Volume 26 Issue 3 by Western Journal of Emergency Medicine

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Expert Commentary

378 Ending Nuclear Weapons, Before They End Us

K Abbasi, P Ali, V Barbour, M Birch, I Blum, P Doherty, A Haines, I Helfand, R Horton, K Juva, JF

Lapena Jr, R Mash, O Mironova, A Mitra, C Monteiro, EN Naumova, D Onazi, T Ruff, P Sahni, J Tumwine, C Umaña, P Yonga, C Zielinski

Health Equity

381 Social Determinants of Health and Health Literacy in Emergency Patients with Diabetic Ketoacidosis

DF Suarez, RM Schneider, M Girardi, G LaRossa, J Yeary, T Kaser, R Ancona, P Cruz Bravo, RT Griffey

387 Emergency Department Comprehensive Social Risk Screening and Resource Referral Program

K Stillman, A Dahut, A Caudill, K Hren, K Green, M Lauzon, S Jackman, A Lawton, T Chopra, J Geiderman, S Torbati

396 Feasibility of an Emergency Department-based Food Insecurity Screening and Referral Program V Cisneros, IDC Olliffe, MS Esteban, J Bui, A Takallou, S Lotfipour, B Chakravarthy

406 Exposure to Community Violence and Adverse Childhood Experiences in the Emergency Department L Cachola, Y Guevara, S Ansari

413 Legislating Fear: How Immigration Status Mandates Threaten Public Health P Sangeyup Yun, L Williams, J Blanchard

415 Evaluation of Disparities in Emergency Department Admission and Wait Times for Non-English Preferred Patients

J Wong-Castillo, D Berger, JC Montoy, R Alwan

425 Validation of a Methodology to Investigate Care Inequities for Transgender Patients

K Engstrom, F Bellolio, MM Jeffrey, SC Sutherland, KP Carpenter, G Jackson, K Cole, V Chedid, CJ Davidge-Pitts, KL Sungga, C Gonzalez, CS Brown

Penn State Health Emergency Medicine

About Us: Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are the only medical facility in Pennsylvania to be accredited as a Level I pediatric trauma center and Level I adult trauma center. The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Health Children’s Hospital and Penn State Cancer Institute based in Hershey, Pa.; Penn State Health Hampden Medical Center in Enola, Pa.; Penn State Health Holy Spirit Medical Center in Camp Hill, Pa.; Penn State Health Lancaster Medical Center in Lancaster, Pa.; Penn State Health St. Joseph Medical Center in Reading, Pa.; Pennsylvania Psychiatric Institute, a specialty provider of inpatient and outpatient behavioral health services, in Harrisburg, Pa.; and 2,450+ physicians and direct care providers at 225 outpatient practices. Additionally, the system jointly operates various healthcare providers, including Penn State Health Rehabilitation Hospital, Hershey Outpatient Surgery Center and Hershey Endoscopy Center.

We foster a collaborative environment rich with diversity, share a passion for patient care, and have a space for those who share our spark of innovative research interests. Our health system is expanding and we have opportunities in both academic hospital as well community hospital settings.

Benefit highlights include:

• Competitive salary with sign-on bonus

• Comprehensive benefits and retirement package

• Relocation assistance & CME allowance

• Attractive neighborhoods in scenic central Pennsylvania

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR CPRP

Penn State Health Lead Physician Recruiter hpeffley@pennstatehealth.psu.edu

Western Journal of Emergency Medicine:

Emergency Care with Population Health Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Andrew W. Phillips, MD, Associate Editor DHR Health-Edinburg, Texas

Edward Michelson, MD, Associate Editor Texas Tech University- El Paso, Texas

Dan Mayer, MD, Associate Editor Retired from Albany Medical College- Niskayuna, New York

Wendy Macias-Konstantopoulos, MD, MPH, Associate Editor Massachusetts General Hospital- Boston, Massachusetts

Gayle Galletta, MD, Associate Editor University of Massachusetts Medical SchoolWorcester, Massachusetts

Yanina Purim-Shem-Tov, MD, MS, Associate Editor Rush University Medical Center-Chicago, Illinois

Section Editors

Behavioral Emergencies

Bradford Brobin, MD, MBA Chicago Medical School

Marc L. Martel, MD

Hennepin County Medical Center

Ryan Ley, MD

Hennepin County Medical Center

Cardiac Care

Sam S. Torbati, MD Cedars-Sinai Medical Center

Emily Sbiroli, MD Palomar Medical Center

Climate Change

Gary Gaddis, MBBS University of Maryland

Clinical Practice

Cortlyn W. Brown, MD Carolinas Medical Center

Casey Clements, MD, PhD Mayo Clinic

Patrick Meloy, MD Emory University

Nicholas Pettit, DO, PhD Indiana University

David Thompson, MD University of California, San Francisco

Kenneth S. Whitlow, DO Kaweah Delta Medical Center

Critical Care

Christopher “Kit” Tainter, MD University of California, San Diego

Gabriel Wardi, MD University of California, San Diego

Joseph Shiber, MD University of Florida-College of Medicine

Matt Prekker MD, MPH Hennepin County Medical Center

David Page, MD University of Alabama

Erik Melnychuk, MD Geisinger Health

Quincy Tran, MD, PhD University of Maryland

Disaster Medicine

John Broach, MD, MPH, MBA, FACEP

University of Massachusetts Medical School UMass Memorial Medical Center

Christopher Kang, MD Madigan Army Medical Center

Mark I. Langdorf, MD, MHPE, Editor-in-Chief University of California, Irvine School of MedicineIrvine, California

Shahram Lotfipour, MD, MPH, Managing Editor University of California, Irvine School of MedicineIrvine, California

Gary Gaddis MBBS, Associate Editor University of Maryland- Baltimore, Maryland

Rick A. McPheeters, DO, Associate Editor Kern Medical- Bakersfield, California

R. Gentry Wilkerson, MD, Associate Editor University of Maryland

Education

Danya Khoujah, MBBS

University of Maryland School of Medicine

Jeffrey Druck, MD University of Colorado

John Burkhardt, MD, MA University of Michigan Medical School

Michael Epter, DO Maricopa Medical Center

ED Administration, Quality, Safety

David C. Lee, MD Northshore University Hospital

Gary Johnson, MD Upstate Medical University

Brian J. Yun, MD, MBA, MPH Harvard Medical School

Laura Walker, MD Mayo Clinic

León D. Sánchez, MD, MPH Beth Israel Deaconess Medical Center

William Fernandez, MD, MPH University of Texas Health-San Antonio

Robert Derlet, MD

Founding Editor, California Journal of

Emergency Medicine

University of California, Davis

Emergency Medical Services

Daniel Joseph, MD Yale University

Joshua B. Gaither, MD University of Arizona, Tuscon

Julian Mapp

University of Texas, San Antonio

Shira A. Schlesinger, MD, MPH Harbor-UCLA Medical Center

Geriatrics

Cameron Gettel, MD Yale School of Medicine

Stephen Meldon, MD Cleveland Clinic

Luna Ragsdale, MD, MPH Duke University

Health Equity

Emily C. Manchanda, MD, MPH Boston University School of Medicine

Faith Quenzer

Temecula Valley Hospital San Ysidro Health Center

Mandy J. Hill, DrPH, MPH UT Health McGovern Medical School

Payal Modi, MD MScPH

Michael Pulia, MD, PhD, Associate Editor University of Wisconsins Hospitals and Clinics- Madison, Wisconsin

Brian Yun, MD, MPH, MBA, Associate Editor Boston Medical Center-Boston, Massachusetts

Quincy Tran, MD, Associate Editor University of Maryland School of Medicine- Baltimore, Maryland

Patrick Joseph Maher, MD, MS, Associate Editor Ichan School of Medicine at Mount Sinai- New York, New York

Donna Mendez, MD, EdD, Associate Editor University of Texas-Houston/McGovern Medical School- Houston Texas

Danya Khoujah, MBBS, Associate Editor University of Maryland School of Medicine- Baltimore, Maryland

University of Massachusetts Medical

Infectious Disease

Elissa Schechter-Perkins, MD, MPH Boston University School of Medicine

Ioannis Koutroulis, MD, MBA, PhD

George Washington University School of Medicine and Health Sciences

Kevin Lunney, MD, MHS, PhD University of Maryland School of Medicine

Stephen Liang, MD, MPHS Washington University School of Medicine

Victor Cisneros, MD, MPH Eisenhower Medical Center

Injury Prevention

Mark Faul, PhD, MA Centers for Disease Control and Prevention

Wirachin Hoonpongsimanont, MD, MSBATS Eisenhower Medical Center

International Medicine

Heather A.. Brown, MD, MPH Prisma Health Richland

Taylor Burkholder, MD, MPH Keck School of Medicine of USC

Christopher Greene, MD, MPH University of Alabama

Chris Mills, MD, MPH

Santa Clara Valley Medical Center

Shada Rouhani, MD

Brigham and Women’s Hospital

Legal Medicine

Melanie S. Heniff, MD, JD Indiana University School of Medicine

Greg P. Moore, MD, JD Madigan Army Medical Center

Statistics and Methodology

Shu B. Chan MD, MS Resurrection Medical Center

Stormy M. Morales Monks, PhD, MPH Texas Tech Health Science University

Soheil Saadat, MD, MPH, PhD University of California, Irvine

James A. Meltzer, MD, MS Albert Einstein College of Medicine

Musculoskeletal

Juan F. Acosta DO, MS Pacific Northwest University

Rick Lucarelli, MD Medical City Dallas Hospital

William D. Whetstone, MD University of California, San Francisco

Neurosciences

Antonio Siniscalchi, MD Annunziata Hospital, Cosenza, Italy

Pediatric Emergency Medicine

Paul Walsh, MD, MSc University of California, Davis

Muhammad Waseem, MD

Lincoln Medical & Mental Health Center

Cristina M. Zeretzke-Bien, MD University of Florida

Public Health

Jacob Manteuffel, MD Henry Ford Hospital

John Ashurst, DO

Lehigh Valley Health Network

Tony Zitek, MD Kendall Regional Medical Center

Trevor Mills, MD, MPH Northern California VA Health Care

Erik S. Anderson, MD Alameda Health System-Highland Hospital

Technology in Emergency Medicine

Nikhil Goyal, MD Henry Ford Hospital

Phillips Perera, MD Stanford University Medical Center

Trauma

Pierre Borczuk, MD

Massachusetts General Hospital/Havard Medical School

Toxicology

Brandon Wills, DO, MS Virginia Commonwealth University

Jeffrey R. Suchard, MD University of California, Irvine

Ultrasound

J. Matthew Fields, MD Thomas Jefferson University

Shane Summers, MD Brooke Army Medical Center

Robert R. Ehrman Wayne State University

Ryan C. Gibbons, MD Temple Health

Official Journal of the California Chapter of the American College of Emergency Physicians, the America College of Osteopathic Emergency Physicians, and the California Chapter of the American Academy of Emergency Medicine

Available in MEDLINE, PubMed, PubMed Central, CINAHL, SCOPUS, Google Scholar, eScholarship, Melvyl, DOAJ, EBSCO, EMBASE, Medscape, HINARI, and MDLinx Emergency Med. Members of OASPA.

Editorial and Publishing Office: WestJEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA Office: 1-714-456-6389; Email: Editor@westjem.org

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Editorial Board

Amin A. Kazzi, MD, MAAEM

The American University of Beirut, Beirut, Lebanon

Anwar Al-Awadhi, MD

Mubarak Al-Kabeer Hospital, Jabriya, Kuwait

Arif A. Cevik, MD

United Arab Emirates University College of Medicine and Health Sciences, Al Ain, United Arab Emirates

Abhinandan A.Desai, MD University of Bombay Grant Medical College, Bombay, India

Bandr Mzahim, MD

King Fahad Medical City, Riyadh, Saudi Arabia

Brent King, MD, MMM University of Texas, Houston

Christopher E. San Miguel, MD Ohio State University Wexner Medical Center

Daniel J. Dire, MD University of Texas Health Sciences Center San Antonio

David F.M. Brown, MD Massachusetts General Hospital/ Harvard Medical School

Douglas Ander, MD Emory University

Edward Michelson, MD Texas Tech University

Edward Panacek, MD, MPH University of South Alabama

Francesco Della Corte, MD

Azienda Ospedaliera Universitaria “Maggiore della Carità,” Novara, Italy

Hoon ChinStevenLim, MBBS, MRCSEd Changi General Hospital

Gayle Galleta, MD

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Jacob (Kobi) Peleg, PhD, MPH Tel-Aviv University, Tel-Aviv, Israel

Jaqueline Le, MD Desert Regional Medical Center

Jeffrey Love, MD The George Washington University School of Medicine and Health Sciences

Jonathan Olshaker, MD Boston University

Katsuhiro Kanemaru, MD University of Miyazaki Hospital, Miyazaki, Japan

Kenneth V. Iserson, MD, MBA University of Arizona, Tucson

Advisory Board

Kimberly Ang, MBA

UC Irvine Health School of Medicine

Elena Lopez-Gusman, JD

California ACEP

American College of Emergency Physicians

Amanda Mahan, Executive Director

American College of Osteopathic Emergency Physicians

John B. Christensen, MD

California Chapter Division of AAEM

Randy Young, MD

California ACEP

American College of Emergency Physicians

Mark I. Langdorf, MD, MHPE UC Irvine Health School of Medicine

Jorge Fernandez, MD

California ACEP

American College of Emergency Physicians University of California, San Diego

Peter A. Bell, DO, MBA

American College of Osteopathic Emergency Physicians Baptist Health Science University

Robert Suter, DO, MHA

American College of Osteopathic Emergency Physicians UT Southwestern Medical Center

Shahram Lotfipour, MD, MPH UC Irvine Health School of Medicine

Brian Potts, MD, MBA California Chapter Division of AAEM Alta Bates Summit-Berkeley Campus

Khrongwong Musikatavorn, MD

King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand

Leslie Zun, MD, MBA Chicago Medical School

Linda S. Murphy, MLIS University of California, Irvine School of Medicine Librarian

Nadeem Qureshi, MD St. Louis University, USA Emirates Society of Emergency Medicine, United Arab Emirates

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de Chile, Región Metropolitana, Chile

Peter A. Bell, DO, MBA Baptist Health Sciences University

Peter Sokolove, MD University of California, San Francisco

Rachel A. Lindor, MD, JD Mayo Clinic

Robert M. Rodriguez, MD University of California, San Francisco

Robert Suter, DO, MHA UT Southwestern Medical Center

Robert W. Derlet, MD University of California, Davis

Rosidah Ibrahim, MD Hospital Serdang, Selangor, Malaysia

Samuel J. Stratton, MD, MPH Orange County, CA, EMS Agency

Scott Rudkin, MD, MBA University of California, Irvine

Scott Zeller, MD University of California, Riverside

Terry Mulligan, DO, MPH, FIFEM ACEP Ambassador to the Netherlands Society of Emergency Physicians

Wirachin Hoonpongsimanont, MD, MSBATS

Siriraj Hospital, Mahidol University, Bangkok, Thailand

Editorial Staff

Ian Oliffe, BS Executive Editorial Director

Sheyda Aquino, BS WestJEM Editorial Director

Tran Nguyen, BS CPC-EM Editorial Director

Stephanie Burmeister, MLIS WestJEM Staff Liaison

Cassandra Saucedo, MS Executive Publishing Director

Isabelle Kawaguchi, BS WestJEM Publishing Director

Alyson Tsai CPC-EM Publishing Director

June Casey, BA Copy Editor

Available in MEDLINE, PubMed, PubMed Central, Europe PubMed Central, PubMed Central Canada, CINAHL, SCOPUS, Google Scholar, eScholarship, Melvyl, DOAJ, EBSCO, EMBASE, Medscape, HINARI, and MDLinx Emergency Med. Members of OASPA. Editorial and Publishing Office: WestJEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA Email: Editor@westjem.org

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

JOURNAL FOCUS

Emergency medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.

431 A Systematic Review of Guidelines for Emergency Department Care of Sexual Minorities: Implementable Actions to Improve Care

MI Kruse, S Karabelas-Pittman, G Northrop, J Stuart, S Upadhye, BL Bigham

441 Moving Beyond “Check A Box”: Shifting Physician Perceptions and Culture with an Antiracism and Equity Curriculum

H Barber Doucet, T Lin, T Wilson

452 Images in Black and White: Disparities in Utilization of Computed Tomography and Ultrasound for Older Adults with Abdominal Pain

IC Unachukwu, MN Adjei-Poku, OC Sailors, R Gonzales, E South, Z Meisel, RR Kelz, AR Cappola, AB Friedman

458 Emergency Medical Service Responders’ Perspectives on Transgender, Intersexual, and Non-Binary Patients in Germany

T Brod, K Afshar, C Schroeder, C Stoetzer, S Stiel

Ultrasound

465 Simulation-based Training Changes Attitudes of Emergency Physicians Toward Transesophageal Echocardiography

M Danta, AY Nguyen-Phuoc, S Gupta, A Sakhpara, J Kurbedin, E Khordipour,A. Likourezos, L Haines, A Aghera, J Drapkin, J Lin

469 Trends in Studies on Transesophageal Echocardiography in Emergency Medicine: A Scoping Review

B-Y Tseng, C-J Yang,J-T Sun, YT Liu, K Yadav, Y-L Hseih, S-E Chu, C-W Lee, Y-K Lee, T-Y Tsai

478 Evaluation of Point-of-Care Ultrasound Use in Emergency Medicine Residents: An Observational Study

M Fareri, M VandeHei, B Schnapp, C Jewell, MR Lasarev, R Alexandridis, D Resop, S Damewood, HI Kuttab

486 Patient Sociodemographic Factors Are Associated with Receiving Point-of-care Ultrasound in the Emergency Department

BM Wubben, D Spolsdoff, KK Harland, M Del Rios

491 Non-invasive Monitor of Effective Chest Compressions with Carotid and Femoral Artery Ultrasound in the Emergency Department

F Yang, H Zou, J Gan, X Zhao, X Tu, C Jiang, J Xia

Emergency Department Operations

500 Emergency Physician Assessment of Productivity and Supervision Practices

K Schreyer, D Kuhn, V Norton

Policies for peer review, author instructions, conflicts of interest and human and animal subjects protections can be found online at www.westjem.com.

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Table of Contents continued

507 Evaluating the Implementation of a “COVID-19 Test” Chief Concern in the Emergency Department

C Michels, DJ Hekman, RJ Schwei, RE Tsuchida, J Gauger, I Hurst, J Glazer, J Brink, C Barclay-Buchanan, MN Shah, AG Hamedani, M Pulia

513 Risk Factors for Hospital Admissions Among Emergency Department Patients: From Triage to Admission

J Koh, OH Choon, S Lim

523 Case Study of How Alleviating “Pebbles in the Shoe” Improves Operations in the Emergency Department

D Savitzky, Y Chavda, S Datta, A Reens, E Conklin, M Scott, C Caspers

Emergency Medical Services

528 Epidemiology of 911 Calls for Opioid Overdose in Nogales, Arizona

M Glenn, D Stratton, K Primeau, A Rice

535 Development and Evaluation of a Novel Curriculum for Whole Blood Transfusion by Paramedics in the Prehospital Environment

E Garfinkel, R May, A Margolis, E Cohn, S Colburn, T Grawey, M Levy

541 Variations in Out-of-Hospital Cardiac Arrest Resuscitation Performance and Outcomes in Ohio

MMJ Nassal, HE Wang, JR Powell, JL Benoit, AR Panchal

549 Dispatch Decisions and Emergency Medical Services Response in the Prehospital Care of Status Epilepticus

RP McInnis, AJ Wood, CL Shay, AA Haggart, RP Crowe, EL Guterman

Medical Education

556 Creation and Implementation of an EMS Elective for Final- Year Medical Students: A 5-year Evaluation

E Peralta, C Evers, T Gonell, M Hodges, D Cohen, LM Maloney

564 Harnessing Residents’ Practice-based Inquiries to Enhance Research Literacy: The Thoughtful Reading of Evidence into Clinical Settings (T-RECS) Initiative

E Worley, EH Suh, L Abrukim, M DeFilippo, JJ Kamler, M Polavarapu, PC Wyer

569 Descriptive Analysis of Resources Used to Learn About Residency Programs Since Transition to Virtual Interviews

R Bounds, J Priester, B Lewis, R King, S Lentz

573 Emergency Medicine Residency Website Wellness Pages: A Content Analysis

A Sappington, B Milman

Behvioral Health

573 Effects of Emergency Department Training on Buprenorphine Prescribing and Opioid Use Disorder- Associated ED Revisits: Retrospective Cohort Study

A Torchiano, B Roberts, R Haroz, C Milburn, K Baston, J Heil, V Ganetsky, M Salzman

588 “Oh, Another Overdose, for the Love of Pete”: First Responder Perspectives on Overdose Response Technology

W Rioux, S Jones, SM Ghosh

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Infectious Disease

Table of Contents continued

600 Randomized Controlled Trial of Atorvastatin in Acute Influenza in the Emergency Department

M CHase, MN Cocchi, AV Grossestreuer, X Liu, J Vine, AL Moskowitz, MW Donnino

609 Age-stratified Association Between Plasma Adiponectin Levels and Mortality in Septic Patients

H Wang, M Ma, J Dong, J Duan

617 Developing Machine-Learning Models to Predict Bacteremia in Febrile Adults Presenting to the Emergency Department: A Retrospective Cohort Study from a Large Center

C-M Fu, I Ngo, P Sheung Lau, Y Ivanchuk, F-Y Chou, C-H Wang, C-Y Lin, C-L Tsai, S-Y Chen, T-C Lu, H-Y Wei

Injury Prevention

627 A Review of Sports-Related, Life-Threatening Injuries Presenting to Emergency Departments, 2009-18

A Ibiebele, R Mannix, W Meehan

632 National Study of Firearm Presence and Storage Practices in Homes of Rural Adolescents

B Linden, M Sinik, K Wetjen, P Hoogerwerf, J Liao, C Jennissen

Toxicology

643 Incidence and Characteristics of Alcohol-Based Hand Sanitizer Ingestion in Florida before and during the Coronavirus Pandemic

J Arnold, A Athanasios, D Nguyen, R Mhaskar

650 Comparing Prehospital Time Among Pediatric Poisoning Patients in Rural and Urban Settings

AT Phillips, M Denning, E Long-Mills, D Tumin, J Parker-Cote, K Bryant

Climate Change

657 Predictive Factors and Nomogram for 30-Day Mortality in Heatstroke Patients: A Retrospective Cohort Study

A Li, Y Zhang, X Zhang, Z Duan, Y Chen, X Jiang, W Deng

667 Association of Heat Index and Patient Presentation Rate at a Stadium

J Wolin, D Wolf, J Su, E Quinn, D Eng, H Ali, D Lobel, M Friedman

Critical Care

674 Emergency Department Blood Pressure Management in Type B Aortic Dissection: An Analysis with Machine Learning

N Chen, JV Downing, J Epstein, S Mudd, A Chan, S Kuppireddy, R Tehrani, I Vashee, E Hart, E Esposito, R Chasm, QK Tran

685 Ultrasound-guided Emergency Pericardiocentesis Simulation on Human Cadavers: A Scoping Review

L Ünlü, F Margenfeld, A Zendehdel, JA Griese, A Poilliot, M Müller-Gerbl, CH Nickel, M Dedic

Neurology

692 Diagnostic Delays Are Common, and Classic Presentations Are Rare in Spinal Epidural Abscess

EJ Durant, S Copos, BF Folck, M Anderson, MS Ghiya, ER Hofmann, P Vuong, J Shan, M Kene

700 Practical Status and Social Background of Current Mobile Stroke Units Worldwide: A Survey and Investigation

M Hiroki, M Kohno, Y Kohno, M Misawa

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Table of Contents continued

Emergency Department Administration

712 Civil Monetary Penalties from Violations of the Emergency Medical Treatment and Labor Act for Patients Arriving or Leaving with Law Enforcement

A Ahmed, Z Reichert, G Santillanes, C Toomer, S Tyler-Mills, N Vontela, J Hsia, S Axeen, S Kashani, J Nakagawa, M Menchine, S Terp

Clinical Practice

720

Validating an Electronic Health Record Algorithm for Diabetes Screening Eligibility in the Emergency Department

MH Smart, JY Lin, BT Layden, Y Eisenberg, KK Danielson, R Pobee, C Tang, B Rydzon, A Bairavi Maheswaran, AS Pickard, LK Sharp, A King

Cardiology

729 Coronary Artery Bypass Grafting Is Rarely Done in the Acute Care of ST-elevation Myocardial Infarction

Patients Treated by Emergency Medical Services

J Toy, C Lauer, AH Kaji, JL Thomas, N Megowan, N Bosson, M Gausche-Hill, P Dhawan, RA Kloner, S Rasnake, W French, S Schlesinger

Clinical Operations

737 Real-time Ultrasound-guided Lumbar Puncture: A Comparison of Two Techniques Using Simulation

K Samsel, D Wasiak, E Situ-LaCasse, S Adhikari, J Acuña

Disaster Medicine

743 Post-Concussion Syndrome Following Blast Injury: A Cross- Sectional Study of Beirut Blast Casualties

H Anan, M Al Hariri, E Hitti, F Kobeissy, A Mufarrij

Trauma

751 Field vs. Emergency Department Intubation: A Retrospective Review of Hospital Outcomes of Trauma Patients

M Vorce, S Galwankar, J Shuck, A Agrawal

Women’s Health

758 Caught Unprepared: The Urgent Need for Reproductive Health Training in Emergency Medicine

P Sangeyup Yun, M Saxena

Letters to the Editor

760 Response to the Letter to the Editor Regarding “Bicarbonate and Serum Lab Markers as Predictors of Mortality in the Trauma Patient”

MM Talbott, D Jehle, K Paul

761 Beyond Efficiency: Considering the Benefits of Residents in the Emergency Department

RE Armstrong

762 Beyond Efficiency: Considering the Benefits of Residents in the Emergency Department

J Valentine, J Poulson

This

Western Journal of Emergency Medicine:

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University of Chicago, Chicago, IL

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Ending Nuclear Weapons, Before They End Us

Kamran Abbasi, MD

Parveen Ali, PhD, MScN, FFPH, SFHEA

Virginia Barbour, MA Camb, MB BChir, DPhil, MRCP

Marion Birch, PGDip., MSc., SRM, SRN, BAHons

Inga Blum, MD

Peter Doherty, BSc, PhD

Andy Haines, F Med Sci

Ira Helfand, MD

Richard Horton, MB, ChB M

Kati Juva, MD

Jose F. Lapena Jr, MA, MD, FPCS, FPSOHNS

Robert Mash, MBChB, DRCOG, DCH, FCFP, FRCGP, PhD

Olga Mironova, MD, PhD

Arun Mitra, MBBS; MS (ENT Surgeon)

Carlos Monteiro, MD, PhD

Elena N. Naumova, PhD

David Onazi, MD

Tilman Ruff, MB, BS (Hons), FRACP

Peush Sahni, MS, DNB, PhD

James Tumwine, MBChB; M.Med; PhD

Carlos Umaña, MD

Paul Yonga, MBChB, MSPH, FRCP EDin

Chris Zielinski, BSc, MSc

Section Editor: Mark I Langdorf, MD, MHPE

Submission history: Submitted March 31, 2025; Accepted March 31, 2025

Electronically published May 19, 2025

Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI 10.5811/westjem.47301

[West J Emerg Med. 2025;26(3)378–380.]

This May, the World Health Assembly (WHA) will vote on re-establishing a mandate for the World Health Organization (WHO) to address the health consequences of nuclear weapons and war.1 Health professionals and their associations should urge their governments to support such a mandate and support the new UN comprehensive study on the effects of nuclear war.

The first atomic bomb exploded in the New Mexico desert 80 years ago, in July 1945. Three weeks later, two relatively small (by today’s standards), tactical-size nuclear weapons unleashed a cataclysm of radioactive incineration on Hiroshima and Nagasaki. By the end of 1945, about 213,000 people were dead.2 Tens of thousands more have died from late effects of the bombings.

Last December, Nihon Hidankyo, a movement that brings together atomic bomb survivors, was awarded the Nobel Peace Prize for its “efforts to achieve a world free of nuclear weapons and for demonstrating through witness testimony

that nuclear weapons must never be used again”.3 For the Norwegian Nobel Committee, the award validated the most fundamental human right: the right to live. The Committee warned that the menace of nuclear weapons is now more urgent than ever before. In the words of Committee Chair Jørgen Watne Frydnes, “it is naive to believe our civilisation can survive a world order in which global security depends on nuclear weapons. The world is not meant to be a prison in which we await collective annihilation.”4 He noted that our survival depended on keeping intact the “nuclear taboo” (which stigmatises the use of nuclear weapons as morally unacceptable).5

The nuclear taboo gains strength from recognition of compelling evidence of the catastrophic humanitarian consequences of nuclear war, its severe global climatic and famine consequences, and the impossibility of any effective humanitarian response. This evidence contributed significantly to ending the Cold War nuclear arms race.6,7

While the numbers of nuclear weapons are down to 12,331 now, from their 1986 peak of 70,300,8 this is still equivalent to 146,605 Hiroshima bombs,9 and does not mean humanity is any safer.10 Even a fraction of the current arsenal could decimate the biosphere in a severe mass extinction event. The global climate disruption caused by the smoke pouring from cities ignited by just 2% of the current arsenal could result in over two billion people starving.11

A worldwide nuclear arms race is underway. Deployed nuclear weapons are increasing again, and China, India, North Korea, Pakistan, Russia and UK are all enlarging their arsenals. An estimated 2,100 nuclear warheads in France, Russia, UK, US and, for the first time, also in China, are on high alert, ready for launch within minutes.8 With disarmament in reverse, extensive nuclear modernisations underway, multiple arms control treaties abrogated without replacement, no disarmament negotiations in evidence, nuclear-armed Russia and Israel engaged in active wars involving repeated nuclear threats, Russia and the US deploying nuclear weapons to additional states, and widespread use of cyberwarfare, the risk of nuclear war is widely assessed to be greater than ever. This year the Doomsday Clock was moved the closest to midnight since the Clock’s founding in 1947.10

Led by Ireland and New Zealand, in late 2024, the United Nations General Assembly (UNGA) voted overwhelmingly to establish a 21-member independent scientific panel to undertake a new comprehensive study on the effects of nuclear war,12 with its final report due in 2027. Noting that “removing the threat of a nuclear war is the most acute and urgent task of the present day”, the panel has been tasked with examining the physical effects and societal consequences of a nuclear war on a local, regional and planetary scale. It will examine the climatic, environmental and radiological effects of nuclear war, and their impact on public health, global socioeconomic systems, agriculture and ecosystems.

The resolution calls upon UN agencies, including WHO, to support the panel’s work, including by “contributing expertise, commissioned studies, data and papers”. All UN Member States are encouraged to provide relevant information, scientific data and analyses; facilitate and host panel meetings, including regional meetings; and make budgetary or in-kind contributions. Such an authoritative international assessment of evidence on the most acute existential threat to humankind and planetary health is long overdue. The last such report dates from 1989. It is shameful that France, UK and Russia opposed this resolution.13

In 1983 and 1987,14 WHO convened an international committee of scientists and health experts to study the health effects of nuclear war. Its landmark, authoritative reports were influential and an excellent example of WHO fulfilling its constitutional mandate “to act as the directing and coordinating authority on international health work”. In 1993, WHO produced an additional shorter report on the health and

environmental effects of nuclear weapons, which included discussion of the production chain of nuclear weapons, including processing, testing and disposal.15

However, despite WHA having mandated WHO to report periodically on relevant developments, no further work was undertaken and in 2020 WHO’s mandate on nuclear weapons and health lapsed.

The Marshall Islands, Samoa and Vanuatu, supported by seven co-sponsoring states and International Physicians for the Prevention of Nuclear War (IPPNW), are working to renew WHO’s mandate. They are seeking wide support for a resolution on the health effects of nuclear weapons/war at this year’s WHA in Geneva on 19-27 May.1 WHO would then reestablish a programme of work on this most critical threat to health, and be able to lead strongly in providing the best health evidence to the UN panel.

Health professionals are well aware how crucial accurate and up-to-date evidence is to making good decisions. We and our organisations should support such a renewed mandate by urging our national WHA delegates to vote in support and commit the modest funds needed to re-establish WHO’s work programme, especially now, as the organisation faces severe financial strain with the US decision to withdraw its membership.

Our joint editorial in 202316 on reducing the risks of nuclear war and the role of health professionals, published in over 150 health journals worldwide, urged three immediate steps by nuclear-armed states and their allies: adopt a “no first use” policy, take their nuclear weapons off hair-trigger alert, and pledge unequivocally that they will not use nuclear weapons in any current conflicts they are involved in. We also urged nuclear-armed states to work for a definitive end to the nuclear threat by urgently starting negotiations for a verifiable, timebound agreement to eliminate their nuclear arsenals, and called on all nations to join the Treaty on the Prohibition of Nuclear Weapons.17

It is an alarming failure of leadership that no progress has been made on these needed measures, nor on many other feasible steps away from the brink, acting on the obligation of all states to achieve nuclear disarmament. Nine states jeopardise all humanity and the biosphere by claiming an exclusive right to wield the most destructive and inhumane weapons ever created. The world desperately needs the leaders of these states to freeze their arsenals, end the modernisation and development of new, more dangerous nuclear weapons, and ensure that new technology such as artificial intelligence can never trigger the launch of nuclear weapons.

The UN scientific panel and a renewed mandate for WHO’s work in this area can provide vital authoritative and up-to-date evidence for health and public education, evidencebased advocacy and policies, and the mobilised public concern needed to trigger decisive political leadership. This is a core health imperative for all of us.

Address for Correspondence: Chris Zielinski, BSc, MSc, University of Winchester and President. Email: CZielinski@ippnw.org.

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Copyright: © 2025 Abbasi et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/ licenses/by/4.0/

REFERENCES

1. World Health Organization. Effects of nuclear weapons and war on health and health services. Available at: https://apps.who.int/gb/ebwha/ pdf_files/EB156/B156_CONF10-en.pdf. Accessed March 4, 2025.

2. Tomonaga M. The atomic bombings of Hiroshima and Nagasaki: a summary of the human consequences, 1945-2018, and lessons for Homo sapiens to end the nuclear weapon age. J Peace Nucl Disarm. 2019;2(2):491-517.

3. The Nobel Prize. The Nobel Peace Prize 2024. 2025. Available at: https://www.nobelprize.org/prizes/peace/2024/summary/. Accessed February 25, 2025.

4. The Nobel Prize. Award ceremony speech. 2025. Available at: https:// www.nobelprize.org/prizes/peace/2024/ceremony-speech/. Accessed February 25, 2025.

5. Tannenwald, Nina. The Nuclear Taboo: The United States and the Normative Basis of Nuclear Non-Use. JSTOR. 1999;53(3):433-68.

6. Robock A, Xia L, Harrison CS, et al. Opinion: How fear of nuclear winter has helped save the world, so far. Atom Chem Phys. 2023;23(12):6691-701.

7. Helfand I, Haines A, Ruff T, et al. The growing threat of nuclear war

and the role of the health community. World Med J. 2016;62(3):86-94.

8. Kristensen H, Korda M, Johns E, et al. Status of world nuclear forces. 2025. Available at: https://fas.org/initiative/status-world-nuclearforces/. Accessed March 18, 2025.

9. Norwegian People’s Aid. Nuclear weapons ban monitor 2024. 2025. Available at: https://banmonitor.org/. Accessed March 25, 2025.

10. Science and Security Board Bulletin of the Atomic Scientists. Closer than ever: It is now 89 seconds to midnight - 2025 Doomsday Clock Statement. 2025. Available at: https://thebulletin.org/doomsdayclock/2025-statement/. Accessed March 4, 2025.

11. Xia L, Robock A, Scherrer K, et al. Global food insecurity and famine from reduced crop, marine fishery and livestock production due to climate disruption from nuclear war soot injection. Nat Food. 2022;3:586–96.

12. United Nations General Assembly. Nuclear war and scientific research. 2024. Available at: https://reachingcriticalwill.org/images/ documents/Disarmament-fora/1com/1com24/resolutions/L39-.pdf Accessed March 4, 2025.

13. United Nations General Assembly. Nuclear war effects and scientific research. 2024. Available at: https://reachingcriticalwill.org/images/ documents/Disarmament-fora/1com/1com24/votes-ga/408DRXVII. pdf. Accessed March 4, 2025.

14. World Health Organization. Effects of nuclear war on health and health services, 2nd ed. 1987. Available at: https://iris.who.int/ handle/10665/39199. Accessed March 4, 2025.

15. World Health Organization. Health and environmental effects of nuclear weapons. 1993. https://iris.who.int/ bitstream/handle/10665/175987/WHA46_30_eng. pdf?isAllowed=y&sequence=1. Accessed March 4, 2025.

16. Abbasi K, Ali P, Barbour V, et al. Reducing the risks of nuclear war. BMJ. 2023;382:p1682.

17. United Nations, 2017. Treaty on the Prohibition of Nuclear Weapons. 2017. Available at: https://www.icanw.org/tpnw_full_text. Accessed March 9, 2025.

Social Determinants of Health and Health Literacy in Emergency Patients with Diabetic Ketoacidosis

Daniel F. Suarez, MD*

Ryan M. Schneider, MSN, ACNP-BC, CPPS*

Margo Girardi, MD†

Gina LaRossa, MD†

Julianne Yeary, Pharm D, BCCCP*

Taylor Kaser, MPH*

Rachel Ancona, PhD*

Paulina Cruz Bravo, MD‡

Richard T. Griffey, MD, MPH*

Section Editor: Quincy K. Tran, MD, PhD

Washington University School of Medicine, Barnes-Jewish Hospital, Department of Emergency Medicine, St. Louis, Missouri

Washington University School of Medicine, Barnes-Jewish Hospital, Department of Internal Medicine Divisions of Hospital Medicine, St. Louis, Missouri

Washington University School of Medicine, Barnes-Jewish Hospital, Department of Endocrinology, St. Louis, Missouri

Submission history: Submitted September 2, 2024; Revision received December 24, 2024; Accepted December 26, 2024

Electronically published March 31, 2025

Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.35262

Introduction: Social determinants of health (SDoH) and health literacy have been demonstrated to significantly impact health outcomes. As part of a study of diabetic ketoacidosis (DKA) treatment from the emergency department (ED), we assessed the burden of SDoH and health literacy among patients with DKA to identify potentially modifiable risk factors in the development of DKA.

Methods: This was an exploratory, prospective, cross-sectional study of adult patients with DKA in a large urban academic ED from March 2023–March 2024. We administered the Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool (SNST) and the Brief Health Literacy Screen (BHLS).

Results: Of 126 identified ED patients with confirmed DKA, 57 completed the SNST and 72 completed the BHLS. Nearly all patients (56 patients, 98%) reported at least one unmet SDoH need, and 32 (56%) patients reported five or more. The most frequently reported SDoH needs were physical activity (77%), mental health (63%), financial strain (60%), substance use (54%), and food insecurity (51%). Seventy-two patients completed the BHLS, which demonstrated high levels of health literacy, with median responses ranging from 4-5 on a Likert scale with 5 corresponding to highest health literacy.

Conclusion: Social determinants of health needs are prominent among patients who develop DKA, highlighting an opportunity for ED-based interventions to address specific SDoH factors to prevent the development of this disease. Self-reported health literacy scores were high in this patient population. [West J Emerg Med. 2025;26(3)381–386.]

INTRODUCTION

Diabetes is one of the most significant diseases afflicting the global population, affecting 8.5% of adults aged 18 years or older.1 Diabetic ketoacidosis (DKA) is the most common acute hyperglycemic emergency in patients with diabetes and is associated with over 200,000 annual emergency department

(ED) visits in the United States,2 with a mortality rate of 2-5%.3 Hospitalization for DKA is costly and traumatic for individuals; it is on the rise but often preventable. The development of DKA is related to poor glycemic control and has been found to disproportionately affect racial and social minorities.1,4 The contemporary study of diabetes and DKA is

expanding focus to emphasize human factors and populationbased outcomes to better understand the socioeconomic distribution of patients who present in DKA. Increasingly, prevention efforts are focusing on social determinants of health (SDoH) that contribute to acute exacerbations of chronic disease.

The World Health Organization defines SDoH as “nonmedical factors that influence health outcomes” including “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.”5 Poor SDoH are associated with negative diabetes-related outcomes including the development of DKA.6 Personal health literacy—the degree to which individuals understand and use information and services to inform health-related decisions7—is an important interface between the healthcare system and the public. Low scores on health literacy measures correlate with poor health outcomes including increased ED utilization and hospital admission.8-10 Varying levels of health literacy can limit patients’ understanding of their disease process and limit participation in their healthcare plan, which illustrates a modifiable risk factor for the improvement of their health.

At our institution, we implemented a new treatment protocol for mild-to-moderate DKA that uses subcutaneously administrated insulin instead of the traditional insulin infusion, which has been successful in safely treating patients with DKA in a non-intensive care unit setting.11 Implementation of this new treatment initiative provided an opportunity for us to examine health literacy and SDoH data with the aim to identify potentially modifiable risk factors leading to the development of DKA in our patient population.

METHODS

Design, Setting, Participants

As part of a broader study related to treatment of DKA, we collected data on SDoH burdens and self-reported health literacy in patients with DKA. This prospective, cross-sectional study took place over one year (March 2023–March 2024) in a large, urban, academic ED. Electronic surveillance notified a research assistant (ML) to contact the patient by telephone while in the hospital for consent and data collection. This study was approved by our hospital institutional review board.

Measurements

We used the Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool (SNST), where patients answer a 26-item questionnaire spanning 13 domains of SDoH.12 We dichotomized patient responses for each domain into “one or more unmet needs” or “no unmet needs” according to the tool guidelines. We also employed the Brief Health Literacy Screen (BHLS), a three-item questionnaire that evaluates selfreported health literacy using a five-point Likert scale from 1 (lowest health literacy) to 5 (highest health literacy).13

Population Health Research Capsule

What do we already know about this issue?

The development of diabetic ketoacidosis (DKA) has been found to disproportionately affect racial and social minorities.

What was the research question?

Can we identify specific social determinants of health (SDoH) as potentially modifiable risk factors in the development of DKA?

What was the major inding of the study?

98% of patients (56/57 patients, 95% CI 89100%) reported at least one unmet SDoH need, and 56% (32 patients) had five or more.

How does this improve population health?

We identified several SDoH burdens among ED patients presenting in DKA, which represent potentially modifiable risk factors for the development of DKA.

Data Analysis

Because this was an exploratory analysis we did not perform a sample size calculation but aimed to enroll patients over a one-year period. In an attempt to determine whether patients completing each questionnaire were similar in demographics to DKA patients who did not complete the surveys (patients who could not be reached for survey participation and patients who initiated the surveys but did not complete them), we used the Mann-Whitney U test to compare age and chi-squared tests and the Fisher exact test to compare sex, race, and ED disposition, where appropriate. We present summary descriptive statistics, reporting frequencies and proportions for the prevalence of all SDoH categories among our patient population and medians and interquartile ranges (IQR) for BHLS scores. We conducted all data management and computed descriptive statistics in R version 4.3.1, employing the packages tidyverse versions 1.3.0 and 1.4.3 (R Foundation for Statistical Computing, Vienna, Austria).14,15

RESULTS

Among 95 patients with DKA contacted, 78 consented to participate with 57 (60% response rate) completing the SNST and 72 (76% response rate) completing the BHLS (Figure 1). Participants completing the SNST were similar to the 36 eligible non-respondents with DKA (31 patients who could not be reached and fivc who initiated the surveys but did not complete them) in terms of age, sex, race, and ED disposition (all P > 0.96) (Table 1). Of the 57 patients, 56 (98%, 95% confidence interval

Table 1. Sociodemographics of patients with diabetic ketoacidosis.

DKA patients who did not participate (N=36) DKA patients who completed the BHLS (N=72) DKA patients who completed the SNST (N=57)

Age (years) –median (IQR) 43 (28, 64) 47 (33, 57) 48 (32, 57)

Sex – n (%)

Male 22 (61) 42 (58) 33 (58)

Female 14 (39) 30 (42) 24 (42)

Race – n (%)

Black 24 (67) 52 (72) 40 (70)

White 11 (31) 15 (21) 13 (23)

Other 1 (3) 1 (1) 1 (2)

Not available 0 (0) 4 (6) 3 (5)

ED disposition –n (%)

Discharged from the ED 1 (3) 6 (8) 4 (7)

Admitted to observation floor 14 (39) 31 (43) 24 (42)

Admitted to medical floor 8 (22) 11 (15) 9 (16)

Admitted to ICU 13 (36) 24 (33) 20 (35)

The group of individuals who did not participate is comprised of 31 patients who could not be reached for survey participation and five who initiated but did not complete either survey and, thus, were dropped from the analysis.

BHLS, Brief Health Literacy Screen; ED, emergency department; ICU, intensive care unit; IQR, interquartile range; SNST, Social Needs Screening Tool.

Social Determinants of Health Among Patients with DKA

[CI] 89-100%) reported at least one unmet SDoH need, and 32 (56%) patients had five or more. Of the identified unmet SDoH needs, the most frequently reported were physical activity (77%), mental health (63%), financial strain (60%), substance use (54%), and food insecurity (51%) (Figure 2).

Patients who completed the BHLS were similar to nonrespondents in terms of age, sex, race, and ED disposition (all P > 0.90). For patients completing the BHLS, health literacy was high, with median responses to all three questions ranging from 4-5 on a Likert scale with 5 corresponding to highest health literacy (Table 2).

DISCUSSION

Social determinants of health are increasingly recognized as significant contributors in the development of DKA. Identifying potentially modifiable factors may be the first step in helping prevent the development of DKA altogether. Using the SNST inventory, we identified several prominent and potentially modifiable SDoH burdens across several domains among ED patients presenting in DKA. Greater than 50% of patients identified physical activity, mental health, financial strain, food insecurity, and substance use as areas of need. Physical activity was the most prominent area of identified SDoH need, affecting over three-quarters of our study population. These results are consistent with previous studies, which have identified specific SDoH factors correlating to higher incidence of DKA including area-level economic deprivation16 and substance use.17 Hamblin et al similarly found recurrent episodes of DKA to be associated with unemployment, low education level, less medical contact, and drug and tobacco use.18

Diabetic ketoacidosis in patients with type 1 diabetes mellitus has also been associated with increased rates of suicide, particularly within 12 months of the DKA episode.19 We were surprised to find health literacy scores were high, despite the high rates of self-reported SDoH burdens. In prior evaluations of health literacy in our ED we found approximately 24% of ED patients had limited or poor health literacy.20 Objective health literacy assessment tools are generally preferred over self-reported instruments, which are felt to be more accurate, but the brief health literacy questions fared well in the ED in our prior study.21

In their 2021 review of SDoH and diabetes, HillBriggs noted a paucity of US-based research examining the impact of interventions designed to target education, income, occupation, toxic environmental exposures, social cohesion, and social capital on diabetes outcomes.6 Since this publication, a number of studies have evaluated the impact of interventions targeted at various SDoH factors on outcomes in diabetes. For example, “produce prescription programs,” which provide vouchers for fresh fruits and vegetables and diabetes education are one area being investigated for their impact on diabetes outcomes including reductions in hemoglobin A1C levels, although results are

Figure 1. Study flow diagram.

BHLS, Brief Health Literacy Screen; DKA, diabetic ketoacidosis; SNST, Social Needs Screening Tool.

2. Unmet social determinants of health needs by category in patients with diabetic ketoacidosis. SDOH, social determinants of health.

health outcomes through federal and community-based initiatives aimed at improving glycemic control in patient with diabetes. They propose strategies to expand “food-ismedicine” programs (produce prescriptions, medical mealdelivery platforms), strengthen existing federal nutrition assistance programs such as the Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants and Children, and emphasize the importance of future research to understand the ideal dose and duration of nutritional support programs.26

LIMITATIONS

2. Health literacy survey results of patients with diabetic ketoacidosis.

BHLS screening question

How often do you have problems learning about your medical condition because of difficulty understanding written information?

How confident are you filling out medical forms by yourself?

Median (IQR) (N=72)

4.00 (3.00, 5.00)

5.00 (4.00, 5.00)

How often do you have someone help you read hospital materials? 4.00 (3.00, 5.00)

mixed.22,23 Educational campaigns to increase awareness of the importance of physical activity and encourage home exercise and lifestyle modifications to prevent the development of type 2 diabetes have also been described.24 However, we are not aware of studies that have specifically explored the impact of interventions on the development of DKA.

Discussions in the diabetes literature also focus on policy, research, and practice pattern adjustments that may reduce diabetes-related health disparities, including the development of DKA. A 2024 international consensus report recognizes SDoH as a “major risk factor” for the development of DKA or hyperosmolar hyperglycemic state and recommends screening for SDoH prior to discharge in patients admitted for DKA. They further assert: “In the USA, policy solutions such as increasing access to health insurance, affordable insulin, medical care, nutritious food and housing would be expected to reduce the incidence of DKA.”25 Levi et al explore specific paths toward improving

This was a single-center study with potential limitations related to generalizability. As this study was exploratory, a sample size calculation was not performed. We aimed to enroll 100 patients, but this number was somewhat arbitrary. Our sample size was lower than anticipated, in part due to a lower volume of patients with DKA during the study period compared to historical averages. In addition, although prior research experience favored the use of telephone contact of patients while in the hospital, we faced some limitations in this area, impacting our enrollment. An evaluation at one year of data collection noted marked stability and lack of variation in our results over time with a low likelihood that additional data would have impacted our results. This prompted us to truncate data collection at that point, which coincided with the end of our funding period.

Additionally, the self-reported nature of these data is a limitation given its reliance on personal perception and vulnerability to recall, social desirability bias, selection bias, and other biases. This work was also limited by the lack of a control group to determine which identified SDoH burdens are unique to ED patients with DKA vs being reflective of our population more broadly. We did attempt but discontinued an effort to capture SDoH information among type 1 diabetes patients not in DKA in the ED due to exceedingly low numbers.

A study comparing SDoH and health literacy among diabetic patients who develop DKA vs those who do not would provide interesting context to the impact of these social factors on glycemic control. A 2011 study found that poor adherence to insulin therapy impacted by behavioral, socioeconomic, psychosocial, and educational factors was the leading cause of recurrent admissions for DKA in urban patients from racial and ethnic minorities.27 A survey of DKA patients on perceptions of the factors that led to the development of DKA and factors impacting their glycemic control, including missed insulin doses, concomitant illness, and/or polypharmacy would be useful. We expect there may be opportunities for local initiatives to make meaningful impacts on selected SDoH burdens.

Our future work will focus on further investigation, perhaps including qualitative methods and obtaining more detailed information about needs within the broad SDoH

Figure

Table

Suarez et al.

domains identified and the degree to which these are modifiable. We also anticipate partnership with our social work, addiction, and mental health colleagues to identify screening, brief intervention, and referral for treatment approaches to improving substance use and mental health burdens identified.

CONCLUSION

We identified several potentially modifiable burdens of social determinants of health among emergency patients with diabetic ketoacidosis. Further study is needed to identify more specific needs, develop interventions to address these burdens, and determine whether these interventions may reduce recurrence of DKA.

Address for Correspondence: Richard T. Griffey MD, MPH, Washington University in St. Louis School of Medicine, Department of Emergency Medicine, Campus Box 8072, 660 S. Euclid Ave., BarnesJewish Hospital, St. Louis, MO 63117. Email: griffeyr@wustl.edu.

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This study was supported by grants from the Barnes-Jewish Hospital Foundation #GR0027481. Dr. Griffey is supported by the Agency for Healthcare Research and Quality 1 R01 HS027811-01. There are no other conflicts of interest to declare.

Copyright: © 2025 Suarez et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/ licenses/by/4.0/