Daniel Keyes

Introduction: Preventive counseling improves long-term health, but primary care clinicians face time constraints limiting patient education. In a prior emergency department pilot study, a brief passive video trended towards increased patients’ willingness to change health behaviors. The current trial, conducted at the primary care clinic, evaluates the feasibility and impact of a short, interactive prevention video delivered during a primary care office visit. Methods and analysis: We will conduct a prospective, randomized, non-blinded clinical trial among adult patients presenting to a primary care clinic. Immediately after their appointment, participants will be randomized to receive either the interactive prevention video or usual care. The video maintains engagement through simple in-video questions and adapts content based on patient responses (e.g., skipping smoking cessation for non-smokers). After the encounter, all participants will complete surveys assessing readiness and confidence to initiate lifestyle change including a transtheoretical “readiness ruler.” Survey items will be drawn from validated instruments, including the Gillespie & Lenz Readiness and Confidence to Participate in Lifestyle Activities Surveys, the Pittsburgh Sleep Quality Index (PSQI), and select questions from the U.S. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. Patients will be asked for medical record access and permission for follow-up contact. Outcomes: The primary outcome is index-visit Lifestyle Readiness and Confidence to Change scores. Secondary outcomes include satisfaction with the clinic visit, intention to change specific lifestyle behaviors, and healthcare use outside the clinic at 30 days and 6 months, as assessed via record review. A 3–12-month follow-up survey will assess self-reported lifestyle changes and new diagnoses. Statistical plan and sample size: Analyses will follow intention-to-treat. Ordinal logistic regression will compare primary outcomes between arms, adjusting for Charlson Comorbidity Index, age, sex, gender, and prespecified predictors. Logistic regression will evaluate binary follow-up outcomes. Complete-case analyses will be used, and differential attrition will be reported. We plan to enroll approximately 350 patients. Trial registration: ClinicalTrials.gov NCT06730737.

Background: The emergency department (ED) may present “teachable moments” for lifestyle medicine (LM) patient education about LM pillars, such as smoking, while they wait. Clinicians may assume that these patients are not motivated to change. This study evaluates readiness to change of ED patients concerning smoking. Methodology: We utilized nested data from the prospective pilot Lifewise prevention study, randomizing lower acuity patients to an evidence-based lifestyle behavior educational video. Patients completed a validated readiness to change (RTC) survey. This analysis used data from before randomization, including patients who did not receive video education. Ordinal logistic regression was used to compare smokers to non-smokers, irrespective of video exposure. Results: The 105 participants included 63 females and 42 males, with 31% being African American, 66% White, and 21% smokers. Individuals who reported smoking had higher odds of being ready to change their lifestyle behavior (OR 3.75, P = .013), however, participants who smoke exhibited significantly lower confidence levels compared to non-smokers (OR: 0.37, P = .043). Conclusion: The ED may provide a “teachable moment” and a ripe opportunity for preventive LM education, including tobacco use. The data contradict some practitioners’ assumptions about these patients’ motivation to change.

Introduction: Preventive counseling improves long-term health, but primary care clinicians face time constraints limiting patient education. In a prior emergency department pilot study, a brief passive video trended towards increased patients’ willingness to change health behaviors. The current trial, conducted at the primary care clinic, evaluates the feasibility and impact of a short, interactive prevention video delivered during a primary care office visit. Methods and analysis: We will conduct a prospective, randomized, non-blinded clinical trial among adult patients presenting to a primary care clinic. Immediately after their appointment, participants will be randomized to receive either the interactive prevention video with a practitioner or usual care. The video maintains engagement through simple in-video questions and adapts content based on patient responses (e.g., skipping smoking cessation for non-smokers). After the encounter, all participants will complete surveys assessing readiness and confidence to initiate lifestyle change including a transtheoretical “readiness ruler.” Survey items will be drawn from validated instruments, including the Gillespie & Lenz Readiness and Confidence to Participate in Lifestyle Activities Surveys, the Pittsburgh Sleep Quality Index (PSQI), and select questions from the U.S. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. Patients will be asked for medical record access and permission for follow-up contact. Outcomes: The primary outcome is index-visit Lifestyle Readiness and Confidence to Change scores. Secondary outcomes include satisfaction with the clinic visit, intention to change specific lifestyle behaviors, and healthcare use outside the clinic at 30 days and 6 months, as assessed via record review. A 3-12-month follow-up survey will assess self-reported lifestyle changes and new diagnoses. Statistical plan and sample size: Analyses will follow intention-to-treat. Ordinal logistic regression will compare primary outcomes between arms, adjusting for Charlson Comorbidity Index, age, sex, gender, and prespecified predictors. Logistic regression will evaluate binary follow-up outcomes. Complete-case analyses will be used, and differential attrition will be reported. We plan to enroll approximately 350 patients. Trial registration: https://ClinicalTrials.gov NCT06730737 .

Background: When evaluating an emergency department (ED) patient who presents with suicidal ideation, it is a common practice to wait until the patient's ethanol level is known or calculated to be less than 80 mg/dl to evaluate patient safety. We know of no study that establishes an association between the degree of alcohol intoxication based on a blood alcohol level (BAL) and reported suicidal ideation (SI) upon recovery.Methods: We conducted a retrospective review of patients evaluated in a Midwestern ED for the calendar year 2017. Cases were selected if they had a psychiatric social work consult and a blood alcohol level drawn while in the ED. Patients were selected on the same 2 days each week throughout the year to meet the sample size requirements of the study, resulting in 1084 cases for review. Chi‐square analysis was used to evaluate the relationship between suicidal ideation and alcohol intoxication as defined by a BAL ≥80 mg/dl.Results: Among patients presenting with suicidal ideation and a concurrent BAL ≥80 mg/dl, 69% no longer reported suicidal ideation when their BAL was p = 0.000012).Conclusion: Our data show that patients presenting to the ED with complaints related to suicidal behavior who have a BAL ≥80 mg/dl are more likely to no longer endorse having suicidal ideation once their BAL is < 80 mg/dl than patients with similar presenting complaints and no alcohol intoxication. This finding supports the common ED practice of re‐assessing suicidal ideation among individuals who are initially intoxicated once their BAL has decreased below 80 mg/dl.

Background It is commonly assumed that patients intoxicated with alcohol are unreliable with respect to their statements of suicidal intent, however no prior literature evaluates the impact of sobriety on suicidal ideation (SI). In typical emergency department (ED) settings, a common practice is to wait until intoxicated suicidal individuals have reached a legally sober limit (ethanol level less than 80 mg/dL) to evaluate safety. We are not aware of any study that establishes the diagnostic reliability of the clinical suicidal ideation evaluation as a function of alcohol intoxication. Methods This study is a retrospective review of medical records for patients evaluated in a pre-COVID Midwestern ED for one calendar year. Cases were generated for review based on criteria of having a Psychiatric SW (Social Work) consult and blood alcohol level drawn while in the ED on every Wednesday and Friday of 2017 which produced 1084 cases for review. Chi-square analysis was used for comparison of variables of suicidal ideation with or without alcohol intoxication as defined by blood alcohol level (BAL) ≥80 mg/dL. Results In reference to our initial hypothesis, patients presenting with suicidal ideation and concurrent alcohol intoxication were no longer reporting suicidal ideation at sobriety in 69% of cases, compared to 38% for patients without alcohol levels on presentation. Chi-square analysis demonstrated p=0.000012. Conclusion The goal of the present study was to demonstrate, with empirical data, a relationship between alcohol intoxication and suicidal ideation. Our data suggests that patients presenting to the ED with complaints related to suicidal behavior who are found to have concurrent alcohol intoxication are more likely to deny suicidal ideation when sober than patients with similar presenting complaints and no alcohol intoxication.

INTRODUCTION: The transfer of individuals (i.e., residents) between senior care facilities (SCF) and the emergency department (ED) remains an ongoing healthcare quality gap as communication of key resident information is often lost. For this study, a sample of SCF representatives were invited to join a collaborative group termed Safe Transition of All Residents For yoU and Me (STARForUM, STAR-F) to improve SCF resident transitions of care. STUDY PURPOSE: The purpose of this pilot study was to invite a convenience sample of SCF facilities to join a collaborative intervention named Safe Transition of All Residents For yoU and Me (STARForUM, STAR-F) to improve information exchange during SCF residents’ transitions of care. The potential influence of a hospital-SCF collaboration program to improve transfer of essential SCF resident information sent to the hospital ED was used as an evaluation measure. METHODS: This study project enrolled a total of 120 residents (i.e., patients) with 40 (33%) transferred from participating STAR-F facilities. RESULTS: Following the authors’ development of a transfer checklist, STAR-F facilities sent a significantly greater number of essential elements comprised of the resident’s medical history information to the ED compared to non-STAR-F facilities. Controlling for the standard classification of skill level of the individual facility, STAR-F residents had significantly higher essential information transmission composite scores (10.5 + 2.9 for STAR-F patients vs. 7.75 + 3.1 for non-STAR-Fs p = < 0.01) that may have served to reduce number of associated transition errors. CONCLUSIONS: The findings of this study suggest that a collaborative hospital-SCF initiative can significantly improve transfer of information for elderly residents during ED visits, help guide clinical decision-making and optimize care coordination.

Objective To assess the trends in visits, overall and by age, to urban and non-urban emergency departments (EDs), and visits resulting in admission to hospital before and during the COVID-19 pandemic using a large regional database. Setting A large regional database of 28 EDs during the COVID-19 pandemic in Michigan, with an index case of 11 March 2020 and peak in the first week of April. Participants ED visits during the first 5 months of the calendar year were included and compared with the previous year. Facilities where these participants were seen were classified as urban or non-urban, with comparisons of total visits, COVID-like cases, paediatric and trauma. Outcome measures Daily visits to EDs of patients presenting with COVID-like symptoms, trauma, age patterns and total cases, and stratified between urban and non-urban settings. Results There were 1 732 852 visits across the 2 years, 953 407 between study and comparison periods, and 457 130 visits defined as COVID-like (median age 44 years). Total ED visits decreased to 48% of the previous year, showing a delayed-inverse relationship with COVID-19. Trauma cases dropped but returned to the pre-COVID-19 rate by the end of May in Urban centres. Paediatric cases decreased to 20% of the previous year by the end of April. The oldest age groups showed the least change in ED visits in response to the pandemic. Conclusions This large US Midwestern state study describes a dramatic decrease in ED visits after the onset of the COVID-19 pandemic in Michigan, including stratification by varying ages and trauma, demonstrating the tangible impact of the COVID-19 pandemic on urban and non-urban EDs.

Background: The Affordable Care Act (ACA) is one of the biggest healthcare reforms in US history. A key issue is the ACAs effect on low acuity, potentially primary care patients. This study evaluates the effect of the ACA on low acuity patients seen in the emergency department (ED). Methods: This is an age-period-cohort analysis for a community hospital ED in Michigan, from 2009 to 2015. Patients were stratified by age, year seen, emergency severity index (ESI) and insurance status. Data were compared between before and after ACA along with descriptive statistics, Chi-square and Student t-tests. The primary outcome was the change in ED usage by low acuity. Patients > 65 were used as a temporal control. Results: 305,350 ED visits were analyzed. ED visits with ESI 4/5 increased from 11.9% to 14.8%. Patients < 19 years increased from 25.5% to 34.3% (p = .0026). Ages 19–25 increased from 16.3% to 19.7% (p = 0.0515). Ages 26–64 increased from 11% to 14.9% (p = 0.0129). Ages > 65 increased from 5.1% to 6.5%. Patients < 65 showed a decreased uninsured rate from 12.30% to 6.28% (p < 0.0001). Comparatively, for age > 65: uninsured rate remained the same 0.46% to 0.49%. Conclusion: Low acuity ED visits increased with the ACA reform in conjunction with a more insured population.