Our Department of Emergency Medicine continues to study clinically important topics and to disseminate these findings. We are currently one of 19 SAEM approved research fellowships and our faculty research interests cover a wide spectrum including traumatic brain injury (TBI), public health issues, and cardiac arrest. Further, under the supervision of our faculty, Georgia Tech students as well as Emory MPH practicum students get first-hand experience collecting research data and exposure to clinical medicine.
The Brain Lab, led by Don Stein, PhD, has been making excellent progress and by fall should have enough data to apply for NIH clinical trial funding to test progesterone in stroke. Our latest results show that progesterone reduces the substantial risk of bleeding when the clot-buster tPA is used, can be used with a smaller tPA dose, and extends tPA’s window of treatment. This is an important finding because only 3-5% of stroke patients get to the hospital in time to be given tPA—if given later it can cause bleeding into the brain. Another set of projects shows that progesterone can reduce the risk of post-stroke systemic infection and sepsis, a co-morbidity seen in about 30% of stroke patients, with often devastating consequences. We now think that some of progesterone’s benefits come from its multiple beneficial systemic effects on inflammation and infection. In collaboration with the Emory Institute for Drug Development, the Brain Lab has identified several water-soluble, shelf-stable analogs of progesterone that overcome its limitations as an emergency therapeutic. We are now preparing to test the lead candidate analog in a stroke model. Our pediatric group is developing data which has been showing that progesterone alleviates the effects of neonatal hypoxia. The most novel project ongoing in the lab is perhaps the glioblastoma work. The lab has replicated their findings multiple times and now has solid data showing that very high-dose progesterone slows tumor progression substantially and kills more tumor cells than the current chemotherapeutic treatment, temozolamide. Notably, the lab was awarded a use patent for the treatment of neuroblastoma and are currently revising their patent application on glioblastoma for the US Patent Office
The Emergency Neurosciences Laboratory is part of the Neurological Emergencies Treatment Trials (NETT) Network and the NIH Stroke Trials Network. These large NIH funded networks are dedicated toward improving outcomes of patients with acute neurologic problems through innovative research focused on the emergent phase of patient care. One study in particular, ProTeCT III, is focused on traumatic brain injury (TBI). TBI is a major cause of death and disability worldwide and is particularly important to Grady as it is the primary trauma center in the Atlanta metropolitan region. BIO-ProTECT is a biomarker study attached to the ProTECT III trial that is attempting to identify a blood marker to help detect TBI and provide a tool for predicting outcome and treatment effect. Another study, the POINT trial aims to determine if aspirin verses Plavix is better than aspirin alone at preventing stroke in patients who present with an initial TIA. Another community relevant project includes a Department of Defense funded multiple site study of a novel device to identify concussions in football and on the battlefield. This study is being conducted in collaboration with the Georgia Tech Research Institute and has the potential to identify minor TBI that clinicians would not pick up on a normal physical exam. Together, these studies have the potential to prevent long term morbidity and mortality from brain injury and stroke.
The academic output of the medical toxicology section over the past year has also been noteworthy. The section presented sixteen abstracts at the two preeminent medical toxicology meetings (the North American Congress of Clinical Toxicology and the annual scientific meeting of the American College of Medical Toxicology), and currently has eleven more abstracts accepted for the next NACCT meeting. In the peer-reviewed literature, the section produced thirteen publications in six different journals. The publications consisted of eight original contributions, three letters, one editorial, and one report in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report. In addition, Emory/Grady is one of 18 centers participating in this study through a new research consortium called Emergency Department Outpatient Prescribing of Opioid Drugs (EDOPIOIDS). The tox faculty will conduct a multicenter survey study using the EDOPIOIDS network examine a large sample of emergency department providers across the country regarding their opioid prescribing practices and attitudes. These studies will inform physician prescribing practices and subsequently help decrease prescription drug abuse.
The Emory Center for Injury Control (ECIC) is dedicated to reducing the health and economic impacts of injuries in Atlanta, the state of Georgia and nationwide. The Center supports a vibrant network of 12 universities, 24 government and non-governmental organizations, and 171 researchers led by Dr. Deb Houry. Spearheaded by ECIC leaders, Emory University became the second university in the U.S. and the first community in the Southeast to receive a Safe Community designation by the National Safety Council. We are now working with city of Atlanta to achieve a designation for the city. Other innovative projects include development of an exposure intervention to prevent PTSD in trauma patients and rape survivors as well as identifying youth at high risk for violent injury. Our Center is active in social media as well as print media and just published our fifth injury-focused special journal issue.
The EMS section faculty are leading several exciting projects including the evaluation of a prehospital severe sepsis screening tool. This will facilitate timely delivery of early fluid resuscitation and antibiotics, two interventions that have the best evidence to date for improving patient outcomes among those with severe sepsis. Dr. McNally continues to lead “CARES”, a community based out-of-hospital cardiac arrest registry, aimed at improving system performance in resuscitation of sudden cardiac death. Two years after CARES was implemented and system changes executed, Atlanta’s out-of-hospital cardiac arrest survival increased from 4% to 15%. Our faculty are also engaged in on-going programmatic design modifications & evaluation of prehospital psychiatric care in collaboration with Georgia Crisis and Access Line and Morehouse School of Medicine Psychiatry.
Our department continues to focus research efforts on the role of the Grady Emergency Department in screening and intervening on health and behavioral issues relating to public health and the well-being of the community at large. In the past year, this research has included studying the potential for use of a kiosk-based alcohol and substance use screening process as a tool for identifying patients with risky substance use and who would benefit from further intervention or referral to treatment. Additionally, the Grady ECC has been a FOCUS HIV site, with implementation of a process to increase routine HIV screening in this high-risk population; as of June, 2014, over 15,000 ECC patients had been screened for HIV, a new diagnosis rate of 1.3%. Under the leadership of Dr. Abigail Hankin and Dr. Bijal Shah, the team how routine HIV testing can be integrated into the busy ED environment, and how to maximize linkage to care after diagnosis.
Dr. Pitts continues to do health services research mainly using secondary data obtained by the National Center for Health Statistics, with a focus on national acute care policy and ED operations. With coauthors from the HHS Emergency Care Coordination Center, he analyzed a national survey of ED boarding of inpatients, published in Academic Emergency Medicine in May, accompanied by a policy roundtable discussion with representatives from academia, HHS, and CMS evaluating the potential impact of our research on current CMS core measures: higher volume EDs were much more likely to board patients than smaller EDs, a factor beyond the control of EDs yet subjecting the hospital to financial penalties. Ongoing studies include an analysis of ED resource use by residents, a study of frequent ED visits by individuals in the Emory EDs, and a national study of ED boarding by patients with psychiatric diagnoses.
Finally, in conjunction with the National Science Foundation and Georgia Institute of Technology Center for Operations Research in Medicine and Healthcare the Grady Emergency Care Center has evaluated prior processes and using an evidence based approach made changes to improve throughput and efficiency in the ECC. These changes have led to millions of dollars in decreased costs while improving throughput and quality of care. This joint research has been presented on a national level and recently earned 2nd place award for Daniel H. Wagner Prize for Excellence in Operations Research Practice. Dr. Angela Fusaro and Dr. Bisan Salhi are studying what motivates ED superutilizers to frequent the ED, and to build resilience in this vulnerable population by enrolling patients who superutilize the ED in a weekly group medical appointment. This intervention has the potential to decrease high emergency department dependence, utilization and cost, and improve patient satisfaction with the healthcare system. The observation medicine section faculty have been studying observation protocols that improve the quality of care for patients, while decreasing their cost of care, improving hospital resource use, and serve as a model for the U.S. The team plans to apply lessons they learned from their landmark studies of transient ischemic attack patients to a new group - small stroke patients. The team will also test a non-invasive new diagnostic technology called the “retina camera” to see if it can determine which transient ischemic attack (mini-stroke) patients are at risk of a stroke in the near future. The scope of the patient populations that will be impacted by this research is vast.