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  1. Article ; Online: Clinical Decision Support: Moving Beyond Interruptive "Pop-up" Alerts.

    Sangal, Rohit B / Sharifi, Mona / Rhodes, Deborah / Melnick, Edward R

    Mayo Clinic proceedings

    2023  Volume 98, Issue 9, Page(s) 1275–1279

    Language English
    Publishing date 2023-09-01
    Publishing country England
    Document type Journal Article
    ZDB-ID 124027-4
    ISSN 1942-5546 ; 0025-6196
    ISSN (online) 1942-5546
    ISSN 0025-6196
    DOI 10.1016/j.mayocp.2023.05.025
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  2. Article ; Online: Emergency department visits in Connecticut for survivors of sexual assault before and during the COVID-19 pandemic.

    Yang, David / Cordone, Alexis / Sun, Wendy W / Gawel, Marcie / Sangal, Rohit B / Dodington, James

    The American journal of emergency medicine

    2023  Volume 67, Page(s) 97–99

    Abstract: Study objective: We evaluate the impact of the COVID-19 pandemic on care for survivors of sexual assault in three urban Emergency Departments (ED) in the United States.: Methods: A retrospective chart review was conducted on patients who presented ... ...

    Abstract Study objective: We evaluate the impact of the COVID-19 pandemic on care for survivors of sexual assault in three urban Emergency Departments (ED) in the United States.
    Methods: A retrospective chart review was conducted on patients who presented after sexual assault to three EDs during 6-month intervals before and during the COVID-19 pandemic. We excluded individuals <18 years old. We performed a structured chart review to ascertain demographics, ED treatments, and adherence to guidelines for care of sexual assault survivors.
    Results: Of 105 patients who received care after a sexual assault, 57 presented during the COVID-19 pandemic. The majority were female, White/Caucasian, and presented within 120 h of sexual assault. There was an increase in ED presentations for sexual assault during the pandemic. While there was no difference in medical care, there were fewer sexual assault advocates called during the pandemic. In addition, there was an increase in non-White survivors in the first 3 months of the pandemic that did not remain at 6 months.
    Conclusion: The care of survivors in the ED was disrupted by the COVID-19 pandemic. While medical care remained similar, fewer calls to sexual assault advocates, a key component of ED and long-term care of survivors, demonstrate a disruption in their care.
    MeSH term(s) Humans ; Male ; United States ; Female ; Adolescent ; Pandemics ; Connecticut/epidemiology ; Retrospective Studies ; COVID-19/epidemiology ; Sex Offenses ; Emergency Service, Hospital ; Survivors
    Language English
    Publishing date 2023-02-14
    Publishing country United States
    Document type Journal Article
    ZDB-ID 605890-5
    ISSN 1532-8171 ; 0735-6757
    ISSN (online) 1532-8171
    ISSN 0735-6757
    DOI 10.1016/j.ajem.2023.02.010
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  3. Article: Choice Architecture to Assist Clinicians with Appropriate COVID-19 Test Ordering.

    Sangal, Rohit B / Venkatesh, Arjun K / Cahill, Justin / Pettker, Christian M / Peaper, David R

    The journal of applied laboratory medicine

    2023  Volume 8, Issue 1, Page(s) 98–105

    Abstract: Background: Despite improving supplies, SARS-CoV-2 nucleic acid amplification tests remain limited during surges and more so given concerns around COVID-19/influenza co-occurrence. Matching clinical guidelines to available supplies ensures resources ... ...

    Abstract Background: Despite improving supplies, SARS-CoV-2 nucleic acid amplification tests remain limited during surges and more so given concerns around COVID-19/influenza co-occurrence. Matching clinical guidelines to available supplies ensures resources remain available to meet clinical needs. We report a change in clinician practice after an electronic health record (EHR) order redesign to impact emergency department (ED) testing patterns.
    Methods: We included all ED visits between December 1, 2021 and January 18, 2022 across a hospital system to assess the impact of EHR order changes on provider behavior 3 weeks before and after the change. The EHR order redesign included embedded symptom-based order guidance. Primary outcomes were the proportion of COVID-19 + flu/respiratory syncytial virus (RSV) testing performed on symptomatic, admitted, and discharged patients, and the proportion of COVID-19 + flu testing on symptomatic, discharged patients.
    Results: A total of 52 215 ED visits were included. For symptomatic, discharged patients, COVID-19 + flu/RSV testing decreased from 11.4 to 5.8 tests per 100 symptomatic visits, and the rate of COVID-19 + flu testing increased from 7.4 to 19.1 before and after the intervention, respectively. The rate of COVID-19 + flu/RSV testing increased from 5.7 to 13.1 tests per 100 symptomatic visits for symptomatic patients admitted to the hospital. All changes were significant (P < 0.0001).
    Conclusions: A simple EHR order redesign was associated with increased adherence to institutional guidelines for SARS-CoV-2 and influenza testing amidst supply chain limitations necessitating optimal allocation of scarce testing resources. With continually shifting resource availability, clinician education is not sufficient. Rather, system-based interventions embedded within exiting workflows can better align resources and serve testing needs of the community.
    MeSH term(s) Humans ; COVID-19/diagnosis ; Influenza, Human ; SARS-CoV-2 ; Hospitalization ; COVID-19 Testing
    Language English
    Publishing date 2023-01-06
    Publishing country England
    Document type Journal Article
    ISSN 2576-9456
    ISSN 2576-9456
    DOI 10.1093/jalm/jfac104
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  4. Article ; Online: Eclampsia.

    Yang, Thomas J / Sangal, Rohit B / Conlon, Lauren W

    Journal of education & teaching in emergency medicine

    2021  Volume 6, Issue 3, Page(s) S33–S61

    Abstract: Audience: Emergency medicine residents.: Introduction: Eclampsia is the development of a generalized seizure in pregnant patients with hypertension of pregnancy.1 Eclampsia exists on the spectrum of hypertension-related disorders in pregnancy, occurs ...

    Abstract Audience: Emergency medicine residents.
    Introduction: Eclampsia is the development of a generalized seizure in pregnant patients with hypertension of pregnancy.1 Eclampsia exists on the spectrum of hypertension-related disorders in pregnancy, occurs in 1 out of 1,000-10,000 deliveries,1-3and is associated with significant maternal and fetal morbidity and mortality.4 Given the emergent nature of eclampsia and the benefit of rapid treatment, emergency medicine (EM) physicians need to quickly recognize and treat this rare pathology. Although residents have three to four years before becoming an attending, not all emergent pathologies may present clinically during their training. It is important to simulate rare, treatable conditions such as eclampsia to give learners exposure confidence in managing this disease.
    Educational objectives: By the end of this simulation session, learners will be able to:Demonstrate care of a gravid patient with altered mental statusDemonstrate care of a gravid patient with seizuresRecognize care involved in assessment of fetal statusExecute appropriate subspecialty consultationRecognize the clinical signs and symptoms of eclampsiaDistinguish different treatment options for eclampsiaIdentify magnesium toxicity and reversal agentDifferentiate the spectrum of preeclampsia.
    Educational methods: As an educational strategy, simulation allows learners to partake in experiential learning. By creating a safe and supportive learning environment, simulation allows learners to facilitate deliberate practice and transfer learning in debriefing sessions. High-fidelity sessions involve software and technology to mimic realistic patient environments, which also activate learners' affective states to aid in decision-making abilities in complex medical cases.This session was conducted using a high-fidelity mannequin, SimMom (Laerdal), and a controlling Laerdal LLEAP Software. Faculty-led debriefing followed the simulation case and included discussion regarding presentation, spectrum, and management of the obstetrical emergency.5.
    Research methods: Resident participants completed an evaluation form consisting of questions on a 5-point Likert scale assessing the realism and usefulness of the simulation.
    Results: All 18 residents who participated in the simulation completed an evaluation form, and all agreed or strongly agreed the case was realistic and useful.
    Discussion: Incorporating high-stakes, low-frequency presentations through simulation can be readily applied in residency education and well-received by residents. Increasing the difficulty through adjusting the clinical history and exam may challenge learners further.
    Topics: Medical simulation, eclampsia, pregnancy, obstetrics, emergency medicine.
    Language English
    Publishing date 2021-07-15
    Publishing country United States
    Document type Journal Article
    ISSN 2474-1949
    ISSN (online) 2474-1949
    DOI 10.21980/J8PS8R
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  5. Article: Man in Motor Vehicle Collision.

    Sangal, Rohit B / Holena, Daniel N

    The Journal of emergency medicine

    2018  Volume 54, Issue 4, Page(s) 544–546

    MeSH term(s) Accidents, Traffic ; Adult ; Aorta/injuries ; Flail Chest/complications ; Flail Chest/etiology ; Humans ; Male ; Motor Vehicles ; Rib Fractures/complications ; Rib Fractures/diagnostic imaging ; Seat Belts ; Tomography, X-Ray Computed/methods
    Language English
    Publishing date 2018-01-05
    Publishing country United States
    Document type Case Reports ; Journal Article
    ZDB-ID 605559-x
    ISSN 0736-4679
    ISSN 0736-4679
    DOI 10.1016/j.jemermed.2017.12.014
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  6. Article ; Online: Rodenticide Causing Lower Gastrointestinal Bleeding: Resident Simulation.

    Sangal, Rohit B / Conlon, Lauren W

    MedEdPORTAL : the journal of teaching and learning resources

    2018  Volume 14, Page(s) 10729

    Abstract: Introduction: Gastrointestinal (GI) bleeding is becoming more common with an aging population. Lower GI bleeding is less common than its upper GI bleed counterpart. Incidence of bleeding is increasing because more patients are on anticoagulation ... ...

    Abstract Introduction: Gastrointestinal (GI) bleeding is becoming more common with an aging population. Lower GI bleeding is less common than its upper GI bleed counterpart. Incidence of bleeding is increasing because more patients are on anticoagulation medication. Abnormal coagulation can lead to this life-threatening condition requiring rapid diagnosis and treatment by a skilled medical provider. Simulation can be used to practice recognition of this disease process and work through treatment algorithms.
    Methods: This simulation case used a high-fidelity simulator to teach emergency medicine providers how to manage lower GI bleeding in a patient with abnormal coagulation secondary to intentional ingestion of rodenticide. The case simulated a 58-year-old female with history of bipolar disorder presenting with brisk rectal bleeding. Residents were expected to identify the type of GI bleed, leading to recognition that the patient was in hemorrhagic shock; they then had to appropriately reverse the anticoagulation and resuscitate with blood products. Afterward, learners were given a short survey to evaluate the case and debriefing process.
    Results: The case was performed at the University of Pennsylvania Simulation Center as part of the Emergency Medicine Resident Simulation Curriculum. Twenty-eight learners took part; of these, 20 (71%) found the simulation realistic, and 24 (86%) agreed or strongly agreed that the simulation was useful.
    Discussion: Main learning points include management of lower GI bleeding and reversal of abnormal anticoagulation. This simulation case is straightforward to run, requires minimal resources, and has been well received by learners at our institution.
    MeSH term(s) Blood Coagulation/drug effects ; Curriculum ; Eating/drug effects ; Emergency Medicine/education ; Female ; Gastrointestinal Hemorrhage/drug therapy ; Humans ; Internship and Residency/methods ; Middle Aged ; Rodenticides/adverse effects ; Shock, Hemorrhagic/diagnosis
    Chemical Substances Rodenticides
    Language English
    Publishing date 2018-06-29
    Publishing country United States
    Document type Journal Article
    ISSN 2374-8265
    ISSN (online) 2374-8265
    DOI 10.15766/mep_2374-8265.10729
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  7. Article ; Online: Rapid serum tubes reduce transport hemolysis and false positive rates for high-sensitivity troponin T.

    Malaeb, Hind / Vera, Michael A / Sangal, Rohit B / Venkatesh, Arjun K / Possick, Stephen / Maciejak, Lisa / Oberle, Erica / El-Khoury, Joe M

    Clinica chimica acta; international journal of clinical chemistry

    2023  Volume 551, Page(s) 117630

    Abstract: Introduction: Hemolysis in the emergency department (ED) can significantly delay results and appropriate action. We evaluated the main sources of hemolysis during sample collection, and to evaluate the use of rapid serum tubes (RST) as a transport ... ...

    Abstract Introduction: Hemolysis in the emergency department (ED) can significantly delay results and appropriate action. We evaluated the main sources of hemolysis during sample collection, and to evaluate the use of rapid serum tubes (RST) as a transport hemolysis-mitigating measure for high-sensitivity troponin T (hs-cTnT) testing.
    Methods: We examined the effect of tube type, tube fill, types of sample draw and collection methods on hemolysis and hs-cTnT in samples (n = 158) from ED patients. We also compared hs-cTnT values in paired RST and plasma separate tube (PST) samples that were hemolysis-free.
    Results: The primary source of hemolysis in samples collected in the ED was underfilling tubes. In both tube types, PST and RST, filled tubes showed a median reduction in hemolysis of 69.1 % (p < 0.0001). Blood collected in RST also experienced less hemolysis compared to PST. In hemolysis-free samples, false positive results in PST were noted in patients with hs-cTnT values < 50 ng/l.
    Conclusion: We suggest that proper tube filling during sample collection and use of RST tubes can significantly reduce the effects of hemolysis. In addition, laboratories should be aware that PST tubes have a non-trivial rate of false positives when hs-cTnT < 50 ng/l.
    MeSH term(s) Humans ; Troponin T ; Hemolysis ; Serum ; Blood Specimen Collection/methods ; Plasma ; Emergency Service, Hospital ; Biomarkers
    Chemical Substances Troponin T ; Biomarkers
    Language English
    Publishing date 2023-11-04
    Publishing country Netherlands
    Document type Journal Article
    ZDB-ID 80228-1
    ISSN 1873-3492 ; 0009-8981
    ISSN (online) 1873-3492
    ISSN 0009-8981
    DOI 10.1016/j.cca.2023.117630
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  8. Article: Exploratory Descriptive Analysis of Smart Speaker Utilization in the Emergency Department During the COVID-19 Pandemic.

    Franco, Jessica / Solad, Yauheni / Venkatesh, Arjun K / Van Tonder, Reinier / Solod, Alexander / Stachowiak, Tomek / Hsiao, Allen L / Sangal, Rohit B

    The Journal of emergency medicine

    2023  Volume 64, Issue 4, Page(s) 506–512

    Abstract: Background: In March 2020, the U.S. Department of Health and Human Services Office for Civil Rights stated that they would use discretion when enforcing the Health Insurance Portability and Accountability Act regarding remote communication technologies ... ...

    Abstract Background: In March 2020, the U.S. Department of Health and Human Services Office for Civil Rights stated that they would use discretion when enforcing the Health Insurance Portability and Accountability Act regarding remote communication technologies that promoted telehealth delivery during the COVID-19 pandemic. This was in an effort to protect patients, clinicians, and staff. More recently, smart speakers-voice-activated, hands-free devices-are being proposed as productivity tools within hospitals.
    Objective: We aimed to characterize the novel use of smart speakers in the emergency department (ED).
    Methods: A retrospective observational study of Amazon Echo Show® utilization from May 2020 to October 2020 in a large academic Northeast health system ED. Voice commands and queries were classified as either patient care-related or non-patient care-related, and then further subcategorized to explore the content of given commands.
    Results: Of 1232 commands analyzed, 200 (16.23%) were determined to be patient care-related. Of these commands, 155 (77.5%) were clinical in nature (i.e., "drop in on triage") and 23 (11.5%) were environment-enhancing commands (i.e., "play calming sounds"). Among non-patient care-related commands, 644 (62.4%) were for entertainment. Among all commands, 804 (65.3%) were during night-shift hours, which was statistically significant (p < 0.001).
    Conclusions: Smart speakers showed notable engagement, primarily being used for patient communication and entertainment. Future studies should examine content of patient care conversations using these devices, effects on frontline staff wellbeing, productivity, patient satisfaction, and even explore opportunities for "smart" hospital rooms.
    MeSH term(s) Humans ; COVID-19 ; Pandemics ; Emergency Service, Hospital ; Telemedicine ; Retrospective Studies
    Language English
    Publishing date 2023-01-13
    Publishing country United States
    Document type Observational Study ; Journal Article
    ZDB-ID 605559-x
    ISSN 0736-4679
    ISSN 0736-4679
    DOI 10.1016/j.jemermed.2023.01.004
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  9. Article ; Online: Automated HEART score determination via ChatGPT: Honing a framework for iterative prompt development.

    Safranek, Conrad W / Huang, Thomas / Wright, Donald S / Wright, Catherine X / Socrates, Vimig / Sangal, Rohit B / Iscoe, Mark / Chartash, David / Taylor, R Andrew

    Journal of the American College of Emergency Physicians open

    2024  Volume 5, Issue 2, Page(s) e13133

    Abstract: Objectives: This study presents a design framework to enhance the accuracy by which large language models (LLMs), like ChatGPT can extract insights from clinical notes. We highlight this framework via prompt refinement for the automated determination of ...

    Abstract Objectives: This study presents a design framework to enhance the accuracy by which large language models (LLMs), like ChatGPT can extract insights from clinical notes. We highlight this framework via prompt refinement for the automated determination of HEART (History, ECG, Age, Risk factors, Troponin risk algorithm) scores in chest pain evaluation.
    Methods: We developed a pipeline for LLM prompt testing, employing stochastic repeat testing and quantifying response errors relative to physician assessment. We evaluated the pipeline for automated HEART score determination across a limited set of 24 synthetic clinical notes representing four simulated patients. To assess whether iterative prompt design could improve the LLMs' ability to extract complex clinical concepts and apply rule-based logic to translate them to HEART subscores, we monitored diagnostic performance during prompt iteration.
    Results: Validation included three iterative rounds of prompt improvement for three HEART subscores with 25 repeat trials totaling 1200 queries each for GPT-3.5 and GPT-4. For both LLM models, from initial to final prompt design, there was a decrease in the rate of responses with erroneous, non-numerical subscore answers. Accuracy of numerical responses for HEART subscores (discrete 0-2 point scale) improved for GPT-4 from the initial to final prompt iteration, decreasing from a mean error of 0.16-0.10 (95% confidence interval: 0.07-0.14) points.
    Conclusion: We established a framework for iterative prompt design in the clinical space. Although the results indicate potential for integrating LLMs in structured clinical note analysis, translation to real, large-scale clinical data with appropriate data privacy safeguards is needed.
    Language English
    Publishing date 2024-03-13
    Publishing country United States
    Document type Journal Article
    ISSN 2688-1152
    ISSN (online) 2688-1152
    DOI 10.1002/emp2.13133
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  10. Article ; Online: Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications.

    Sangal, Rohit B / Rothenberg, Craig / Hawk, Kathryn / D'Onofrio, Gail / Hsiao, Allen L / Solad, Yauheni / Venkatesh, Arjun K

    Joint Commission journal on quality and patient safety

    2023  Volume 49, Issue 5, Page(s) 239–246

    Abstract: Background: Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real- ... ...

    Abstract Background: Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions.
    Methods: The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions.
    Results: A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65).
    Conclusion: EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.
    MeSH term(s) Humans ; Analgesics, Opioid/therapeutic use ; Practice Patterns, Physicians' ; Hospitals ; Electronic Health Records ; Emergency Service, Hospital ; Retrospective Studies
    Chemical Substances Analgesics, Opioid
    Language English
    Publishing date 2023-02-03
    Publishing country Netherlands
    Document type Observational Study ; Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't
    ZDB-ID 1189890-2
    ISSN 1938-131X ; 1549-425X ; 1553-7250 ; 1070-3241 ; 1549-3741
    ISSN (online) 1938-131X ; 1549-425X
    ISSN 1553-7250 ; 1070-3241 ; 1549-3741
    DOI 10.1016/j.jcjq.2023.01.013
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