Emergency Medicine 2019 Projects

Project Title: Advocacy for Emergency Medicine-International Federation for Emergency Medicine Review

Faculty Mentor’s Name: Dr. Elizabeth DeVos
Phone: 904-244-4405
Email: elizabeth.devos@jax.ufl.edu

Student Name: Jorge Zaldivar
Email: jurgezaldi@gmail.com

Project Description:

The International Federation for Emergency Medicine is an organization that promotes access to, and leads the development of, the highest quality of emergency medical care for all people worldwide. Its missions are to advance the growth of high quality emergency medical care through education and standards and to lead the collaboration and networking necessary to establish universal equality in service and care to promote the creation and growth of the specialty of emergency medicine in every country. The IFEM Specialty Implementation Committee (SIC) aids in achieving these goals but supporting countries and national specialty organizations in their development of specialists and the frameworks to allow emergency medicine systems. The SIC is working to develop toolkits and workshops for advocacy in the development of Emergency Medicine worldwide. A medical student engaged in this project is likely to assist in literature review, interviews of key stakeholders, resource and training material development, as well as manuscript preparation in collaboration with the team of global leaders in the specialty. Additional future projects may be developed from interaction with the IFEM SIC. More information about IFEM and the SIC may be found at www.ifem.cc. Students completing this MSRP will have opportunities to present posters at global health and emergency medicine meetings at regional, national or international levels as well as developing a publishable manuscript.

Project Title: Assessing willingness of patients in acute pain to accept alternatives therapeutics to opioids

Faculty Mentor’s Name: Dr. Henry Young II
Phone: 352-265-5911
Email: hyoungii@ufl.edu

Student Name: Jordan Zeldin
Email: jurgezaldi@gmail.com

 Project Description:

Exploration of pain treatments that are less addictive than opioids is a research priority of the National Institute on Drug Abuse. Several non-pharmacological agents and procedures have been shown to be effective in the treatment of these conditions. Pain is the most commonly treated symptom in the emergency department and opioids are often prescribed from the emergency department to treat pain. Individuals presenting to the emergency department have been found to be at greater risk to abuse or misuse opioids than those who do not seek medical treatment in the emergency department. Unfortunately, there has been little research on the willingness of ED patients at high risk of opioid abuse to accept these agents. In this study we will assess the willingness of ED patients to receive ALTO. The role of the medical student will be to assist with data collection, analysis and presenting the data at a regional or national conference. The medical student will also have the opportunity to participate in drafting a manuscript from the results of the data.

Project Title: Deploying In Situ Simulation to Improve Team Performance and Identify Safety Threats

Faculty Mentor’s Name: Dr. Mary Patterson
Email: parkerd@ufl.edu

Student Name: Phillip Jenkins
Email: phillip.jenkins@ufl.edu

Project Description:

The 1999 IOM report stated, “Most care delivered today is done by teams of people yet training often remains focused on individual responsibilities leaving practitioners inadequately prepared to enter complex settings”. As part of the solution, the IOM recommended that, “Patient safety programs should…establish interdisciplinary team training programs for providers that incorporate proven methods of team training such as simulation” (1) In addition, the Joint Commission reports that more than 70% of the sentinel events investigated in 2015 identified inadequate communication as a root cause. (2) Siloed training and inadequate team and communication skills are a dual threat to the delivery of safe patient care in the United States.

The long-term goal of this work is to improve the quality and safety of the healthcare delivered at UF Health by developing the teamwork and communication skills of healthcare professionals. We will accomplish this using multidisciplinary simulation-based teamwork training in high risk clinical settings.

The proposed project builds on our previous work in interdisciplinary simulation-based training and incorporates proven safety practices such as crisis resource management (CRM) behaviors and standardized communication, especially the use of shared mental models. It is unique in that the simulations will take place in the actual clinical setting (in situ) during the workday of the participants. In addition, findings from our previous projects demonstrate that interdisciplinary simulation training is a valuable method to uncover latent threats to patient safety.(3,4) These findings serve as the basis for this proposal and enable us to use simulation as a tool for the identification of safety threats and system issues in the clinical environment as well as providing ongoing education and reinforcement of crew resource management principles for the clinical care team. This project will allow us to evaluate, reinforce and remediate teamwork training in the actual clinical setting. We will also use simulation to learn about the clinical environment and to impact this environment.

Project Title: Development of a Risk Prediction Screening Tool for Opioid-Prescription Injury (STOP Injury) in Older Adults Initiated on Opioids from the Emergency Department

Faculty Mentor’s Name: Dr. Sophia Sheikh
Email: sophia.Sheikh@jax.ufl.edu

Student Name: Divya James
Email: divyajames@ufl.edu

Project Description:

Rates of opioid prescribing have remained high over the past few decades. For example, in 2017 alone, the number of opioid prescriptions dispensed in the United States was approximately 191 million. Among the largest users of prescription opioids are individuals over the age of 50. While opioid medications may provide relief in non-cancer pain, it is problematic given the high rates of fall-related injuries. Older adults are especially at an increased risk for fall-related injuries as compared to injuries derived from other mechanisms. Such increases in fall-related injuries following opioid prescription use has been most notable within the first week of starting the opioid. Additionally, patients taking prescription opioids are at an increased risk for experiencing other adverse effects, such as loss of consciousness and respiratory depression. Therefore, it would be beneficial to develop a tool which takes into consideration a patient’s pharmacogenetics, psychosocial, and clinical aspects in order to best assess the patient’s risk of developing an opioid related adverse effect. This could potentially promote safer prescribing practices for older patients presenting to the emergency department for chronic inflammation related-pain.

There are several tools that currently exist in order to assess a patient’s risk for experiencing an opioid-prescription injury, such as Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (CIP-RIOSORD). Additional tools to assess for an older patient’s risk of falling include Stopping Elderly Accidents, Death, and Injuries (STEADI). However, these have been limited in the breadth of risk factors that are included in the screening assessment. Factors that have been observed to be associated with higher fall-related injuries subsequent to initiation of an opioid prescription include, but are not limited to, previous history of fall, psychiatric condition, loss of sensation in the feet, and concurrent use of other medications, such as antidepressants and benzodiazepines. Some of the clinical factors associated with increased risk for opioid overdose and respiratory depression have included heart failure, kidney disease, chronic pulmonary disease, and stroke. These tools are limited by only utilizing clinical and psychosocial risk factors; they do not account for genetic risk factors. An ideal tool for clinical decision making regarding opioid prescriptions would incorporate risk factors from all of these areas.

Similar to psychosocial and clinical factors, specific genetic polymorphisms can potentially increase the risk of opioid related injury given that these can affect how the drug is metabolized and how it is available in a given patient. One such gene is CYP2D6, which plays a role in the metabolism of various opioids, such as the metabolism of codeine to morphine. Polymorphisms in this gene are associated with both rapid and poor metabolizers of opioids, with rapid metabolizers leading to increased morphine plasma concentrations in the patient. OCT1, which encodes for morphine hepatocyte transporters, has polymorphisms associated with increased risk of opioid adverse effects, especially with respect to the presence of loss-of-function mutations. OPRM1, encodes for the μ1 opioid receptor. It has been observed that certain variants of this gene, most notably the A118G variant, has been associated with decreased efficacy of opioids in the patient due to decreased opioid receptor binding capacity. COMT, a gene encoding for an enzyme involved in the metabolism of catecholamines, has polymorphisms associated with decreased or increased pain perception. ABCB1, a gene encoding for a p-glycoprotein transporter responsible for the efflux of morphine, has polymorphisms that have been implicated in having an increased risk of opioid-induced respiratory depression. An evaluation that includes assessing various genetic polymorphisms involved in opioid metabolism could enhance the ability to predict the risk of certain adverse effects in a given population compared to solely assessing clinical and psychosocial risks.

Project Title: Diagnostic yield of non-invasive imaging in patients following non-traumatic sudden cardiac arrest

Faculty Mentor’s Name: Dr. Charles Hwang
Email: c7places@ufl.edu

Student Name: Dru Curtis and Jon Wiese
Email: drucurtis@ufl.edu; jonwiese@ufl.edu

Project Description:

Out-of-hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality in the United States. Patients presenting with ventricular fibrillation or ventricular tachycardia are considered to have sudden cardiac arrest from cardiac etiology. Current American Heart Association (AHA) guidelines recommend urgent coronary angiography in patients suspected of having acute coronary syndrome (ACS). Non-invasive cross-sectional imaging is frequently performed after OHCA; the AHA, however, does not provide any guidance on the role of non-invasive imaging in the diagnosis of OHCA. Previous studies, including a systematic review, have attempted to evaluate the role of diagnostic imaging in diagnosing causes of OHCA; however, its diagnostic utility remains poorly characterized. We intend to perform a retrospective observational study assessing the down-stream effects of ED diagnostic CT/MRI imaging after return of spontaneous circulation (ROSC) from OHCA.

Project Title: Primary Palliative Care in Emergency Medicine (PRIM-ER)

Faculty Mentor’s Name: Dr. Marie-Carmelle Elie
Email: elie@ufl.edu

Student’s name: Nabeel Mirza
Email: nmirza@ufl.edu

Project Description:

Palliative care represents a spectrum of resources and a care paradigm that has been traditionally reserved to the outpatient or inpatient environment. Recent studies have demonstrated a significant benefit to patients when palliative care was delivered early in emergency departments. Primary Palliative Care Education, Training, and Technical Support for Emergency Medicine (PRIM-ER) is a dissemination project funded by the NIH which will be implemented in 33 Emergency Departments (EDs) including the University of Florida. Over 200 providers will participate in a palliative care education course. This study aims to assess the practice and attitudes of providers before and up to 30 days following the education intervention.
The medical student will be responsible for the development (jointly with PI), enrollment and dissemination of surveys to all providers.