Attending Emergency Physicians Research Articles

Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department

BackgroundBariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. MethodsWe conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. ResultsWe included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). ConclusionThis is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

Emergency physician resource utilization varies by years of experience.

One of the most pivotal decisions an emergency physician (EP) makes is whether to admit or discharge a patient. The emergency department (ED) work-up leading to this decision involves several resource-intensive tests. Previous studies have demonstrated significant differences in EP resource utilization, measured by lab tests, advanced imaging (magnetic resonance imaging [MRI], computed tomography [CT], ultrasound), consultations, and propensity to admit a patient. However, how an EP's years of experience may impact their resource utilization and propensity to admit patients has not been well characterized. This study seeks to better understand how EPs' years of experience, post-residency, relates to their use of advanced imaging and patient disposition. Ten years of ED visits were analyzed for this study from a single, academic tertiary care center in the urban Northeast United States. The primary outcomes were utilization of advanced imaging during the visit (CT, MRI, or formal ultrasound) and whether the patient was admitted. EP years of experience was categorized into 0-2years, 3-5years, 6-8years, 9-11years, and 12 or more years. Patient age, sex, Emergency Severity Index (ESI), and the attending EP's years of experience were collected. The relationship between EP years of experience and each outcome was assessed with a linear mixed model with a random effect for provider and patient age, sex, and ESI as covariates. A total of 460,937 visits seen by 65 EPs were included in the study. Over one-third (37.6%) of visits had an advanced imaging study ordered and nearly half (49.5%) resulted in admission. Compared to visits with EPs with 0-2years of experience, visits with EPs with 3-5 or 6-8years of experience had significantly lower odds of advanced imaging occurring. Visits seen by EPs with more than 2 years of experience had lower odds of admission than visits by EPs with 0-2years of experience. More junior EPs tend to order more advanced imaging studies and have a higher propensity to admit patients. This may be due to less comfort in decision-making without advanced imaging or a lower risk tolerance. Conversely, the additional clinical experience of the most senior EPs, with greater than 9years of experience,likely impacts their resource utilization patterns such that their use of advanced imaging does not significantly differ from the most junior EPs.

Ultrasound Performed by Emergency Physicians for Deep Vein Thrombosis: A Systematic Review.

Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of lower extremity deep vein thrombosis (DVT). Systematic reviews suggested good sensitivity and specificity overall for EP-performed POCUS for DVT diagnosis, yet high levels of heterogeneity were reported. In this systematic review and meta-analysis, we aimed to provide the most up-to-date estimates of the accuracy of EP-performed POCUS for diagnosis of DVT and to explore potential correlations with test performance. We performed systematic searches in MEDLINE and Embase for original, primary data articles from January 2012-June 2021 comparing the efficacy of POCUS performed by EPs to the local standard. Quality Assessment of Diagnostic Accuracy Studies-2 for individual articles are reported. We obtained summary measures of sensitivity, specificity, and their corresponding 95% confidence intervals (CI) using bivariate mixed-effects regression models. We performed meta-regression, subgroup, and sensitivity analyses as planned in the protocol CRD42021268799 submitted to PROSPERO. Fifteen publications fit the inclusion criteria, totaling 2,511 examinations. Pooled sensitivity and specificity were 90% (95% CI 82%-95%) and 95% (CI 91%-97%), respectively. Subgroup analyses by EP experience found significantly better accuracy for exams performed by EP specialists (93%, CI 88%-97%) vs trainees (77%, CI 60%-94%). Specificity for EP specialists (97%, CI 94%-99%) was higher than for trainees (87%, CI 76%-99%, P = 0.01). Three-point compression ultrasound (CUS) was more sensitive than two-point CUS but was only statistically significant when limited to EP specialists (92% vs 88%, P = 0.07, and 95% vs 88%, P = 0.02, respectively). Point-of-care ultrasound performed by emergency physicians is sensitive and specific for the diagnosis of suspected DVT when performed by trained attending EPs. Three-point compression ultrasound examination may be more sensitive than two-point CUS.

Abstract WP72: National Assessment of Trainee and Non-Vascular Neurology Acute Stroke Decision-Making at StrokeNet Regional Coordinating Centers

Background: The impact of acute stroke treatment changes, including development of Vascular Neurology, advances in neuroimaging, and endovascular treatment (EVT), on stroke team trainee utilization and decision-making are unknown. For insight into high-performance teams, we surveyed StrokeNet Regional Coordinating Centers (RCCs). Methods: A confidential, self-administered, pilot-tested survey was distributed to the site PIs of all 27 StrokeNet RCCs. The survey assessed in-person acute stroke response staffing, involvement of trainees, decisional autonomy, and attitudes regarding decision-makers. Absent data fields excluded. Descriptive statistics presented. Results: 18 of 27 RCCs completed the survey (gross response rate 66%). 67% (12/18) reported trainees (Resident and/or Fellow) always respond to ED and inpatient activations and 39% (7/18) that trainees always respond to EVT activations. 44% (7/16) and 27% (4/15) reported Nurse Practioner (NP) and Physician Assistant (PA) involvement in ED stroke responses, respectively. Thrombolytic decision-making authority (prior to attending staffing) rested with Fellows and Residents in 61% (11/18) and 18% (3/17), respectively. No NP or PA independent use was identified (0%). 89% (16/18) reported attending Emergency Physicians did not order thrombolytics prior to stroke team consultation. Apart from Vascular Neurology, which was universally acceptable, acceptability by attending specialty for thrombolytic ordering was: Emer Med (88%), Gen Neurology (75%), Neurosurgery (33%), Fam Med (12%), Int Med (11%) and Radiology (6%). Acceptability for EVT decisions was Neurosurgery (94%), Gen Neurology (59%), Radiology (50%), Emer Med (44%), Fam Med (12%) and Int Med (11%). Conclusions: At StrokeNet RCCs, acute stroke teams have significant trainee involvement in both ED and inpatient acute stroke responses and allow trainees significant autonomy. Stroke team involvement likely occurs early in the ED, as few reported attending emergency physicians ordering thrombolytics prior to consultation. Respondents varied in acceptability of different specialties as decision-makers for both thrombolytics and EVT. These findings have potential workforce, education, and training implications.

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine.

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Impact of an Institutional Clinical Pathway on Emergency Physicians' Stated Preferences in Treating Patients with Low-Risk Pulmonary Embolism.

Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool. We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway. Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE. Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

Comparing Direct and Video Laryngoscopy Skills Between Resident and Attending Emergency Physicians.

Introduction Advances in airway technology, in particular video laryngoscopy, are forcing attending emergency medicine physicians to master and maintain innovative airway skills. This study compares intubation times and other airway outcomes between resident and attending physicians using direct and video laryngoscopy in a mannequin model. Methods Fifty emergency medicine resident and attending physicians were asked to intubate a mannequin, using direct laryngoscopy, a C-MAC standard geometry blade, and a GlideScope hyperangulated blade. Intubation times, intubation success and accuracy, Cormack-Lehane grades, and the physician's opinion of the ease of the intubation were recorded for each intubation. Results Second-year residents had significantly quicker intubation times than attending physicians with all 3 intubation modalities. They also outperformed the interns when using the C-MAC standard geometry blade and had faster intubation times compared to third-year residents using direct laryngoscopy. When using the GlideScope hyperangulated blade, all 3 years of residents had lower intubation times compared to attending physicians and they were more accurate with endotracheal tube placement. Unlike the second-year residents, the third-year residents were not faster at direct laryngoscopy compared to the attending physicians. Conclusion Second-year residents outperformed their resident counterparts and the attending physicians with improved intubation times. Nontraditional intubation techniques associated with the GlideScope hyperangulated blade must be learned, practiced, and maintained by attending physicians, which is reflected in their longer intubation times compared to the residents. In addition, DL skills can deteriorate among resident physicians if they are not used on a regular basis.

A case for lifelong learning in emergency medicine: The perspective from a rural state.

The expansive practice of emergency medicine cannot be fully taught or learned in 3 or 4 years. Lifelong learning, self-assessment,1 and ongoing skill acquisition and retention are necessary. How do we teach and acknowledge this during residency training and how do we support our isolated, rural colleagues? Importantly, there is a growing shortage of rural emergency physicians and many of our trainees may work in these environments.2 As educators, we must study potential solutions and bridge these gaps for our trainees entering independent practice and for our colleagues far removed from formal training. Recent cases, and many like them, illustrate this point. A rural emergency physician expertly places a small-bore chest tube for an atraumatic pneumothorax, the pneumothorax resolved, they requested transfer to a larger center for ongoing management. The tertiary care center is at full capacity. A phone consultation with a specialist recommends removal of the chest tube in the emergency department (ED) and discharge home if a follow up chest x-ray shows sustained resolution. The emergency physician has never removed a chest tube before and the patient is transferred to a larger regional ED for uncomplicated removal. In a second case, a patient is transferred from an hour away, during a snowstorm, for a peritonsillar abscess. The procedure is within an emergency physician's scope of practice. The referring physician had never performed this procedure in their decades of practice. The patient is transferred to the tertiary care center where it is drained by the attending emergency physician and emergency medicine resident. On a winter night, an emergency physician intubates a patient with a head injury in their critical-access emergency department. They request lifesaving medications and the respiratory therapist to set the ventilator. It is nighttime; there is no respiratory therapist or pharmacist. The physician must assist in mixing the medications and setting up the ventilator. The skills required for an emergency physician are ever expanding, particularly as access to tertiary care becomes more difficult. Lifelong learning and practice development to best serve our patients is a necessity in our specialty. Solutions may include regional conferences, collaborative case reviews, real-time peer-based decision support with telemedicine, maintenance of board certification, asynchronous, self-directed learning through free open-access medical education (FOAM), podcasts, textbooks or journal articles, and academic–rural partnerships that create shared faculty positions between rural and tertiary sites and rural rotations for trainees. Each of these has its limitations and time represents a major barrier.3-5 The American Board of Emergency Medicine requires continuous learning for maintenance of certification; this is beneficial but is not tailored to the physician's practice environment.6, 7 Our own work in the rural state of Vermont and upstate New York has led us to offer high-acuity, low occurrence (HALO) courses at the regional academic center twice a year for both residents and practicing emergency physicians within our region and create a rural-specific simulation lab at one of our critical-access sites. Additionally, we established a tele-emergency medicine program to offer a virtual resource from the tertiary care center in times of high-acuity, high-complexity care, or volume surge. The skill of delivering and accepting tele-emergency medicine assistance must also be learned and taught. Our education must continue to adapt to meet the needs of our unique and evolving practice environments. We must also acknowledge that many scenarios cannot be predicted. Instilling the motivation for lifelong learning, self-assessment1 and exposure to resource limited settings during training may help prepare trainees for these challenges. Although these issues are not unique to emergency medicine, we are a specialty that prides itself on adaptability. We must confront this challenge with creative solutions. Skyler Lentz, Ashley Weisman, Jordan Ship, and Matthew S. Siket conceived the idea for this manuscript and contributed substantially to the content, design, writing and editing of the commentary. The authors declare no conflicts of interest.

Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care

BackgroundGuidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations. ObjectiveWe sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians. MethodsThis was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering. ResultsAmong 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99–12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08–3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51–0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62–0.91) or no insurance (OR 0.54; 95% CI 0.35–0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period. ConclusionsAn ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

Impact of acute intoxication on quantitative pupillometry assessment in the emergency department.

Study Hypothesis/ObjectiveThis prospective cohort study aimed to assess whether and to what extent different quantitative pupillometry (QP) metrics are associated with different intoxicant drug classes as well as investigate the potential benefit of QP as a tool in the rapid assessment of clinically intoxicated patients in the emergency department (ED).MethodsBetween February 25, 2019 and April 24, 2021, 325 patients were enrolled in the EDs of the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC). Patients deemed clinically intoxicated or in withdrawal by an attending emergency physician were considered for eligibility. Patients <18 years old, with a chief complaint indicative of head trauma or stroke or without a urine drug screen (UDS) positive for drugs of abuse were excluded. QP data were also collected from a cohort of 82 healthy control subjects.ResultsNeurological Pupil index (NPi) values did not vary significantly between control and study groups nor between study group patients with a UDS positive for opioids. With exception of latency of constriction, all other QP metrics for the study group were depressed relative to controls (P < 0.005).ConclusionsThis work demonstrated the feasibility of QP measurement in the ED, finding that NPi remains unaffected by clinical intoxication and therefore can potentially be used for ED patient evaluation without risk of confounding by key intoxicants of abuse. Future work will evaluate the value of QP as a means of rapid and reproducible neurological assessment to identify various pathologies.

Medication-induced hospitalization and clinical pharmacists role regarding, at an al-Basra teaching hospital in Iraq

Study objective: Our objective is to determine the proportion of medication-related problems that lead to patient admission, such as drug interactions, side effects, and drug abuse. The study also aims to evaluate the significance of the clinical pharmacist's contribution to patient care and follow-up regarding the appropriate use of safe and effective treatments. Methods: This study was conducted at al Basra Teaching Hospital. All 115 patients with drug-related hospitalization (DRH) who were admitted between May 1 and June 30, 2022, were included in the study. The patients' ages ranged from 35-75 years, with a median of 52 ±3.5 years. Hospitalized patients’ due to drug-related reasons are as follows: Approximately 32% of cases are antibiotics, 20% are cardio-logical cases, 7.8% are diabetic cases, 13% are monoclonal antibody therapies, 7.8% are NSAIDs, and 19% are other cases. One of three clinical pharmacists with residency training and the attending emergency physician assessed each enrolled patient for the existence or absence of an adverse drug event resulting in hospitalization. Clinical pharmacists collected data on the patient's medication usage, medical history, previous allergies and intolerances, and the complaint they were presenting with.

Training to Enhance the Knowledge and Comfort Level of Emergency Physicians Providing Care for Survivors of Sexual Assault.

Although sexual assault (SA) is a substantial public health problem, emergency physicians do not universally undergo continuing education on caring for survivors of SA. The goal of this intervention was to develop a training course that improves physician understanding of trauma-sensitive care in the emergency department and equips physicians with knowledge of the specialized care required to treat SA survivors. Thirty-nine attending emergency physicians underwent a 4-hour training on trauma-sensitive care for survivors of SA and completed prequestionnaires and postquestionnaires to assess training efficacy in improving knowledge base and comfort level providing care. The training consisted of didactic portions focused on the neurobiology of trauma, communication skills, and forensic evidence collection techniques and a simulation portion with standardized patients to practice evidence collection and a trauma-sensitive anogenital examination. Physicians demonstrated significantly improved performance (P < .05) on 12 of 18 knowledge-based questions. Physicians also showed significant improvement (P < .001) on 11 of 11 Likert scale questions that assessed comfort level communicating with survivors and using trauma-sensitive techniques during medical and forensic examinations. Physicians who received the training course demonstrated a significantly improved knowledge base and comfort level treating survivors of SA. Considering the prevalence of sexual violence, it is imperative that physicians are appropriately educated on trauma-sensitive care.

Bronchoscopy in the emergency department

BackgroundFlexible bronchoscopy has been safely used for decades in ambulatory and critical care settings to aid in the diagnosis and treatment of tracheobronchial tree disorders. Although emergency physicians have the requisite skills to operate and interpret flexible bronchoscopy, no reports exist on the use of bronchoscopy by emergency physicians apart from endotracheal tube placement and confirmation. ObjectiveThe primary goal of this study was to describe the indications, outcomes and complications of flexible bronchoscopy performed by emergency physicians in an urban academic emergency department. MethodsThis was a single-center retrospective cohort study involving chart and video review of 146 patients over a 10.5-year study period. Patients of any age were included if they had been tracheally intubated or mechanically ventilated and underwent flexible bronchoscopy in the emergency department. After patients were identified, manual chart and video review was used to collect data on patient demographics, indications for intubation, indications for bronchoscopy, details of the bronchoscopy procedure, procedural findings, outcomes of the procedure, complications, provider training levels, and additional bronchoscopies performed after admission. The data was analyzed using descriptive statistics. Results146 patients were included in the study and all bronchoscopies were performed or supervised by attending emergency physicians. After bronchoscopy, 24% of patients displayed improvement in oxygenation or lobar collapse while most patients had no change in clinical status. One patient had temporary hypoxemia after bronchoscopy. When another physician performed a subsequent bronchoscopy during admission, the findings were in agreement with the ED bronchoscopy 86% of the time. ConclusionAt our institution, emergency physicians can safely and effectively use flexible bronchoscopy to diagnose and treat critically ill patients.

Rapid deployment of a virtual simulation curriculum to prepare for critical care triage during the COVID-19 pandemic.

BackgroundDuring the COVID-19 pandemic in Ontario, Canada, an Emergency Standard of Care for Major Surge was created to establish a uniform process for the “triage” of finite critical care resources. This proposed departure from usual clinical care highlighted the need for an educational tool to prepare physicians for making and communicating difficult triage decisions. We created a just-in-time, virtual, simulation-based curriculum and evaluated its impact for our group of academic Emergency Physicians.MethodsOur curriculum was developed and evaluated following Stufflebeam’s Context-Input-Process–Product model. Our virtual simulation sessions, delivered online using Microsoft Teams, addressed a range of clinical scenarios involving decisions about critical care prioritization (i.e., Triage). Simulation participants completed a pre-course multiple-choice knowledge test and rating scales pertaining to their attitudes about using the Emergency Standard of Care protocol before and 2–4 weeks after participating. Qualitative feedback about the curriculum was solicited through surveys.ResultsNine virtual simulation sessions were delivered over 3 weeks, reaching a total of 47 attending emergency physicians (74% of our active department members). Overall, our intervention led to a 36% (95% CI 22.9–48.3%) improvement in participants’ self-rated comfort and attitudes in navigating triage decisions and communicating with patients at the end of life. Scores on the knowledge test improved by 13% (95% CI 0.4–25.6%). 95% of participants provided highly favorable ratings of the course content and similarly indicated that the session was likely or very likely to change their practice. The curriculum has since been adopted at multiple sites around the province.ConclusionOur novel virtual simulation curriculum facilitated rapid dissemination of the Emergency Standard of Care for Major Surge to our group of Emergency Physicians despite COVID-19-related constraints on gathering. The active learning afforded by this method improved physician confidence and knowledge with these difficult protocols.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43678-022-00280-6.

Cognitive load and processes during chest radiograph interpretation in the emergency department across the spectrum of expertise.

In the emergency department (ED), chest radiographs (CXRs) provide essential information for clinical diagnostic reasoning. Errors in interpretation by emergency physicians can lead to negative patient outcomes. To aid in teaching this important skill, an understanding of cognitive processes and cognitive load (CL) in CXR interpretation in emergency medicine (EM) personnel is warranted. This study adopted a concurrent mixed-methods research design. Participant groups included medical students (M), junior (J) and senior (S) EM residents, and attending emergency physicians (P) in the ED at an academic hospital. To elucidate cognitive processes, a real-time cognitive task analysis during CXR interpretation was performed. Interviews were audio recorded, transcribed verbatim, and analyzed thematically. The interview was followed by a questionnaire, where participants rated their CL, stress, and confidence level. Levels of CL (M vs. S and M vs. P, p=0.002; J vs. S, p=0.004; J vs. P, p=0.005) and stress (J vs. P, p=0.002) decreased, while confidence levels increased (M vs. S, p=0.006; J vs. S, p≤0.001; J vs. P, p=0.003) as experience level increased. Qualitative analysis of interviews revealed four themes: checking behavior, information reduction, pattern recognition versus systematic viewing, and recognizing scope of practice. Experts commonly utilized checking behavior (e.g., comparison to prior radiographs) and deprioritized task irrelevant data. Experts used a general overview technique as their initial approach as opposed to a systematic viewing approach, and they more readily recognized an EM physicians' scope of practice in this task. This study characterized differences in cognition that led to increased CL, stress, and lower level of confidence in EM learners during CXR interpretation and provided insight into expertise development in this important skill.

57 EMBED: A Pragmatic Trial of User-Centered Clinical Decision Support to Implement EMergency Department-Initiated BuprenorphinE for Opioid Use Disorder

Emergency departments (ED) are a critical access point for individuals with opioid use disorder (OUD). Medications for OUD decrease: (1) mortality after nonfatal overdose, (2) withdrawal symptoms, (3) craving, and (4) illicit opioid use. Buprenorphine (BUP) can be safely initiated in the ED and increases retention in outpatient treatment programs. Adoption of ED-initiated BUP has been slow due to lack of physician knowledge, experience, and time. The study objective was to determine the effect of a user-friendly clinical decision support system (CDS) on rates of ED-initiated BUP in the routine emergency care of individuals with OUD. A parallel group randomized pragmatic trial was conducted in 18 EDs across 5 health care systems in the United States. The EMBED intervention is a user-centered, physician-facing CDS system integrated into the electronic health record (EHR) to facilitate ED-initiation of BUP by: (1) determining a diagnosis of OUD, (2) assessing withdrawal severity, (3) motivating patients to accept treatment, and (4) automating EHR workflow including clinical and after visit documentation, order entry, prescribing, and referral. EDs were randomly allocated to the intervention versus usual care using stratified covariate constrained randomization of clusters to arms with a ratio of 1:1. Constraining covariates included EHR vendor, patient volume, practice setting, ongoing resources for OUD patients, and proportion of attending physicians waivered to prescribe BUP. Participants included adult ED OUD patients meeting a predetermined EHR phenotype for OUD and the attending emergency physicians caring for them. Control site visits associated with attending physicians who practiced at both intervention and control sites were excluded. The primary outcome was the rate of ED-initiated BUP (administration or prescription of BUP). Implementation outcomes as compared to usual care were measured using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. 354, 800 ED visits (166, 184 intervention and 188, 616 control) from November 2019-March 2021 were assessed for eligibility. Overall, 4, 561 OUD patients (2, 457 intervention, 2, 104 controls) under the care of 607 attending physicians (335 intervention, 272 controls) were included in the analysis. Among these patients, 33% and 36% were female and the mean age (SD) was 39.4 y (13.3) and 38.5 y (13.0) in the intervention and control groups, respectively. Though the analysis is not complete at this time, full results are forthcoming and will be available in advance of the ACEP21 Research Forum. This pragmatic trial involving patients with OUD will report the effect of a user-centered CDS system that automates EHR workflow to initiate BUP in the ED.

149 Examining the Relationship Between Markers of Emergency Department Crowding and Physician Wellbeing

Literature on emergency department (ED) crowding and boarding has primarily focused on adverse patient outcomes including increased patient mortality, and longer hospital length-of-stay. Few studies have explored relationships between ED crowding, boarding and physician wellbeing (burnout, professional satisfaction) despite evidence demonstrating that EM specialists are consistently among those with the highest rates of burnout. Therefore, we sought to evaluate the relationships between markers of ED crowding and boarding and physician wellbeing. Data for this prospective, observational study were collected from resident and attending emergency physicians employed at our Level-I, tertiary care referral center ED. Participants completed the 7- item Physician Well-Being Index (PWBI) twice weekly for three months following clinical shifts. The PWBI assesses physician distress across several dimensions using a score from 0 to 7 and has previously demonstrated validity with similar physician groups. For the same period, we collected markers of ED crowding and boarding: ED volume, numbers of arriving and boarding patients by shift, and average census by shift. Generalized Estimating Equations (GEE) analyses were performed to examine relationships between ED crowding and boarding markers and physician PWBI scores. Hierarchical regression models were constructed to control for the potentially confounding effects of the day of the week, shift type, and provider role (resident/attending). 42 emergency physicians (18 (43%) resident, 24 (57%) attending) participated in the study, providing 273 PWBI assessments. Data for 4, 318 ED patient encounters were summarized for the same period. Mean PWBI scores were 2.3 (SD 1.53, 95% CI: 2.1-2.5); no significant differences between the resident and attending groups were noted (2.0, ±1.50, 95% CI: 1.5-2.6 vs. 2.5, ±1.52, 95% CI: 1.9-3.0, respectively). After adjusting for the effects of day of week, shift type, and provider role, we did not observe statistically significant relationships between PWBI scores and count of arrivals in 24 hours (b=-0.089, SE=0.0593, CI: -0.206-0.027, p=0.133), patient arrivals by shift (b=-0.006, SE=0.013, CI: -0.031-0.02, p=0.667), average census by shift (b=0.004, SE=0.019, CI: 0.041-0.047, p=0.829), or average boarding census by shift (b=-0.161, SE=0.1051, CI: -0.367-0.045, p=0.127). In this study, ED crowding and boarding were not significantly related to physician wellbeing, as measured by the PWBI. Findings suggest further research is needed to validate the PWBI in capturing ED physician wellbeing during periods of ED crowding and boarding. Next steps are to explore the relationships between individual dimensions of wellbeing (fatigue, mental quality of life) and ED busyness, given the important impact of dimensions of burnout on care team wellbeing and patient outcomes.

Novel cricothyrotomy assessment tool for attending physicians: A multicenter study of an error avoidance checklist.

This study used existing literature and expert feedback to develop and pilot a novel error-avoidance checklist tool for cricothyrotomy in attending physicians. Prior literature has not focused on expert cricothyrotomy performance. While published checklists teach a specific procedural method, ideal for novice learners, this may hinder expert learners. We endeavored to create a succinct error-avoidance checklist for cricothyrotomy. We hypothesized that such a checklist would prove feasible and acceptable to attending physicians. This is a multicenter prospective checklist creation, evaluation, and feasibility study. Multiple experts pursued an iterative process to reach consensus on a 7-item error-avoidance checklist. The checklist was trialed for feasibility in pilot sessions at two sites by 45 attending emergency physicians who used the checklist for peer performance assessment and provided feedback. During the pilot implementation, 94% of respondents completed the procedure within the allotted 120s. Greater than 85% of respondents agreed that four of the five procedural errors on the checklist were very or somewhat critical to avoid, including cutting >2cm from midline, creating a false passage, failing to continuously maintain an object in the trachea, and injuring oneself during the procedure. Only 66% of participants felt severing the cricoid cartilage was critical. Successful breath administration and time under 120s were critical for 100% and 95% of participants, respectively. The checklist was rated "easy" or "very easy" to use by 93% of participants, and 95% found this checklist reasonable for evaluating attending physicians. We present the multicenter development and implementation of a novel error-avoidance checklist tool for use in expert cricothyrotomy performance. Attending emergency medicine (EM) physicians rated our tool easy to use and agreed that most of the proposed errors were critical. Participants overwhelmingly agreed this tool would be reasonable for evaluation of cricothyrotomy performance among attending EM physicians.

Contribution of lung ultrasound in diagnosis of community-acquired pneumonia in the emergency department: a prospective multicentre study

Lung ultrasound (LUS) can help clinicians make a timely diagnosis of community-acquired pneumonia (CAP).ObjectivesTo assess if LUS can improve diagnosis and antibiotic initiation in emergency department (ED) patients with suspected...

An exploratory investigation of the measurement of cognitive load on shift: Application of cognitive load theory in emergency medicine.

Emergency physicians often experience a high cognitive load (CL) due to the inherent nature of working in acute care settings. CL has traditionally been measured in educational studies but has not been well studied in the clinical environment. Emergency medicine attending physicians and residents working in an academic urgent care center completed psychometric questionnaires while on shift to measure overall CL, intrinsic cognitive load (ICL), extraneous cognitive load (ECL), and acute stress. Data regarding the patient load, patient acuity, and the number of patients in the waiting room were also collected. Correlational analysis and simple linear regression were used to evaluate predictors of CL on shift. Forty-two questionnaires were completed (26 by attending physicians, 16 by residents). Attending physicians carried a significantly higher patient load compared to residents (p<0.001). No differences in mean overall CL, ICL, ECL, and acute stress were observed between attending physicians and residents. Bivariate analysis demonstrated associations between ICL, ECL, acute stress, and overall CL in attending physicians. In residents, acute stress was the only variable associated with overall CL and the number of high-acuity patients was associated with ICL. Factors influencing reported CL during clinical work are different between attending emergency physicians and residents. Further study to appreciate the impact of these differences is required and may help educators elucidate strategies to better manage CL, thereby improving clinical performance and potentially improving patient care.