The BEST-MSU study, supported by the Patient-Centered Outcomes Research Institute (PCORI), examined the effectiveness of prehospital diagnosis and treatment of patients with stroke symptoms using a mobile stroke unit with subsequent transfer to a comprehensive stroke center emergency department (CSC ED) for further management, compared with standard prehospital triage and transport by emergency medical services to a CSC ED for evaluation and treatment.
The Grand Rounds session will be held on Friday, November 5, at 1:00 pm eastern. Join the online meeting.
Drs. Semler and Casey are leaders of the Pragmatic Critical Care Research Group, a network of clinical centers conducting comparative effectiveness clinical trials of common interventions in critical care.
The Grand Rounds session will be held on Friday, October 29, at 1:00 pm eastern. Join the online meeting.
In an analysis of data collected as part of EMBED, an NIH Collaboratory Demonstration Project, the rate of opioid overdose visits per 100 all-cause visits to emergency departments rose nearly 30% in 2020. The absolute number of opioid overdose visits increased by more than 10%, even while visits for other life-threatening conditions declined. The findings provide insight into the widespread worsening of the opioid epidemic during the COVID-19 pandemic in the United States.
The study accessed data from 25 emergency departments in Alabama, Colorado, Connecticut, Massachusetts, North Carolina, and Rhode Island. Five of the 6 healthcare systems in the study are participating in EMBED, a pragmatic trial of prescribing practices for opioid use disorder in emergency departments. An amended study protocol enabled the researchers to collect the data as part of an effort to better understand the impact of the COVID-19 pandemic on trial enrollment.
EMBED is supported within the NIH Collaboratory by a cooperative agreement from the National Institute on Drug Abuse and receives logistical and technical support from the NIH Collaboratory Coordinating Center. Read more about EMBED in the Living Textbook, and learn more about the NIH Collaboratory Demonstration Projects.
For more news and resources related to the COVID-19 public health emergency, see our COVID-19 Resources page.
A team of frontline healthcare workers in a level I trauma center recorded observations and summaries of conversations with other healthcare workers and patients about the impacts of a local surge in COVID-19 cases on care delivery.
The ethnographic study at Seattle’s Harborview Medical Center identified impacts in 4 thematic areas, including impacts on procedures, providers, patients, and quality of care. The study also identified strategies healthcare workers used to cope with the physical and mental health demands associated with the pandemic.
The article, published this week in BMJ Open, offers lessons for healthcare systems responding to the COVID-19 pandemic in other settings.
Team members recorded their observations in the context of an ongoing comparative effectiveness trial of multidisciplinary, peer-integrated care coordination for patients with severe injury, and of the ongoing Trauma Survivors Outcomes and Support (TSOS) study. TSOS, an NIH Collaboratory Trial, is a stepped-wedge, cluster randomized pragmatic trial testing the delivery of screening and intervention strategies for patients with posttraumatic stress disorder and comorbid conditions at 24 level I trauma centers in the United States.
This work was supported in part by the Patient-Centered Outcomes Research Institute (PCORI). TSOS is supported within the NIH Collaboratory by a cooperative agreement from the National Institute of Mental Health and by the NIH Common Fund through a cooperative agreement from the Office of Strategic Coordination within the Office of the NIH Director.
For more news and resources related to the COVID-19 public health emergency, see the COVID-19 Resources page.
Edward R. Melnick, MD, MHS
Assistant Professor of Emergency Medicine
Program Director, Yale-VA Clinical Informatics Fellowship Program
Principal Investigator, EMBED Trial
Gail D’Onofrio, MD
Professor & Chair
Department of Emergency Medicine
Yale School of Medicine
Topic
EMBED Update: Challenges and Solutions
Keywords
Embedded clinical research; Buprenorphine; EMBED; Opioid use disorder; Emergency department; Electronic health record; Clinical decision support tool; User-centered design; Clinical informatics
Key Points
Evidence shows that buprenorphine (BUP) treatment for patients with opioid use disorder (OUD) can safely and effectively be initiated from the emergency department (ED). As yet, BUP is rarely initiated as a part of routine ED care. Clinical decision support could accelerate adoption of ED-initiated BUP into routine emergency care.
The EMBED pragmatic trial is evaluating the effectiveness of a user-friendly, web-based clinical decision support tool to enable ED-initiated buprenorphine treatment for OUD. The goal is to optimize the tool’s usability, EHR integration, automation of EHR workflow, and scalability across a variety of healthcare systems.
EMBED is being conducted in 20 EDs across 5 healthcare systems.
Discussion Themes
The study team developed a computable phenotype to identify ED patients with OUD. Validation was conducted through physician chart review.
EMBED clinical decision support is a flexible tool that supports clinicians with varied levels of experience with the intervention by providing one-click options for direct activation of care pathways and user-activated support for critical decision points.
Newer versions of EHR systems have integrated pathways to allow for more automation of clinical decision support.
Corita R. Grudzen, MD, MSHS, FACEP
Vice Chair for Research
Associate Professor of Emergency Medicine and Population Health
Ronald O. Perelman Department of Emergency Medicine
NYU School of Medicine
Topic
Primary Palliative Care for Emergency Medicine (PRIM-ER)
Keywords
PRIM-ER; Emergency department; Palliative care; NIH Collaboratory Trial; Pragmatic trial; Stepped-wedge study design; Clinical decision support; Best practice alerts; Advance care planning
Key Point
The PRIM-ER trial is a pragmatic, cluster-randomized, stepped wedge NIH Collaboratory Trial that will implement primary palliative care in emergency medicine across a diverse group of 35 emergency departments (EDs).
PRIM-ER’s clinical decision support intervention is tailored to each ED site. The study aims to enable system, organizational, and provider change in the emergency department workflow.
The study team is identifying and preparing site champions by conducting communication skills training in serious illness for emergency physicians and staff using the EM Talk program.
Discussion Themes
It is important to consider sustainability of the intervention during the planning phase of the trial. Plan for staff turnover and how new staff will be educated and oriented to the intervention.
The volume and sophistication of best practice alerts (BPAs) received by physicians varies across U.S. emergency departments. Alert “fatigue” can be a concern.
The EMBED pragmatic trial is evaluating a clinical decision support tool designed to automatically identify and facilitate management of eligible patients with opioid use disorder in the emergency department (ED).
From July 2016 to Sep 2017, there was a 30% increase in visits to the ED for opioid overdose (Morbidity and Mortality Weekly Report, March 9, 2018).
With medication-assisted treatment, patients are 2 times more likely to be engaged in addiction treatment at 30 days.
EMBED’s user-centered design aims to streamline workflows, address barriers to adoption, embed ED-initiated buprenorphine into routine ED care, and optimize adoption, dissemination, implementation, and scalability.
Discussion Themes
Poor usability of health information technology (HIT) is major source of frustration for clinicians. Electronic health record usability is a fundamental barrier to implementation of evidence-based medicine.
The science of usability in healthcare is still in the early stages. The EMBED study wants to improve the HIT experience.
How much does the study rely on EHR data for outcomes, and how detailed are the pilot outcomes data requested from each system? How do you plan to verify the accuracy of those data?
