital interventions are in fact successful in engaging parents and may possibly decrease the risky behaviors of their adolescents [4]. This data illustrates how combating the digital divide can be life changing, affecting generations of communities.

Barriers for patients with Chronic Medical Conditions

Patients with chronic illness are represented in all of the communities previously mentioned and they present with unique needs. Ongoing care is challenging to sustain, and it has been found that quality of life declines when chronic illness is combined with rural locality [6]. Interventions for this patient population are needed, but they are difficult to implement when patients are far from their providers. In one study,

researchers debated if the benefits of digital health for cancer patients in Central Virginia could truly overcome given limitations [6]. It was determined that only 58% of patients were able to access broadband networks and that the travel time to a telemedicine site was approximately 30 min [6]. Additionally, even when given a tablet, some patients lacked the digital literacy to use them effectively, which reduced the benefit of the intervention [6].

Conclusion

The digital divide highlights a huge area for improvement within the healthcare system with regards to accessing care. The elderly, rural populations, racial and ethnic minorities, and chronically ill patients make up a large portion of healthcare communities, so the need to reduce the digital divide among these groups is pressing. By working with individual patients, recognizing and respecting backgrounds, and determining how to best offer resources to members of overlapping high-risk digital divide communities, we have the potential to understand and combat digital barriers and improve patient outcomes by providing access to regular, continuous care.

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Acknowledgements

A special acknowledgement to Dr. Lisa Fitzpatrick of Grapevine Health for her contribution to this research brief.

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Reference List

1 — Van Dijk, J. The digital divide. John Wiley & Sons; 2020.

2 — Martins Van Jaarsveld G. The effects of COVID-19 among the elderly population: A case for closing the digital divide. Frontiers in Psychiatry. 2020;11:577427–577427. https://doi.org/10.3389/fpsyt.2020.577427.

3 — Hansmann KJ, Cotton QD, Kind AJ. Mind the gaps: Supporting key social safety nets across the digital divide in rural Wisconsin. Wisconsin Medical Journal (Madison, Wis). 2020;119(4):227–228. https://wmjonline.org/wp-content/uploads/2020/119/4/227.pdf.

4 — Mitchell UA, Chebli PG, Ruggiero L, Muramatsu N. The digital divide in health-related technology use: The significance of race/ethnicity. The Gerontologist. 2019;59(1):6–14. https://doi.org/10.1093/geront/gny138.

5 — Murry VM, Berkel C, Liu N. The closing digital divide: Delivery modality and family attendance in the pathways for African American success (PAAS) program. Prevention Science. 2018;19(5):642–651. https://doi.org/10.1007/s11121-018-0863-z.

6 — DeGuzman PB, Bernacchi V, Cupp CA, et al. Beyond broadband: digital inclusion as a driver of inequities in access to rural cancer care. Journal of Cancer Survivorship. 2020;14(5):643–652. https://doi.org/10.1007/s11764-020-00874-y.

7 — Ahmed MZ, Ahmed O, Aibao Z, Hanbin S, Siyu L, Ahmad A. Epidemic of COVID-19 in China and associated psychological problems. Asian Journal of Psychiatry. 2020;51:102092–102092. https://doi.org/10.1016/j.ajp.2020.102092.

8 — Meda N, Pardini S, Slongo I, Bodini L, Rigobello P, Visioli F, et al. COVID-19 and depressive symptoms in students before and during lockdown. MedRxiv [Preprint]. 2020. https://doi.org/10.1101/2020.04.27.20081695.

9 — Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav. Immun. 2020;87:100–6. https://doi.org/10.1016/j.bbi.2020.04.069.

10 — Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatr. 2020;7:e19. https://doi.org/10.1016/S2215-0366(20)30079-1.

11 — Geerlings MI, Schoevers RA, Beekman ATF, Jonker C, Deeg DJH, Schmand B, et al. Depression and risk of cognitive decline and Alzheimer’s disease. Br. J. Psychiatr. 2000;176:568–75. https://doi.org/10.1192/bjp.176.6.568.

12 — Sachs-Ericsson N, Joiner T, Plant EA, Blazer DG. The influence of depression on cognitive decline in community-dwelling elderly persons. Am. J. Geriatr. Psychiatr. 2005;13:402–8. https://doi.org/10.1097/00019442-200505000-00009.

13 — Friemel TN. The digital divide has grown old: determinants of a digital divide among seniors. N. Media Soc. 2016;18:313–31. https://doi.org/10.1177/1461444814538648.

14 — Chesser A, Burke A, Reyes J, Rohrberg T. Navigating the digital divide: A systematic review of eHealth literacy in underserved populations in the United States. Informatics for Health & Social Care. 2016;41(1):1–19. https://doi.org/10.3109/17538157.2014.948171.

15 — Moore M, Bias RG, Prentice K, et al. Web usability testing with a Hispanic medically underserved population. J Med Libr Assoc. 2009;97:114–21. https://dx.doi.org/10.3163%2F1536-5050.97.2.008.

16 — Berkel, C., Murry, V.M., Hurt, T.R. et al. It takes a village: Protecting rural African American youth in the context of racism. J Youth Adolescence. 38, 175–188 (2009). https://doi.org/10.1007/s10964-008-9346-z.

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Emma Wellington is a second-year medical student at George Washington University School of Medicine and Health Sciences. She is passionate about creating equitable care through medical technology, especially in the realm of mental health services.

Grapevine or Screen Time? The digital divide is making communication less organic. was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

Vera Pertsovskaya; Divya Shan; Andrew C. Meltzer, MD

Additional Risk Factors for Restraint Use

In addition to race, other patient characteristics are associated with the use of restraints. In a cross-sectional study conducted of patients with physical restraint orders from five adult EDs in New England from 2013 to 2015, the median age of restrained patients was 47 years, and 67% of the patients were men. Moreover, 48% of the sampled patients were unemployed, and 45% had Medicaid insurance. Thus, patients who were male and had public or no insurance were more likely to be physically restrained. When examining patient history, it was found that 69% of the patients had a history of alcohol or drug use and 62% had a history of psychiatric illness (Wong et al., 2019). Especially among the younger patients, there was a strong association between alcohol and drug use and being physically restrained.

A mixed methods study of ED staff corroborates this finding, indicating that alcohol and substance use were associated with high rates of patient agitation and the use of restraints (Wong et al., 2018). A study conducted at the Massachusetts General Hospital from 2016 to 2018 similarly found that ED patients with diagnoses related to substance use or psychotic and bipolar disorders were more likely to be restrained. This study also found that patients who had a history of violence or homelessness also had a greater chance of being restrained (Schnitzer et al., 2020).

Overall, two significantly different cohorts of patients with physical restraint orders were identified: (1) a younger, predominantly male population with chief complaints of alcohol or drug use and (2) an older population with medical complaints. When looking at the reasons for restraint, a majority of the patients in Cohort 1 were restrained because they presented a danger to themselves or others, whereas a majority of the patients in Cohort 2 were restrained because they were unwilling or unable to follow commands (Wong et al., 2019). Thus, factors such as age, sex, diagnosis, insurance, homelessness, and violence have their own independent effects on the use of restraints in EDs.

Moving Forward

As restraints may lead to an erosion of trust between the patient and the healthcare team, they should be used only as a last resort and after all other interventions have proven to be unsuccessful. Several programs, such as “No Force First’’ (Ashcraft et al., 2008), “Engagement Model” (Borckardt et al., 2011), and “Six Core Strategies” (National Association of State Mental Health Program Directors., 2011), have proven to be effective at reducing and preventing the use of restraints. These programs should be carefully examined by hospital administrators and adopted if applicable.

It is important that medical institutions conceive of protocols to promote interdisciplinary partnerships between security, nursing, and hospital leadership to mitigate racial bias. One solution is to encourage staff to collaboratively debrief after a patient is restrained in order to analyze what events preceded the event and identify whether de-escalation could have occurred at any point prior. This debriefing is similar to what many hospitals do after a CPR event and will allow facilities to address underlying causative factors and potential implicit bias. Furthermore, diversity training and cultural competence courses will decrease the rate of non-conscious stereotyping (Stone et al., 2011). By having each member of the healthcare team made more aware of their implicit bias, the rate of restraint utilization among minority patients can be reduced.

Ashcraft, A. (2008). Rein in seclusion and restraints. They are not compatible with recovery-oriented services. Behavioral Healthcare, 28(12), 6–7.

Borckardt, M. (2011). Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services (Washington, D.C.), 62(5), 477–483. https://doi.org/10.1176/appi.ps.62.5.477

National Association of State Mental Health Program Directors (NASMHPD), 2011. National Executive Training Institute: A Training Curriculum for the Reduction of Seclusion and Restraint, 9th edition National Association of State Mental Health Program Directors, Office of Technical Assistance, Alexandria, VA.

Stone, J., & Moskowitz, G. B. (2011). Non-conscious bias in medical decision making: what can be done to reduce it?. Medical Education, 45(8), 768–776. https://doi.org/10.1111/j.1365-2923.2011.04026.x

Schnitzer, K., Merideth, F., Macias‐Konstantopoulos, W., Hayden, D., Shtasel, D., & Bird, S. (2020). Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Academic Emergency Medicine, 27(10), 943–950. https://doi.org/10.1111/acem.14092

Wong, A. H., Ruppel, H., Crispino, L. J., Rosenberg, A., Iennaco, J. D., & Vaca, F. E. (2018). Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department. The Joint Commission Journal on Quality and Patient Safety, 44(5), 279–292. https://doi.org/10.1016/j.jcjq.2017.11.011

Wong, A. H., Taylor, R. A., Ray, J. M., & Bernstein, S. L. (2019). Physical Restraint Use in Adult Patients Presenting to a General Emergency Department. Annals of Emergency Medicine, 73(2), 183–192. https://doi.org/10.1016/j.annemergmed.2018.06.020

The Role of Race on Restraint Use: Additional Risk Factors for Restraint Use and Moving Forward… was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

Vera Pertsovskaya; Divya Shan; Andrew C. Meltzer, MD

Racial Bias in Healthcare

Restraint use, like other disparities in healthcare, can stem from the impact of racial bias in clinical encounters. A disparity, according to the Institute of Medicine in its Unequal Report, is a difference in the quality of healthcare provided to patients that is not attributable to the patients’ wishes or healthcare needs (Smedley et al., 2002). The majority of clinician bias is associated with implicit attitudes, which are unconscious thoughts and feelings that can influence behavior. Clinician bias is common, with physicians often having positive attitudes toward white patients and negative attitudes toward non-white patients (Hall, 2015). A recent systematic review found that health care professionals tend to associate Black patients with being less cooperative, compliant, and responsible in comparison to white patients (Hall, 2015), while another study found that clinicians tend to associate Hispanic patients with medical non-compliance and partaking in risky behaviors (Bean et al., 2013). This bias can manifest in terms of talking to patients with a condescending tone, not providing interpreters when necessary, and not recommending treatment plans due to assumptions about the patient’s likelihood to adhere (Dehon et al., 2017).

Although there is no conclusive evidence to establish a direct relationship between implicit physician bias and clinical decision making (Dehon et al., 2017), implicit bias among healthcare professionals indirectly emerges in terms of access to care, the quality of healthcare received, and health outcomes. For example, a National Healthcare Disparities report found that non-white patients received less patient-centered care and worse overall quality of treatment (U.S. Department of Health and Human Services, 2018). Indeed, analysis of data from 350 EDs across the U.S. found that white patients who present with abdominal pain are nearly three times as likely to be treated with analgesics in comparison to minority patients (Shah, 2015). Additionally, Black patients were both less likely to receive percutaneous coronary intervention after being diagnosed with acute coronary syndrome (Musey, 2016) and thrombolytic therapy for acute ischemic stroke (Aparicio et al., 2015). It also should be noted that even after adjusting for medical comorbidities, Black patients being treated in the ED in comparison to white patients experienced longer wait times and were twice as likely to be triaged to a lower level of acuity (Schrader et al., 2013). These systemic inequities contribute to the higher rates of asthma, diabetes, HIV/AIDS, hypertension, obesity, preterm births, and tuberculosis present among minorities (U.S. Department of Health and Human Services, 2018).

Racial Disparities in Psychiatric Diseases

Disparities are also present between racial groups not only in the access to and utilization of mental health services, but also in receiving appropriate treatment for psychiatric disorders (U.S. Department of Health and Human Services, 1999). While Black patients are 50% less likely to be treated for similar psychiatric disorders as white patients, they are more likely to have chronic conditions, such as major depression (Kessler et al., 2005; Williams et al., 2007). Although it should be noted that research has indicated that clinicians tend to overdiagnose Black patients with schizophrenia (Strakowski et al., 1996). Moreover, when controlling for behavior, traumatic experiences, and other confounding variables, Black adolescents were found to have a higher likelihood of being diagnosed with conduct disorder, whereas white adolescents were more likely to be diagnosed with ADHD (Baglivio et al., 2016). This is significant as these disparities in psychiatric diagnoses and treatments predispose Black patients to poorer health outcomes. These disparities quite possibly arise from the physicians’ implicit biases — physicians who tend to see Black patients as being more aggressive and hostile may diagnose these patients with more severe and chronic disorders. A substantial amount of research, in both the outpatient and inpatient settings, indicates that Black patients are more likely to be seen by healthcare providers as being aggressive which can cause a greater chance of security being called, the patient being involuntarily hospitalized, and placed in both seclusion and in restraints (Rosenfield, 1984; Sleath et al., 1998; Whaley, 1998). For patients who do not have equal access to mental health or drug treatment services, a deteriorating clinical condition may culminate with being restrained in the ED.

Racial Bias in Utilization of Restraints

The lack of standardized thresholds to initiate use of restraints causes the utilization of physical and chemical restraints to be partially determined by the clinician’s implicit bias. Indeed, several studies have indicated that racial disparities are present in the decision to restrain a patient. For example, one study found that 73% of patients who were physically restrained in the ED were Black (Zun, 2003), and another study determined that even when controlling for confounding variables, such as sex, diagnosis, homelessness, age, and violence, Black patients were more likely to be restrained while in the ED (Schnitzer et al., 2020). These racial disparities are consistent even beyond the ED, as a study that used a nationally representative sample of nursing homes in the U.S. found that even when controlling for dementia, fall rate, and ADLs impairments, there is a statistically significant correlation between race and the use of physical restraints (Cassie, 2013). Although states have passed legislation to limit the utilization of restraints in medical facilities, it is clear that a significant racial disparity yet remains.

References

Smedley, B., Stith, A., & Nelson, A. (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academy Press.

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903

Bean, M. G., Stone, J., Moskowitz, G. B., Badger, T. A., & Focella, E. S. (2013). Evidence of nonconscious stereotyping of Hispanic patients by nursing and medical students. Nursing Research, 62(5), 362–367. https://doi.org/10.1097/NNR.0b013e31829e02ec

Dehon, E., Weiss, N., Jones, J., Faulconer, W., Hinton, E., & Sterling, S. (2017). A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 24(8), 895–904. https://doi.org/10.1111/acem.13214

Shah, A. A., Zogg, C. K., Zafar, S. N., Schneider, E. B., Cooper, L. A., Chapital, A. B., Peterson, S. M., Havens, J. M., Thorpe, R. J., Jr, Roter, D. L., Castillo, R. C., Salim, A., & Haider, A. H. (2015). Analgesic Access for Acute Abdominal Pain in the Emergency Department Among Racial/Ethnic Minority Patients: A Nationwide Examination. Medical Care, 53(12), 1000–1009. https://doi.org/10.1097/MLR.0000000000000444

Musey, P. I., Jr, Studnek, J. R., & Garvey, L. (2016). Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation. Criticalathways in Cardiology, 15(1), 16–21. https://doi.org/10.1097/HPC.0000000000000069

Schrader, C. D., & Lewis, L. M. (2013). Racial disparity in emergency department triage. The Journal of Emergency Medicine, 44(2), 511–518. https://doi.org/10.1016/j.jemermed.2012.05.010

Aparicio, H. J., Carr, B. G., Kasner, S. E., Kallan, M. J., Albright, K. C., Kleindorfer, D. O., & Mullen, M. T. (2015). Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers. Journal of the American Heart Association, 4(10), e001877. https://doi.org/10.1161/JAHA.115.001877

(1999) Mental health: a report of the Surgeon General. [Rockville, MD.: Dept. of Health and Human Services, U.S. Public Health Service ; Pittsburgh, PA: For sale by the Supt. of Docs] [Web.] Retrieved from the Library of Congress, https://lccn.loc.gov/2002495357

Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., Wang, P., Wells, K. B., & Zaslavsky, A. M. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. The New England Journal of Medicine, 352(24), 2515–2523. https://doi.org/10.1056/NEJMsa043266

Williams D. R. (2005). The health of U.S. racial and ethnic populations. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 60 Spec No 2, 53–62. https://doi.org/10.1093/geronb/60.special_issue_2.s53

Baglivio, M. T., Wolff, K. T., Piquero, A. R., Greenwald, M. A., & Epps, N. (2017). Racial/Ethnic Disproportionality in Psychiatric Diagnoses and Treatment in a Sample of Serious Juvenile Offenders. Journal of Youth and Adolescence, 46(7), 1424–1451. https://doi.org/10.1007/s10964-016-0573-4

Rosenfield S. (1984). Race differences in involuntary hospitalization: psychiatric vs. labeling perspectives. Journal of Health and Social Behavior, 25(1), 14–23.

Sleath, S. (1998). Patient race and psychotropic prescribing during medical encounters. Patient Education and Counseling, 34(3), 227–238. https://doi.org/10.1016/S0738-3991(98)00030-5

Whaley, A. (1998). RACISM IN THE PROVISION OF MENTAL HEALTH SERVICES: A Social-Cognitive Analysis. American Journal of Orthopsychiatry, 68(1), 47–57. https://doi.org/10.1037/h0080269.

Zun L. S. (2003). A prospective study of the complication rate of use of patient restraint in the emergency department. The Journal of Emergency Medicine, 24(2), 119–124. https://doi.org/10.1016/s0736-4679(02)00738-2

Schnitzer, K., Merideth, F., Macias‐Konstantopoulos, W., Hayden, D., Shtasel, D., & Bird, S. (2020). Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Academic Emergency Medicine, 27(10), 943–950. https://doi.org/10.1111/acem.14092

Cassie, K. M., & Cassie, W. (2013). Racial disparities in the use of physical restraints in U.S. nursing homes. Health & Social Work, 38(4), 207–213. https://doi.org/10.1093/hsw/hlt020

The Role of Race on Restraint Use: Racial Bias in Healthcare, Psychiatric Diseases, and Utilization… was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.

In recent years, the number of patients presenting to Emergency Departments (EDs) in the United States has been increasing.¹ Outpacing that number, however, is the number of patients presenting to EDs who require critical care services.² This surge of critically ill patients, coupled with a growing shortage of critical care capacity nationwide, has led to increasing ED boarding times for intensive care unit (ICU) patients.³ Prolonged ED boarding for ICU patients is well known to be associated with significant increases in mortality and length of stay.⁴ ⁵ This problem, in conjunction with the strain the COVID-19 pandemic has put on hospital systems, requires an innovative solution.

One such possible solution is the ED-ICU. In an effort pioneered by Drs. Scott Weingart of Stony Brook Medicine and Kyle Gunnerson of the University of Michigan, a number of EDs across the country have implemented the ED-ICU model. There is not currently any official certification process to become an ED-ICU. Experts cite four key elements:

1. A dedicated physical area in the ED with both resuscitation bays and inpatient rooms that allow for critical care to be provided.
2. Staffing by an emergency medicine attending who is board certified in critical care 24 hours per day, 7 days per week;
3. Staffing with critical care nursing staff 24/7;
4. Nursing to patient ratio of 1:2 or 1:1.6

There are a number of advantages to the ED-ICU model. Gunnerson et al. demonstrated a significant decrease in adjusted mortality after the implementation of the ED-ICU at the University of Michigan.⁷ Decreases were also seen in mean time to ICU care and overall inpatient ICU admissions. Such early critical care intervention was associated with >$10 million yearly savings along with 3,800 fewer hospital days for the Henry Ford Health System.⁸ Moreover, the ED-ICU has the potential to decrease the burden of “short-stay” ICU admissions. These “short-stay” admissions are typically defined as <1 day and have been shown to make up as many as 38% of ICU admissions.⁹

While there are significant advantages to the ED-ICU, there are a number of challenges in its implementation. First, the establishment of an ED-ICU requires significant investment in both additional staff and physical space. Given the financial impact of the COVID-19 pandemic, such investment is unlikely to be possible for the majority of EDs across the country. Additionally, the model may not be generalizable to EDs that are not a part of tertiary academic centers. Finally, while the ED-ICU model is likely beneficial for the “short-stay” ICU admissions, it may actually delay transfer of critically ill patients to the traditional ICU.

The establishment of an ED-ICU requires significant investment and approval from a broad range of hospital stakeholders. However, with such investment comes the opportunity to improve patient outcomes, decrease boarding times, and decrease the burden on an already strained critical care infrastructure. Such improvements would be particularly beneficial during the current COVID-19 surge that has placed enormous strain on both EDs and ICUs.

References

1. Emergency Department Visits. CDC. https://www.cdc.gov/nchs/fastats/emergency-department.htm. Accessed 11/1/20.
2. Herring AA, Ginde AA, Fahimi J, et al. Increasing critical care admissions from U.S. emergency departments, 2001‐2009. Crit Care Med 2013;41:1197–204.
3. Gunnerson KJ. The Emergency Department’s Impact on Inpatient Critical Care Resources. Acad Emerg Med. 2017;24(10):1283–85
4. Chaflin DB, Trzeciak S, Likourezos A, et al. Impact of Delayed Transfer of Critically Ill Patients from the Emergency Department to the Intensive Care Unit”. Crit Care Med. 2007;35(6)1477–83
5. Mathews KS, Durst MS, Vargas-Torres C, et al. “Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients”. Crit Care Med. 2018;46(5):720–727
6. Weingart SD, Sherwin RL, Emlet LL, Tawil I, Mayglothling J, Rittenberger JC. ED intensivists and ED intensive care units. Am J Emerg Med. 2013 Mar;31(3):617–20
7. Gunnerson KJ, Bassin BS, Havey RA, et al. Association of an Emergency Department-Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions. JAMA network open. 2019; 2(7):e197584
8. Rivers EP, Nguyen HB, Huang DT, Donnino MW. Critical care and emergency medicine. Curr Opin Crit Care 2002;8:600–6
9. Chidi OO, Perman SM, Ginde AA. Characteristics of Short-Stay Critical Care Admissions From Emergency Departments in Maryland. Acad Emerg Med. 2017. 24(10):1204–1211

Dr. Joseph T Brooks graduated from Georgetown University with a B.S. in Human Science and went on to medical school at the University of Toledo. He is currently a PGY-2 in Emergency Medicine at George Washington University Hospital.

ED-ICUs: Instead of Sending ED patients to the ICU, Send the ICU to the ED. was originally published in Urgent Matters on Medium, where people are continuing the conversation by highlighting and responding to this story.