Board-certified Emergency Physicians Research Articles

Diagnostic performance of ChatGPT in tibial plateau fracture in knee X-ray.

Tibial plateau fractures are relatively common and require accurate diagnosis. Chat Generative Pre-Trained Transformer (ChatGPT) has emerged as a tool to improve medical diagnosis. This study aims to investigate the accuracy of this tool in diagnosing tibial plateau fractures. A secondary analysis was performed on 111 knee radiographs from emergency department patients, with 29 confirmed fractures by computed tomography (CT) imaging. The X-rays were reviewed by a board-certified emergency physician (EP) and radiologist and then analyzed by ChatGPT-4 and ChatGPT-4o. The diagnostic performances were compared using the area under the receiver operating characteristic curve (AUC). Sensitivity, specificity, and likelihood ratios were also calculated. The results indicated a sensitivity and negative likelihood ratio of 58.6% (95% CI: 38.9 - 76.4%) and 0.4 (95% CI: 0.3-0.7) for the EP, 72.4% (95% CI: 52.7 - 87.2%) and 0.3 (95% CI: 0.2-0.6) for the radiologist, 27.5% (95% CI: 12.7 - 47.2%) and 0.7 (95% CI: 0.6-0.9) for ChatGPT-4, and 55.1% (95% CI: 35.6 - 73.5%) and 0.4 (95% CI: 0.3-0.7) for ChatGPT4o. The specificity and positive likelihood ratio were 85.3% (95% CI: 75.8 - 92.2%) and 4.0 (95% CI: 2.1-7.3) for the EP, 76.8% (95% CI: 66.2 - 85.4%) and 3.1 (95% CI: 1.9-4.9) for the radiologist, 95.1% (95% CI: 87.9 - 98.6%) and 5.6 (95% CI: 1.8-17.3) for ChatGPT-4, and 93.9% (95% CI: 86.3 - 97.9%) and 9.0 (95% CI: 3.6-22.4) for ChatGPT4o. The area under the receiver operating characteristic curve (AUC) was 0.72 (95% CI: 0.6-0.8) for the EP, 0.75 (95% CI: 0.6-0.8) for the radiologist, 0.61 (95% CI: 0.4-0.7) for ChatGPT-4, and 0.74 (95% CI: 0.6-0.8) for ChatGPT4-o. The EP and radiologist significantly outperformed ChatGPT-4 (P value = 0.02 and 0.01, respectively), whereas there was no significant difference between the EP, ChatGPT-4o, and radiologist. ChatGPT-4o matched the physicians' performance and also had the highest specificity. Similar to the physicians, ChatGPT chatbots were not suitable for ruling out the fracture.

Emergency physicians perspectives of state continuing medical education requirements for medical licensure.

This study aims to better understand the perspectives of emergency medicine physicians' on the role that state-mandated, topic-specific continuing medical education (CME) plays in addressing knowledge gaps, its relevance to current emergency practice, its reported burden and costs of CME activities to emergency physicians, and its perceived improvement in patient care. A cross-sectional survey was designed by the Coalition of Board-Certified Emergency Physicians (COBCEP) and distributed in February 2023 to all American Board of Emergency Medicine (ABEM)-certified physicians. Statistical tests of significance (Pearson's chi-square and Fisher's exact test) assessed the cost and time spent on CME as well as the perceived value placed on CME by ABEM-certified physicians to improve patient care. Data were summarized using descriptive statistics. There were 5562 (13.0%) responses from the 43656 physicians who received the survey-5506 responses were included for analysis. Over half of the physicians (53.0%) had more than 15 years of post-residency practice experience. Most physicians (57.3%) spent less than $5,000 per year on obtaining CME. Most physicians practicing in states with state-mandated, topic-specific CME requirements believed that participation in ABEM continuing certification could be used to reduce the need for state-mandated, topic-specific CME requirements (83.6%) and state-mandated, topic-specific requirements were believed to be unlikely to improve patient care (70.8%). Although well-intended, state CME requirements may lack relevancy and can, at times, place an undue burden on emergency physicians. Tailoring CME requirements to increase relevance to their patient populations and reduce barriers to completing CME could enhance knowledge translation and improve patient outcomes.

The Evolution of Board-Certified Emergency Physicians and Staffing of Emergency Departments in Israel.

Emergency medicine (EM) was recognized as a specialty in Israel in 1999. Fifty-nine of the 234 (25%) attending physicians working in emergency departments (ED) nationwide in 2002 were board-certified emergency physicians (EP). A 2012 study revealed that 123/270 (45%) of ED attendings were EPs, and that there were 71 EM residents. The EPs primarily worked midweek morning shifts, leaving the EDs mostly staffed by other specialties. Our objective in this study was to re-evaluate the EP workforce in Israeli EDs and their employment status and satisfaction 10years after the last study, which was conducted in 2012. We performed a three-part, prospective cross-sectional study: 1) a survey, sent to all EDs in Israel, to assess the numbers, level of training, and specialties of physicians working in EDs; 2) an anonymous questionnaire, sent to EPs in Israel, to assess their demographics, training, employment, and work satisfaction; and 3) interviews of a convenience sample of EPs analyzed by a thematic approach. There were 266 board-certified EPs, 141 (53%) of whom were employed in EDs full-time or part-time. Sixty-two non-EPs also worked in EDs. The EPs were present in the EDs primarily during weekday morning shifts. There were 273 EM residents nationwide. A total of 101 questionnaires were completed and revealed that EPs working part-time in the ED worked fewer hours, received higher salaries, and had more years of experience compared to EPs working full time or not working in the ED. Satisfaction correlated only with working part time. Meaningful work, diversity, and rewarding relationships with patients and colleagues were major positive reasons for working in the ED. Feeling undervalued, carrying a heavy caseload, and having complicated relationships with other hospital departments were reasons against working in the ED. Our study findings showed an increase in the number of trained and in-training EPs, and a decrease in the percentage of board-certified EPs who persevere in the EDs. Emergency medicine in Israel is at a crossroads: more physicians are choosing EM than a decade ago, but retention of board-certified EPs is a major concern, as it is worldwide. We recommend taking measures to maintain trained and experienced EPs working in the ED by allowing part-time ED positions, introducing dedicated academic time, and diversifying EP roles, functioning, and work routine.

Using an artificial intelligence software improves emergency medicine physician intracranial haemorrhage detection to radiologist levels

BackgroundTools to increase the turnaround speed and accuracy of imaging reports could positively influence ED logistics. The Caire ICH is an artificial intelligence (AI) software developed for ED physicians to...

Individual Attributes and Environmental Conditions of Registered Nurses Working in Freestanding Emergency Departments in the United States: A Descriptive Exploratory Study

IntroductionFreestanding emergency departments (FSEDs) are emergency facilities not connected to inpatient services. The percentage of FSEDs of all EDs grew from 1% in 2001 to 12% in 2017, making FSEDs a substantial subset of US emergency care. The purpose of this study was to describe the individual attributes and environmental conditions of registered nurses working in FSEDs in the US. MethodsA quantitative descriptive exploratory design with cross-sectional survey methodology. ResultsA total of 364 emergency nurses responded to the survey. Most reported their FSED was open 24 hours/day (99.5%), with board-certified emergency physicians onsite (91.5%) and a mean of 3.6 RNs working per shift. Resources immediately available in more than 50% of FSEDs included laboratory and imaging services, and in fewer than 30% of FSEDs included behavioral health care, MRI, obstetric care, orthopedic care, neurologic care, and surgical consult care. Respiratory therapy was reported by 39.6% of respondents as being immediately available. A significant minority of respondents expressed concerns about adequacy of resources and training and the effect on patient care in both survey (30% of respondents) and open-ended questions (42.5% of respondents). DiscussionThe practice environment of emergency nurses in FSEDs was reported as having positive elements; however, a substantial subpopulation reported serious concerns. FSEDs adhere to some of the standards put forward by the American College of Emergency Physicians, with notable exceptions in the areas of staffing RNs, staffing ancillary staff, and availability of some resources.

Smartphone AI vs. Medical Experts: A Comparative Study in Prehospital STEMI Diagnosis.

Prehospital telecardiology facilitates early ST-elevation myocardial infarction (STEMI) detection, yet its widespread implementation remains challenging. Extracting digital STEMI biomarkers from printed electrocardiograms (ECGs) using phone cameras could offer an affordable and scalable solution. This study assessed the feasibility of this approach with real-world prehospital ECGs. Patients suspected of having STEMI by emergency medical technicians (EMTs) were identified from a policy research dataset. A deep learning-based ECG analyzer (QCG™ analyzer) extracted a STEMI biomarker (qSTEMI) from prehospital ECGs. The biomarker was compared to a group of human experts, including five emergency medical service directors (board-certified emergency physicians) and three interventional cardiologists based on their consensus score (number of participants answering "yes" for STEMI). Non-inferiority of the biomarker was tested using a 0.100 margin of difference in sensitivity and specificity. Among 53 analyzed patients (24 STEMI, 45.3%), the area under the receiver operating characteristic curve of qSTEMI and consensus score were 0.815 (0.691-0.938) and 0.736 (0.594-0.879), respectively (p=0.081). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of qSTEMI were 0.750 (0.583-0.917), 0.862 (0.690-0.966), 0.826 (0.679-0.955), and 0.813 (0.714-0.929), respectively. For the consensus score, sensitivity, specificity, PPV, and NPV were 0.708 (0.500-0.875), 0.793 (0.655-0.966), 0.750 (0.600-0.941), and 0.760 (0.655-0.880), respectively. The 95% confidence interval of sensitivity and specificity differences between qSTEMI and consensus score were 0.042 (-0.099-0.182) and 0.103 (-0.043-0.250), respectively, confirming qSTEMI's non-inferiority. The digital STEMI biomarker, derived from printed prehospital ECGs, demonstrated non-inferiority to expert consensus, indicating a promising approach for enhancing prehospital telecardiology.

Attrition From the US Emergency Medicine Workforce During Early Stages of the COVID-19 Pandemic.

Attrition From the US Emergency Medicine Workforce During Early Stages of the COVID-19 Pandemic.

Hyperkalemia Detection in Emergency Departments Using Initial ECGs: A Smartphone AI ECG Analyzer vs. Board-Certified Physicians.

Hyperkalemia is a potentially fatal condition that mandates rapid identification in emergency departments (EDs). Although a 12-lead electrocardiogram (ECG) can indicate hyperkalemia, subtle changes in the ECG often pose detection challenges. An artificial intelligence application that accurately assesses hyperkalemia risk from ECGs could revolutionize patient screening and treatment. We aimed to evaluate the efficacy and reliability of a smartphone application, which utilizes camera-captured ECG images, in quantifying hyperkalemia risk compared to human experts. We performed a retrospective analysis of ED hyperkalemic patients (serum potassium ≥ 6 mmol/L) and their age- and sex-matched non-hyperkalemic controls. The application was tested by five users and its performance was compared to five board-certified emergency physicians (EPs). Our study included 125 patients. The area under the curve (AUC)-receiver operating characteristic of the application's output was nearly identical among the users, ranging from 0.898 to 0.904 (median: 0.902), indicating almost perfect interrater agreement (Fleiss' kappa 0.948). The application demonstrated high sensitivity (0.797), specificity (0.934), negative predictive value (NPV) (0.815), and positive predictive value (PPV) (0.927). In contrast, the EPs showed moderate interrater agreement (Fleiss' kappa 0.551), and their consensus score had a significantly lower AUC of 0.662. The physicians' consensus demonstrated a sensitivity of 0.203, specificity of 0.934, NPV of 0.527, and PPV of 0.765. Notably, this performance difference remained significant regardless of patients' sex and age (P < 0.001 for both). Our findings suggest that a smartphone application can accurately and reliably quantify hyperkalemia risk using initial ECGs in the ED.

Barriers to the use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia: a cross-sectional study

The use of ultrasound-guided central venous catheter (USG-CVC) placement is still low among emergency physicians in many countries, including Saudi Arabia, because of several inherent perceived barriers. We assessed the barriers to the use of USG-CVC placement in clinical practice among Saudis currently in training, residents and board-certified physicians and evaluated the association of these barriers with the demographic characteristics of EPs. We conducted a cross-sectional survey among all emergency physicians (EPs) practicing in Saudi Arabia who completed a residency program in emergency medicine (EM) or were board-certified emergency physicians from October to December 2018. The survey material was sent via SurveyMonkey through the Saudi Commission for Health Specialties to target EPs. Two hundred thirty-four EPs completed the survey (response rate: 66.9%), and 177 (75.6%) were males. EPs from nongovernment institutions tended to agree significantly more than EPs from government institutions with the perception that USG-CVC placement is a time-consuming process (17.9% vs. 20.3%, respectively, p = 0.022). Residents were 3.8 times more likely to perceive loss of their skill in using Ultrasound (US) for CVC placement Odds ratio (OR) = 3.806, 95% Confidence interval (CI) = 0.218–0.686, p &lt; 0.001), 2 times more likely to believe that USG-CVC placement was not proven in randomized controlled trials (OR = 2.061, 95% CI = 0.010–0.460, p = 0.040), and 5.5 times more likely to believe that USG-CVC placement was not a cost-effective procedure (OR = 5.490, 95% CI = 0.411–0.870, p &lt; 0.001) than board-certified EPs. Many EPs, particularly those in training, believe there are several barriers to using USG-CVC placement, including loss of skill, a lack of support of the procedure in randomized controlled trials and cost-effectiveness. This is true, although there is existing evidence and a consensus regarding the superiority of USG-CVC placement over the landmark technique. In comparison to the more experienced and well-trained board-certified EPs, residents’ confidence and skill in using USG-CVC placement may have been influenced by their training and experience.

Simulation-based Mastery Learning Improves Emergency Medicine Residents' Ability to Perform Temporary Transvenous Cardiac Pacing.

Temporary transvenous cardiac pacing (TVP) is a critical intervention that emergency physicians perform infrequently in clinical practice. Prior simulation studies revealed that emergency medicine (EM) residents and board-certified emergency physicians perform TVP poorly during checklist-based assessments. Our objective in this report was to describe the design and implementation of a simulation-based mastery learning (SBML) curriculum and evaluate its impact on EM residents' ability to perform TVP. An expert panel of emergency physicians and cardiologists set a minimum passing standard (MPS) for a previously developed 30-item TVP checklist using the Mastery Angoff approach. Emergency medicine residents were assessed using this checklist and a high-fidelity TVP task trainer. Residents who did not meet the MPS during baseline testing viewed a procedure video and completed a 30-minute individual deliberate practice session before retesting. Residents who did not meet the MPS during initial post-testing completed additional deliberate practice and assessment until meeting or exceeding the MPS. The expert panel set an MPS of correctly performing 28 (93.3%) checklist items. Fifty-seven EM residents participated. Mean checklist scores improved from 13.4 (95% CI 11.8-15.0) during baseline testing to 27.5 (95% CI 26.9-28.1) during initial post-testing (P < 0.01). No residents met the MPS at baseline testing. The 21 (36.8%) residents who did not meet the MPS during initial post-testing all met or exceeded the MPS after completing one additional 30-minute deliberate practice session. Emergency medicine residents demonstrated significantly improved TVP performance with reduced variability in checklist scores after completing a simulation-based mastery learning curriculum.

107 Real-Time Computer Vision TTE Analytics using Existing Ultrasound Workflows

Real time ‘AI’ applications utilizing point-of-care ultrasound are often commercialized, expensive and do not work with existing ultrasound machines and workflows, hampering the reach of effective computer vision techniques to assist at the bedside for diagnostic and teaching purposes. The purpose of this study is to evaluate whether formal transthoracic echocardiogram studies can be used for transfer learning on ED echocardiogram views and to build a portable model for real-time cardiac function categorization at the bedside that works with existing ultrasound equipment. The ultimate goal of the project is to create a portable hardware and software solution that works with existing ED ultrasound machines and workflows. A previously described three-dimensional convolutional neural network (CNN), trained on 10, 030 formal transthoracic echocardiogram apical 4-chamber (A4C), was adapted for use in the ED. Expert sonographer tracings were used through weak supervision to generate frame-level semantic segmentations of the left ventricle to output video of cardiac function over time. 1123 ED A4C videos from July 2020 to December 2020 were intermixed by labeling them into four categories (‘normal,’ ‘slightly reduced,’ ‘moderately reduced,’ ‘severely reduced’) by board certified emergency physicians and consensus labeling was done by an ultrasound division faculty member. Given variability of ED A4C videos and to assist with CNN training, an interpretability label (‘yes,’ ‘partial,’ ‘no’) was also obtained corresponding to all, some, and none of the beats complete and clinically interpretable. These labeled videos were intermixed with the formal echocardiogram video set and the CNN was retrained to provide binary output (normal vs hypo- contractile) and segmented video of left ventricular cardiac function over time. Receiver operating characteristic curves (ROC) were generated to assess diagnostic ability. Finally, the video output port of an ultrasound machine was used to generate model outputs (label and segmented video) available to providers in near real-time (<0.2 seconds to create model output) using inexpensive hardware at the bedside. An initial set of 133 A4C videos were evaluated by the model before any retraining was done with a ROC of 0.81 (95% CI: 0.77 - 0.85) for a binary classifier. After intermixing the remaining ED videos and retraining the CNN, an improved ROC of 0.91 (95% CI: 0.89 - 0.94) was observed for a binary classifier. For test set A4C videos that the model deemed interpretable, segmented videos accurately demonstrated contractility by shading left ventricular cardiac function. A three-dimensional CNN trained on a cardiology echocardiogram dataset can be retrained using ED A4C videos to provide high discriminatory value and be adapted for existing ED ultrasound machines and workflows providing an inexpensive tool for real-time feedback at the bedside. Along with categorical labeling, segmented video output can help with uptake of and understanding model output, potentially lowering the barrier to entry to ED echocardiography for providers lacking formal ultrasound training and providing guidance to trainees.

The Emergency Medicine Physician Workforce: Projections for 2030

The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in2030. The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

After the Match

After the Match

The future of simulation-based medical education: Adaptive simulation utilizing a deep multitask neural network.

In resuscitation medicine, effectively managing cognitive load in high-stakes environments has important implications for education and expertise development. There exists the potential to tailor educational experiences to an individual's cognitive processes via real-time physiologic measurement of cognitive load in simulation environments. The goal of this research was to test a novel simulation platform that utilized artificial intelligence to deliver a medical simulation that was adaptable to a participant's measured cognitive load. The research was conducted in 2019. Two board-certified emergency physicians and two medical students participated in a 10-minute pilot trial of a novel simulation platform. The system utilized artificial intelligence algorithms to measure cognitive load in real time via electrocardiography and galvanic skin response. In turn, modulation of simulation difficulty, determined by a participant's cognitive load, was facilitated through symptom severity changes of an augmented reality (AR) patient. A postsimulation survey assessed the participants' experience. Participants completed a simulation that successfully measured cognitive load in real time through physiological signals. The simulation difficulty was adapted to the participant's cognitive load, which was reflected in changes in the AR patient's symptoms. Participants found the novel adaptive simulation platform to be valuable in supporting their learning. Our research team created a simulation platform that adapts to a participant's cognitive load in real-time. The ability to customize a medical simulation to a participant's cognitive state has potential implications for the development of expertise in resuscitation medicine.

Feasibility and outcomes from an integrated bridge treatment program for opioid use disorder.

ObjectiveWith a significant proportion of individuals with opioid use disorder not currently receiving treatment, it is critical to find novel ways to engage and retain patients in treatment. Our objective is to describe the feasibility and preliminary outcomes of a program that used emergency physicians to initiate a bridge treatment, followed by peer support services, behavioral counseling, and ongoing treatment and follow‐up.MethodsWe developed a program called the Houston Emergency Opioid Engagement System (HEROES) that provides rapid access to board‐certified emergency physicians for initiation of buprenorphine, plus at least 1 behavioral counseling session and 4 weekly peer support sessions over the course of 30 days. Follow‐ups were conducted by phone and in person to obtain patient‐reported outcomes. Primary outcomes included percentage of patients who completed the 30‐day program and the percentage for successful linkage to more permanent ongoing treatment after the initial program.ResultsThere were 324 participants who initiated treatment on buprenorphine from April 2018 to July 2019, with an average age of 36 (±9.6 years) and 52% of participants were males. At 30 days, 293/324 (90.43%) completed the program, and 203 of these (63%) were successfully connected to a subsequent community addiction medicine physician. There was a significant improvement (36%) in health‐related quality of life.ConclusionLack of insurance is a predictor for treatment failure. Implementation of a multipronged treatment program is feasible and was associated with positive patient‐reported outcomes. This approach holds promise as a strategy for engaging and retaining patients in treatment.

Abstract P168: Who Are You Going to Call?: Emergency Physician Stroke Champions

Introduction: A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients. Methods: Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology. Results: Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor. Conclusion: Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.

Virtual powers of observation: A telemedicine approach for the suspected COVID-19 patient.

Prior to COVID-19, telemedicine and its applications to the emergency department (ED) had made significant inroads toward remote evaluation and care. During the local peak of the COVID-19 pandemic in New York City (NYC), there was a dramatic increase in telemedicine based patient encounters for suspected COVID-19 symptoms. In response, pathways were developed to promote a standardized telemedicine approach to remote evaluation and assessment of suspected COVID-19 patients. A pathway was developed and implemented at two academic EDs in NYC, which collectively had approximately 8,300 telemedicine visits for suspected COVID-19 from March 2020 to June 2020. A protocol was developed by an expert consensus panel of four board-certified emergency physicians and two pediatric emergency physicians, all with telemedicine training/administrative roles. The pathway was initiated for any telehealth patient with suspected COVID-19 symptoms (cough, fever, shortness of breath, and bodyaches). A standardized history solicited known or suspected risk factors for worse prognosis, including age > 50, cardiovascular or lung disease, obesity, immunosuppression, and living alone, as well as a focused assessment of symptom severity and exercise tolerance. An exam at rest included visual counting of breaths along with instruction on palpation of radial pulse. Saturation was included if pulse oximetry was available. If exam at rest was reassuring, providers were instructed to repeat the respiratory assessment on exertion by having the patient walk in place briskly for 1 minute. Patients with severe illness defined by resting or exertional respiratory rate greater than 30 and/or oxygen saturation less than 90 percent were instructed to go to the ED. Patients with moderate illness defined by exertional metrics of respiratory rate less than 22, oxygen saturation greater than 94 percent, and heart rate less than 125 were discharged from the virtual urgent care visit with a repeat telehealth follow-up call at either 12 or 24 hours depending on the number of risk factors. Patients without risk factors and with reassuring respiratory assessment were discharged from the telemedicine encounter with reassurance and standard discharge precautions for escalation of care. Designing and disseminating a standardized pathway helped to provide a framework to approach patients suspected of COVID-19 over telemedicine. Future work focusing on patient outcome data will help guide and refine any standardized telehealth approach to the COVID-19-suspected patient.

Emergency Medicine Residents Experience Acute Stress While Working in the Emergency Department.

IntroductionAcute stress may impair cognitive performance and multitasking, both vital in the practice of emergency medicine (EM). Previous research has demonstrated that board-certified emergency physicians experience physiologic stress while working clinically. We sought to determine whether EM residents have a similar stress response, and hypothesized that residents experience acute stress while working clinically.MethodsWe performed a prospective observational study of physiologic stress including heart rate (HR), heart rate variability (HRV), and subjective stress in EM residents during clinical shifts in the emergency department. HR and HRV were measured via 3-lead Holter monitors and compared to baseline data obtained during weekly educational didactics. Subjective stress was assessed before and after clinical shifts via a Likert-scale questionnaire and written comments.ResultsWe enrolled 21 residents and acquired data from 40 shifts. Residents experienced an increase in mean HR of eight beats per minute (P < 0.001) and decrease in HRV of 53.9 milliseconds (P = 0.005) while working clinically. Subjective stress increased during clinical work (P <0.001). HRV was negatively correlated with subjective stress, but this did not reach statistical significance (P = 0.09).ConclusionEM residents experience acute subjective and physiologic stress while working clinically. HR, HRV, and self-reported stress are feasible indicators to assess the acute stress response during residency training. These findings should be studied in a larger, more diverse cohort of residents and efforts made to identify characteristics that contribute to acute stress and to elicit targeted educational interventions to mitigate the acute stress response.

Supply and Demand of Emergency Medicine Board-certified Emergency Physicians by U.S. State, 2017.

Our objective was to estimate the emergency medicine board-certified emergency physician (EMBC EP) workforce supply and demand by U.S. state. To estimate state demand, we applied the methodology from our 2005 analysis to calculate full-time equivalent (FTE) EMBC EP demand for each emergency department (ED). The 2017 National Emergency Department Inventory-USA provided visit volumes for all EDs, while the American Board of Medical Specialties supplied the 2017 number of EMBC EPs per state. Assuming that at least one EMBC EP should be present 24/7 in each ED (requiring 5.35 FTEs minimum), we calculated the total FTEs required by dividing each ED's visit volume by the estimated average visits seen by an EMBC EP (3,548 visits per year) and then summed FTEs by state. The U.S. Census Bureau provided state demographic characteristics. We used multivariable linear regression to examine the association between state demographics and the density of EMBC EPs per state and compared 2017 results to our prior 2005 analysis. There were 40,716 total EMBC EPs in 2017, fulfilling 77% of the estimated national demand. This was a substantial increase from 23,035 total EMBC EPs fulfilling 58% of demand in 2005. The 2017 supply ranged from 24% of demand in North Dakota to 142% in Hawaii. A lower density of EMBC EPs was associated with states in the Midwest and South (p<0.001) and with a more rural population (p=0.02). The absolute shortage of EMBC EPs worsened or remained the same in one-fourth of states. While the total number of EMBC EPs nearly doubled between 2005 and 2017, a shortage of full-time coverage persists. The supply and demand vary greatly by state. Worsening absolute shortages in several states show that the distribution of EMBC EPs is not meeting demand across the United States, particularly in rural areas.

129 The Safety of Rapid Triage in a Coronavirus Epicenter

The COVID-19 pandemic has strained health care systems with massive influxes of potentially infectious patients with a respiratory virus. As the epicenter of COVID-19 in the United States, NYC public hospitals were strained well past their limits. Rapid triage, assessment, and disposition is essential in providing safe and appropriate care in a disaster scenario. Multiple studies have shown length of stay times as well as patient elopements improved with a brief physician assessment in triage. Our objective was to determine if rapid assessment medical screening exams are safe and effective means to decompress overcrowded waiting rooms during a respiratory pandemic. All patients presenting to Elmhurst Hospital Center during peak capacity were rapidly assessed by board certified emergency physicians in the waiting room in lieu of formal triaging processes. Each medical screening exam was expected to last no longer than 5 min. In an institutionally approved IRB study, demographic data, chief complaint, medical comorbidities, and a full set of vitals were collected and recorded. Patients were then triaged to the emergency department or instructed to return home to self-quarantine with a comprehensive quarantine instructional packet. Patients sent home were contacted by nursing staff periodically to monitor their health status. Data was collected on patient returns, clinical status, and ultimate disposition. 219 patients were followed after a brief medical screening exam. 162 patients were discharged directly from the waiting room. Out of the discharged patients 14 (9%) returned to an HHC emergency department, and 3 (2%) of those patients ultimately required admission to the hospital. Based on preliminary data, rapid assessment by board certified emergency physicians appears to be a safe and effective means to risk stratify all comers during a respiratory pandemic scenario. Patients who appear well, do not have significant comorbidities, and present with oxygen saturations above 95% can reasonably be reassured and sent home. Such processes are easily reproducible and can be rapidly implemented in times of mass patient influxes.