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The 4D Approach -An Effective Strategy to Improve Emergency Department Boarding and Operational Outcomes
No full textEmergency Department (ED) boarding is a nationwide issue that has detrimental effects on morbidity and mortality of patients in the ED. Literature suggests that boarding in the ED is directly correlated with left without being seen rates. To address these challenges at our institution, we implemented the 4D Approach : a homegrown change management methodology designed to drive systemic transformation. The 4D Approach (Desire, Data, Direction, Dedication) involves building desire for change, organizing data to empower decision making, choosing a direction for hospital-wide alignment of goals, and nurturing dedication to the ever-evolving process. We found this approach to have an impact in reducing left without being seen rates and ED boarding despite increasing daily patient arrivals and admissions during the study period at a single tertiary care academic medical center.
Keywords: administration; boarding; change management; crowding; data; dedication; desire; direction; emergency department; healthcare; methodology; operations; strategy; system
The Experiences and Needs of Individuals with a Variant of Uncertain Significance on Genetic Tests for Hereditary Cancer Syndromes:A Grounded Theory Study
No full textObjectives: The use of multigene panel testing to identify hereditary cancer susceptibility has led to a growing number of individuals receiving a variant of uncertain significance (VUS) result. This qualitative study aimed to describe the experiences of individuals with a VUS, with a focus on their communication with healthcare providers (HCPs) and family members.
Methods: This study employed a constructivist grounded theory approach. Participants (N = 20) were recruited between January and July 2021 through social media and nonprofit organizations. Data were collected using semistructured interviews and verified transcripts.
Results: Categories identified included motivations, communication with family, family characteristics, communication with HCPs, other factors affecting the testing experiences, feelings about having a VUS, recall and understanding of the test result and its implications, coping strategies used, and risk management strategies used.
Conclusions: The proposed theoretical model included the key themes impacting the experience: context; decision-making; communication with HCPs and family; and the need for knowledgeable and trustworthy providers; met emotional needs; and open lines of communication. This model provides a framework to be used to meet the needs of individuals with VUS from pre- to post-testing process.
Implications for nursing practice: The proposed theoretical model offers guidance for structuring patient-centered care, emphasizing the importance of trust, continuity, and accessible support from pre- to post-testing. Integrating this framework into nursing practice can enhance patient understanding, reduce uncertainty, and promote informed decision-making regarding risk management.
Keywords: Cancer; Genetic testing; Hereditary cancer; Patient experience; VUS
Recurrent Gastrointestinal Bleeding in Patients With Atrial Fibrillation Treated With Left Atrial Appendage Occlusion
No full textBackground: Concomitant atrial fibrillation (AF) and gastrointestinal (GI) bleeding present a clinical challenge due to recurrent bleeding risk associated with anticoagulation for AF-associated stroke prevention. Left atrial appendage occlusion (LAAO) offers an alternative stroke prevention strategy, but its impact on recurrent GI bleeding remains unknown.
Methods: This retrospective, multicenter cohort study used the TriNetX database to identify adults with AF on oral anticoagulation and a history of GI bleeding. Patients were stratified by treatment with or without LAAO. 1:1 propensity score matching (PSM) was employed. The primary outcome was recurrent GI bleeding. Cox regression analysis was used to generate hazard ratios (HRs) with 95% confidence intervals (CIs). Odds ratios (ORs) were used to evaluate effect sizes between groups. Kaplan-Meier curves were used for time-to-event analyses.
Results: After PSM, 9259 patients were compared in each group. Odds of recurrent GI bleeding were consistently lower in patients undergoing LAAO than without LAAO across all follow-up intervals: at 3 months (OR 0.84; 95% CI 0.78-0.91), 6 months, 1 year, 3 years, and 5 years (OR 0.87; 95% CI 0.82-0.92). Kaplan-Meier analysis demonstrated significantly lower risk of recurrent GI bleeding with LAAO (HR 0.80; 95% CI 0.76-0.84; p \u3c 0.01).
Conclusion: In patients with AF and prior GI bleeding, LAAO was associated with a significantly lower risk of recurrent GI bleeding at short-term and long-term time intervals.
Keywords: LAAO; anticoagulation; atrial fibrillation; gastrointestinal bleeding
The RAMS Hunt: A Multiyear Gamified Approach for Teaching Sex-Specific Medicine at a National Conference
No full textBackground: Sex-specific medicine (SSM) is increasingly recognized as vital for patient care yet remains underrepresented in graduate medical education curricula. Traditional didactics and workshops have limited reach at national conferences. Gamification has emerged as a strategy to increase engagement, though its use in professional networking and conference settings is not well described.
Methods: The Resident and Medical Student (RAMS) Hunt is a novel, gamified, team-based event incorporating topics in SSM, health equity, and professional development. The Hunt was implemented at three consecutive Society for Academic Emergency Medicine (SAEM) Annual Meetings (2023-2025). At each conference, teams visited four city landmarks, completing content-based challenges at each site. Post-event surveys assessed enjoyment, perceived educational effectiveness, and design preferences. Quantitative data were summarized descriptively, and qualitative responses underwent thematic analysis. Future iterations will include pre- and post-event knowledge and attitude assessments to enhance rigor.
Results: Across three Hunts, more than 66 teams registered, and there were 88 completed surveys (Austin 2023 n = 23; Phoenix 2024 n = 48; Philadelphia 2025 n = 17). Mean enjoyment ratings were 4.52, 4.44, and 3.47 (out of 5), respectively. Perceived educational effectiveness ratings were 4.09, 4.11, and 3.47. Participants reported that ideal numbers of challenge sites and participants per team were 3-4. Qualitative themes highlighted enhanced awareness of how biological sex and sociocultural attributes influence health outcomes, the value of interactive learning, and networking opportunities. Logistical barriers included registration, inclement weather including a downpour in Philadelphia, and course navigation.
Conclusions: The RAMS Hunt demonstrated feasibility and strong learner engagement in disseminating SSM content through a novel conference-based gamification model. This innovation offers a replicable framework for integrating experiential, team-based learning into professional society meetings. Opportunities remain to hone game logistics to enhance sustainability and broader adoption. Future evaluations will include objective measures of learning and knowledge retention
Rapidly Progressive Necrotizing Soft Tissue Infection of the Chest Wall After Skeletal Muscle Injury in a Healthy Young Adult Leading to Death: A Case Report
No full textBackground: Necrotizing soft tissue infections (NSTIs) are life-threatening surgical emergencies characterized by rapid tissue destruction, systemic toxicity, and high mortality. Early recognition and aggressive treatment are critical.
Case presentation: A previously healthy 28-year-old male presented with one week of right shoulder and chest wall pain. Initially diagnosed with muscle strains via MRI, he re-presented to the emergency department five days later with hypotension. Blood cultures grew Streptococcus pyogenes, and imaging revealed extensive soft tissue involvement. Emergent fasciotomy and serial debridement revealed NSTI extending from the right shoulder to the scrotum and contralateral shoulder. Despite broad-spectrum antibiotics, debridements, continuous renal replacement therapy, and vasopressors, the patient developed multi-organ failure and died within 24 h of ICU admission.
Conclusion: This case highlights the aggressive nature of NSTIs, the importance of early diagnosis, a non-classical presentation, and the potential for rapid progression to multi-organ failure and death even in young, previously healthy individuals.
Keywords: case report; chest wall infection; group A Streptococcus; multi-organ failure; necrotizing soft tissue infection; septic shock
Isoquercetin and Zafirlukast Cooperatively Suppress Tumor Growth and Thromboinflammatory Signaling in a Xenograft Model of Ovarian Cancer
No full textVirtual Mentored Implementation to Improve Care Transitions in Chronic Obstructive Pulmonary Disease: Protocol for a Pragmatic Implementation Study
No full textBackground: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity among US adults, including recurrent emergency department (ED) visits and unplanned hospital admissions. Despite this, the transition of care (TOC) from the inpatient to outpatient setting remains under-studied.
Objective: The objectives of the Reduce Respiratory Emergent Visits using Implementation Science Interventions Tailored to Setting (Reduce REVISITS) study are to conduct contextual assessments to inform implementation plans for COPD TOC interventions, conduct a cluster randomized trial evaluating implementation over 1 year of COPD TOC bundles, and monitor sustainment of implementation over a 2-year period across 20 sites.
Methods: This pragmatic, multisite study uses a hybrid type II effectiveness-implementation design to evaluate clinical and implementation outcomes of COPD TOC programs across 20 sites. Sites are cluster-randomized to 1 of 4 intervention groups, varying by program delivery method (in-person vs virtual) and implementation strategy (mentored implementation with or without co-design). Sites select evidence-based interventions they wish to incorporate into their COPD TOC program and are randomized to in-person or virtual delivery. During the 1-year active implementation period of the study, assigned mentors will meet monthly with sites (for a total of 12 sessions) to enable on-the-ground troubleshooting of site-specific difficulties with TOC interventions. The primary effectiveness outcome for this study will be COPD-specific acute health care use, defined as a composite of all ED visits and hospitalizations within 30 days of index hospitalization for a COPD exacerbation. The primary implementation outcome will be reach, defined as the proportion of patients receiving their assigned TOC interventions (the whole bundle).
Results: As of August 2025, 21 sites completed the contextual assessments and developed site-specific implementation plans. Publication of the qualitative data from this pre-implementation phase is anticipated in December 2025. Site randomization is complete; sites randomized to co-design have completed 3 sessions. Baseline data collection on use is complete. Implementation-year data collection on use is nearly complete. Year 1 and 2 post-implementation-phase data collection on use is ongoing. Quantitative data analyses of the baseline and implementation-phase reports are nearly complete. Manuscript submission for the primary implementation-phase manuscript is anticipated for December 2025. Manuscript submission for the implementation-sustainment analyses are anticipated for September 2026. Qualitative data collection for year 1 of the post-implementation phase is complete, and analysis is under way. Qualitative data collection for year 2 began in August 2025.
Conclusions: The Reduce REVISITS study will use novel integrated implementation science and human-centered design methodology to investigate bundles of effective COPD TOC interventions with the goal of reducing COPD hospital revisits. The study will evaluate evidence-based programs for effectiveness and implementation across a wide variety of health care sites to ultimately improve outcomes in this high-risk patient population.
Trial registration: ClinicalTrials.gov NCT05568043; https://clinicaltrials.gov/study/NCT05568043.
International registered report identifier (irrid): DERR1-10.2196/82043.
Keywords: COPD; COPD exacerbation; chronic obstructive pulmonary disease; hospital readmissions; hybrid effectiveness-implementation design; transitions of care
Digitally delivered, systemically challenged: A qualitative study of health system readiness for digital care
No full textDigital health technologies (DHTs) expand healthcare access, improve care coordination, and reduce costs. However, integrating these tools into care faces complex barriers. Understanding the perspectives of health system leaders is essential for developing sustainable DHTs. The objective of this project is to explore the experiences and priorities of health system stakeholders regarding the implementation of DHTs. The study team conducted semi-structured interviews with 12 stakeholders from diverse U.S. health systems, including clinical, operational, and executive leadership. Interviewees were selected using purposeful and snowball sampling. Interviews were transcribed and analyzed thematically using the Consolidated Framework for Implementation Research (CFIR). A constant comparative coding process was used to identify and organize key themes. Participants viewed DHTs as a way to enhance healthcare access and efficiency and improve public health operations, especially in rural or underserved settings. However, several major adoption challenges emerged: (1) integrating DHTs into existing workflows and electronic health records is operationally burdensome; (2) digital care can introduce risks to quality, continuity, and equity; and (3) external factors (reimbursement policy, regulatory constraints, infrastructure investment) are critical to long-term adoption. Digital health is seen as essential to the future of healthcare delivery, but meaningful integration requires alignment across clinical, operational, and policy domains. Coordinated investment, regulatory reform, and robust data infrastructure are needed to ensure DHTs are scalable and sustainable
Continuity of Care and Patient Outcomes in Populations With Schizophrenia: A Systematic Review
No full textObjective: Previous systematic reviews have assessed associations between care continuity and health outcomes broadly and specifically for individuals with mental illness. However, little is known about this relationship for individuals with schizophrenia, who may experience substantial barriers to care. This study aimed to systematically review and compare estimates of associations between continuity of care (CoC) and outcomes for individuals with schizophrenia.
Methods: The authors searched PubMed and PsycInfo for articles published in English between database initiation and January 8, 2025, by using search terms related to CoC and outcomes for adults with schizophrenia and related psychotic disorders. Inclusion criteria required measurement of associations between a quantitative measure of CoC and an outcome.
Results: Twenty-nine studies were included, over half of which were published after 2013. More than 60% reported a positive association between increased CoC and improved outcomes. Service continuity was the most widely used CoC measure, with 67% (k=8 of 12) of these studies finding an association with improved outcomes. Approximately two-thirds of studies evaluated hospitalizations as an outcome, with 47% (k=9 of 19) of these studies finding an association with improved outcomes.
Conclusions: Studies varied widely with regard to CoC measures and outcomes measured. Although many studies found a positive association between increased CoC and improved outcomes, this result was not universal. Differences may have stemmed from measurement issues and differences in associations based on populations, service types, and other key study factors. The findings suggest a potential need for standardized CoC measures that can be monitored in clinical practice.
Keywords: Continuity of Care; Mental Health Systems/Hospitals; Outcome Studies; Research/Service Delivery; Schizophrenia