The OHSU Center for Policy and Research in Emergency Medicine's breakthrough research leads to new standards of care and a better understanding of important issues involving emergency medicine, disaster preparedness, and toxicology.
At the OHSU Center for Policy and Research in Emergency Medicine (CPR-EM), our mission consists of reducing inequities, including, but not limited to, those based on race, ethnicity, gender, sexual orientation, gender identity, immigration status, religion, and disability. In particular, we acknowledge the legacy of racism that is embedded in American society and institutions, and we are actively working to be catalysts of change to dismantle these harmful structures. Our commitment involves reflecting principles of equity across all functions of our organization, including in its culture, governance, hiring practices, salaries, research areas of focus, and the conduct of our research.
To those new to OHSU, welcome to our Emergency Department. As part of OHSU’s triple mission, our ED team is leading research studies on multiple fronts, from studying the impacts of fentanyl, MPox, targeted temperature management in cardiac arrest patients, ultrasound in cardiac arrest, to self-care coaching for patients with heart failure. The list of topics is impressive, and I encourage you to read further and engage with the study teams to learn more. Some of our research students and staff had the opportunity to present at the National Conference for the Society of Academic Emergency Medicine in May 2023 (pictured below). We’re excited that research is increasing at OHSU, Hillsboro Medical Center, and Adventist Hospital Portland, and appreciate all your support to make these studies successful. Enjoy the sunshine!
Interested in expanding your career to include Emergency Care Research? CPR-EM offers a variety of training programs for many experiential levels. Learn about all of our opportunities here, or click on a link below to be directed to that specific program.
The Art of the Consult Call: Improving Communication Through Shared Mental Models. Saladik M, Noelck M, Bailey J. MedEdPORTAL. 2023 Sep 29;19:11347. doi: 10.15766/mep_2374-8265.11347. eCollection 2023.PMID: 37779863
Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity. Jenkins PC, Lin A, Ames SG, Newgard CD, Lang B, Winslow JE, Marin JR, Cook JNB, Goldhaber-Fiebert JD, Papa L, Zonfrillo MR, Hansen M, Wall SP, Malveau S, Kuppermann N; Pediatric Readiness Study Group. JAMA Netw Open. 2023 Sep 5;6(9):e2332160. doi: 10.1001/jamanetworkopen.2023.32160.PMID: 37669053
Machine Learning Algorithm Detection of Confluent B-Lines. Baloescu C, Rucki AA, Chen A, Zahiri M, Ghoshal G, Wang J, Chew R, Kessler D, Chan DKI, Hicks B, Schnittke N, Shupp J, Gregory K, Raju B, Moore C. Ultrasound Med Biol. 2023 Sep;49(9):2095-2102. doi: 10.1016/j.ultrasmedbio.2023.05.016. Epub 2023 Jun 24.PMID: 37365065
Warning symptoms associated with imminent sudden cardiac arrest: a population-based case-control study with external validation. Reinier K, Dizon B, Chugh H, Bhanji Z, Seifer M, Sargsyan A, Uy-Evanado A, Norby FL, Nakamura K, Hadduck K, Shepherd D, Grogan T, Elashoff D, Jui J, Salvucci A, Chugh SS. Lancet Digit Health. 2023 Aug 25:S2589-7500(23)00147-4. doi: 10.1016/S2589-7500(23)00147-4. Online ahead of print.PMID: 37640599
Emergency department course of patients with asthma receiving initial emergency medical services care-Perspectives From the National Hospital Ambulatory Medical Care Survey. Delamare Fauvel A, Southerland LT, Panchal AR, Camargo CA Jr, Hansen ML, Wang HE. J Am Coll Emerg Physicians Open. 2023 Aug 18;4(4):e13026. doi: 10.1002/emp2.13026. eCollection 2023 Aug.PMID: 37600901
Polymer Fume Fever. Correia MS, Horowitz BZ. 2023 Aug 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–.PMID: 37603667
Lipid emulsion therapy during management of the critically-ill poisoned patient: a prospective cohort study. Levine M, Brent J, Wiegand T, Maguire B, Cohen N, Vaerrier D, Beuhler M, Leikin JB, Ganetsky M, Stellpflug S, Ruha AM, Carey J, Geib AJ, Cao DJ, Kleinschmidt K, Vohra R, Riley BD, Moore P, Schwarz E, Neavyn M, Rusyniak DE, Greene S, Nogar J, Manini A, Wermuth M, Pizon A, Hendrickson RG, Griswold M, Aldy K, Wax P, Spyres MB, Campleman S, Macdonald E, Finkelstein Y; Toxicology Investigators Consortium. Clin Toxicol (Phila). 2023 Aug;61(8):584-590. doi: 10.1080/15563650.2023.2248372. Epub 2023 Sep 1.PMID: 37655788
Disparities in effective contraceptive use in the United States among individuals dually eligible for Medicare and Medicaid. Rodriguez MI, Meath THA, Daly A, Watson K, Kim H, McConnell KJ. AJOG Glob Rep. 2023 May 6;3(3):100221. doi: 10.1016/j.xagr.2023.100221. eCollection 2023 Aug.PMID: 37645649
Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry. Cohen N, Mathew M, Brent J, Wax P, Davis AL, Obilom C, Burns MM, Canning J, Baumgartner K, Koons AL, Wiegand TJ, Judge B, Hoyte C, Chenoweth JA, Froberg B, Farrar H, Carey JL, Hendrickson RG, Hodgman M, Caravati EM, Christian MR, Wolk BJ, Seifert SA, Bentur Y, Levine M, Farrugia LA, Vearrier D, Minns AB, Kennedy JM, Kirschner RI, Aldy K, Schuh S, Campleman S, Li S, Myran DT, Feng L, Freedman SB, Finkelstein Y. Clin Toxicol (Phila). 2023 Aug;61(8):591-598. doi: 10.1080/15563650.2023.2238121. Epub 2023 Aug 21.PMID: 37603042
Postgraduate Selection in Medical Education: A Scoping Review of Current Priorities and Values. Caretta-Weyer HA, Eva KW, Schumacher DJ, Yarris LM, Teunissen PW. Acad Med. 2023 Aug 1. doi: 10.1097/ACM.0000000000005365. Online ahead of print.PMID: 37556804
Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement. Dart RC, Mullins ME, Matoushek T, Ruha AM, Burns MM, Simone K, Beuhler MC, Heard KJ, Mazer-Amirshahi M, Stork CM, Varney SM, Funk AR, Cantrell LF, Cole JB, Banner W, Stolbach AI, Hendrickson RG, Lucyk SN, Sivilotti MLA, Su MK, Nelson LS, Rumack BH. JAMA Netw Open. 2023 Aug 1;6(8):e2327739. doi: 10.1001/jamanetworkopen.2023.27739.PMID: 37552484
Director, Center for Policy & Research in Emergency Medicine
As an emergency physician and physician-scientist, Dr. Newgard has ample experience studying, evaluating, and seeking to improve emergency care. He is the Director of the Center for Policy and Research in Emergency Medicine at OHSU, a position that bridges emergency care research and health policy. To date, his research has focused on EMS, field trauma triage, trauma systems, and the use of advanced statistical methods to evaluate these areas. Dr. Newgard has been continuously funded through federal research grants for over 20 years and has been very involved in large, collaborative, multi-site research efforts during this time.
1. Improving emergency services and trauma care for children and adults.
Emergency services and trauma systems have had large gaps in the evidence base for patients at the extremes of age, namely children and older adults. Differences in these populations are due to unique responses to injury, differences in clinical management, the need for different provider training, comorbidity burdens, plus different trajectories and outcomes after injury. Dr. Newgard has worked to fill this void through multi-site research linking records across multiple phases of care and hundreds of hospitals, targeting key aspects of emergency care for children and adults.
2. Improving the process, efficiency and understanding of out-of-hospital trauma triage.
Trauma is the most common reason for 911 EMS transports, which is directed by national guidelines for field triage, one of the few aspects of EMS care that has national guidelines. Dr Newgard published a large body of work seeking to understand the process, outcomes, and costs associated with field triage, including the only prospective validation and cost-effectiveness analysis of the national guidelines. Many of these aspects have been poorly understood prior to this work. Five publications were cited in the 2011 revision of the national guidelines for field triage (the most recent revision), helping to shape the day-to-day practice of out-of-hospital care for injured patients across the U.S.
3. Statistics and methodology of emergency care research.
Dr. Newgard has helped catalyze the integration of several advanced statistical methods into the field of emergency care research. While these methods had been developed and used in other fields (biostatistics, econometrics), they have been under-utilized in emergency care research. The topics include multiple imputation of missing values, probabilistic linkage (combining disparate datasets without a unique identifier), and the use of electronic health records for EMS research. His methodologic expertise combined with an intimate understanding of emergency care delivery systems has been utilized in multiple federally-funded research projects.
4. Generating large, multi-site data registries to catalyze scientific discovery in emergency care.
Dr. Newgard has used his methodological skills and interest in large, population-based data to develop multiple data registries in emergency care. Two of these registries were developed through the NHLBI-funded Resuscitation Outcomes Consortium (ROC) and generated over 40 original research publications through the ROC network. Several of these publications have been integrated to national and international guidelines (e.g., National Guidelines for Field Triage and the AHA Advanced Cardiac Life Support algorithm) and serve as the basis for national quality improvement efforts (e.g., ACS Trauma Quality Improvement Project). Development of these registries demonstrates “team science” through collaboration with large inter-disciplinary teams.
Complete List of Published Work in: MyBibliography: https://www.ncbi.nlm.nih.gov/myncbi/craig.newgard.1/bibliography/public/
Dr. Choo is an emergency medicine physician and core research faculty in the Center for Policy & Research, Department of Emergency Medicine, Oregon Health & Science University. She has considerable expertise in employing quantitative, qualitative, and mixed-method study designs to examine the experience of patients, clinicians, and administrators in emergency and primary care systems. One of Dr. Choo's focused interests has been on the impact of gender on emergency presentations and care. She co-founded the Division of Sex and Gender in Emergency Care at Brown University, including establishing the division’s two-year research fellowship that trains early investigators in methodologic approaches to gender-related research. Dr. Choo is the health services fellowship director in the Center for Policy and Research in Emergency Medicine at OHSU.
- Investigating epidemiologic data related to opioid and cannabis use and drug use policy. Dr. Choo has applied her skill set to examining large, complex state and national datasets to examine trends in drug use, particularly related to opioid and marijuana use, gaining experience in managing and analyzing such data to inform policy and shape future areas of research.
- Understanding the influence of gender on emergency care interventions. Emergency care drug and alcohol interventions have largely failed to include gender-specific considerations or common co-existing problems. Her research has focused on the differences between men and women with substance use disorders and the influence of co-existing violence involvement and substance use disorders on screening and interventions. By drawing attention to the important role of gender and violence in the development of substance use disorders, specific barriers to treatment and recovery, and differential responsiveness to ED-based interventions based on gender and violence involvement, my body of work has supported interventions specific to these factors. Dr. Choo developed a Web-based brief intervention for women with drug use and IPV, using interviews with the target population to guide the language, content, and format of the intervention.
- Establishing gender-focused technology-based screening interventions for drug use and violence in the emergency care setting. Dr. Choo's work has included integrated qualitative and quantitative research to develop technology-based screening and behavioral interventions for the emergency care setting and to evaluate their feasibility and acceptability. She has used tailored Web-based screening assessments and developed videos incorporating women with coexisting disorders to increase the relevance and human connection of interventions delivered through a Web-based medium.
- Investigating epidemiologic data related to opioid and cannabis use and drug use policy. Dr. Choo completed fellowship training in health services and health policy research. She has applied this skill set to examining large, complex state and national datasets to examine trends in drug use, particularly related to opioid and marijuana use, gaining experience in managing and analyzing such data to inform policy and shape future areas of research.
- Understanding influences on the careers of women in medicine. Dr. Choo's research has included investigations of the persistent gender gaps in the careers of women in medicine and science, including experiences of discrimination and the sequelae on mental health and burnout.
Complete List of Published Work in MyBibliography:
Dr. Hansen is a physician-scientist dual-boarded in Emergency Medicine and Pediatric Emergency Medicine. His research training includes a K12 award from NHLBI in emergency care research as well as a K23 award, also from NHLBI, to study different airway management strategies in pediatric EMS. Dr. Hansen's overall research focus is on pediatric airway management and other aspects of resuscitation by Emergency Medical Services (EMS) providers outside of the hospital.
- Pediatric Cardiovascular Medicine and Electronic Health Record Data: Using approximately 10 years of electronic health record data from a large outpatient clinic system, Dr. Hansen was the first author of a study that described pediatric hypertension is a diagnosis more commonly missed than not in outpatient clinics. This study resulted in a publication in the Journal of the American Medical Association.
- Pediatric Patient Safety in Out-of-Hospital Care: Dr. Hansen has been interested in improving out-of-hospital care for severely ill or injured children. He completed a study published in JAMA pediatrics that identifies a previously unrecognized problem in safety dosing epinephrine to children suffering a cardiac arrest. In order to help provide an evidence base for pediatric education for out-of-hospital care providers, he completed a study that used a national Delphi survey focused on pediatric patient safety in out-of-hospital care. The results of this study were used to create an evidence-based educational needs assessment for Emergency Medical Services providers. Dr. Hansen's focus has been on improving out-of-hospital pediatric airway management. Using the results of the national Delphi study mentioned above, he identified the specific aspects of airway management most likely to lead to errors. This study identified that technical procedural skills were only one aspect of airway management that can contribute to errors, but that other specific provider factors such as anxiety, and scene factors such as family members can contribute to errors in airway management. Dr. Hansen also conducted a medical record review that identified the major types and rates of safety events that take place during out-of-hospital pediatric airway management.
- Out-of-hospital Airway Management: Dr. Hansen was a co-investigator in the landmark EMS clinical trial of airway management in out-of-hospital cardiac arrest in adults comparing the King LT to endotracheal intubation. He completed a large study on out-of-hospital pediatric airway management using a national database to describe the rates of specific airway management procedures, success rates of these procedures, as well as patient and clinical factors that are associated with higher and lower success rates. He has another paper in press that relates to out-of-hospital airway management of children with upper airway obstruction that finds patients are frequently treated with inhaled albuterol, which is ineffective for upper airway obstructive processes. procedures performed in rural and urban areas in Oregon.
- Emergency Care for Pediatric Critical Illness: Dr. Hansen is interested in using large databases to help improve emergency care for pediatric patients suffering from critical illness. He used the AHRQ National ED Sample (NEDS) database to identify hospital characteristics associated with improved outcomes in critically ill children. In addition, he conducted one of the largest studies on intraosseous vascular access and identified it as a safe route with few serious complications. This study gives clinicians confidence that this route can be used when a child is critically ill with few adverse events as a result.
- Out-of-Hospital Cardiac Arrest Resuscitation Science: One of Dr. Hansen's publications was a key article cited in changes to the 2019 American Heart Association Pediatric Advanced Life Support guidelines where BVM is recommended as a reasonable option for Pediatric OHCA. He is interested in identifying interventions or changes in practice that can improve outcomes for patients who have suffered an out-of-hospital cardiac arrest. Dr. Hansen has focused work on airway management in these patients and has conducted work finding that intubation is associated with poorer outcomes from cardiac arrest. In addition, he led a study that identified the time to the first dose of epinephrine was associated with improved survival from cardiac arrest from non-shockable rhythms.
Complete List of Published Work in MyBibliography:
Dr. Lupton is a passionate and experienced physician-scientist focusing on research related to out-of-hospital cardiac arrest interventions and outcomes. He is also a survivor of an out-of-hospital cardiac arrest during medical school who made a full recovery. This experience drives his interest in improving outcomes from cardiac arrest and will forever be his passion. Dr. Lupton has experience, both leading research projects with multiple stakeholders and analyzing large datasets. He has a background in public health (MPH) and biomedical research (MPhil). He has worked on a grant to develop a clinical decision rule for the earlier prediction of shock-refractory out-of-hospital cardiac arrest – to find factors available on EMS arrival that can identify patients at high risk for shock-failure early, a group that may benefit the most from earlier interventions.
- Exploring the role of intervention timing in out-of-hospital cardiac arrest care.
Dr. Lupton contributed to the science of cardiac arrest through multiple publications evaluating how patient outcomes after cardiac arrest are impacted by the timing of both critical interventions and diagnostic testing. He performed a secondary analysis of the Pragmatic Airway Resuscitation Trial to examine the impact of airway choice (endotracheal intubation vs supraglottic) on the timing to other critical cardiac arrest interventions, namely epinephrine administration and found no significant differences in the timing of these interventions by airway choice. Time-to-antiarrhythmic was not assessed in this publication. Dr. Lupton subsequently served as a co-author in a study evaluating the impact of timing of airway placement (endotracheal intubation or supraglottic) on patient outcomes (accepted, in press), finding no clear benefit to early endotracheal intubation or supraglottic placement. He was involved as the senior author in a review of the safety and efficacy of hands-on defibrillation as a strategy for reducing pause duration in out-of-hospital cardiac arrest, finding that the published literature strongly supports the safety of this practice with proper insulating barriers. Finally, Dr. Lupton published a review on the timing of neuroprognostication after out-of-hospital cardiac arrest as it relates to the emergency department setting with the overall conclusion that there are no diagnostic studies in the time-frame of the emergency department setting that can provide accurate prognostication of who has no chance for neurologic recovery after cardiac arrest.
- Investigating variations in efficacy and disparities of prehospital cardiac arrest interventions.
Dr. Lupton has contributed to the knowledge of intervention efficacy in out-of-hospital cardiac arrest, including evaluating disparities in interventions. He was the first author on a secondary analysis examining outcomes with the use of bag-valve-mask ventilation during out-of-hospital cardiac arrest compared to endotracheal or supraglottic airway management. This study found the surprising finding that bag-valve-mask, even after failed advanced airway attempts, was associated with improved survival to discharge and functional survival. Dr. Lupton was a coauthor for a secondary analysis evaluating the ideal route of access (intravenous compared to intraosseous) for antiarrhythmic administration during out-of-hospital cardiac arrest. This study found that when given via an intravenous route, both amiodarone and lidocaine resulted in significantly better patient outcomes compared to placebo. There were no differences when these antiarrhythmics were given via an intraosseous route. Finally, he also published an analysis of racial disparities in out-of-hospital cardiac arrest interventions by paramedics, findings no evidence of clear differences in care by patient race when adjusting for confounders.
- Utilizing large datasets for exploratory analyses to catalyze further research.
Dr. Lupton has extensive experience with the analysis of large datasets. He explored blood values associated with an atherogenic lipid profile in a large dataset involving hundreds of thousands of patients with detailed laboratory data. Dr. Lupton served as the primary author and statistician on two projects and the primary statistician and coauthor on two additional projects resulting in four peer-reviewed manuscripts that have more than 100 citations combined.
Complete List of Published Work in MyBibliography:
Dr. Kea is a physician-scientist in emergency medicine in the Department of Emergency Medicine, and Director of Clinical Trial in the Center for Policy and Research in Emergency Medicine. Her research has focused on improving acute cardiovascular care through evidence-based guidelines and novel treatment strategies to improve clinical outcomes. Dr. Kea has a diverse range of research experiences, from the initiation of two clinical trials in medical school, from IRB application, protocol development, patient recruitment to subsequent intervention and laboratory testing, to development of clinical decision instruments for chest imaging in blunt trauma and endocarditis in intravenous drug users. At OHSU, she has worked on adding value to cardiovascular care through large database analyses, retrospective data collection, and qualitative interviews in the areas of atrial fibrillation. Dr. Kea's K08 grant is a comparative observational study of a clinical cohort of 21 hospitals from a large, demographically diverse, integrated health care system, which aims to determine whether prognosis and response to treatment for ED patients with new AF are similar to published studies of outpatient patients with chronic AF. And similarly, she found a large gap in guideline-recommended care in this integrated system. Dr. Kea is translating these findings into action with an interventional study utilizing a novel clinical decision support tool for the emergency department.
- Atrial fibrillation (AF) is a common arrhythmia presenting to the Emergency Department (ED) with wide inter-variation of EM management globally. Dr. Kea is utilizing multiple different methodologies to determine current prescribing practices of EM providers and practice gaps from current professional AF guidelines on both a local and national level, and provider barriers to optimal oral anticoagulation (OACs) prescribing. On a local level, she performed a chart review of all OHSU ED patients with AF diagnoses from 2012-2015. The results of this study informed the design of her K08 and the decision to obtain a larger sample of patients from a network of hospitals. On a national level, Dr. Kea obtained a representative cohort of Medicare beneficiaries from 2011-2012. The results were subsequently published last year in the Journal of American College of Cardiology. To further understand practice gaps, Dr. Kea undertook a qualitative study interviewing both ED providers and patients regarding barriers to optimal AF management, and more specifically around OACs. Other than editorials, this is the first qualitative study addressing EM provider barriers to ED AF management and OAC prescribing and will lay the groundwork for future interventions to improve clinical outcomes in AF. Dr. Kea's K08 work with Kaiser Northern California’s 21 hospitals has similarly demonstrated low amounts of ED prescribing, with women less likely to receive appropriate stroke prophylaxis compared to men (submitted to Ann of EM).
- In order to improve the reliability of manuscripts and create a more informed and discriminating reader, she and her colleagues wrote a two-part series on bias in studies of diagnostic tests. The ability to recognize and discern different types of bias is important to understanding the relevance, flaws, and applicability of a study to the reader’s population. They created examples that an emergency provider would encounter and whether renowned studies would apply to those examples, and flaws within them. Dr. Kea and colleagues also discussed that sometimes bias may be necessary due to the ethics of a study, but does not discount the study. In all, they are a practical and readily usable methods of recognizing bias.
- Opioid abuse is a well-known epidemic, and emergency populations are potentially at high risk for abuse. To determine the contribution of ED to the epidemic of opioid prescribing, she described the trends of ED opioid prescribing using a multistage, probability sample of US ED visits. This data of 502.4 million ED discharges from 2006-2010, showed no increasing trends in ED prescribing and contributed the national EM discussion on the role EM in opioid prescribing.
- Dr. Kea has contributed to the derivation of two clinical decision instruments by playing a key role in the data analysis phase using recursive partitioning: (1) a pilot study on the development of a clinical decision instrument for endocarditis in intravenous drugs users, and (2) derivation of criteria for selective chest x-ray imaging in blunt trauma. This second project led to funding from a CTSI grant, which she used to develop a multi-center study to determine the utility of chest CT in blunt trauma patients. During this project, Dr. Kea managed many research assistants, performed data management of a large data set, communicated with other institutions, and performed statistical analyses, and manuscript composition. This study was awarded the American College of Emergency Physician’s Best Resident Paper in 2011, and has prompted a larger multi-center study on a clinical decision instrument for selective chest CT in blunt trauma.
- Dr. Kea's early publications focused on clinical trials work. The first project addressed the lack of a standard oxygen concentration for incubating in-vitro fertilized embryos. To address this issue, she cluster randomized in-vitro fertilized embryos to different oxygen concentrations to determine fertility outcomes. This publication helped set the standard for incubating embryos at lower oxygen concentrations as they had improved fertility outcomes compared to higher concentrations. Dr. Kea was awarded the best poster award for this work at a conference. In the second project, she sought to determine a genetic basis for dermatomyositis (DM) as there was little knowledge about DM or its treatment options. Dr. Kea collected skin biopsies from both healthy controls and patients with dermatomyositis. She developed the protocol for RNA extraction (still in use at Stanford) and gene expression analysis on gene chips developed by their lab (Dr. Patrick Brown). This work laid the foundation for determining the biologic signatures for DM and potential gene targets for treatment.
Complete List of Published Work in MyBibliography: https://www.ncbi.nlm.nih.gov/myncbi/bory.kea.1/bibliography/public/
Dr. Maughan completed a two- year research fellowship in the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania. His research training primarily focused on epidemiology, study design, regression analysis, and experimental quantitative methods for health services research. Dr. Maughan's long-term career goal is to become an independently funded physician-scientist with expertise in identifying biological (sex-based) and behavioral (gender-based) differences in diagnosis and treatment of acute cardiopulmonary disease in the emergency care setting, with the aim of developing interventions to improve patient outcomes and equity of care. He studies these elements to regard to the care of pulmonary embolism (PE), the third leading cardiovascular cause of death in the US and a frequent diagnostic consideration in emergency department (ED) patients with chest pain or shortness of breath. Diagnosis of PE is challenging since only 1-2% of the 16 million annual ED patients with these common symptoms have PE. Insufficient testing can result in harm from missed PE diagnosis, while overtesting leads to wasteful resource use and unnecessary radiation exposure from diagnostic imaging such as CT pulmonary angiography (CTPA). To reduce these harms, guidelines recommend physicians use d-dimer, a plasma biomarker of thrombosis, to initially screen patients who have concerning symptoms but are not at high risk for PE. While PE incidence is similar by sex, women undergo PE testing nearly twice as often as men,suggesting risks of missed diagnosis in men and harms of overtesting in women.
- Pulmonary embolism (PE) is the third leading cardiovascular cause of death in the United States and is a frequent diagnostic consideration in emergency department (ED) patients with chest pain or shortness of breath. Historically, treatment options for PE were rather narrow in scope and typically require hospital admission, yet recent advances have broadened the available treatments for both high-risk (i.e., severe) and low-risk PE. Dr. Maughan's research summarized recent advances in PE treatment and identified key unmet research needs for future investigation.
- Over 75,000 people die of opioid overdoses each year in the United States. A key strategy for reducing opioid-related mortality includes a reduction in the quantity and duration of opioid analgesic prescriptions, especially for patients in whom pain can be treated effectively with other analgesics. As a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania, Dr. Maughan explored opioid use patterns in these populations. First, with grant support from the Leonard Davis Institute for Health Economics, he conducted a pilot randomized trial that assessed the quantity of opioid analgesic used after dental surgery (wisdom tooth extraction) and assessed patient response to an educational intervention regarding disposal of unused pills. Dr. Maughan helped identify that more than half (54%) of opioids prescribed in this setting were not used, suggesting that oral surgeons could substantially reduce opioid prescribing and reduce the risk of drug misuse or diversion. Dr. Maughan also examined prescription opioid use patterns among women following the delivery of an infant. Using a large national claims dataset that included 870,000 postpartum women, they found a 7-fold variation (7.6–53.4%) in the proportion of women who filled opioid prescriptions within four days of uncomplicated vaginal delivery. Another important policy strategy for reducing overdose morbidity is to identify patients with substance use disorders who are at especially high risk for overdose. In collaboration with the Texas Department of State Health Services, Dr. Maughan conducted two record-linkage studies to assess short-term overdose death rates among patients recently discharged from substance abuse treatment programs. They identified that drug-related death was significantly higher after treatment discharge among patients who used opioids, particularly after completion of residential therapy.
- Although nearly all states have established prescription drug monitoring programs (PDMPs) to improve the safety of high-risk prescription medications, the effect of these programs on rates of fatal and nonfatal overdose was unclear. Using Drug Abuse Warning Network public use files in a generalized estimating equations framework, Dr. Maughan conducted two analyses to measure the impact of these programs on rates of emergency department visits for opioid-related and benzodiazepine-related overdose. An important policy consideration in PDMP implementation is selecting who can access the database. Some state health departments required PDMP use for routine opioid prescriptions yet restricted PDMP access to a narrow set of clinicians. To inform further policy development, Dr. Maughan conducted a study to measure the time burden and financial cost of mandating physician PDMP use rather than permitting the delegation of this task to other clinical staff members. The analysis concluded that PDMP use could be maintained yet costs to the health system could be reduced by over 60% if policies were adopted to permit other clinical staff to use these data.
- Payment for healthcare services has a major impact on the availability and quality of care. Bundled payment models for Medicare have successfully reduced payments for services, yet policymakers have raised concerns that the financial incentives of these programs could restrict access to care or result in poorer outcomes for patients with vulnerabilities such as low socioeconomic status or dementia. Dr. Maughan analyzed the Bundled Payment for Care Improvement (BPCI) program, an alternative Medicare payment model authorized by the Affordable Care Act, and our research identified that this program was not associated with reductions in quality of care for patients with vulnerabilities.
- Choosing Wisely is a national program from the American Board of Internal Medicine Foundation that is designed to improve medical resource stewardship by promoting discussions between physicians and patients regarding the value of medical tests and treatment. The emergency department is a high-risk clinical environment in which physicians often must make time-sensitive decisions on the use of expensive medical resources for patients with whom they have no existing relationship. Dr. Maughan measured awareness of the Choosing Wisely program among leaders in the emergency medicine community and identified opportunities for emergency physicians to collaborate with other specialists on reducing unnecessary testing and improving the value of emergency care.
Complete List of Published Works in MyBibliography:
Dr. Schnittke is an assistant professor at Oregon Health & Science University in the Department of Emergency Medicine, with an overarching career goal of understanding the basic mechanisms of disease by combining his training as a scientist and a bedside clinician. His interest in acute injury and clinical care of patients with an immediate need for intervention drew him to Emergency Medicine. During residency training, he grew a deep interest in point-of-care ultrasound (POCUS) and the care of undifferentiated, critically ill patients. This interest provides an opportunity to bridge pathophysiology with direct patient care. During residency and fellowship, Dr. Schnittke gave several talks at national and local conferences, and developed a research program focused on characterizing POCUS findings in undifferentiated patients with presumed sepsis. Since joining the faculty in the Department of Emergency Medicine and the Center for Regenerative Medicine at OHSU, Dr. Schnittke has continued investigating the role of ultrasound in critically ill patients.
As a graduate student, Dr. Schnittke investigated the response of the olfactory epithelium to acute tissue injury. The olfactory epithelium is one of few sites of continuous neurogenesis in mammals and has promise in providing cell-based therapies for neurodegenerative diseases. He identified a molecular circuit mediated by the transcription factor p63, which sits at the crux of activation of neural stem cells during acute injury. The combination of cellular, inflammatory, and molecular changes in injury models first piqued his interest in the response of biologic systems to severe acute injury.
The literature strongly supports the use of POCUS during on-shift decision-making; however, the incorporation and proper documentation of ultrasound into actual clinical scenarios are often not performed even when clinically indicated. Dr. Schnittke's quality improvement and research project focused on identifying and reducing barriers to resident-performed ultrasound during clinical shifts. He found that residents are keen to use ultrasound but required firm guidelines and education on documentation protocols. Incorporating a documentation protocol significantly increased resident performed POCUS on shift.
Complete List of Published Work in MyBibliography:
Dr. Sheridan is a pediatric emergency physician and a physician-scientist in the Oregon Health & Science University Department of Emergency Medicine, with a joint appointment in the Department of Pediatrics. In addition to his clinical training, he earned a Master’s degree in Clinical Research (MCR), which provided coursework in epidemiology, biostatistics, clinical trial design, implementation science, and data analysis. Dr. Sheridan's research includes publications mainly in emergency care on the prevalence of disease, development of new technology, evaluation of new interventions, observational research, and randomized controlled trials. Much of his work has focused on medical device development as an academic physician-scientist. He has filed 7 patents and one technology has become an OHSU startup company. Through this innovation work Dr. Sheridan has had to learn first-hand the processes and methods for moving a device from concept to commercialization.
1. Device Development in Pediatric Emergency Care
Medical devices are often created by industry with little clinician involvement, resulting in technology that is often too expensive, not indicated, or ineffective. Dr. Sheridan has founded an innovation division in our department that has developed infrastructure for combining physicians and engineers to develop technology through an innovation based process. This has resulted in funding, intellectual property and prototypes in clinical testing. One technology has been spun out of OHSU as a startup company.
2. Adolescent Mental Health Crises and Emergency Care
Through problem-based innovation in the ED, Dr. Sheridan has recognized the critical need for improved emergency care research in adolescent mental health. There has been a paucity of literature on adolescent children presenting to EDs in crisis, which my work has begun to address. Dr. Sheridan's foundational work has shown evidence of a rapidly growing population of children presenting to EDs in crisis, the prevalence of adolescent suicidality and care received in the ED, and the need for improved outpatient monitoring. His K12 project was aimed at providing a foundation in this area.
3. New Imaging Modalities with Decreased Risk for Acute Pediatric Head Trauma
Pediatric head injuries account for millions of ED visits per year and carry significant morbidity and mortality in children. The current imaging test of choice is a CT scan, but this entails significant radiation exposure that can result in future malignancy at a risk of approximately 1:1000 scans. “Quick brain” MRI has introduced the possibility of obtaining rapid-sequence neuroimaging without radiation. Dr. Sheridan completed a retrospective study showing 100% sensitivity of MRI to detect injuries that catalyzed a prospective observational study at our pediatric trauma center evaluating the diagnostic utility of quick brain MRI versus head CT among children presenting with acute head trauma. As the PI, he brought together 5 specialties across the institution to collaborate on the trial resulting in a publication that has resulted in practice guidelines for neuroimaging in pediatric trauma.
Complete List of Published Work in MyBibliography: