Over the past two decades, there has been a marked increase in partisan social polarization, leaving scholars in search of solutions to partisan conflict. The psychology of intergroup relations identifies empathy as one of the key mechanisms that reduces intergroup conflict, and some have suggested that a lack of empathy has contributed to partisan polarization. Yet, empathy may not always live up to this promise. We argue that, in practice, the experience of empathy is biased toward one’s ingroup and can actually exacerbate political polarization. First, using a large, national sample, we demonstrate that higher levels of dispositional empathic concern are associated with higher levels of affective polarization. Second, using an experimental design, we show that individuals high in empathic concern show greater partisan bias in evaluating contentious political events. Taken together, our results suggest that, contrary to popular views, higher levels of dispositional empathy actually facilitate partisan polarization.

Introduction: Patients with advanced or end-stage illness frequently present to emergency departments (EDs), many of whom are in need of palliative care (PC). Emergency physicians have struggled in providing high quality care to these patients and there is a need to identify cost-effective PC interventions delivered in the ED to improve patient outcomes. The objective of this systematic review was to examine the effectiveness of ED-based PC interventions. Methods: A comprehensive search of nine electronic databases and grey literature sources was conducted to identify any comparative studies assessing the effectiveness of ED-based PC interventions to improve health outcomes of patients with advanced or end-stage illness. Two independent reviewers completed study selection, quality assessment, and data extraction. Differences were mediated via third-party adjudication. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: From 5882 potentially eligible citations, 12 studies were included. Two studies are currently on-going clinical trials, and as such, 10 studies were included in this analysis. The studies consisted of before-after studies (n = 5), RCTs (n = 4), and an observational cohort (n = 1). Interventions assessed among the included studies consisted primarily of ED-directed PC consultations (n = 6), while other studies assessed screening of patients with advanced or end-stage illness and PC needs (n = 2), education on PC for ED-staff (n = 1), and an ED-based critical care unit (n = 1). Infrequent reporting of important outcomes (e.g., Mortality, ED relapse) limited the ability of this review to conduct meaningful meta-analysis. There was no difference in patient mortality between two studies assessing ED-directed PC consultations (RR = 0.89; 95% CI: 0.71, 1.13; I2 = 0%). One before-after study (RR = 0.73; 95% CI: 0.47, 1.13) and two RCTs (RR = 2.19; 95% CI: 0.40, 11.92; I2 = 96%) did not identify significant differences in PC consultations intervention (implementation of ED-directed PC consultations) and control (usual care) patients. Conclusion: This review found limited evidence to support the recommendation of any particular ED-based intervention for patients presenting to the ED with advanced or end-stage illness. High quality studies and standardized outcome reporting are needed to better understand the impact of PC interventions in the ED setting.

Introduction: Acute migraine headaches are common causes of presentation to the emergency department (ED). There is great variability in the efficacy of the available parenteral agents to manage pain, though triptans are among the recommended treatments. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review examined pain management in emergency settings and assessed the effectiveness of triptan agents. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Pain scale scores were analyzed using standardized mean difference (SMD) with 95% confidence intervals (CIs) calculated using a random effects model; heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Pain was measured within the ED or equivalent acute care setting using a variety of pain scales, most commonly the 0-10 cm or 100 mm visual analog scale. Four studies compared pain scores between patients receiving sumatriptan vs. other agents, of which, patients receiving sumatriptan reported higher pain scale scores (SMD = 0.53; 95% CI: 0.04, 1.02; I2 = 80%). In particular, patients receiving sumatriptan reported higher pain scale scores than patients receiving metoclopramide (SMD = 0.68; 95% CI: 0.31, 1.04; n = 1) or ketorolac (SMD = 1.39; 95% CI: 0.56, 2.21; n = 1). Overall, studies comparing anti-inflammatory agents (i.e., ketorolac or dexketoprofen) to other agents reported improved pain scale scores among patients receiving anti-inflammatory agents (SMD = -0.38; 95% CI: -0.73, -0.03; I2 = 66%; n = 5). Conclusion: Limited evidence suggests that patients treated with metoclopramide or anti-inflammatory agents experience greater pain reduction compared to patients treated with sumatriptan. This review will conduct a network analysis of parenteral agents to examine the comparative effectiveness of parenteral agents to manage pain among patients with acute migraine. Further analysis will also consider the balance between efficacy and adverse events.

Introduction: Emergency Department (ED) consultations are often necessary for safe and effective patient care. Delays in throughput related to ED consultations can increase a patient's ED length of stay (LOS) and contribute to ED crowding. This review aimed to characterize and evaluate interventions to improve consultation metrics. Methods: Eight primary literature databases and the grey literature were comprehensively searched. Comparative studies of interventions to improve ED consultation metrics were included. Unique citations were screened for relevance and the full-texts of relevant articles were reviewed by two independent reviewers. Data on study characteristics and outcomes were extracted in duplicate onto standardized forms. Disagreements were resolved through consensus. Categorical variables are reported as proportions. Continuous variables are reported as the median of the means and total range. Results: After screening 2632 unique citations and 19 from the grey literature items, 24 studies were included. Seventeen interventions targeted specific conditions or speciality services, while the remainder targeted all ED presentations. Interventions fell into three broad categories: strategies to expedite patient care, including clinical pathways (42%); interventions to improve consultant responsiveness (33%); and addition of a specialized care team to the ED (25%). Overall, eight studies reported on the overall proportion of consults in the ED, of which six reported an increase in the consultation proportion (median: +0.6%, range: −11.3% to +49.6%). Six studies reported the proportion of consulted patients who were admitted, of which four reported an increase (median: +1.1%, range: −5.9% to +3.5%). On the other hand, six of seven studies reporting on time from request to consult arrival reported a decrease (median: −25 minutes, range: −66 to +3.8 minutes). Similarly, overall ED LOS was reported to be lower in 17/19 studies reporting this metric (median: −47.6 minutes, range: −600 minutes to +59 minutes). Conclusion: A variety of strategies have been employed to improve ED consultation processes and outcomes. Neither the proportion of consulted patients in the ED nor the proportion of admissions were improved; however, interventions appeared successful at improving consultant arrival times and overall ED LOS. Improvements in consultation processes may be an effective strategy to improve ED throughput and thereby reduce ED crowding.

Introduction: While consultation is a common and important aspect of emergency department (ED) care, a previous systematic review identified significant utilization and process variation across ED's. The aim of this review update was to examine the proportion of the patients undergoing consultation in the ED among recent studies. Methods: Eight primary literature databases and the grey literature were searched. Studies published from 2007 to 2018 focusing on all-comers to the ED and reporting a consultation-related outcome were included. Disease- and specialty-specific studies were not eligible. Two independent reviewers screened studies for relevance, inclusion, quality assessment, and data extraction. Disagreements were resolved through consensus. Means, medians and interquartile ranges are reported. Wilcoxon-rank sum test and one-way ANOVA were used to identify differences between groups, as appropriate. Results: A total of 2632 unique citations and 49 studies from the grey literature were screened, of which 29 primary studies were included. Fifteen studies reported on the proportion of ED patients undergoing consultation, involving EDs in the Middle East (n = 4), North America (n = 4), Asia (n = 4), and Europe (n = 3). Overall, the proportion of patients receiving consultation ranged from 7% to 78% (median: 26%; IQR: 20%, 38%). There were no differences in the proportions of consulted patients based on country of origin. Ten studies were conducted prior to 2013, while five studies recruited patients during and after 2013. The mean proportion of consulted patients was lower for post-2012 studies compared to pre-2012 studies (mean: 18% vs. 36%; p = 0.0048). The proportion of consulted patients admitted to hospital ranged considerably between the 14 reporting studies (median: 56%; IQR: 49%, 76%). No differences in the proportion of admitted patients undergoing a consult were identified based on country of origin or year of recruitment for the study. Conclusion: Although consultation utilization appears to be decreasing overall, there is considerable practice variation in EDs around the world. These differences may result from variation in patient acuity, case-load, staffing levels, institutional and health-system organization, and medical training and future research should explore reasons for these differences.

Introduction: With an increasing proportion of patients in need of end-of-life (EOL) care presenting to the emergency department (ED), many of these patients may benefit from early palliative care (PC) referral. In fact, early PC referral is one of the Choosing Wisely ED recommendations in the USA. As such, there is a potential benefit to identifying patients with advanced or end-stage illness with PC needs. The objective of this systematic review is to identify and synthesize the available evidence regarding the existence and psychometric properties of screening tools to identify patients with advanced or end-stage illness and PC needs presenting to EDs. Methods: A comprehensive search of eight electronic databases and the grey literature was conducted. Studies assessing the ability of a screening instrument to identify ED patients with advanced or end-stage illness in need of PC were eligible for inclusion. Two independent reviewers completed study selection, quality assessment, and data extraction. Disagreements were resolved through third-party adjudication. Due to the significant heterogeneity, as well as inconsistent outcome reporting, a descriptive summary of the results was completed. Results: Once duplicates were removed, the title and abstracts of 3516 studies were screened, of which, 15 studies were included. Overall, 10 unique screening instruments were assessed across the studies. The most commonly assessed screening tool was the use of the modified surprise question (SQ), in which physicians were asked if they would be surprised if the patient died within a specified period of time. Only four of the included studies assessed the diagnostic or psychometric properties of the screening tools. One study reported that the modified SQ predicted PC consultation with 35% sensitivity, 89% specificity, and a negative predictive value of 97%. The proportion of patients identified with PC needs ranged from 12% to 73%, with studies utilizing the SQ reporting a range of 12% to 33%. Conclusion: A variety of screening tools are available to identify ED patients with advanced or end-stage illness who would benefit from a referral for PC. While the modified SQ was the most common instrument assessed and appears to be simple to implement, it is unclear if the diagnostic and psychometric properties of this tool are sufficiently robust to warrant widespread implementation.

Introduction: Patients with end-stage conditions require integrated physical, spiritual, psychological and social care. Despite efforts to provide comprehensive community care, those with severe symptoms often present to emergency departments (EDs) with palliative care (PC) needs. The objective of this study was to identify patients with end-stage diagnoses presenting to EDs, and to document and compare their PC needs. Methods: A four-month prospective cohort study was conducted in two Canadian EDs. Using a modified PC screening tool, volunteer emergency physicians identified adult patients with end-stage illnesses and documented their PC needs. This tool has the ability to classify patients as having met vs. unmet PC needs based on the documentation of risk factors. Research assistants documented demographic information, severity at presentation (Canadian Triage and Acuity Scale {CTAS}), disposition and revisits from an electronic repository. Bivariate comparisons between patients with met vs. unmet PC needs were completed. Results: Overall, 663 patients were enrolled, of which 78% (n = 518/663) were identified as having unmet PC needs according to the screening tool. Cancer was the most prevalent condition in each group (43% unmet needs, 37% met needs). There was no significant difference between the two groups in terms of age, sex or CTAS score. The unmet PC needs group was more likely to be admitted (68% vs. 50%; p = 0.0001) when compared to patients with PC needs assessed as being met. No significant difference was noted in terms of time to physician assessment or ED length of stay. The two groups did not significantly differ in the proportion of return visits within 30 days (34% vs. 32%) or the average number of return visits (3 vs. 2 visits). A higher proportion of patients with unmet PC needs made at least one visit to the ED in the 6 months prior to their index visit compared to patients with met PC needs (74% vs. 51%, p < 0.001); yet, the average number of ED visits was similar between the groups (3 visits). Conclusion: This study revealed that patients with end-stage diagnoses, especially cancer, commonly have unmet PC needs. They are also more likely to present to the ED and to require hospitalization than patients in whom PC needs have been met. Further investigations into their clinical profile and health care utilization may clarify the impact of their unmet PC needs on the healthcare system.

Introduction: Although a variety of parenteral agents exist for the treatment of acute migraine, relapse after an emergency department (ED) visit is still a common occurrence. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review focused on those studies aiming a reduction in relapse after an ED visit. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to identify comparative studies to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Relapse was reported in 44 (38%) included studies and occurred commonly in patients receiving placebo or no interventions (median = 39%; IQR: 14%, 47%). Overall, no differences in headache relapse were found between patients receiving sumatriptan or placebo (RR = 1.09; 95% CI: 0.55, 2.17; I2 = 93%; n = 8). Conversely, patients receiving neuroleptic agents experienced fewer relapses compared to placebo (RR = 0.27; 95% CI: 0.12, 0.58; I2 = 0%; n = 3); however, patients receiving neuroleptics reported an increase in adverse events (RR = 1.87; 95% CI: 1.17, 3.00; I2 = 0%; n = 3). Compared to placebo, patients receiving dexamethasone were less likely to experience a headache recurrence (RR = 0.71; 95% CI: 0.53, 0.95; I2 = 60%, n = 9); however, no differences were found in reported adverse events (RR = 1.09; 95% CI: 0.81, 1.47; I2 = 0%; n = 3). Conclusion: Relapse is a common occurrence for patients with migraine headaches. This review found patients receiving neuroleptics or dexamethasone experienced fewer headache recurrences. Conversely, triptan agents appear to have minimal effect on reducing the risk for headache recurrence following discharge from an acute care setting. Limited available data on adverse events is an important limitation to inform decision-making. Guidelines should be revised to reflect these results.

Introduction: An increasing number of patients with end-stage diseases present to emergency departments (EDs) for physical, spiritual, psychological and social care. The objective of this study was to identify patients with end-stage diseases with palliative care (PC) needs and document their frequency of ED visits. Methods: This prospective cohort study was conducted in two Canadian EDs. Using a modified palliative care screening tool, volunteer ED physicians were asked to identify adult patients with end-stage, chronic conditions including cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), heart failure (HF), cirrhosis, dementia and/or progressive central nervous system (PCNS) disease. Demographic data were collected from these tools and data regarding patients’ visits in both the 6 months prior to and 30 days following their index visits were collected from the ED Information System. Bivariate analyses were completed using Student's t and chi-square test. Results: A total of 663 patients with end-stage illness were identified; 338 (51%) were female and the median age was 76 (IQR: 63, 85). Cancer was the most common presentation (41%), followed by dementia (23%), COPD (16%), HF (9%), CKD (9%), PCNS disease (9%) and cirrhosis (7%). These patients made a total of 1277 visits in the 6 months prior to and 288 in the 30 days following the index visit. Patients presenting to the EDs with cancer (p = 0.001), cirrhosis (p = 0.005) and CKD (p = 0.03) were more likely to visit an ED in the 6 months prior to their index visit. In contrast, patients presenting with dementia (p < 0.0001) and PCNS disease (p = 0.02) were significantly less likely to present to an ED in the 6 months prior to their index visit. Patients presenting with cirrhosis or CKD had the highest average number of ED visits in the 6 months prior to their index visit (cirrhosis: 4.59 visits, SD: 3.8, p < 0.0001; CKD: 4.39 visits, SD: 3.8, p = 0.0001). Of these patients, those presenting with end-stage cirrhosis were significantly more likely to make a return visit to an ED within 30 days after their index visit (p = 0.014). Conclusion: Cancer is the most common condition for patients with end-stage, chronic illnesses in these EDs. Those presenting with cirrhosis or CKD are at a significantly higher risk of repeat visits to the EDs. This study has identified potential deficits in care and can serve as a baseline for future intervention studies.