Emergency Department Physicians Research Articles

Emergency planned re-infusion therapy and hospitalisation for community-acquired pneumonia: a retrospective case-control study.

Community-acquired pneumonia (CAP) is a frequent reason for emergency department visits and leads to increased direct medical costs, particularly due to hospitalisation. This study aims to examine the differences between emergency planned re-infusion therapy and hospitalisation in patients with CAP. This retrospective case-control study involved 1889 CAP patients treated at the Emergency Internal Medicine Department of Class A tertiary Hospital in China from 1 January 2020 to 31 December 2022. Patients were divided into groups receiving either emergency planned re-infusion therapy or hospitalisation. Independent sample t tests and χ2 tests were used to compare the clinical outcomes and economic impacts between the two groups across different pneumonia severity index (PSI) classifications. The study enrolled 1889 CAP patients. For PSI I-II patients, the improvement rates were 99.51% in the emergency planned re-infusion therapy group and 99.69% in the hospitalisation group, showing no statistically significant difference (P > 0.05). Similarly, no significant difference was observed for PSI III patients (84.16 vs. 89.82%). However, significant differences emerged for PSI IV patients, with improvement rates of 50% in the emergency planned re-infusion therapy group and 90.59% in the hospitalisation group (P < 0.001). Statistically significant differences were also noted in treatment duration (5.13 ± 1.65 days vs. 7.60 ± 3.93 days, P < 0.001) and total treatment costs (1921.57 Chinese Yuan (CNY) ± 923.16 vs. 9083.80 CNY ± 3583.55, P < 0.001) between the two groups. Emergency planned re-infusion therapy for CAP is an effective and cost-efficient alternative that can reduce both treatment duration and costs, particularly for patients with PSI I-III. It is recommended that emergency physicians give priority to emergency re-infusion therapy for patients with PSI I-III. In addition, it is recommended that hospitals strengthen the classification and treatment training programmes for emergency department physicians to recognise the patients with PSI I-IV. The hospital's ethics committee (XMCGIRB2024034-01).

P-2106. Streamlining Care Delivery in the Pediatric Emergency Department Using Rapid Point-Of-Care Molecular Diagnostics For Group A Streptococcus: A Randomized Controlled Trial

Abstract Background As per IDSA guidelines, throat swab testing for group A Streptococcus is important to ensure appropriate antimicrobial use for children with pharyngitis that is not obviously viral. Bacterial culture is the diagnostic reference standard but takes days to result. With culture, physicians often initially provide a prescription that is only to be filled later on if GAS testing is positive. Unfortunately, this strategy can result in inappropriate treatment if parents of children with negative tests fill the script anyway, or if parents of children with positive tests cannot be contacted later. Point-of-care (POC) antigen testing in children is specific but not sensitive, so a negative test still requires culture verification, which limits its overall usefulness. POC molecular GAS testing is as sensitive as culture, and provides a result in minutes, which simplifies prescribing. ED physician satisfaction at enrolment Satisfaction was captured using a 5-point Likert scale on the day of enrolment. Methods A randomized controlled trial was done in a Canadian children’s emergency department (ED). Children aged &amp;gt;3 y with throat swabs ordered to diagnose GAS pharyngitis were eligible. Participants were randomized 1:1 to either the IDNOW Strep A2 (intervention) or bacterial culture (control). The primary outcome was appropriate treatment, ie taking antibiotics if GAS-positive or not taking antibiotics if GAS-negative. Secondary outcomes included physician and parent satisfaction and time to symptom resolution. Caregiver satisfaction at enrolment Satisfaction was captured using a 5-point Likert scale on the day of enrolment. Results 392 participants were recruited from Jan 2021 – Mar 2024. Intervention and control groups were similar in terms of mean age (8.2 vs 8.3 y) and mean MacIsaac score (both 3.3); 29% of the intervention group and 41% of the control group were GAS-positive. Participants in the intervention group were significantly more likely to receive appropriate antibiotics (90.8% vs 76.3%, OR 3.1 [95%CI 1.7-5.7], p&amp;lt; 0.001). ED physicians (pOR 147, p&amp;lt; 0.001) and parents (pOR 2.4, p&amp;lt; 0.001) were also much more likely to be satisfied with POC molecular testing. There were no statistically significant differences in time to resolution of symptoms, though comparisons favoured the intervention. Conclusion In the largest RCT of molecular GAS testing yet done, the intervention was associated with substantial improvements in appropriate antibiotic prescribing and was clearly preferred by both ED physicians and parents. Disclosures Jeffrey Pernica, MD, MSc, FRCPC, DTMH, MedImmune: Grant/Research Support|Merck: Grant/Research Support

414. Culture Clash: A Comparison of Approach to Blood Culture Diagnostic Stewardship across 3 Emergency Departments in a Healthcare Network

Abstract Background Blood culture (BCx) diagnostic stewardship aids in accurately identifying microbial pathogens and guiding appropriate antibiotic therapy. We compared effects of a BCx algorithm (Fig 1) on BCx rates (BCx/100 ED visits) in the emergency department (ED) using two implementation approaches: 1) an intensive approach including weekly, individualized BCx appropriateness data feedback and modifications to electronic health record order sets, and 2) a passive approach with group-level, BCx appropriateness data feedback of a random BCx sample.Figure 1:ED Blood culture algorithmAlgorithm used by emergency department providers to determine if blood cultures are necessary Methods We performed a quasi-experimental pre-/post-intervention study from 12/1/2020 to 2/29/2024 using data from 3 academic-affiliated EDs. The BCx algorithm was introduced in 12/2022 in ED1. 7 ED providers reviewed BCxs ordered each week for appropriateness of BCx indication according to the algorithm and provided weekly, individualized feedback to colleagues regarding their performance in. In addition, BCx were removed from order sets for low-risk clinical scenarios, such as simple cystitis or community-acquired pneumonia. The algorithm was introduced to ED2 in 7/2023. In ED2, a pharmacist reviewed 5 BCx per week for appropriateness and one ED physician provided a secondary review when the clinical scenario was unclear. Feedback was provided to ED leadership every 2 months regarding appropriateness and BCx utilization. ED3 served as control and did not have the algorithm introduced. BCx rates were analyzed using interrupted time series models evaluating each ED separately. Incidence rate ratios (IRR) compared BCx rates before the intervention to BCx rates after the intervention.Figure 2.Monthly blood culture event rate (per 100 ED admissions) for the emergency department before (12/2020-11/2022) and after (12/2022-2/2024) the blood culture algorithm introduction. Intensive chart reviews occurred during 12/2022 to 5/2023. After that time only the algorithm was used without audit and feedback.β1= -0.004 (95% CI -0.0057, -0.0014, p-value &amp;lt;0.01)]. At the time of the intervention there was an acute drop measured by the β2 coefficient -0.16(95% CI -0.38, -0.01, p-value 0.04), followed by a slow increase in slope (β3= 0.007, 95% CI -0.003, 0.010,p-value 0.06). Results A total of 105,975 BCxs over 572,776 ED visits were included in the analysis. ED1 saw a 25% decrease in BCx rate with IRR 0.80 (95% CI 0.74, 0.86, p-value 0.01). (Fig 2) ED2 experienced a 4% decrease in BCx rate with IRR 0.72 (95% CI 0.54, 0.95, p-value 0.02). (Fig 3) ED3 did not experience any change (Fig 4).Figure 3.Monthly blood culture event rate (per 100 ED admissions) for emergency department 2 before (12/2020-6/2023) and after (7/2023-2/2024) the blood culture algorithm introduction. Random, small sampling of chart reviews occurred during 7/2023 to 2/2024.β1= -0.044 (95% CI -0.0059, -0.0028, p-value &amp;lt;0.01)]. At the time of the intervention there was an acute drop measured by the β2 coefficient -0.43(95% CI -0.83, -0.03, p-value 0.03), followed by an increase in slope (β3= 0.014, 95% CI 0.002, 0.025,p-value 0.02). Conclusion The BCx rate was most significantly impacted in ED1 by combining audit and feedback with modifications to the electronic medical record. However, both EDs saw drift back towards prior BCx utilization rates after the intervention. Sustainability can likely be improved by implementing computerized clinical decision support systems.Figure 4.Monthly blood culture event rate (per 100 ED admissions) for the emergency department from 12/2020 to 2/2024. No algorithm was used in this emergency department.β1= -0.004 (95% CI -0.0027, 0.0019, p-value 0.74)]. At the time of the intervention there was no significant change measured by the β2 coefficient 0.13 (95% CI -0.0241, 0.279, p-value 0.99), followed by stable slope (β3= -0.004, 95% CI -0.009, 0.002,p-value 0.17). Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Jessica Seidelman, MD, MPH, 3M: Expert Testimony

Organisational factors associated with burnout among emergency and internal medicine physicians: a qualitative study

ObjectiveTo identify physician perspectives on factors associated with physician burnout, protective factors against burnout, and to seek potential solutions for this pervasive problem.DesignA qualitative study with semistructured focus group interviews...

The influence of continuous improvement and clinical practice on emergency department (ED) operational performance.

The study tests the relationships between continuous improvement (CI) and clinical practices (CP) with perceived operational performance in Australian and New Zealand (NZ) emergency departments. A survey instrument was designed to collect data from Australian and NZ Emergency Department physicians to test a model developed from the literature, the continuous improvement and clinical practice (CICP) model. Hypotheses were developed and tested using bivariate correlation analysis and multiple regression analysis. ED operational performance is positively impacted by CI culture, reinforced by an established CI governance structure built on employee education of CI tools and methods. The lack of nonclinical time allocation for CI activities has remained a major impediment for the implementation of a sustainable CI culture. The study found physicians experience tension between continuous improvement and clinical practice. Developing a CI mindset across all levels of emergency departments would encourage staff to embrace change to support the implementation of CI and to improve clinical practices. The study highlights potential implications for national bodies, academics, policymakers and ED physicians. Study insights suggest that continuous improvement and effective clinical practices are crucial for enhancing ED performance results in their day-to-day responsibilities. The paper is original by applying methodological rigour to identify the best predictors of performance in EDs and how a theoretical causal model can be tested to identify the best predictors of operational performance in EDs.

Iowa emergency departments lack board-certified emergency physicians: A comprehensive statewide emergency department workforce study.

The emergency physician (EP) workforce has been a recent focus after a workforce projection predicted a surplus of EPs by 2030. A previous study of Iowa emergency departments (EDs) demonstrated wide variability in ED staffing patterns and attributed it to the lack of EP job candidates. With the recent increase in emergency medicine (EM) residency positions, the objectives of this study were to understand how Iowa ED physician staffing has changed in regard to presence of board-certified EPs and what operational differences in Iowa EDs may be associated with staffing to provide insight into what may be occurring in other predominantly rural states. An electronic and telephone survey of nonfederal Iowa EDs was conducted using a structured data collection instrument. Responses were collected from a leadership representative at each facility (medical director or nurse manager). The data collection included both objective staffing data and Likert-style questions about reasons for staffing and operational practices. We obtained hospital characteristics from the American Hospital Association and directly compared these results to a similar Iowa study conducted in 2013. Summary data were presented as counts and percentages, and physician staffing was compared between critical-access hospitals (CAHs) and non-CAHs. CAHs represent a type of rural hospital in the rural setting. Responses from 113 of 116 (97%) Iowa EDs were recorded. Of responding EDs, 19 (17%) were staffed exclusively by EM residency-trained and/or EM board-certified physicians (EPs), 72 (66%) were staffed by a combination of EPs and non-EPs (physicians who completed a residency other than EM), 19 (17%) were staffed exclusively by non-EPs, and 52 (46%) were staffed either fully or at times by advanced practice providers (APPs) without in-house supervision. In the subgroup of CAHs, only three (4%) staff only EPs, compared with 16 (42%) of non-CAHs (difference 38%, 95% confidence interval [CI] 24.6%-51.2%). Providers staffing CAHs were more likely than those at non-CAHs (88% vs. 63%, difference 25%, 95% confidence interval [CI] 9.5%-40.2%) to have responsibilities outside the ED, the most common being inpatient cardiac arrest management (n = 84, 74%). The most common reason for hiring EPs was the quality of care they provide (n = 47, 58%), and the most common reason for hiring non-EPs was low availability of EPs (n = 56, 70%). Compared to the 2013 Iowa ED workforce study, the proportion staffed by EPs only were similar (increased by 5.5%, 95% CI -14.7% to 3.7%) and by non-EPs only was similar (decreased by 10.5%, 95% CI -0.4% to 21.3%). EDs staffed solely by APPs decreased from decreased by 13.2% (95% CI 0.3%-26.2%) to 47% in 2023. Iowa EDs are predominantly staffed by non-EPs, and this remains unchanged despite a decade of increasing EM residency positions nationally. There remains a significant disparity between CAHs and non-CAHs. This study demonstrates that EM residency position increases have not penetrated rural Iowa EDs, where there remains both a substantial shortage and desire for EP staffing.

The impact of an All-Hazard mass casualty event on emergency department operations: A retrospective study.

Mass Casualty Events (MCI) which have a direct and persisting impact on the safety and well-being of an emergency department (ED) and its staff, secondary to specific targeting of the healthcare setting, represent a distinct and complex operational challenge. ED physicians may be faced with the prospect of providing ongoing patient care while simultaneously experiencing direct threats to their own health or physical safety. In our study we considered the unique operational challenges encountered, and management strategies adopted, by the ED staff and its leadership to an all-hazard MCI impacting an academic urban emergency department. We conducted a retrospective, observational study of data from a tertiary academic medical center of patients arriving to the ED during a protracted MCI lasting from May 11th to May 21st, 2021. No arriving patients were excluded from analysis. Patient demographics, ED resource utilization, throughput, disposition and other pertinent data were considered. Analysis was done of three distinct patient populations including the event-group (EG), a non-event-group (NEG) and a control group (CG). Descriptive statistics were used to evaluating observational findings. We reviewed the records of 8527 total patients presenting to the Shamir Medical Center ED during the event and control periods. Of those, 283 patients were identified as an EG consisting of casualties from the MCI. 3563 patients were identified as the NEG presenting with complaints not related to the event. Our CG consisted of the 4681 patients who presented in the two weeks prior to the MCI. EG patients were noted to have important characteristics including higher relative numbers of men n=173 (61.6%), higher CTAS triage acuities [n=10 (3.8%), classified as CTAS 1], and an increase utilization of specialty consultation and admission consistent with observed injury patterns, most notably for the orthopedic services [orthopedic consultations: n=126 (44.5%) / orthopedic admissions: n=13 (4.6%)]. Findings from our observational study suggested that in the absence of larger public health interventions a manmade MCI, with direct threats to an ED and its staff, could force EDs to concurrently address the unique clinical needs of two distinct patient populations while simultaneously needing to take measures to protect hospital staff. Additionally, a higher burden of patient volumes and clinical acuity are likely to be encountered by select specialty consultation services. Further studies could focus on quantitative analysis to better understand the operational impact of these types of events on both patients and staff.

Antimicrobial Stewardship in the Pediatric Emergency Department: An Observational Pre-Post Study.

Background/Objectives: To face antimicrobial resistance, antimicrobial stewardship programs (ASPs) have been implemented in the pediatric age, but the area of urgency remains understudied. We aimed to assess the impact of an educational program on optimizing antibiotic appropriateness in a pediatric ED. Methods: We conducted a pre-post observational study with an audit, intervention, and feedback given to prescribers. We recorded all systemic antibiotic prescriptions for children attending our pediatric ED from January to March and from July to September 2020. The study's team assigned a score to each prescription, regarding the appropriate molecule, dose, and duration of therapy, according to the diagnosis. From April to June 2020, we held weekly meetings focusing on different pediatric infectious diseases, with interaction between one to three ED physicians and the infectious disease (ID) specialist of the study's team. We then distributed synthetic digital guidelines adapted to our reality to all prescribers. Results: Optimal antibiotic prescriptions increased after the intervention, with statistical significance (p < 0.001) in four main aspects (overall adequacy: 13% PRE vs. 43% POST; need of antibiotics: 53% vs. 68%; adequacy of the spectrum: 55% vs. 63%; adequacy of the chosen molecule: 54% vs. 62%). We observed an improvement in all the main infectious diseases and concerns all the ED physicians. The prescription of first-choice drugs increased in specific and common illnesses such as otitis and pharyngotonsillitis. Conclusions: An antimicrobial stewardship program is a relevant method for improving the appropriateness of antimicrobial use also in the complex setting of a pediatric ED.

Machine-learning based prediction of appendicitis for patients presenting with acute abdominal pain at the emergency department

Abstract Background Acute abdominal pain (AAP) constitutes 5–10% of all emergency department (ED) visits, with appendicitis being a prevalent AAP etiology often necessitating surgical intervention. The variability in AAP symptoms and causes, combined with the challenge of identifying appendicitis, complicate timely intervention. To estimate the risk of appendicitis, scoring systems such as the Alvarado score have been developed. However, diagnostic errors and delays remain common. Although various machine learning (ML) models have been proposed to enhance appendicitis detection, none have been seamlessly integrated into the ED workflows for AAP or are specifically designed to diagnose appendicitis as early as possible within the clinical decision-making process. To mimic daily clinical practice, this proof-of-concept study aims to develop ML models that support decision-making using comprehensive clinical data up to key decision points in the ED workflow to detect appendicitis in patients presenting with AAP. Methods Data from the Dutch triage system at the ED, vital signs, complete medical history and physical examination findings and routine laboratory test results were retrospectively extracted from 350 AAP patients presenting to the ED of a Dutch teaching hospital from 2016 to 2023. Two eXtreme Gradient Boosting ML models were developed to differentiate cases with appendicitis from other AAP causes: one model used all data up to and including physical examination, and the other was extended with routine laboratory test results. The performance of both models was evaluated on a validation set (n = 68) and compared to the Alvarado scoring system as well as three ED physicians in a reader study. Results The ML models achieved AUROCs of 0.919 without laboratory test results and 0.923 with the addition of laboratory test results. The Alvarado scoring system attained an AUROC of 0.824. ED physicians achieved AUROCs of 0.894, 0.826, and 0.791 without laboratory test results, increasing to AUROCs of 0.923, 0.892, and 0.859 with laboratory test results. Conclusions Both ML models demonstrated comparable high accuracy in predicting appendicitis in patients with AAP, outperforming the Alvarado scoring system. The ML models matched or surpassed ED physician performance in detecting appendicitis, with the largest potential performance gain observed in absence of laboratory test results. Integration could assist ED physicians in early and accurate diagnosis of appendicitis. Graphical abstract

Variation in Emergency Department Physician Admitting Practices and Subsequent Mortality

An emergency department (ED) physician's decision to admit a patient to the hospital plays a pivotal role in determining the type and intensity of care that patient will receive. ED physicians vary widely in their propensity to admit patients to the hospital, but it is unknown whether higher admission propensities result in lower subsequent mortality rates. To measure the variation in ED physicians' admission propensities and estimate their association with patients' subsequent mortality rates. This cross-sectional study used nationwide Veterans Affairs electronic health record data from January 2011 to December 2019, comparing physicians practicing within the same ED. The study population was composed of patients visiting the ED with 1 of the 3 most frequent chief complaints in US EDs (chest pain, shortness of breath, and abdominal pain). The data analyses were performed from May 2022 to October 2024. The main outcomes were variation in physicians' adjusted admission rates, short inpatient stays (<24 hours), and 30-day mortality. The study population included 2098 physicians seeing 2 137 681 patient visits across 105 EDs. The mean (SD) patient age was 63 (15) years, and 9.8% of patients were female. The mean admission rate was 41.2%, and the mean 30-day mortality rate was 2.5%. Physicians' adjusted admission rates varied greatly within the same ED (eg, for chest pain: 90th percentile of physicians, 56.6% admitted vs 10th percentile, 32.6% admitted; difference, 24.0 percentage points), despite finding no association between these adjusted admission rates and patients' prior health status as measured by their Elixhauser Comorbidity Index score before the ED visit. However, patients admitted by physicians with higher admission rates were more likely to be discharged within 24 hours (eg, 31.0% vs 24.8%, respectively), while patients of physicians with higher admission rates had subsequent mortality rates that were no less than those of patients of physicians with lower admission rates. This cross-sectional study demonstrated that ED physicians vary widely in their admission propensity, despite seeing patients with similar prior health status. The results suggest that patients treated by physicians with higher admission propensities are more likely to be discharged after only a short inpatient stay and experience no reduction in subsequent mortality rates.

Optimizing the Use of Computed Tomography for Appendicitis Diagnosis in the Pediatric Emergency Department Through the Quality Improvement Methodology.

Acute appendicitis is one of the most common causes of an acute abdomen among pediatric patients. The diagnosis of appendicitis is challenging due to the nonspecific presentation. Diagnosis is based on historical, physical, and serologic information as well as right lower quadrant ultrasound (RLQ US). In equivocal patients, or those with a high degree of suspicion, computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast can be utilized to rule in appendicitis. However, optimizing diagnostic protocols to minimize ionizing radiation exposure while maintaining diagnostic accuracy is important. We performed a monthly retrospective analysis of CT usage among pediatric patients with suspected acute appendicitis presenting to the pediatric emergency department (ED) from June 2023 to December 2023. We used quality improvement methodology to decrease CT use with monthly Plan-Do-Study-Act (PDSA) cycles with an aim to decrease CT use by 50%. The main intervention was coordination between the ED and surgical providers to require surgical consult before ordering a CT. We quantified the number of patients who received a surgical consult before CT, the number of RLQ US performed, the number of CTs performed, and the number of appendectomies, specifically the number with perforation. A total of 249 patients under 18 years of age presented to the pediatric ED with symptoms of acute appendicitis during the study period. All 249 patients underwent an initial RLQ US.The number of CTs performed decreased from a baseline of 14 in June to a nadir of four in September (71% decrease, p=0.029). There was a decrease in the percentage of patients who underwent a CT scan after an RLQ US from 36.5% in June to 11.8% in September after our intervention. In June, a total of 38 RLQ USwere performed and 14 patients underwent additional CT (36.5%) and in September a total of 34 US were performed and 14 patients underwent additional CT (11.8%).There was an increase in the surgical consults rate from a baseline of seven surgical consults with 14 total CTs in June 2023 (50%) to seven consults with a total of seven CTs performed(100%) in December 2023. There was no increase in appendiceal perforation rates. Multidisciplinary discussions between pediatric ED physicians and pediatric surgeons reduced CT usage, and corresponding radiation exposure and cost, in the evaluation of appendicitis.

Implementation of medications for opioid use disorder in U.S. emergency departments: A systematic review.

Patients with opioid use disorder (OUD) experiencing withdrawal or nonfatal overdose often present to emergency departments (EDs). While professional societies endorse the initiation of evidence-based medications for OUD (MOUD) in the ED, low uptake persists. The purpose of this systematic review is to synthesize what is known about implementation of MOUD in EDs and to identify potential strategies to improve the uptake of MOUD in the ED. We reviewed articles that examined implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability, and cost) of MOUD in United States EDs. Peer-reviewed studies that used quantitative, qualitative, or mixed methods approaches were eligible for inclusion. Twenty-seven articles met the inclusion criteria for one or more implementation outcomes. Forty-four percent (n=11) reported on acceptability, 78% (n=21) reported on adoption, 26% (n=7) reported on appropriateness, and 15% (n=4) reported on feasibility. Eleven percent (n=3) reported on fidelity, 7% (n=2) reported on penetration, and 7% (n=2) reported on sustainability. No articles reported on implementation cost. While physicians found MOUD acceptable, their comfort levels with the intervention varied. Rates of MOUD adoption were often low, but uptake may be facilitated by implementation strategies. MOUD may constrain ED time resources and exacerbate overcrowding, hindering appropriateness. Results suggest that ED physicians and administrators have encountered barriers to the initiation of MOUD. There may be opportunities to overcome these implementation barriers using multi-component strategies consisting of educational interventions that address safety and monitoring and process interventions, such as clinical decision support systems.

Accuracy of the diagnosis of pneumonia in Canadian pediatric emergency departments: A prospective cohort study.

The diagnosis of pediatric pneumonia and determination of the likely pathogen are complicated as the clinical picture overlaps with other respiratory illnesses, interpretation of radiographs is subjective, and laboratory results are rarely diagnostic. This study was designed to describe the relative rates of bacterial and viral pneumonia in the pediatric Emergency Department (ED), determine the accuracy of pediatric ED physicians' ability to diagnose pneumonia and distinguish bacterial from viral etiology, and to determine clinical and laboratory predictors of bacterial pneumonia. Children 3 months to 16 years of age presenting to seven Canadian pediatric EDs before the COVID-19 pandemic with fever and cough who had a chest radiograph performed for possible pneumonia were enrolled and underwent standardized clinical investigations. An expert panel was convened and reached a Consensus Diagnosis of typical or atypical bacterial pneumonia, viral pneumonia or not pneumonia for each case. The expert panel assessed 247 cases with the Consensus Diagnosis being typical bacterial pneumonia (N = 44(18%)), atypical bacterial pneumonia (N = 18(7%)), viral pneumonia (N = 46(19%)) and no pneumonia (N = 139(56%)). Treating ED physician diagnoses were typical bacterial pneumonia (N = 126(51%)), atypical bacterial pneumonia (N = 3(1%)), viral pneumonia (N = 10(4%)) and no pneumonia (N = 108(44%)) with low agreement between a diagnosis of bacterial pneumonia by the ED physician and the panel's Consensus Diagnosis (Kappa 0.15 (95% CI 0.08, 0.21)). Cut off values that predicted bacterial pneumonia as the Consensus Diagnosis were ESR ≥ 47 mm/hour, CRP ≥ 42 mg/L and procalcitonin ≥0.85 ng/m. Age greater than 5 years and cough for 5 or more days also predict bacterial pneumonia. In this cohort, pediatric ED physicians over-diagnosed typical bacterial pneumonia and underdiagnosed viral and atypical bacterial pneumonia. Bacterial pneumonia is most likely in children over 5 years of age, with cough for 5 or more days and/or with elevated inflammatory markers.

Human trafficking screening in Saskatoon Emergency Departments: What can be learned from high-risk patient presentations?

ObjectiveStudies have shown that Emergency Department physicians have little to no training in recognizing and supporting victims of human trafficking despite being uniquely situated to identify and intervene on behalf of these patients. We assessed if screening for human trafficking was being completed by emergency physicians in three Saskatoon emergency departments.MethodsWe performed a retrospective chart review of patients presenting to three Saskatoon emergency departments deemed to potentially be at risk of human trafficking, based on discharge diagnosis. Of the 223 included charts, data extracted included sex, age, ethnicity, chief complaint, diagnosis, disposition, HT Screening (Y/N), specific quotes relating to HT, time of visit, intimate partner violence (Y/N), and travel history. Both quantitative and qualitative thematic analyses were conducted on this data.ResultsNone of the charts (0%) included in this study had any documentation around screening for human trafficking. Furthermore, 21.1% of the high-risk patient charts included in this study -- which included many patients with a discharge diagnosis of sexually transmitted disease or pelvic inflammatory disease -- did not contain a documented sexual history. Thematic analysis revealed that the patients included in this study frequently had challenges with sexual health, substance use, and houselessness.ConclusionThis study found that Emergency physicians in Saskatoon were not routinely screening for human trafficking. Implementation of further training is needed to help these physicians recognize and subsequently support potential victims of human trafficking.

EP107 Attitudes and awareness of emergency department (ED) physicians toward the management of common dentofacial emergencies what has changed a decade later?

EP107 Attitudes and awareness of emergency department (ED) physicians toward the management of common dentofacial emergencies what has changed a decade later?

The nutritional knowledge and the perception of weight‐loss strategies for obese patients among emergency medicine doctors in Hong Kong

AbstractIntroductionObesity is commonly seen in patients attending the emergency department (ED). Opportunities to provide nutritional advice to patients with obesity are often overlooked in ED settings. Numerous barriers and perceptions exist among healthcare professionals. This study aimed to explore the ED physicians' attitudes, practices, nutritional knowledge and barriers towards nutrition advice in weight management for obese patients in the ED.MethodsThis was a cross‐sectional survey conducted from February to April 2024. The self‐designed questionnaire consisted of questions regarding respondents' characteristics, attitudes, practices and barriers towards providing nutrition advice for obese patients in the ED and assessing the knowledge of nutrition among ED doctors. Non‐parametric tests and Pearson correlation were performed for statistical analysis. The responses between doctors with normal body mass index (BMI) and extreme BMI groups (“BMI &lt; 18.5” and “BMI &gt; 25.0”) were compared.ResultsThis study included 120 responses with a response rate of 16.9%. The mean nutritional knowledge score for doctors with normal BMI was 54.4 ± 14.5, and it was significantly higher than that of doctors who self‐reported as underweight (46.3 ± 5.6 and p = 0.049) or overweight (48.9 ± 16.1 and p = 0.029). The top barrier to nutrition support for obese patients in ED settings was “too busy to give nutrition advice” (77.5%).ConclusionsOur study highlighted the common barriers to offering nutritional advice and insufficient nutrition training among ED physicians. Integrating comprehensive nutrition education into our undergraduate medical training and providing regular evidence‐based nutritional courses may improve patients' and physicians' health.

Defensive Medicine in an Emergency Department: The Overuse of High-Sensitivity Cardiac Troponin I Testing.

Cardiac troponin I is routinely measured in patients with suspected acute coronary syndrome. However, when a high-sensitivity cardiac troponin I (hs-cTnI) test is ordered without a clear clinical indication, unexpectedly elevated levels can lead to unnecessary diagnostic workups and inappropriate management. This study aimed to investigate physicians' rationale for performing hs-cTnI tests in an emergency department (ED). In this prospective study, 1890 patients who underwent hs-cTnI measurement during their stay in an ED were included. Upon arrival, patients were classified into two groups based on their chief complaints: cardiac (36.6%) and non-cardiac (63.4%). Forty-seven ED physicians were asked to complete a questionnaire to assess their perspectives on the use of high-sensitivity cardiac troponin I (hs-cTnI) testing in the ED. Out of the 47 ED physicians who responded to the questionnaire (94% response rate), 97.9% indicated that the purpose of hs-cTnI testing in the ED was to diagnose an acute cardiac event. However, 38.3% reported ordering hs-cTnI tests in non-cardiac patients due to medicolegal concerns. Additionally, 53% admitted to working under medicolegal pressure, and 50% believe they would have ordered fewer hs-cTnI tests if not for this medicolegal threat. defensive medicine is prevalent among ED physicians, and routine use of hs-cTnI testing as part of an evaluation can be explained in part by concern about liability and defensive medicine.

Evaluating Large Language Model-Assisted Emergency Triage: A Comparison of Acuity Assessments by GPT-4 and Medical Experts.

To evaluate the accuracy of the Emergency Severity Index (ESI) assignments by GPT-4, a large language model (LLM), compared to senior emergency department (ED) nurses and physicians. An observational study of 100 consecutive adult ED patients was conducted. ESI scores assigned by GPT-4, triage nurses, and by a senior clinician. Both model and human experts were provided the same patient data. GPT-4 assigned a lower median ESI score (2.0) compared to human evaluators (median 3.0; p < 0.001), suggesting a potential overestimation of patient severity by the LLM. The results showed differences in the triage assessment approaches between GPT-4 and the human evaluators, including variations in how patient age and vital signs were considered in the ESI assignments. While GPT-4 offers a novel methodology for patient triage, its propensity to overestimate patient severity highlights the necessity for further development and calibration of LLM tools in clinical environments. The findings underscore the potential and limitations of LLM in clinical decision-making, advocating for cautious integration of LLMs in healthcare settings. This study adhered to relevant EQUATOR guidelines for reporting observational studies.

Evaluating the Utility of ChatGPT in Diagnosing and Managing Maxillofacial Trauma.

Maxillofacial trauma is a significant concern in emergency departments (EDs) due to its high prevalence and the complexity of its management. However, many ED physicians lack specialized training and confidence in handling these cases, leading to a high rate of facial trauma referrals and increased stress on consult services. Recent advancements in artificial intelligence, particularly in large language models such as ChatGPT, have shown potential in aiding clinical decision-making. This study specifically examines the efficacy of ChatGPT in diagnosing and managing maxillofacial trauma. Ten clinical vignettes describing common facial trauma scenarios were presented to a group of plastic surgery residents from a tertiary care center and to ChatGPT. The chatbot and residents were asked to provide their diagnosis, ED management, and definitive management for each scenario. Responses were scored by attending plastic surgeons who were blinded to the response source. The study included 13 resident and ChatGPT responses. The mean total scores were similar between residents and ChatGPT (23.23 versus 22.77, P > 0.05). ChatGPT outperformed residents in diagnostic accuracy (9.85 versus 8.54, P < 0.001) but underperformed in definitive management (8.35 versus 6.35, P < 0.001). There was no significant difference in ED management scores between ChatGPT and the residents. ChatGPT demonstrated high accuracy in diagnosing maxillofacial trauma. However, its ability to suggest appropriate ED management and definitive treatment plans was limited. These findings suggest that while ChatGPT may serve as a valuable diagnostic tool in ED settings, further advancements are necessary before it can reliably contribute to treatment planning in emergent maxillofacial clinical scenarios.

Variability in choosing to report child maltreatment cases by pediatric emergency medicine physicians

BackgroundChild maltreatment is a significant public health problem. Emergency departments are often the first contact points for suspected child maltreatment. Variability in the decision of whether or not to report maltreatment cases to Child Protective Services (CPS) may lead to missed opportunities for diagnosis and intervention or unnecessary medical and social interventions. ObjectiveTo evaluate the variability in choosing to report child maltreatment cases among emergency department physicians. Participantsand Setting: Our survey was conducted on Emergency physicians through the PED-EM-L@LISTSERV.BROWN.EDU listserv MethodsWe queried emergency physicians with a 19-question survey. Seven clinical scenarios were designed by our Pediatric Emergency division in consultation with a child abuse specialist. Scenarios were created with varying degrees of suspicion for child maltreatment. Our survey asked physicians if they would report each case to CPS. We collected demographic information regarding the physician, their work setting, and their patient population. The responses for individual scenarios were analyzed as percentages and compared with demographic data by Fisher's exact test. Our survey received 307 responses. ResultsMost of our 307 respondents are specialized in pediatric emergency medicine (95.6%). Of the seven scenarios, physicians near-unanimously (99.3%, 95% CI 97.9–99.9%) agreed in only one scenario. For the other six scenarios, agreement ranged from 54.4% (95%CI: 48.8–59.9%) to 80.1% (95%CI: 75.4–84.3%). Demographics, including physician age, gender, ethnicity, years of experience, population ethnicity, and hospital location, did not explain variability in choosing to report to CPS. ConclusionOur study shows significant variability in reporting child maltreatment cases, not explained by hospital or physician demographics.