Emergency Department Medical Directors Research Articles

A National Study of Expedited Partner Therapy Use in Emergency Departments: A Survey of Medical Director Knowledge, Attitudes, and Practices.

Emergency departments (EDs) are the primary source of health care for many patients diagnosed with sexually transmitted infections (STIs). Expedited partner therapy (EPT), treating the partner of patients with STIs, is an evidence-based practice for patients who might not otherwise seek care. Little is known about the use of EPT in the ED. In a national survey, we describe ED medical directors' knowledge, attitudes, and practices of EPT. A cross-sectional survey of medical directors from academic EDs was conducted from July to September 2020 using the Academy of Academic Administrators of Emergency Medicine Benchmarking Group. Primary outcomes were EPT awareness, support, and use. The survey also examined barriers and facilitators. Forty-eight of 70 medical directors (69%) responded. Seventy-three percent were aware of EPT, but fewer knew how to prescribe it (38%), and only 19% of EDs had implemented EPT. Seventy-nine percent supported EPT and were more likely to if they were aware of EPT (89% vs. 54%; P = 0.01). Of nonimplementers, 41% thought EPT was feasible, and 56% thought departmental support would be likely. Emergency department directors were most concerned about legal liability, but a large proportion (44%) viewed preventing sequelae of untreated STIs as "extremely important." Emergency department medical directors expressed strong support for EPT and reasonable levels of feasibility for implementation but low utilization. Our findings highlight the need to identify mechanisms for EPT implementation in EDs.

Preventive Cardiovascular Care for Hypercholesterolemia in US Emergency Departments: A National Missed Opportunity.

Hypercholesterolemia (HCL) affects nearly half of Emergency Department (ED) patients who present with possible acute coronary syndrome (ACS). However, it is unknown whether US ED providers obtain lipid panels, calculate 10-year atherosclerotic cardiovascular disease (ASCVD) risk, and prescribe cholesterol-lowering medications for these patients. We conducted a nationwide cross-sectional ED survey from April 18, 2023, to May 12, 2023. An electronic survey assessing current preventive HCL care practices for patients being evaluated for ACS. A convenience sample was obtained by sharing the survey with ED medical directors, chairs, and senior leaders using emergency medicine professional organization listservs and snowball sampling. Responding EDs were categorized as being associated with an academic medical center (AMC) or not (non-AMC). During the 4-week study period, 110 EDs (50 AMC and 60 non-AMC EDs) across 39 states responded. Just 1.8% (2/110) stated that their providers obtain a lipid panel on at least half of patients with possible ACS and only one ED (0.9%) responded that its providers calculate 10-year ASCVD risk and prescribe cholesterol medication for the majority of eligible patients. Most reported never obtaining lipid panels (60.9%, 67/110), calculating 10-year ASCVD risk (55.5%, 61/110), or prescribing cholesterol-lowering medications (52.7%, 58/110). The vast majority of US ED providers do not provide preventive cardiovascular care for patients presenting with possible ACS. Most ED providers do not evaluate for HCL, calculate ASCVD risk, or prescribe cholesterol-lowering medications for these patients.

Impact of a 1-Year Pediatric Emergency Medicine Training Program for International Medical Graduates.

The Hospital for Sick Children in Toronto has offered a 1-year subspecialty residency training program in pediatric emergency medicine (PEM) to Canadian and internationally trained pediatricians and emergency physicians since 1993. The program is intended to support clinical service delivery while simultaneously offering a unique educational opportunity to Canadian and international physicians who desire 1 year of clinically focused training. We describe the experiences and career outcomes of participants who completed this program. Two surveys were sent to the 68 individuals who completed the clinical fellowship program from its inception in 1993 until 2014. A blinded survey focused on the fellowship experience and subsequent career activities. A nonblinded survey subsequently determined whether participants had served as a medical director or training program director. Sixty of the 68 participants (88%) completed the blinded survey. Ninety-one percent were in practice in emergency medicine. Twenty-five percent of the participants were living in Canada, compared with 17% before completing the program. This net migration of 8% was not significant (P = 0.26). Thirty-six of the 50 participants (72%) who applied from outside Canada responded to the nonanonymous survey; 18 (50%) had served as an emergency department medical director, and 18 (50%) reported serving as a PEM training program director. Many participants attained leadership positions in PEM in countries outside of North America and/or participated in training program development. There was no significant change in the proportion of participants living in North America at the time of application compared with the time of survey completion.

Access to Point-of-Care Ultrasound in Maine Emergency Departments

Introduction: Point-of-care ultrasound (POCUS) is an essential tool in emergency medicine. We evaluated access to bedside ultrasound machines and characterized POCUS use in Maine emergency departments (EDs). Methods: We conducted a cross-sectional electronic survey of all ED medical directors in Maine. The survey included questions on ED characteristics, access to ultrasound machines, POCUS use patterns, POCUS administration, and barriers to use. Results: Thirty-four EDs were identified, and 24 medical directors completed the survey, yielding a response rate of 71%. EDs were predominantly small and rural. Only 21% identified as urban, and 54% reported less than 20 000 annual visits. Surveys showed that 88% of EDs had immediate access to a bedside ultrasound machine in the ED. Also, 76% used ultrasound guidance to place more than 75% of internal jugular central venous catheters, while 24% used ultrasound to place less than 10% of catheters. Of EDs with ultrasound access, 90% had hospital privileges for providers, 71% had a credentialing process, 52% had quality assurance processes, and 48% had a designated ultrasound director. Discussion: Compared to other states, Maine EDs were lower-volume and more rural but had similar access to ultrasound machines. Previous studies showed poor adherence to national guidelines for ultrasound quality assurance practices and provider credentialing. Our results demonstrate that this issue is ongoing. Conclusions: Maine’s predominantly rural EDs have excellent access to ultrasound machines. Areas for improvement in POCUS use and administration were identified, including enhancing quality assurance practices, boosting provider credentialing, and increasing the use of ultrasound guidance for vascular access.

Abstract 13118: The Use of Automated Daily Reporting Improves Utilization of the HEART Score in Evaluation of Patients With Chest Pain in the Emergency Department

Introduction: Despite the proven effectiveness of the HEART Score in discriminating the need for further observation versus discharge of patients presenting to the Emergency Department (ED) for evaluation of chest pain, utilization rates remain low in many institutions. One reason frequently cited for failure to use this tool is concern by the ED providers that discharged patients will not receive appropriate follow-up. Hypothesis: We hypothesized that the use of a simple daily report (DR) of treated patients would improve utilization rates of the HEART score, and allow for close follow-up of patients discharged from the ED. Methods: We created an electronically-generated report which listed all patients presenting to the ED with a complaint of chest pain in a community hospital, along with their HEART score, and their admission or discharge status. The report was provided on a daily basis to the ED medical director, who could provide counseling to providers who were not utilizing the HEART score regularly, and to case management, who could contact each discharged patient to assess their clinical status and ensure that they had appropriate follow-up plans. Results: Baseline utilization of the HEART Score in chest pain patients (n=305) over a 4 month period prior to the use of this DR was 51.8%. After instituting the DR, utilization rose to 66% (n=339 patients) over the next four months (p=0.0003). Furthermore, correlation of the numbers of ER discharges vs. patients kept for observation or admitted continued to correlate well with the calculated HEART score. Conclusions: The use of a simple DR significantly increased the utilization of the HEART score in the ED of a community hospital to identify patients who could be discharged safely, versus those who required further observation or admission.

Assessment of Prehospital Management of Patients Transported to a Thai University Hospital

Objective: To assess the quality of prehospital care given to patients transported to a Thai university hospital.   Methods: This prospective observational study collected data from EMS providers who transported patients to Siriraj Hospital during August 2017 to November 2017. Collected data was evaluated by at least 2 EMS medical directors for appropriateness of EMS dispatch and prehospital care. The primary outcome was to determine the quality of prehospital management among patients transported by EMS. Inter-rater variability in the evaluation of patient care between EMS medical directors and medical providers in the emergency department (ED) was performed using Cohen’s kappa coefficient, with a value lower than 0.7 indicating significant variability.Results: Data was collected from 246 EMS providers that transported patients to our center. Evaluation by EMS medical directors found EMS dispatch to be appropriate in 216 cases (87.8%), and patient management to be appropriate in 198 cases (80.5%). Inappropriate prehospital management was found most often in patients who presented with out-of-hospital cardiac arrest (OHCA) (87.5%), and with chest pain (63.6%). Medical providers in the ED rated prehospital management to be appropriate in 93.1% of cases. Cohen’s kappa coefficient between EMS medical directors and ED providers was 0.2, which indicates significant variability between the two groups of assessors.Conclusion: Quality assessment of the Thai EMS system revealed opportunities for improvement in prehospital management of patients dispatched by Thai EMS. Moreover, this study found variability in the evaluation of prehospital care between medical providers at the ED and EMS medical directors. Information from this study will help to influence and guide improvement in prehospital patient care in Thailand.

Pediatric Trauma Readiness: A Trauma-Specific Assessment to Complement the National Pediatric Readiness Project.

The National Pediatric Readiness Project of the Emergency Medical Services for Children surveyed emergency departments in the United States in 2013 for readiness to provide emergency care to children. However, that survey did not query for many elements considered essential to Advanced Trauma Life Support (ATLS). Our pediatric trauma center and state department of health collaborated to develop a survey reflecting ATLS principles regarding pediatric-specific trauma stabilization, clinical/administrative resources, and interfacility transfer to complement the 2017 PedsReady survey. We distributed the survey to all emergency department medical directors in our state in 2017. Medical directors of all 11 emergency departments responded. Only 2 reported having physician or nurse pediatric trauma coordinators. Two reported comfort with all emergency procedures at all ages (eg, airway, traumatic pneumothorax treatment, etc), whereas 9 had variable thresholds of comfort by age and procedure. Reported utilization of pediatric trauma-specific protocols varied the following: hyperosmolar therapy (1), neurological assessment (3), chest injury (4), massive transfusion (1), triage (5), trauma transfer agreements (10), imaging-limitation protocols (4), internal (1) and inter-facility (4) quality assurance/quality improvement process (1), and real-time image transfer (11). This survey identified gaps in the readiness of emergency departments to treat injured children in our state that were not detected by the 2013 PedsReady surveys. Future surveys of emergency department pediatric readiness should consider more detailed, trauma-specific readiness questions. This will allow for assignment of more accurate goals and benchmarking standards for national pediatric trauma readiness.

Implementing a pharmacist-led emergency department microbiology follow-up collaborative practice agreement

ObjectiveDescribe the use of an emergency department (ED) pharmacist–driven microbiology follow-up collaborative practice agreement (CPA) at a community hospital ED. SettingA 297-bed community hospital that serves several counties in south-central Indiana. Practice descriptionThe 40-bed ED had 48,550 visits in 2018. The clinical staff consists of 14 physicians, 14 advanced practice providers, and 2 ED pharmacists. Practice innovationA CPA exists between the ED medical director and the ED clinical pharmacists. The pharmacist reviews the patient’s case, culture result(s), and medications administered in or prescribed at the ED. If supported by the CPA, the pharmacist will intervene independently. If the intervention is not supported by the CPA, the pharmacist will discuss treatment options with an ED provider. EvaluationThe primary end point was the number of cases reviewed and acted upon independently by the ED pharmacists using the CPA. The secondary end points included the average number of culture cases reviewed per day, average time spent daily reviewing culture data, number of cases not requiring further action under the CPA because the treatment is appropriate, type of intervention used under the CPA, number of culture cases unable to be executed under the CPA, reason for CPA exclusion, and ED provider satisfaction with the CPA. Descriptive statistics were used for data analysis. ResultsThe CPA covered 1094 microbiology follow-up cases. Of these, 36% (n = 394) required further intervention under the CPA. The CPA was unable to be used in 31% (n = 493) of the cases. Typically, a pharmacist reviewed 5.5 new cases daily over an estimated 2 hours. The ED providers strongly support the ED clinical pharmacists’ current use of the CPA and also its expansion. ConclusionThe CPA has several avenues for potential expansion that are being explored in response to the information gathered in this study.

Optimizing the Economic Impact of Sickle Cell Hospitalization By Effective Care Plans

Background: Adults with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED) which often results in hospital admissions. The Hematology-Oncology at Ellis Fischel Cancer Center collaborated with organization's ED to develop and implement individualized care plans for adults with SCD presenting to the ED with the goal of adequate outpatient management, reduction in hospital admissions and optimizing the economic impact of sickle cell hospitalization. Methods: Baseline data was collected from November 2014 through June 2018. Medical Director, Oncology Unit Manager, and Performance Improvement Professional (PIP) collaborated with the ED Medical Director and representatives to develop a disease-specific individualized acute care plan for our adult SCD patient population. 100% case were reviewed by PIP and bi-monthly aggregate case review were done by the Medical Director/Unit Manager. The care plan include pathways for lab collection, pain medication regimens, prescription opioid refill policies, a timeline for outpatient follow-up, and criteria for hospital admission. These care pathways were then transitioned to order sets within the organization's electronic medical record. Results: Implementation of the SCD care plans resulted in significant improvement of length of stay(LOS) index indicating better management during the hospital stay, resulting in reduction of the inpatient pharmacy cost per encounter in half as mentioned in Table 1. Admissions per patient did not change significantly, but ED visits per patient went down and clinic visits per patient went up pointing to better management outside of acute care as shown in Table 2. Last 4 quarters of this study showed marked decrease in cost per patient as indicated in Table 3. Conclusions: This study clearly demonstrates that collaboration with the ED and development of care plans can improve the overall patient care for this population resulting in better outpatient management. Implementing this protocol has not only improved the patient experience but also has decreased the financial toxicity for the patient and the institution. We would encourage other institutions to implement such protocol in the ED and in the outpatient setting to meet the patient needs. Table 3 Disclosures No relevant conflicts of interest to declare.

Emergency Medicine Physicians' Perceptions of Pediatric Tele-Emergency Services.

Introduction: This study evaluated general emergency medicine (GEM) physicians' opinions on the barriers, perceptions, and utility of pediatric tele-emergency services, or the use of telemedicine for critically ill children in the emergency department (ED). Methods: Based on previously published surveys, a 27-item survey was created to assess GEM physicians' perspective on tele-emergency services provided by a regional group of pediatric critical care physicians. The survey was distributed to ED medical directors at 15 hospitals who actively participate in tele-emergency services. Results: Twelve of the 15 medical directors responded to the survey (80%). Results demonstrated that GEM physicians consider the pediatric critical care tele-emergency consultations clinically helpful (92%), particularly for the management of patients with respiratory distress, congenital anomalies, and cardiovascular processes. The most common barriers to using tele-emergency services included limited time (42%), integrating new technology and processes in existing workflows (42%), and the lack of clinical utility (42%), particularly for patients with nonacute and/or routine conditions. Lastly, half of GEM physicians felt that families preferred telemedicine to telephone consultations (50%). Conclusion: GEM physicians support the premise that pediatric tele-emergency services help with the clinical management of critically ill children. However, physicians do not consistently believe that tele-emergency services are always clinically necessary and time constraints continue to be a significant barrier. Selected use on specific clinical conditions and improving the integration in workflow processes would help increase the appropriate use of tele-emergency services in the ED.

Pandemic influenza and major disease outbreak preparedness in US emergency departments: A survey of medical directors and department chairs.

To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, χ2, and ANOVA. ED medical directors and department chairs. One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak. Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

95 An Analysis of Patient Complaints at a Community Teaching Hospital’s Emergency Department and Its Correlation to Litigation

The purpose of this study is to analyze emergency department (ED) complaints received at a community teaching hospital, create benchmarks with complaint rates and to correlate this with litigation. A prospective study analyzed logged patient complaints forwarded to the ED Medical Director between 2014 and 2018. Our community teaching ED has an approximate annual volume of 50,000 visits with ED attending and mid-level provider coverage. Our ED satisfaction scores place us in the 85th percentile in our peer group and 65th percentile nationally. Qualitative evaluation was performed based on a systematic taxonomy and the following data was extracted: patient’s provider, reason of complaint, origin of complaint, patient date of service, the date case opened, and the date the case closed. The complaints were totaled by year and categorized, correlating to the context of complaints, mode of case opening, and time frame for resolution. ED litigation was reviewed over the same five-year interval and correlated to the complaint log. The most common reason for a complaint was based on clinical care concerns, followed by billing issues, and then by patient satisfaction issues. Satisfaction concerns were received the earliest at 19.7 days, clinical concerns occurred in 38 days and finally billing at 160 days. Most complaints were resolved within 19.5 days after the case was opened. Cases that took more than 90 days to open from the date of service were most likely associated to billing. Most complaints originated from the Patient Satisfaction and Billing Departments. We have found that our facility had an annual complaint rate ranging from 24.2 to 33.3 per 10,000 visits during the observation period, with an overall rate of 29.1 per 10,000 visits. The hospital had nine total lawsuits attributed to the ED over the five-year period, for a rate of 9 per 251,012 or 0.36 lawsuits per 10,000 patient visits. The rate of a complaint associated with a lawsuit was 2 per 731 or 27.4 lawsuits per 10,000 complaints when extrapolated. Only one suit would assign attribution to the ED provider; all others were related to supporting services. The complaint incidence in our ED is low at 29.1 per 10,000 visits and remained constant over the five-year observation period. Only two complaints out of the 731 complaints led to litigation for a rate of 27.4 lawsuits per 10,000 complaints. This rate was substantially higher in magnitude than the general rate of 0.36 per 10,000. Moreover, most cases that ended up in litigation did not have an associated complaint filed in advance of the claim. Clinical complaints of quality of care, billing, and satisfaction were the most common. Satisfaction and quality of care complaints tend to come in earlier, while billing complaints are more likely to come in later and take longer to be resolved.

1272. A Routine, HIV and HCV Testing and Treatment Program in a Large, Multi-Campus Emergency Department Finds High Prevalence of Acute HIV and Chronic Hepatitis C

BackgroundOne in seven people living with HIV in the United States are unaware of their serostatus. Approximately 11,280 annual HIV infections (30.2%) are caused by this subset of individuals (CDC, 2017). In addition, acute HCV infections have nearly tripled since 2011, with many states seeing a dramatic increase in incidence among younger people outside the birth cohort (CDC, 2017). Because many individuals still use emergency departments (EDs) for their healthcare needs, these institutions play an increasingly important role in screening patients for HIV and HCV and linking them to medical services. Routine, opt-out testing initiatives are particularly effective at identifying new cases of HIV and HCV that could have otherwise been missed by a risk-based approach to screening.MethodsIn early May 2017, physicians and advanced practice nurses from Sutter Health’s Alta Bates Summit Medical Center (ABSMC) and a nearby outpatient HIV clinic implemented a routine HIV and HCV screening program at the hospital’s large, two-campus ED system in Oakland, CA. ED medical directors created a Nursing Standardized Procedure (NSP) to allow registered nurses (RNs) to independently order both blood tests using an automated, best practice authority (BPA) screen in the electronic health record (EHR) of any patient who met CDC-defined age criteria for testing.ResultsOf the 6,315 people screened for HIV between May 1, 2017 and March 31, 2018, 43 (0.7%) patients tested positive. Twelve (57%) of the 21 patients found to have a new HIV diagnosis also had symptomatic, acute HIV infection (AHI). All 12 patients with AHI initiated anti-retroviral therapy (ART) within five to 96 hours of their preliminary positive test result. Of the 5,820 patients screened for HCV, 424 (7.3%) were anti-HCV positive, while 185 (3.2%) patients had chronic infection. Thirty-nine percent of chronic HCV cases were among younger patients born before 1965. All patients with HIV or chronic HCV were referred to medical care at East Bay Advanced Care (EBAC).ConclusionAn automated, routine HIV-HCV testing program integrated into standard nursing workflow at a community ED resulted in the timely screening, diagnosis, and treatment of many patients with acute HIV, and identified a high prevalence of chronic HCV infections among younger patients.Disclosures R. Anson, Frontline of Communities in the United States (Gilead, Inc.): Grant Investigator, Grant recipient. C. Hall, Frontline of Communities in the United States (Gilead, Inc.): Grant Investigator, Grant recipient.

Pediatric Readiness in the Emergency Department.

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Role of effective care plans in reducing admissions for sickle cell patients.

156 Background: Adults with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED) which often results in hospital admissions. The Hematology-Oncology at Ellis Fischel Cancer Center collaborated with organization’s ED to develop and implement individualized care plans for adults with SCD presenting to the ED with the goal of adequate outpatient management and a reduction in hospital admissions. Methods: Baseline data collected from November 2014 through December 2016 indicated that 108 SCD patients accounted for 195 inpatient hospital admissions, and 40% of all 30-day readmissions for the Hematology-Oncology service line. Further, the average length of stay for patients admitted for SCD crisis was 6.8 days per stay. Medical Director, Oncology Unit Manager, and Performance Improvement Professional collaborated with the ED Medical Director and representatives to develop a disease-specific acute care plan for our adult SCD patient population. The care plan include pathways for lab collection, pain medication regimens, prescription opioid refill policies, a timeline for outpatient follow-up, and criteria for hospital admission. These care pathways were then transitioned to order sets in within the organization’s electronic medical record. Results: Implementation of the SCD care plans resulted in significant improvement in the 30-day readmission rate among the SCD patient population, from 40% to 3%. Further, use the SCD care plans helped reduce the average length of stay for patients admitted with SCD crisis from 6.8 days to 3 days. More importantly, we have been able to sustain this improvement over time. Conclusions: This study clearly demonstrates that collaboration with the ED and development of care plans are key to reducing ED and hospital utilization among patients with SCD, and reducing the average length of stay for SCD patients who require hospitalization for disease management.

Emergency Physicians’ Perception of Barriers and Facilitators for Adopting an Opioid Prescribing Guideline in Ohio: A Qualitative Interview Study

BackgroundOhio has the fifth highest rate of prescription opioid overdose deaths in the United States. One strategy implemented to address this concern is a state-wide opioid prescribing guideline in the emergency department (ED). ObjectiveOur aim was to explore emergency physicians’ perceptions on barriers and strategies for the Ohio ED opioid prescribing guideline. MethodsSemi-structured interviews with emergency physicians in Ohio were conducted from October to December 2016. Emergency physicians were recruited through the American College of Emergency Physicians Ohio State Chapter. The interview guide explored issues related to the implementation of the guidelines. Interview data were transcribed and thematically analyzed and coded using a scheme of inductively determined labels. ResultsIn total, we conducted 20 interviews. Of these, 11 were also the ED medical director at their institution. Main themes we identified were: 1) increased organizational responsibility, 2) improved prescription drug monitoring program (PDMP) integration, 3) concerns regarding patient satisfaction scores, and 4) increased patient involvement. In addition, some physicians wanted the guidelines to contain more clinical information and be worded more strongly against opioid prescribing. Emergency physicians felt patient satisfaction scores were perceived to negatively impact opioid prescribing guidelines, as they may encourage physicians to prescribe opioids. Furthermore, some participants reported that this is compounded if the emergency physicians’ income was linked to their patient satisfaction score. ConclusionsEmergency physicians interviewed generally supported the state-wide opioid prescribing guideline but felt hospitals needed to take additional organizational responsibility for addressing inappropriate opioid prescribing.

Emergency Department Directors Are Willing to Expand Reproductive Health Services for Adolescents.

Nearly 20 million adolescents receive emergency department (ED) care each year, many of whom have untreated reproductive health issues. ED visits represent an opportunity to provide appropriate care, however, ED physician reproductive health care practices and capabilities in the United States have not been described. We sought to characterize pediatric ED director's individual practice and ED system resources for providing adolescent reproductive health care. We invited pediatric ED division and/or medical directors nationally to participate in an anonymous, online survey. Outcomes included ED directors' personal practice regarding providing adolescent patients reproductive health care, and their ED's resources and standard practice regarding screening adolescents for sexually transmitted infections (STIs) and other reproductive health concerns. One hundred thirty-five of 442 (30.5%) ED directors responded. Respondents were 73% (90/124)male, with a median of 18 (interquartile range, 13-23) years of experience and 63% (84/134) working in urban EDs. Seventy-one percent (90/130) preferred face-to-face interviews for obtaining a sexual history, but only 59% (77/130) of participants "always ask parents to leave the room for sensitive questions." Eighty-four percent (106/127) were receptive to pregnancy prevention interventions being initiated in the ED, with 75% (80/106) of those willing to provide an intervention. Only 16% (21/128) indicated their ED has a universal STI screening program, and only 18% (23/126) "always" successfully notify patients of a positive STI test. ED directors are comfortable providing adolescent reproductive health care, and many individual- and ED-level opportunities exist to provide improved reproductive health care for adolescents in the ED.

A Conceptual Model for Emergency Department Patient Experience.

Emergency department (ED) patient experience continues to be a growing area of focus for ED physicians, administrators, and regulatory agencies. Recent literature has suggested a strong correlation between positive ratings of patient experience and important health system goals, including improved clinical outcomes and care quality, increased staff satisfaction, and reduced medicolegal risk. However, given the myriad of factors driving ED patient experience, identifying effective and synergistic interventions can present a challenge, especially in the setting of limited ED resources. Utilizing the themes identified in a recent systematic review of the ED patient experience literature, we developed a conceptual “logic model” of ED patient experience in order to provide a broadly applicable framework for practical intervention and to guide further study of ED patient experience interventions. The logic model was modified in an iterative fashion through review by local patient and staff groups as well as a national interest group until arriving at the current, comprehensive version. Here, we describe the creation of the logic model and, with the aim of providing a framework for readers to develop similar models for their practice settings, provide a case discussion of its use by an ED medical director.

Key High-efficiency Practices of Emergency Department Providers: A Mixed-methods Study.

The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs). A mixed-methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety-nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000- to 55,000-visit) community EDs during two 4-hour periods and recorded in minute-by-minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site. Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, "inefficiency practices," demonstrated significant negative correlations: non-work-related tasks and documentation on patients no longer in the ED. Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.

Current State of Antimicrobial Stewardship in Children's Hospital Emergency Departments.

BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described. OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs. METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation. RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR. CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support. Infect Control Hosp Epidemiol 2017;38:469-475.