Current Research Projects

A Hands-On, Peer-Based Education Model of Ultrasound Training For Medical Students

Second year medical students along with Dr. Nathan Teismann created a new UCSF ultrasound training program for first year medical students. We collected data to assess if our program helped students retain anatomy knowledge and to determine how much their ultrasound skills improved as a result of the program. We would now like to analyze these data and publish our findings as an example of a peer-based ultrasound education program.

Principal Investigator: Nathan Teismann

CTPE Rule Evaluation

As part of the Caring Wisely initiative, a clinical decision support tool was built into CT PE orders in APeX. Our goal is to study the impact this change had on CT PE ordering and CT PE yield in the Emergency Department.

Principal Investigator: Ellen Weber

Additional Investigators: Ralph Wang

National Emergency Airway Registry

This protocol will expand on the research of the previous NEAR studies by continuing self-reported surveillance of emergency intubation practices. The National Emergency Airway Registry (NEAR) will continue to characterize intubation practices in an effort to ultimately enhance patient safety. Some of the specific topics to be addressed with these data include, but are not limited to, gaining a more detailed understanding of the following topics:

1) Intubation in shocked states

2) Operator suspicion of sepsis and how this influences drug selection as well as overall intubation management.

3) Intubation practices of patients who experience seizure(s)

4) Geriatric airway management

Principal Investigator: Guy Shochat

Do Social Factors Affect the Time to Diagnosis and Treatment of Strokes?

Stroke is a clinical diagnosis, and as such is highly based on initial presentation and history for recognition more so than any specific imaging study or lab result.  As such, factors that affect clinician's ability to get that history, such as language or acuity of presentation, or that affect the time to clinician evaluation, such as time of day and mode of transport, may greatly affect the time to diagnosis and treatment of this time sensitive disease process.  This study aims to look at the correlation between various social and demographic factors in a known stroke population and the times to diagnosis and treatment.

Principal Investigator: William Whetstone 

Is Consent for CT in Acute Trauma Feasible?

Respect for patient autonomy mandates providing informed consent for procedures that carry risk whenever possible. Yet, despite emerging knowledge about the potential cancer risks of CT, trauma imaging is typically obtained without informing patients of its risks or discussing their preferences. Our objectives of this study are therefore to determine whether two components of feasiblity are present: time for consent and level of alertness of patients.

Principal Investigator: Robert Rodriguez

Does the Use of A Single Dose of 4mg IV Ondansetron Cause Clinically Prolonged QTc in the Undifferentiated Nauseated Patient in the Emergency Department?

A majority of the current data supporting QTc prolongation following ondansetron administration comes primarily from the anesthesia literature that examines both post-operative and perioperative data. These studies are often confounded by the concomitant use of anesthetics and procedure-induced hypothermia, and are therefore not directly applicable to the emergency department population. This will be the first prospective study attempting to examine the risk of QTc prolongation in the undifferentiated emergency department patient that is given 4mg IV ondansetron for the treatment of nausea.

Principal Investigator: Zlatan Coralic

Additional Investigators: Kathy Vo

Is There An “Appropriate Use” of CT-Pulmonary Angiography in the Emergency Department? – A Two-Year Audit

Patients with low-to-moderate risk of Pulmonary Embolism (PE) can present to the ED with nonspecific chief complaints such as “chest pain” or ”difficulty breathing” which need to be taken very seriously. Because these patients can be quite heterogeneous it remains challenging for clinicians to quickly rule–out PE or distinguish it from other high-risk diagnosis without conclusive evidence obtained by using CT-Pulmonary Angiography (CTPA). At UCSF, use of any one specific decision support tool for PE is not institutionally standardized or mandated at present, but ED clinicians are likely to use several of the respective criteria in their own decision-making process. This timely investigation of CTPA use in this study will inform planned study of a computerized decision support intervention for PE imaging in UCSF’s ED.

Principal Investigator: Ellen Weber

What is the Yield of Pan-Scan CT Imaging of the Chest/Abdomen/Pelvis?

The desire to detect injuries with a near-zero miss rate and the widespread availability of rapid CT have driven this multi-fold increase in CT use and led to the adoption at many trauma centers of complete head- to- pelvis CT scanning protocols for blunt trauma evaluation. Although proponents of this “pan-scan” approach cite high sensitivity for radiologic injury diagnosis in blunt trauma of the head and cervical spine, other investigators have shown that this can be a low-yield practice clinically in terms of actual patient care. This work ultimately will help define the value of pursuit of a decision instrument to guide pan-scan in the setting of blunt trauma.

Principal Investigator: Robert Rodriguez

The Palliative Care and Rapid Emergency Screening Project (P-CaRES); Effects of a Validated Screening Tool for Palliative Care Consultation.

To help ER providers screen for unmet palliative care needs, a validation screening tool is being built into APeX. In order to determine its effectiveness, we first need to determine the number of palliative care consults occuring in the hospital and in the emergency department. This study seeks to identify the unmet needs prior to implementation.

Principal Investigator: Christopher Fee 

Additional Investigators: Steve Polevoi

San Francisco Health Plan Care Support Intervention

The purpose of the CareSupport CHAMP intervention is to coordinate often-fragmented care for SFHP members with heavy use of acute health care services, reducing cost of care for the San Francisco safety net. Community Coordinators provide patient-centered, community-based advocacy and navigation across systems of care, to improve coordination and unify health and treatment goals. UCSF will analyze the data provided by SFHP to evaluate the program effectiveness based on both health services use outcomes, patient centered outcomes, and health outcomes.

Principal Investigator: Maria Raven 

Tanzania Physician Tracking Study

Trainees and graduates of the Muhimbili Emergency Medicine Training Programs will participate in a series of voluntary "mini surveys" via cell phones and/or internet forms in order to evaluate the curriculum of the residency program and the emergency care needs in the region. This survey of providers will address topics such as practice site (rural vs. urban) and the general characteristics of patients seen, including age, diagnosis, and chief complaints.

Principal Investigator: Teri Reynolds 

Intubation Study

UCSF recently implemented a checklist for intubations. We are comparing outcomes in patients from a year prior to the checklist implementation to outcomes after the list was introduced.

Principal Investigator: Steve Polevoi

Diagnostic Impact of Emergency Ultrasound at Muhimbili National Hospital in Dar Es Salaam, Tanzania

This study will analyze the use of ultrasound at Muhimbili National Hospital in Dar es Salaam, Tanzania, documenting which ultrasound studies are being done and how often  ultrasound changes the diagnosis or management plan. Invetsigators will receive only de-identified data from data sheets that local provideres fill out an each ultrasound done as part of their department protocol.

Principal Investigator: Teri Reynolds

Healthcare Utilization Patterns Among Homicide Victims

This study seeks to investigate healthcare utilization among a population of homicide victims in California in the period of time prior to death. Understanding the patterns of use among patients who ultimately are victims of homicide may provide healthcare practitioners with a means to identify those at high risk of subsequent injury and/or death. This exploratory analysis will identify high risk sociodemographic factors as well as clinical features associated with an ultimate outcome of homicide.

Principal Investigator: Jahan Fahimi 

Harnessing the Power of the EMR for Quality Improvement: Diagnostic Discrepancies

Errors in medical care can lead to negative outcomes and emergency medical care is no exception. Our institution recently deployed an enterprise-wide electronic medical record (EMR) that permits identification of diagnostic discrepancies between the Emergency Department and the admitting services.  The primary objective of this study is to utilize the EMR to quantify the diagnostic discrepancy rate of an academic Emergency Department for patients admitted to an inpatient service over a one-month period. 

Principal Investigator: Steve Polevoi

Are Electronic Health Record Automated Screens for Systemic Inflammatory Response Syndrome (SIRS) Criteria and Severe Sepsis Associated with Increased Mortality Among Adult Emergency Department Patients?

Severe sepsis (overwhelming systemic infection with associated end-organ dysfunction) and septic shock (same with the presence of low blood pressure) are common conditions in the ED but can have subtle initial presentations that may go unnoticed by even the most well-intentioned teams of providers. We designed and implemented an automated electronic screening process within our electronic health record that continuously screens for criteria of systemic inflammatory response syndrome (SIRS, based on vital sign and white blood cell count abnormalities) and severe sepsis (SIRS plus the presence of end-organ dysfunction). We aim to determine if patients who trigger the automated SIRS or severe sepsis alert in our system have a higher mortality rate than those who do not.

Principal Investigator: Christopher Fee 

Incidence of Clinically Significant Circulatory Overload After Appropriate Fluid Infusion in the Resuscitation of Emergency Department Patients With Severe Sepsis and Septic Shock

Currently, administration of 20-30 ml / kg of IV fluids for patients with severe infections is considered standard of care. There is a risk that for some patients this may be too much fluid, and may be potentially harmful. The purpose of this study is to try to quantify how frequently patients with severe infections are harmed by what is considered appropriate fluid administration.

Principal Investigator: Christopher Fee 

Emergency Medical Service (EMS) Providers' Attitudes Towards Acting as Intelligence Sensors

It has been suggested that Emergency Medical Service (EMS) providers may be able to play a role in homeland security by acting as "intelligence sensors" to gather and report counter-terrorist information. This study is a written survey of EMS providers' attitudes towards working in this role.

Principal Investigator: John Brown 

Adult Emergency Department Patients with Acute Asthma and Survey of Local Asthma Centers: 36th Multicenter Airway Research Collaboration (MARC-36) Study

To assist ongoing efforts to improve ED management of acute asthma and to reduce the number of ED asthma visits and associated health care expenditures, we propose to characterize today’s ED asthma patients, determine the concordance of their ED care with US asthma guidelines, and characterize their local hospital-affiliated asthma center.

Principal Investigator: Christopher Fee

Advancing the Quality of Emergency Department Renal Stone Management - Stone Decision Instrument

This is a secondary analysis of an ongoing randomized controlled trial, the STONE trial. The purpose of this study is to 1) develop a decision instrument for patients with suspected kidney stone, and 2) to examine the effiicacy of medical expulsicve therapy in emergency department patients diagnosed with ureteral stone.

Principal Investigator: Ralph Wang 

Timing of Early Management Bundle in Severe Sepsis and Septic Shock: Retrospective Cohort Study of Patients Presenting to the ED

We hypothesize that the National Quality Forum time-from-ED-arrival standard does not accurately identify patients with severe sepsis and septic shock presenting to the UCSF ED. Rather, we hypothesize that time-from-meeting-severe-sepsis-criteria accurately identifies patients who will potentially benefit from aggressive bundled management approaches to their diseases.

Principal Investigator: Christopher Fee 

Prospective Observational Study of Ketamine Adverse Drug Events During Procedural Sedation in Muhimbili National Hospital Emergency Department in Dar Es Salaam Tanzania

Ketamine is a dissociative anesthetic that is used for procedural sedation in the United States and many developing nations in the world. Ketamine requires strict monitoring criteria in the emergency department in the United States. Few if any monitoring capabilities are available in low resource areas and little is known about adverse drug events in this setting. Our study will examine adverse drug events from ketamine in a low-resource emergency department at Muhimbili National Hospital in Dar es Salaam, Tanzania.

Principal Investigator: Teri Reynolds

Additional Investigators: Zlatan Coralic

A Randomized Trial of Hypothesis-Driven Versus Screening Neurologic Examination for Emergency Department Residents.

Emergency Department residents will receive a didactic about a hypothesis-driven neurologic exam or a traditional screening exam.  Residents will document neurologic exam findings, localization, and a differential diagnosis for patients who present to the ED with neurologic complaints.  We will then compare EM resident and examination findings, localization, and differential diagnoses to those documented by the Neurology consult service.  The goal is to determine if emergency medicine residents who learned hypothesis-driven approach to the neurologic exam performed more accurate examinations and neuro-anatomic localization compared to EM residents who learned a screening exam approach.

Principal Investigator: Scott Josephson

Additional Investigators: William Whetstone

Identifying Factors Associated with Frequent Use of Emergency Medical Services in a One Year Period: Cross Sectional Study Using Paramedic Records

This is a retrospective analysis of the San Francisco Fire Department (SFFD) database for all emergency medical service (EMS) transports from 2009. Analysis will be performed to identify predictor variables associated with frequent EMS use. Additionally, a cost analysis will be performed to assess the impact of very high users.

Principal Investigator: John Brown

Additional Investigators: Robert Rodriguez

A Pre- And Post-Intervention Analysis of Prospective Pharmacist Review of Emergency Department Medication Orders to Prevent Adverse Drug Events

We aim to conduct a pre- and post-intervention analysis (observational) to determine if implementing pharmacist review of emergency department medication orders reduces adverse drug events.          

Principal Investigator: Christopher Fee
Sequential Organ Failure Assessment

Experts have expressed concerns regarding the validity of the new qSOFA score for use in general and in the emergency department (ED) specifically. The objectives of this study are to assess the screening performance of qSOFA for poor outcomes in patients presenting to the ED with infections and possible sepsis and to compare the screening performance of q SOFA with current ED sepsis identification protocols.

Principal Investigator: Robert Rodriguez 
Clinical Presentation, Management and Outcomes of Pediatric Sepsis Patients in Dar es Salaam, Tanzania

Pediatric sepsis is preventable and treatable and early recognition and appropriate therapy can greatly impact survival; however, children in limited-resource settings often present late in the course of illness, and have high mortality rates. There is a critical lack of regionally specific pediatric sepsis data from sub-Saharan Africa, without which, we cannot accurately risk stratify patients, nor develop appropriate evidenced-based sepsis protocols. To understand the scale of the problem, characterize risk factors, identify high-risk patients who would benefit from early intervention, and develop future evidence-based protocols for our specific population, we have developed this prospective cohort study with a mixed methods approach.

Principal Investigator: N T Bleakly

Additional Investigators: Teri Reynolds

Point of Care Ultrasound for the Diagnosis of Pneumoperitoneum: A Retrospective Case Series

Case series review of bedside ultrasounds done by emergency physicians in Tazanania and UCSF which demonstrate free intra-abdominal air

Principal Investigator: Roneesha Knight 
Time of Shift and Likelihood of CT Ordering: Decision Fatigue in the Emergency Department

The goal of this chart review is to evaluate the effects of decision fatigue on emergency providers as measured by likelihood of positive findings on CT orders for low-acuity trauma patients. We hypothesize that as emergency providers near the end of their shift, they will be more likely to rely on radiographic imaging rather than clinical decision rules and/or gestalt in evaluation their patients.

Principal Investigator: Christopher Fee

Long-Term Mortality in Pediatric Gunshot Assault Survivors

This is the first study to our knowledge to examine the long-term impacts of gun violence in children and adolescents living in an urban environment relative to other types of violence and trauma by (1) comparing the long-term risk of death among survivors of gunshot assault, non-gunshot assault, and non-assault based trauma and (2) determining the factors that serve to diminish or enhance this risk, including staying in or dropping out of school.

Principal Investigator: Ashkon Shaahinfar

Additional Investigators: Jahan Fahimi

Feasibility of Ultrasound Guided Regional Nerve Blocks for Pain Management in Low-Resource Settings

The purpose of this study is to determine the feasibility and utility of training in ultrasound-guided regional nerve blocks for emergent pain management of soft tissue injuries, infections, burns, fractures and dislocations in a resource-limited setting. The impact of this technique has never been quantified in this setting and to our knowledge, no studies to date have investigated the feasibility of teaching ultrasound-guided nerve block techniques to local care providers in resource-limited settings.

Principal Investigator: Teri Reynolds

Regionalization of Endovascular Therapy for Acute Ischemic Stroke in California

Few studies have focused on the regionalization of endovascular therapy for patients with acute ischemic stroke and the trends and predictors of AIS admission to hospitals with high endovascular stroke therapy volume. The aim of current study is to describe the regionalization of endovascular therapies for the treatment of acute ischemic stroke in California.

Principal Investigator: Anthony Kim

Additional Investigators: Renee Hsia