Emergency Department Physicians Research Articles

Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care.

More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians. We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ 2 to compare subgroups. Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%). Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

Abstract WP111: Stroke Team Member Perspectives on Factors That Influence Hospital Door-to-Needle Time Performance: A Qualitative Analysis

Background: Despite substantial to minimize ischemic stroke treatment delays, hospital door-to-needle (DTN) time variations persist. We sought to identify sources of variation in practice as well as understand stroke team member perceptions of factors that influence DTN performance in a sample of hospitals that participate in a statewide stroke registry. Methods: We conducted a series of semi-structured interviews with stroke coordinators and emergency department (ED) staff. Participants were invited from hospitals with the fastest or slowest DTN times in 2022. Transcripts of the interviews were coded to identify differences in hospital acute stroke code processes as well as interviewee perceptions of facilitators and barriers to optimal performance. Results: Ten individuals from 6 hospitals participated in interviews (6 stroke coordinators, 3 ED physicians, 1 ED nurse). Variations in stroke code processes included location of initial patient evaluation, stroke team composition (inclusion of pharmacy or in-person neurology provider), imaging strategy for large-vessel occlusion stroke screening, thrombolytic medication utilized, and team members primarily responsible for thrombolytic decision-making, mixing, and delivery. Common facilitators of rapid DTN times included integration of EMS, multidisciplinary engagement with quality improvement teams (especially physician engagement), embedding critical care nurses in stroke teams, and providing rapid, individualized feedback to clinical personnel. Common barriers included identifying stroke in triage, staff turnover, and inadequate stroke coordinator resources. Participants from higher performing hospitals reported having larger stroke teams with in-person neurology support. Participants from lower performing hospitals highlighted staffing shortages and difficulties with video-based teleneurology. Conclusion: Stroke code process variation is common and largely driven by hospital resources. Highly engaged, physician-led multidisciplinary teams and timely, actionable feedback were seen as key elements of achieving DTN goals. Staffing shortages and lack of access to timely neurological consultation are system-level barriers to optimal stroke care.

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol

IntroductionThe burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk...

Abstract TP45: A Nurse-Driven Pre-hospital Telemedicine Program Supports Care of Patients With Suspected Stroke

Background: Because of the time-sensitive nature of stroke treatment, extensive efforts focus on reducing treatment time in the hospital and prehospital setting. Recent studies exploring the use of telemedicine within the ambulance setting report positive results. Non-recordable paramedic-assisted videos allowed patients to be examined by an ED physician while in route to the receiving hospital, improving stroke treatment times. Ambulance teleconsultations are reported to be reliable and a good method to aide emergency triage facilitating accurate diagnosis. To the best of our knowledge, these studies have used EMS tele-health services to connect with a physician. In this study we assessed the treatment benefits of a nurse-driven pre-hospital telemedicine program in a community comprehensive stroke center (CSC). Methods: Telemedicine services was installed in 4 ambulance units. A tablet was supplied to highly specialized stroke nurses. Using the current dispatch notification system, the stroke nurse was alerted to an incoming suspected stroke patient and prepared to receive the telemedicine video connection. During the telemedicine video call a paramedic-assisted assessment occurred, patient history, contact information, and pre-thrombolytic consent was obtained. Upon arrival, the stroke alert proceeded as normal. Telemedicine data was retrospectively matched with data extracted from the medical record to evaluate treatment volume (thrombolytics (TNK), endovascular procedure (EP), or both), treatment times [door to CT(D2CT), door to needle (D2N), door to puncture(D2P), door to device(D2D)], and coded stroke volume for all EMS-telemedicine cases between Jan 2020-May 2022. Results: Over the course of the pilot, 41 cases were successfully matched, and pre-hospital video assessments occurred for 17 (41%) cases. Treatment rates were 20% (n=8), 15% (n=6), and 10% (n=4) for TNK, EP, and both respectfully. Median times were 7 min (4-21), 20min (12-32), 58min (48-124), and 82 min (64-140) for D2CT, D2N, D2P, D2D respectively. Lastly, 71% (n=29) received a stroke diagnosis. Conclusion: This study shows that a nurse-driven prehospital telemedicine system can be successfully implemented in a community CRC with excellent treatment time metrics.

Abstract WP71: Early Stroke Alert and Telestroke Notification Reduces Door to Needle Time

Background: Door to telestroke request times (DTSR) contribute to door to needle time (DTN) in telestroke networks, however, data is limited on the relationship between DTSR, DTN and other contributing factors. We aimed to evaluate the relationship between processes at the spoke, by EMS and how these contributed to DTN in telestroke spokes. Methods: This is a multi-center retrospective analysis of telestroke patients treated with IV thrombolysis from a hub and spoke telestroke network from June 2018 to March 2023. Patients were excluded from this study due to missing data. The Primary outcome was to examine the relationship between DTSR, DTN and other contributing variables. Multiple regression analyses evaluated which factors contributed to DTSR and DTN. A simple mediation model with covariates NIHSS and average telestroke volume was used to determine if DTSR mediates the relationship between door to stroke alert and DTN. A subgroup analysis examined which variables contributed to DTSR in patients arriving by EMS. A hierarchical multivariable regression analysis entering potential confounding variables as identified in preliminary analyses then variables of interest was used in the subgroup analysis. Results: There were 582 telestroke patients treated with IV thrombolysis and after exclusions, 471 (80.9%) patients were included in the study. The mean age ± SD of the patients was 69.50 ± 15.11 and 238 (50.5%) were female. Door to telestroke request partially mediated the relationship between door to stroke alert and DTN as door to stroke alert was significantly associated with DTN after adjustment for DTSR, B = 0.25 [95% Confidence Interval (CI), 0.10 - 0.41], p &lt; 0.001. In the adjusted model, DTSR explained 29% [95%CI, 22% - 35%] of the variance in DTN. Prehospital stroke alert by EMS reduced DTSR by 6.99 minutes [95%CI, 3.31 - 10.68], p &lt; 0.001, after adjustment of confounding variables. In patients with prehospital stroke alert, earlier ED physician evaluation was associated with quicker DTSR, B = 0.48 [95%CI, 0.01 - 0.95], p = 0.045. Conclusion: Early notification of the local stroke alert team and telestroke physician is associated with quicker DTN. Prehospital stroke alerts by EMS allow for quicker evaluation by ED physician which results in reduced DTSR.

Abstract WP38: Nurse-Driven Emergency Evaluation Improves Timely Acute Stroke Response

Background: Stroke is associated with high rates of death and disability; prompt and effective interventions are imperative. Depending on emergency department (ED) physicians to initiate stroke codes may delay critical time targets, especially for patients arriving by private vehicle (POV). This study examines existing stroke care protocols in the ED of a Comprehensive Stroke Center and evaluates a new nurse-driven acute stroke response protocol. Purpose: The primary goal of this initiative was to improve outcomes for patients arriving by POV, by reducing triage delays and accelerating time-sensitive acute stroke interventions. Methods: This retrospective study implemented a nurse-led stroke activation process, in lieu of the conventional physician-led method. Nurses received comprehensive training in intervention goals and identification of stroke symptoms and last known-well times. The nurse-led model targeted patients presenting to the ED with a minimum of 2 stroke symptoms within 6 hours of symptom onset—an assessment tool, incorporating the FAST algorithm (Face, Arm, Speech, Time) and key National Institutes of Health Stroke Scale (NIHSS) exam components, enhanced symptom specificity. Critical intervention times were evaluated for improvement. Results: ED POV arrival patients with acute stroke symptoms were studied from 11/7/21-7/31/23; the nurse-driven process was implemented on 11/7/22. Pre-intervention review included 247 patients with 216 patients in the post-intervention review. Median door-to-activation times fell from 17 to 10 minutes, door-to-CT from 24 to 19 minutes, and door-to-needle times from 49 to 43.5 minutes. Median NIHSS scores in tPA-treated patients were compared pre- and post-intervention. In the physician-led group, initial median NIHSS scores were 6, reducing to 1 at discharge. The nurse-led group showed an initial median NIHSS score of 5, also reducing to 1 at discharge. Conclusions: The nurse-driven method effectively shortened critical time metrics in the stroke code process, while maintaining optimal patient outcomes. A paradigm shift towards ED triage nurse-led stroke code activation for acute stroke may lead to higher quality acute stroke care.

Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments

Background: Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees. Methods: Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards. Results: There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time. Conclusion: Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.

Physician’s conceptions of the decision-making process when managing febrile infants ≤ 60 days old: a phenomenographic qualitative study

BackgroundThe management of febrile infants aged ≤ 60 days and adherence to guidelines vary greatly. Our objective was to describe the process of decision-making when managing febrile infants aged ≤ 60 days and to describe the factors that influenced this decision.MethodsWe conducted 6 focus group discussions with 19 clinically active physicians in the pediatric emergency departments of 2 university hospitals in Skåne region, Sweden. We followed an inductive qualitative design, using a phenomenological approach. A second-order perspective was used, focusing on how physicians perceived the phenomenon (managing fever in infants) rather than the phenomenon itself. The transcribed interviews were analyzed using a 7-step approach.ResultsPerforming a lumbar puncture (LP) was conceived as a complex, emotionally and mentally laden procedure and dominated the group discussions. Three central categories emerged as factors that influenced the decision-making process on whether to perform an LP: 1) a possible focus of infection that could explain the origin of the fever, 2) questioning whether the temperature at home reported by the parents was a fever, especially if it was ≤ 38.2°C, and 3) the infant’s general condition and questioning the need for LP in case of well-appearing infants. Around these 3 central categories evolved 6 secondary categories that influenced the decision-making process of whether to perform an LP or not: 1) the physicians’ desire to be able to trust their judgement, 2) fearing the risk of failure, 3) avoiding burdensome work, 4) taking others into account, 5) balancing guidelines and resources, and 6) seeing a need to practice and learn to perform LP.ConclusionsThe difficulty and emotional load of performing an LP were important factors that influenced the decision-making process regarding whether to perform an LP. Physicians highlighted the importance of being able to rely on their clinical judgment and make independent decisions. Guidelines may consider allowing a degree of flexibility and independent thinking to take into account patients’ characteristics and needs.

Prevalence of occupational injury and its associated factors among emergency department physicians in China: A large sample, cross-sectional study

BackgroundMedical personnel, particularly emergency department (ED) physicians, face a variety of occupational hazards. However, the current state of occupational injuries among ED physicians remains unknown. This study aimed to assess the occupational injury of Chinese ED physicians and to identify its associated factors. MethodsFrom July to August 2018, a cross-sectional survey was conducted in Chinese emergency departments. A structured questionnaire covering sociodemographic characteristics, individual health behaviours, and work-related characteristics was completed by 10,457 ED physicians. Binary logistic regression was used to analyse the factors associated with occupational injuries. ResultsIn this study, 81.13% of ED physicians reported occupational injuries in the previous 12 months. All participants who had experienced occupational injuries had suffered verbal violence. Among physicians who experienced at least one injury, 76.57% and 71.30% reported injuries sustained while moving patients and from falls, slips, and sprains during office visits, respectively. Occupational injuries were significantly associated with gender, education level, drinking behaviour, sleep quality, the frequency of night shifts per month, self-perceived physician shortage, and work-family conflict. Physicians who experienced effort–reward imbalance were at a higher risk of occupational injury. ConclusionIn China, occupational injuries are common among ED physicians. Individual factors as well as work-related factors are independently linked to occupational injuries. To reduce the rate of occupational injuries among ED physicians, health policymakers and healthcare facility managers should consider multi-injury interventions.

The effectiveness of allied health and nurse practitioner models-of-care in managing musculoskeletal conditions in the emergency department: a systematic review and meta-analysis

BackgroundMusculoskeletal conditions are the most common health condition seen in emergency departments. Hence, the most effective approaches to managing these conditions is of interest. This systematic review aimed to evaluate the effectiveness of allied health and nursing models of care for the management of musculoskeletal pain in ED.MethodsMEDLINE, EMBASE, CINAHL and LILACS databases were searched from inception to March 2023 for published randomised trials that compared the effectiveness of allied health and nursing models of care for musculoskeletal conditions in ED to usual ED care. Trials were eligible if they enrolled participants presenting to ED with a musculoskeletal condition including low back pain, neck pain, upper or lower limb pain and any soft tissue injury. Trials that included patients with serious pathology (e.g. malignancy, infection or cauda equina syndrome) were excluded. The primary outcome was patient-flow; other outcomes included pain intensity, disability, hospital admission and re-presentation rates, patient satisfaction, medication prescription and adverse events. Two reviewers performed search screening, data extraction, quality and certainty of evidence assessments.ResultsWe identified 1746 records and included 5 randomised trials (n = 1512 patients). Only one trial (n = 260) reported on patient-flow. The study provides very-low certainty evidence that a greater proportion of patients were seen within 20 min when seen by a physician (98%) than when seen by a nurse (86%) or physiotherapist (77%). There was no difference in pain intensity and disability between patients managed by ED physicians and those managed by physiotherapists. Evidence was limited regarding patient satisfaction, inpatient admission and ED re-presentation rates, medication prescription and adverse events. The certainty of evidence for secondary outcomes ranged from very-low to low, but generally did not suggest a benefit of one model over another.ConclusionThere is limited research to judge the effectiveness of allied health and nursing models of care for the management of musculoskeletal conditions in ED. Currently, it is unclear as to whether allied health and nurse practitioners are more effective than ED physicians at managing musculoskeletal conditions in ED. Further high-quality trials investigating the impact of models of care on service and health outcomes are needed.

Information and approaches of emergency department physicians in the Cappadocia region regarding the preparation of forensic reports

Aims: Forensic reports; these are physician’s opinion and opinion reports, which are mostly prepared by emergency room physicians regarding the medical conditions of people and reported to the judicial authorities. In this study; it was aimed to examine the attitudes and behaviors of emergency physicians working in the Cappadocia region regarding the preparation of forensic reports. Methods: This cross-sectional study; it was conducted with a survey applied to 73 emergency physicians working in Nevşehir city center and districts. The data was created based on the answers given to this survey form. Results: The majority of physicians participating in the study are general practitioners (87.7%). The average length of service of the participants is 2.3 1.1 years. Most physicians reported that the forensic medicine training they received was insufficient (75.3%). Survey answers of the participants; They were compared in terms of their titles, length of service and forensic medicine training. Conclusion: Regular in-service training should be provided at intervals so that more appropriate forensic reports can be kept and physicians can have more information about the legal part of forensic reports.

The effectiveness of telehealth for chronic neurological disorders in rural or underserved areas

Background The shortage of neurologists in rural areas limits patient access, making it hard for those with neurological conditions to receive timely care. Long travel distances are a barrier, often resulting in worsened health outcomes. The review aims to assess the current landscape of tele-neurology, examining existing services, evaluating patient outcomes, and identifying challenges and legal concerns. Methods This review brings together insights from multiple studies and programs, with a particular focus on initiatives like the clinical video tele-health (CVT) system created by the Veterans Health Administration, allowing neurologists to deliver direct care to veterans. We also look into the web-based tele-stroke program established by the University of South Carolina, enabling neurologists to oversee acute ischemic stroke patients in rural Emergency Departments in collaboration with local ED physicians. Additionally, we explore global partnerships in telemedicine that are being tailored for tele-neurology. Results Tele-neurology has demonstrated significant potential in delivering quality neurological care, resulting in high patient satisfaction and notable time and cost savings. The TRUST-tPA trial established a tele-stroke network connecting ten community hospital emergency rooms to a centralized stroke center, effectively serving patients unable to reach stroke units within the critical 4.5-hour window.

Perspectives of emergency department physicians and nurses on reasons for preventable emergency department visits by patients with cancer

BackgroundPatients with cancer frequently visit the emergency department (ED) for medical care, yet approximately half of ED visits for patients with cancer are thought to be preventable. Preventable ED visits are associated with increased healthcare costs and poor patient experiences and outcomes. The voices of ED providers who work with patients with cancer in their everyday practices have not been solicited as it pertains to preventable visits. ObjectivesThe purpose of this study is to describe the perspectives of ED physicians and nurses on reasons for preventable ED visits by patients with cancer. MethodsA qualitative descriptive design guided the study. We conducted 23 semi-structured interviews with ED physicians and nurses to query them about their perspectives on the reasons for preventable ED visits by patients with cancer. Content analysis was conducted to list and describe the reasons they discussed. ResultsParticipants identified five “medical” and five “non-medical” causes of preventable ED visits. Medical reasons included uncontrolled cancer pain, gastrointestinal symptoms, anemia, fever, and on-going undiagnosed signs and symptoms. Non-medical reasons include patient hesitancy to contact primary care providers, lack of availability or responsiveness of primary providers, lack of access, lack of care coordination, and fears about diagnosis and treatment. ConclusionThe voices of ED providers should be included in discussions about the problem of preventable ED visits by patients with cancer. The reasons supplied by the participants suggest that solutions to the problem will need to occur at the patient, provider, system, and societal levels.

Non-Fatal Strangulation Injuries: Improving Physician Knowledge and Attitudes

Background and Objective:In the emergency department, providers are expected to evaluate patients who have experienced strangulation resulting from sexual assault or interpersonal violence. Non-fatal strangulation can lead to significant injuries, including carotid artery dissection. Given the prevalence of strangulation injuries, providers must feel confident in their decision-making for this population. Previous educational interventions effectively improved provider knowledge of sexual assault and domestic violence patients, however, no studies have been conducted with the goal of improving provider knowledge about strangulation injuries in this population. We aimed to assess and improve emergency department provider knowledge surrounding nonfatal strangulation injuries.&#x0D; Project Methods:Preintervention and postintervention surveys were administered to emergency department physicians and advanced practice providers assessing both provider comfort and knowledge regarding treatment of survivors of sexual assault, domestic violence, and strangulation. Key content areas included: physician comfort in treating sexual assault survivors, understanding of trauma-informed care, satisfaction with prior training regarding nonfatal strangulation, and physician attitudes. 6 vignette-style questions designed to evaluate knowledge in clinical scenarios were also administered. A 15-minute, interactive, educational presentation was administered during the pre-existing departmental meeting. Survey responses were collected via email and data was stored in REDCAP. Preintervention and postintervention results were compared via t-tests.&#x0D; Results:There were 22 pre-intervention and 10 post-intervention responses. Median years of practice were 8. Survey participants tended to rate awareness of imaging recommendations and resources, decisionmaking, history taking, and use of trauma-informed care higher than preintervention participants. Postintervention participants tended to answer more clinical vignettes correctly than preintervention participants.&#x0D; Conclusion and Potential Impact:A 15-minute educational intervention was effective in improving provider knowledge, confidence, and comfort in treating patients who have experienced non-fatal strangulation. In the future, similar interventions may be implemented in other emergency departments to increase awareness about the evaluation and treatment of nonfatal strangulation injuries.

The impact of the COVID-19 pandemic on transfers between long-term care and emergency departments across Alberta

BackgroundLong-term care (LTC) was overwhelmingly impacted by COVID-19 and unnecessary transfer to emergency departments (ED) can have negative health outcomes. This study aimed to explore how the COVID-19 pandemic impacted LTC to ED transfers and hospitalizations, utilization of community paramedics and facilitated conversations between LTC and ED physicians during the first four waves of the pandemic in Alberta, Canada.MethodsIn this retrospective population-based study, administrative databases were linked to identify episodes of care for LTC residents who resided in facilities in Alberta, Canada. This study included data from January 1, 2018 to December 31, 2021 to capture outcomes prior to the onset of the pandemic and across the first four waves. Individuals were included if they visited an emergency department, received care from a community paramedic or whose care involved a facilitated conversation between LTC and ED physicians during this time period.ResultsTransfers to ED and hospitalizations from LTC have been gradually declining since 2018 with a sharp decline seen during wave 1 of the pandemic that was greatest in the lowest-priority triage classification (CTAS 5). Community paramedic visits were highest during the first two waves of the pandemic before declining in subsequent waves; facilitated calls between LTC and ED physicians increased during the waves.ConclusionsThere was a reduction in number of transfers from LTC to EDs and in hospitalizations during the first four waves of the pandemic. This was supported by increased conversations between LTC and ED physicians, but was not associated with increased community paramedic visits. Additional work is needed to explore how programs such as community paramedics and facilitated conversations between LTC and ED providers can help to reduce unnecessary transfers to hospital.

Point-of-Care Cardiac Ultrasound Training Programme: Experience from the University Hospital Hradec Králové.

Point-of-care ultrasound examinations performed by physicians of different specialties are a rapidly growing phenomenon, which has led to a worldwide effort to create a standardised approach to ultrasound examination training. The implementation of emergency echocardiography by noncardiologists is mainly aimed at the standardisation of the procedure, a structured training system, and an agreement on competencies. This article summarises the current training programmes for nonechocardiographers at the University Hospital in Hradec Králové. In cooperation with cardiologists specialised in cardiac ultrasound (ECHO), an extended acute echo protocol dedicated to emergency department physicians was developed and validated in daily practice. According to our retrospective evaluation, after one year of clinical practice, we can confirm that point-of-care ultrasound examinations performed using the standardised limited echo protocol are safe and accurate. The observed concordance with comprehensive ECHO was 78%. This trial is registered with NCT05306730.

Family and emergency physicians' knowledge and attitudes toward organ donation and deemed consent: Human Organ and Tissue Donation Act in Nova Scotia.

To understand Nova Scotian family physicians' and emergency department (ED) physicians' knowledge of, attitudes about, and experience with organ donation and transplantation in the context of the Human Organ and Tissue Donation Act (HOTDA). An electronic, self-administered survey. Nova Scotia. All family physicians and ED physicians practising in Nova Scotia. Demographic characteristics, experience with organ donation and transplantation, knowledge about organ donation and HOTDA, attitudes toward organ donation and HOTDA, and opportunities for and barriers to the implementation of the HOTDA in clinical practice. Survey results were analyzed using descriptive statistics. Overall, 211 family physicians and 73 ED physicians responded to the survey. Most respondents had favourable attitudes around organ donation and most supported a deemed consent model. Nearly three-quarters of family physicians indicated they have a conversation around organ donation only if it is initiated by the patient. In the ED setting, the most common barriers to organ donation and deemed consent were lack of familiarity with the organ donation referral process, refusal of permission from families, and unknown wishes of the deceased. Family physicians and ED physicians had positive attitudes toward organ donation, including high support for a deemed consent model. However, specific knowledge gaps and training topics were identified that should be addressed within the context of this model.

Success of the emergency physician to recognize pathological diffusion-weighted magnetic resonance imaging in acute stroke patients

This study is aimed to evaluate the proficiency of emergency physicians in identifying ischemic strokes via diffusion-weighted magnetic resonance imaging (DW-MRI), and to determine the inter-rater agreement between emergency department (ED) residents and radiologists. The suspected ischemic stroke patients undergoing DW-MRI and not the candidates for thrombolytic therapy were eligible for the study. Diffusion MRI images were evaluated by the on-duty senior ED residents having two or more years in residency program, and a radiologist. Prior to the study, an instructor from radiology department delivered 2-hour theoretical and 2-hour practical lectures to ED physicians on the evaluation of diffusion MRI. A total of 604 patients were included in the study wherein 145 patients (24%) were detected with ischemic areas. The parietal lobe was the most prevalent ischemic area according to ED physicians’ and radiologist’s findings. ED residents and the radiologist had different interpretations for 54 patients. ED physicians ascribed 15 (3.4%) ischemic stroke patients as normal and 39 (23.1%) normal patients as stroke. ED physicians had 89.7% sensitivity (95% confidence interval (CI): 84% to 94%) and 91.5% specificity (95% CI: 89% to 94%) in diagnosing ischemic stroke. A good inter-rater agreement was found between ED physicians and the radiologist with kappa value of 0.77 (95% CI: 0.71 to 0.83). ED physicians have better success rate in interpreting DW-MRI to detect ischemic stroke in non-candidate cases of thrombolytic therapy (cases whose National Institutes of Health Stroke Skale (NIHSS) score is not appropriate, symptom onset exceeds 4.5 hours, and thrombolytic administration is contraindicated). There is a good inter-rater agreement between ED physicians and radiologist.

Accuracy of FAST-ED for Assessment Large Vessel Occlusion of Acute Ischemic Stroke in Emergency Department.

Acute large vessel occlusion stroke (LVOS) requires swift and precise assessment for effective treatment. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) protocol shows promise for rapid LVOS evaluation but lacks extensive validation. This study aims to assess the accuracy of FAST-ED in predicting LVOS and compare its predictive capability with the National Institute of Health Stroke Scale (NIHSS). This prospective cross-sectional study was conducted at Thammasat University Hospital. Participants included those aged 18 years or older who presented with symptoms of acute stroke syndrome within 24 hours of onset. The study focused on comparing FAST-ED assessments by emergency department physicians with NIHSS evaluations by neurologists, followed by vascular imaging, which included brain multiphase CT angiography, MRI with MRA, and transcranial Doppler ultrasound combined with carotid Doppler ultrasound. Statistical analyses included the use of AuROC to assess the effectiveness of FAST-ED and to compare FAST-ED with NIHSS. 130 patients were included in the analysis, with 47 diagnosed with LVOS. No significant differences were found in most baseline characteristics between LVOS and non-LVOS groups, except for a higher prevalence of atrial fibrillation and lower systolic blood pressure in the LVOS group. The FAST-ED scale demonstrated a fair ability to predict LVOS with an AuROC of 0.79 (95% confidence interval (CI); 0.70, 0.87). A FAST-ED cut point of ≥4 showed improved specificity and likelihood ratio. Comparing FAST-ED≥4 with NIHSS≥6 revealed similar AuROC (0.74, 95% CI; 0.65, 0.82 and 0.72, 95% CI; 0.64, 0.80, respectively), with no significant statistical difference (p=0.661). FAST-ED scale, especially with a cut-off point of ≥4, exhibits fair overall accuracy in predicting LVOS in patients who presented with suspected acute stroke within 24 hours at the ED. This predictive capability is closely comparable to that of the NIHSS at a cut-off point of ≥6.

Standardizing Medication Reconciliation in a Pediatric Emergency Department.

Medication errors are common during transitions of care, such as discharge from the emergency department (ED) or urgent care (UC). The Joint Commission has identified medication reconciliation as a key safety practice. Our aim was to increase the percentage of patients with completed medication reconciliation at discharge from our pediatric ED and 4 UCs from 25% to 75% in 12 months. Key stakeholders included ED and UC physicians and nurses, informatics, and quality management. The baseline process for medication reconciliation was mapped and modified to create a standard process for nurses and physicians. An Ishikawa diagram was created to assess potential failures. Electronic health record interventions included adapting an inpatient workflow and using a clinical decision support tool. Educational interventions included just-in-time training, physician education via division meeting presentations, video tutorials, and physician-specific and group feedback using funnel plots. The secondary process measure was the proportion of patients discharged from the ED and UCs with completed home medication nursing review. We used statistical process control to analyze changes in measures over time. In the UCs, home medication nursing review increased from 91% to 98% and medication reconciliation increased from 35% to 82% within 4 months. In the ED, home medication nursing review increased from 2% to 83% within 8 months and medication reconciliation increased from 26% to 64% within 18 months. We successfully increased the proportion of UC and ED discharged patients with completed medication reconciliation.