Board-certified Emergency Physicians Research Articles

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.

4340 Piloting Implementation and Dissemination of Best Practice Guidelines Using BPM+Health

OBJECTIVES/GOALS: Clinical translational studies inform clinical practice patterns through dissemination of clinical practice guidelines (CPG). In EM practices change to rapidly for timely local EHR implementation. We test the OMG BPM+Health specification for rapid deployment of best practices relevant to EM. METHODS/STUDY POPULATION: The OMG Business Process Management for Healthcare (BPM+Health) specification combines BPMN™ with Case Management Model and Notation (CMMN™) and Decision Model and Notations (DMN™) to “disseminate and leverage evidence-based best-practices at the point of care.” The American College of Emergency Physicians (ACEP) Board-certified Emergency Physicians modeled practice guidelines in the BPM+ modeling language during on-line meetings. Two common emergency conditions were selected for initial pilot testing: 1) evaluation and treatment of first trimester bleeding in pregnant patients, and 2) the evaluation and treatment of non-traumatic low back pain. RESULTS/ANTICIPATED RESULTS: The protocols were successfully modeled during four on-line meetings in less than 2 months. Process steps from initial evaluation to disposition were implemented using BPMN™. When clinicians need to evaluate the patient to collect data for decision making the inputs and outputs were modeled in CMMN™. Decision logic is represented as DMN™. The software tool linked the components for easy browsing and authoring the logic. The Physicians easily followed the displayed logic. The practice recommendations from each policy were successfully modeled, using the standard BPM+ notation to support rapid implementation in EHRs. Detailed implementation specifications will be shared. DISCUSSION/SIGNIFICANCE OF IMPACT: This pilot project demonstrated the feasibility of the OMG approach to solving Clinical Practice Guideline Implementation and Dissemination Barriers. Ongoing work by involved specialty societies will be necessary to demonstrate the scalability and sustainability of this approach.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work. A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N>2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N=1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD. Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery.

Developing an emergency medicine handoff tool: an electronic Delphi approach

BackgroundHandoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation.MethodsAn electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements.ResultsTwenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach’s alpha 0.93).ConclusionsThis study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.

Maybe It's Time to Rethink Freestanding Emergency Departments.

Maybe It's Time to Rethink Freestanding Emergency Departments.

A comprehensive validation of very early rule-out strategies for non-ST-segment elevation myocardial infarction in emergency departments: protocol for a multicentre prospective cohort study

IntroductionRecent advances in troponin sensitivity enabled early and accurate judgement of ruling-out myocardial infarction, especially non-ST elevation myocardial infarction (NSTEMI) in emergency departments (EDs) with development of various prediction-rules and...

Feasibility of point-of-care knee ultrasonography for diagnosing anterior cruciate and posterior cruciate ligament tears in the ED

ObjectiveTo evaluate the feasibility of point-of-care knee ultrasonography (POCUS) compared with knee magnetic resonance imaging (MRI) for diagnosing anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears in patients with acute knee trauma. Material and methodsA prospective study was conducted in a tertiary hospital emergency department; acute (within 1-week) knee trauma patients with suspected ACL or PCL tear were recruited. Two POCUS performers (a board-certified emergency physician and a musculoskeletal radiologist) independently evaluated the ACL and PCL using POCUS. Findings were classified as normal appearance or ligament tear. Final radiology reports of knee MRI were used as the reference standard. We calculated the diagnostic values (sensitivity, specificity, and accuracy) for POCUS obtained by both POCUS performers. Kappa values (k) were calculated for inter-observer agreement between the two POCUS performers. ResultsSixty-two patients were enrolled. Compared with the reference standard, POCUS showed acceptable sensitivity (90.6–100%), specificity (90.0–97.7%), and accuracy (91.9–96.8%). Inter-observer agreement between the two POCUS performers was excellent (k = 0.853–0.903). ConclusionPOCUS demonstrates excellent precision as compared to MRI in the diagnosis of ACL and PCL tears. The findings of POCUS could be used for immediate diagnosis and further pre-operative imaging in patients with acute knee trauma.

End-tidal CO2 Monitoring is Available in Most Community Hospitals in a Rural State: A Health System Survey.

IntroductionProcedural sedation and analgesia (PSA) provides safe and effective relief for pain, anxiety and discomfort during procedures performed in the emergency department (ED). Our objective was to identify hospital-level factors associated with routine PSA capnography use in the ED.MethodsThis study was a cross-sectional telephone survey of ED nurse managers and designees in a Midwestern state. Respondents identified information about hospital infrastructure, physician staffing, family practice (FP) physicians only, board-certified emergency physicians (EPs) only (or both), and critical intervention capabilities. Additional characteristics including ED volume and hospital designation (i.e., rural-urban classification) were obtained from the Centers for Medicare and Medicaid Services and the state hospital association database, respectively. The primary outcome was reported use of PSA capnography. We conducted univariate analyses (relative risks, 95% confidence interval [CI]) to identify associations between hospital-level characteristics and PSA capnography use.ResultsWe had an overall response rate of 98% (n=118 participating hospitals). The majority of EDs were in rural settings (78%), with a median of 5,057 visits per year (interquartile range 2,823–14,322). Nearly half of the EDs were staffed by FP physicians only, while 16% had board-certified EPs only. Nearly all hospitals (n=114, 97%), reported using continuous capnography for ventilated patients, and 74% reported use of capnography during PSA. Urban hospitals were more likely to use PSA capnography than critical access hospitals (relative risk 1.45; 95% CI, 1.22–1.73), and PSA capnography use increased with each ED volume quartile. Facilities with only EPs were 1.46 (95% CI, 1.15–1.87) times more likely to use PSA capnography than facilities with FP physicians only.ConclusionContinuous capnography was available in nearly all EDs, independent of size, location or patient volume. The implementation of capnography during PSA was less penetrant. Smaller, rural departments were less likely than their larger, urban counterparts to implement these national guidelines. Rurality and hospital size may be potential institutional barriers to capnography implementation.

Concomitant leukocytosis and lymphopenia predict significant pathology at CT of acute abdomen: a case-control study

BackgroundAcute abdominal pain accounts for about 10% of emergency department visits and has progressively become the primary indication for CT scanning in most centers. The goal of our study is to identify biological or clinical variables able to predict or rule out significant pathology (conditions requiring urgent medical or surgical treatment) on abdominal CT in patients presenting to an emergency department with acute abdominal pain.MethodsThis was a retrospective cohort study performed in the emergency department of an academic center with an annual census of 60′000 patients. One hundred and-nine consecutive patients presenting with an acute non-traumatic abdominal pain, not suspected of appendicitis or renal colic, during the first semester of 2013, who underwent an abdominal CT were included.Two medical students, completing their last year of medical school, extracted the data from patients’ electronic health record. Ambiguities in the formulations of clinical symptoms and signs in the patients’ records were solved by consulting a board certified emergency physician. Nine clinical and biological variables were extracted: shock index, peritonism, abnormal bowel sounds, fever (> 38 °C), intensity and duration of the pain, leukocytosis (white blood cell count >11G/L), relative lymphopenia (< 15% of total leukocytes), and C-reactive Protein (CRP). These variables were compared to the CT results (reference standard) to determine their ability to predict a significant pathology.ResultsSignificant pathology was detected on CT in 71 (65%) patients. Only leukocytosis (odds ratio 3.3, p = 0.008) and relative lymphopenia (odds ratio 3.8, p = 0.002) were associated with significant pathology on CT. The joint presence of these two anomalies was strongly associated with significant pathology on CT (odds ratio 8.2, p = 0.033). Leukocytosis with relative lymphopenia had a specificity of 89% (33/37) and sensitivity of 48% (33/69) for the detection of significant pathology on CT.ConclusionThe high specificity of the association between leukocytosis and relative lymphopenia amongst the study population suggests that these parameters would be sufficient to justify an emergency CT. However, none of the parameters could be used to rule out a significant pathology.

A collaborative educational intervention on procedural sedation and analgesia across the Pacific.

AimWorldwide, health‐care providers carry out procedural sedation and analgesia (PSA) in the emergency department. However, training opportunities are limited in many Asian countries, including Japan. We formed an educational group consisting of board‐certified emergency physicians in the USA and Japanese physicians and developed a PSA training module. The aims of our study were to demonstrate the effectiveness of training and to describe PSA practice in Japan.MethodsWe undertook a pretest of PSA knowledge questions and a retest immediately after the training intervention. We also carried out a survey and asked about participants' PSA practice. The training module consisted of four didactic hours and three simulation and skills laboratory hours. Results of all pre‐ and post‐intervention knowledge questions were analyzed with McNemar's test, and overall scores were analyzed with a paired t‐test.ResultsOne hundred and forty‐four health‐care providers including 123 physicians, 16 nurses, two pharmacists, and three medical students participated in the training. A total of 119 (83%) completed both the pre‐ and post‐intervention knowledge questions. Before the training, participants scored an average 66% (63%–69%) on the written knowledge test. After the intervention, participants showed significant improvement on the knowledge test (improvement 17%; 14%–20%). Among participants who answered the practice survey, 121 (88%) have undertaken PSA. Only 14 (12%) participants always or often use a continuous capnography for PSA. Only 32 (26.4%) participants undertook pre‐PSA systematic evaluation.ConclusionOur educational intervention successfully increased participants' knowledge. Only the minority of health‐care providers use capnography routinely for PSA, and pre‐PSA evaluation is not commonly carried out.

Is There a Neurologist in the House? A Summary of the Current State of Neurovascular Rotations for Emergency Medicine Residents.

Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time-window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents. A panel of 13 board-certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications-three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed-methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro-IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty. Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro-IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive. Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.

Do emergency physicians rely on point-of-care ultrasound for clinical decision making without additional confirmatory testing?

It is unknown if Emergency Physicians (EPs) rely solely on Emergency Medicine performed Point-Of-Care Ultrasound (EM-POCUS) for clinical decision making or if they proceed to subsequent "gold standard" studies for confirmatory diagnosis. After Institutional Review Board approval, an online survey was distributed by the Ohio Chapter of the American College of Emergency Physicians to its members. The most common EM-POCUS procedures used without confirmatory testing were: determination of cardiac activity during cardiac arrest (81.3%), differentiating cellulitis from abscess (63.2%), central venous catheter placement confirmation (43.2%), pericardial effusion evaluation (41.9%) and focused assessment with sonography for trauma (FAST-37.4%). The responses regarding remaining procedures suggest most physicians do not use EM-POCUS or verify EM-POCUS findings with additional testing. One hundred fifty-five survey responses provided a confidence interval of >90%. Two-thirds (67.7%) of respondents were board-certified EPs with 43.8% in practice for less than 5 years. EM-POCUS examinations were performed at least weekly by 37.4% of respondents; 28.4% performed at least 1 EM-POCUS examination per shift. Nearly half (47.7%) responded they had no concerns regarding use of EM-POCUS. This study describes the results of a survey on the use of EM-POCUS for clinical decision making by Ohio EPs. A majority of them continues to rely on gold standard testing for confirmatory diagnosis, in addition to EM-POCUS.

LO57: Very low concentrations of high-sensitivity troponin T at presentation can rapidly exclude acute myocardial infarction in a significant proportion of ED chest pain patients

Introduction: Chest pain is one of the most common presenting complaints to emergency departments (EDs) across the world, and the exclusion of acute myocardial infarction (AMI) using troponin testing is central to the care of many of these patients. While testing strategies using conventional troponin assays require repeat testing over many hours to avoid missed diagnoses, high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in a large proportion of patients with a single result at presentation. This objective of this study is to validate the ability of very low concentrations of hs-cTn at presentation to exclude AMI in ED chest pain patients. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at presentation. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. This study was REB approved. Results: A total of 1,167 patients were enrolled from August 2014 September 2016, of which 191 (16.3%) patients had an initial troponin below the limit of blank (LoB, &lt;3 ng/L) and 416 (32.8%) were below the limit of detection (LoD, &lt;5 ng/L). The sensitivity of a single troponin below the LoB (&lt;3 ng/L) for index AMI was 100% (95% CI 96.2%-100%) and for 30-day AMI was 100% (95% CI 96.4-100%). The sensitivity of a troponin below the LoD (&lt;5 ng/L) for index AMI was 97.9% (95% CI 92.7%-99.8%) and for 30-day AMI was 98.0% (95% CI 93.0-99.8%). Sensitivity for 30-day MACE at both cutoffs was lower: 98.4% (95% CI 94.3-99.8%) for &lt;3 ng/L, and 94.4% (95% CI 88.8-97.7%) for &lt;5 ng/L, respectively; however, negative predictive values remained high at both cutoffs: &lt;3 ng/L, 99.0% (95% CI 96.3-99.9%) and &lt;5 ng/L, 98.3% (95% CI 96.6-99.3%). Conclusion: A high sensitivity troponin T result below the LoB (&lt;3 ng/L) is highly sensitive for excluding AMI and identifies patients at low risk of 30-day MACE. A result below the LoB (&lt;5 ng/L) will identify a larger population of patients as low risk but has a greater risk of missed AMI and MACE.

LO59: External validation of a 2-hour rapid diagnostic algorithm for ruling out acute myocardial infarction in emergency department patients with chest pain using a high-sensitivity troponin-T assay

Introduction: Ruling out acute myocardial infarction (AMI) using serial troponin testing is central to the care of many emergency department (ED) patients with chest pain. While diagnostic strategies using conventional troponin assays require repeat sampling over many hours to avoid missed diagnoses, serial high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in most patients within 1 or 2 hours. However, many of the initial studies deriving and validating these rapid diagnostic algorithms had all hs-cTn samples analyzed in a central core lab likely representing optimal assay performance. This objective of this study is to validate a 2-hour rapid diagnostic algorithm to exclude AMI in ED chest pain patients using an hs-cTn assay in real world practice. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at ED presentation and 2-hours later. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and 30-day major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. This study was REB approved. Results: A total of 549 patients were enrolled from August 2014 September 2016 with 2-hour serial hs-cTnT results, of which 349 (63.6%) met the 2-hour rapid diagnostic algorithm low risk criteria (time 0 h/2 h hs-cTnT &lt;14 ng/L and delta 2 h &lt;4 ng/L). The sensitivity of the 2-hour low risk criteria for index AMI was 98.4% (95% CI 91.3%-100%) and for 30-day AMI was 98.4% (95% CI 91.6-100%). The sensitivity for 30day MACE was lower 84.4% (95% CI 74.4-91.7%) but maintained a high negative predictive value, 96.6% (95% CI 94.1-98.2%). Conclusion: A 2-hour rapid diagnostic algorithm using an hs-cTnT assay was highly sensitive for AMI on the index visit and successfully identified patients at low risk of 30-day AMI. Sensitivity for MACE was lower, reminding us that while biomarker-only rapid diagnostic algorithms excel at ruling out AMI, careful clinical risk stratification is needed to avoid missed MACE events.

LO56: External validation of a 1-hour rapid diagnostic algorithm for ruling out acute myocardial infarction in emergency department patients with chest pain using a high-sensitivity troponin-T assay

Introduction: Ruling out acute myocardial infarction (AMI) using serial troponin testing is central to the care of many emergency department (ED) patients with chest pain. While diagnostic strategies using conventional troponin assays require repeat sampling over many hours to avoid missed diagnoses, serial high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in most patients within 1 or 2 hours. However, many of the initial studies deriving and validating these rapid diagnostic algorithms had all hs-cTn samples analyzed in a central core lab likely representing optimal assay performance. This objective of this study is to validate a 1-hour rapid diagnostic algorithm to exclude AMI in ED chest pain patients using an hs-cTn assay in real world practice. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at ED presentation and 1-hour later. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and 30-day major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. The study was REB approved. Results: A total of 350 patients were enrolled from August 2014 September 2016 with 1-hour serial hs-cTnT results, of which 219 (62.6%) met the 1-hour rapid diagnostic algorithm low risk criteria (time 0h hs-cTnT &lt;12ng/L and delta 1h &lt;3ng/L). The sensitivity of the 1-hour low risk criteria for index AMI was 97.2% (95% CI 85.5%-99.9%) and for 30-day AMI was 97.3% (95% CI 85.8-99.9%). The sensitivity of the low risk criteria for 30-day MACE was lower 80.9% (95% CI 66.7-90.9%) but maintained a high negative predictive value, 95.9% (95% CI 92.3-98.1%). Conclusion: A 1-hour rapid diagnostic algorithm using an hs-cTnT assay was highly sensitive for AMI on the index visit and successfully identified patients at low risk of 30-day AMI; however, sensitivity for 30-day MACE was much lower. Of note, the 1-hour algorithm appears to be less sensitive for both AMI and 30-day MACE than a 2-hour algorithm validated in the same population.

Innovations in Emergency Nursing: Transforming Emergency Care Through a Novel Nurse-Driven ED Telehealth Express Care Service

ProblemEmergency department overcrowding and acuity are significant challenges to patients and staff. Low-acuity patients have extended wait times, and decreased satisfaction can have a negative effect on patient flow. MethodsA multidisciplinary ED team developed and launched the first ED-based Telehealth Express Care Service, where patients who present to the emergency department with minor complaints are offered a “virtual visit” with a board-certified emergency physician located remotely. ResultsMore than 6 months into the program, more than 1,300 patients have been treated. These patients experienced decreased length of stay (2.5 hours to 38 minutes) and increased satisfaction. The program is very well received by staff members who appreciate its efficiency. DiscussionTelehealth has the potential to optimize ED efficiency, increase patient satisfaction, and promote safe, high-quality provision of care.Image 1

Analyzing the role of practice-assisting manpower and its impact in emergency medical care settings

Purpose: To investigate and analyse the role of practice-assisting manpower in the emergency care centers of teaching hospitals for more efficient allocation of the workload in hospitals to provide better medical care. Methods: We enrolled a total of eight practice-assisting manpower in four emergency care centers of teaching hospitals located in Daejeon Metropolitan City and Chungcheong Province areas. The current demographics and conditions of practice-assisting manpower and their work schedules were surveyed and collected. Board-certified emergency physicians from each hospital observed tasks performed by practice-assisting manpower for 60 minutes during both day and night shifts, and data collected were analysed by time-motion study method. Results: The practice-assisting manpower participants were of certified first-ranked Emergency Medical Technician (EMT). The mean working hours per week were 42.5 ± 3.3 h. The total number of performed tasks during the study period was 275 items (day shift: 141, night shift: 134) in total observation time. Tasks performed were divided into three categories: procedure-assisting (87 items), treatment-assisting (169 items), and personal activities (19 items). The time consumed for procedure-assisting tasks, treatment-assisting tasks, and personal activities were recorded as 8 h 35 min 47 s, 4 h 27 min 41 s, and 2 h 56 min 32 s, relatively. Conclusion: Though some items in both procedure-assisting and treatment-assisting tasks were classified as beyond the scope of work of EMT, it is observed that the role of practice-assisting manpower in emergency care is critical and significant for efficient patient care in the emergency care settings. This further suggests reconsidering the functions of practice-assisting manpower and reallocates duties among the workforce of emergency medical service providers for the present and future.

Use of a Modified Fishbone Diagram to Analyze Diagnostic Errors in Emergency Physicians.

Reilly et al. described a structured approach to the analysis of diagnostic errors by using a novel modifi ed fi shbone diagram. The application of this tool in emergency medicine had not previously been reported. The objective of this study is to use the modified fishbone diagram analysis method in examining the causes of common diagnostic errors committed by emergency physicians and the circumstances associating errors in cognitive processes. Sixty-one cases of diagnostic errors involving ten board-certified emergency physicians (EPs) were identifi ed through a peer review process. Using a qualitative study approach, in-depth semi structured interviews with EPs was conducted. All interview audiotapes were transcribed verbatim. Content analysis was performed on all textual data to identify the factors underlying errors using the modified fishbone diagram. In 61 cases, 165 diagnostic errors were identified (2.7 per case). The underlying contributions to errors fell into 7 categories: cognitive process (54/61, 89%), specific presentation (32/61, 52%), clinical data gathering (24/61, 39%), organization issues (12/61, 20%), affective factors (9/61, 15%), context of care (9/61, 15%), and communication (5/61, 8%). Of these cognitive errors were the most common. However, only six cases occurred in isolation (6/54, 11%), with the remaining 48 cases (48/54, 89%) occurring with other types of errors, the most common being specific presentation (28/54, 52%) and clinical data gathering (24/54, 44%). The modified fishbone diagram is a useful tool to identify various categories of errors on diagnostic process in emergency department (ED). These fi ndings provide a basis on which to build a framework for teaching EPs how to avoid misdiagnoses in the ED setting.

Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department.

Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.

193 Impact of Implementation of Emergency Medicine Training on Emergency Department Mortality in Kigali, Rwanda: An Interrupted Time-Series Quasi-Experimental Design

Although emergency medicine (EM) training programs have recently been introduced in low- and middle-income countries (LMICs), no data exists on their effects on patient-centered outcomes in resource-limited settings. This study evaluated the impact of EM training on emergency department (ED) mortality among patients treated at the University Teaching Hospital of Kigali (UTH-K) ED. The study was conducted at UTH-K, the primary public referral hospital in Rwanda. An EM post-graduate diploma program was begun at UTH-K in October 2013 and full EM residency training program was begun in September 2015. Prior to initiation of these training programs, care was provided exclusively by general practice physicians (GPs); since initiation, ED care has been provided through mutually exclusive shifts allocated between GPs and EM resident (EMR) trainees who have oversight by board certified emergency physicians. All patients presenting to the ED during the nine-month period prior to initiation of the EM training (Jan.-Sept., 2013) and nine-months following the start of the EM residency program (Sept. 2015-June 2016) were eligible for inclusion. Study personnel abstracted data from a random sample of hospital records using a structured collection instrument. Prevalence and risk differences (RD) of all cause ED mortality were compared for cases treated before and after EM training initiation and based on provider type (GPs or EMRs). Secular trends were assessed and magnitudes of effects were quantified using odds ratios (OR) with 95% confidence intervals (CI). Multivariate models were adjusted a priori for age, type and severity of illness. From the 35,491 encounters during the study period, 2,580 cases were randomly sampled. There were 1,480 cases prior to training initiation and 1,100 after. The median age was 32 years (inter-quartile range (IQR): 22, 49) with a male predominance (59.9%). Medical patients comprised 54.0% of cases and injuries account for 46.0%. Median ED length of stay (LOS) was 1 day (IQR: 0, 3). The majority of cases were admitted (55.4%). Compared to the pre-implementation period, post implementation cases were more likely to be admitted (p<0.001). Pre-implementation mortality prevalence was 6.8% (95% CI: 5.4, 8.2%); post-implementation prevalence was 1.2% (95% CI: 0.5, 1.9%). In multivariate regression, as compared to ED cases treated prior to the initiation of the EM training program, those treated after were less likely to suffer ED mortality (aOR=0.14, 95% CI: 0.07, 0.30; p<0.001). In assessment by provider type, ED mortality among cases treated by GPs was 6.6% (95% CI: 5.5, 7.6%) and 1.3% (95% CI: 1.6, 2.4%) for those treated by EMRs. In regression analysis, compared to cases treated by GPs those treated by EM trainees were significantly less likely to experience ED mortality (aOR=0.08, 95% CI: 0.01, 0.55; p=0.011). No differences in secular trends in mortality were identified based on shift type either prior to (RD: 0.5%, 95% CI: -0.4, 4.6%; p=0.79) or after training initiation (RD: 0.9%, 95% CI: -0.8, 2.6%; p=0.35). ED mortality was significantly reduced with implementation of EM training in the studied population in Rwanda. Although limited by design aspects, these results demonstrate the benefit on an objective patient-centered outcome of EM training in a LMIC, and supports further research and investment in EM training in resource-limited settings.