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Abstract Shannon entropy is a core concept in machine learning and information theory, particularly in decision tree modeling. To date, no studies have extensively and quantitatively applied Shannon entropy in a systematic way to quantify the entropy of clinical situations using diagnostic variables (true and false positives and negatives, respectively). Decision tree representations of medical decision-making tools can be generated using diagnostic variables found in literature and entropy removal can be calculated for these tools. This concept of clinical entropy removal has significant potential for further use to bring forth healthcare innovation, such as quantifying the impact of clinical guidelines and value of care and applications to Emergency Medicine scenarios where diagnostic accuracy in a limited time window is paramount. This analysis was done for 623 diagnostic tools and provided unique insights into their utility. For studies that provided detailed data on medical decision-making algorithms, bootstrapped datasets were generated from source data to perform comprehensive machine learning analysis on these algorithms and their constituent steps, which revealed a novel and thorough evaluation of medical diagnostic algorithms.

Introduction: While emergency department (ED) crowding has deleterious effects on patient care outcomes and operational efficiency, impacts on the experience for patients discharged from the ED are unknown. We aimed to study how patient-reported experience is affected by ED crowding to characterize which factors most impact discharged patient experience. Methods: This institutional review board-exempt, retrospective, cohort study included all discharged adult ED patients July 1, 2020–June 30, 2021 with at least some response data to the the National Research Corporation Health survey, sent to most patients discharged from our large, academic medical center ED. Our query yielded 9,401 unique encounters for 9,221 patients. Based on responses to the summary question of whether the patient was likely to recommend our ED, patients were categorized as “detractors” (scores 0–6) or “non-detractors” (scores 7–10). We assessed the relationship between census and patient experience by 1) computing percentage of detractors within each care area and assessing for differences in census and boarder burden between detractors and non-detractors, and 2) multivariable logistic regression assessing the relationship between likelihood of being a detractor in terms of the ED census and the patient’s last ED care area. A second logistic regression controlled for additional patient- and encounter-specific covariates. Results: Survey response rate was 24.8%. Overall, 13.9% of responders were detractors. There was a significant difference in the average overall ED census for detractors (average 3.70 more patients physically present at the time of arrival, 95% CI 2.33–5.07). In unadjusted multivariable analyses, three lower acuity ED care areas showed statistically significant differences of detractor likelihood with changes in patient census. The overall area under the curve (AUC) for the unadjusted model was 0.594 (CI 0.577–0.610). The adjusted model had higher AUC (0.673, CI 0.657–.690]; P

Introduction: English proficiency and race are both independently known to affect surgical access and quality, but relatively little is known about the impact of race and limited English proficiency (LEP) on admission for emergency surgery from the emergency department (ED). Our objective was to examine the influence of race and English proficiency on admission for emergency surgery from the ED. Methods: We conducted a retrospective observational cohort study from January 1–December 31, 2019 at a large, quaternary-care urban, academic medical center with a 66-bed ED Level I trauma and burn center. We included ED patients of all self-reported races reporting a preferred language other than English and requiring an interpreter or declaring English as their preferred language (control group). A multivariable logistic regression was fit to assess the association of LEP status, race, age, gender, method of arrival to the ED, insurance status, and the interaction between LEP status and race with admission for surgery from the ED. Results: A total of 85,899 patients (48.1% female) were included in this analysis, of whom 3,179 (3.7%) were admitted for emergent surgery. Regardless of LEP status, patients identifying as Black (odds ratio [OR] 0.456, 95% CI 0.388–0.533; P

Abstract Study Objective The objective of this study was to conduct a systematic review and meta‐analysis of the diagnostic accuracy of the clinical signs, symptoms, laboratory investigations, and imaging modalities commonly used in patients with clinically suspected renal colic. Methods We conducted this systematic review and meta‐analysis according to an a priori, registered protocol (PROSPERO CRD42017055153). A literature search was performed using MEDLINE and EMBASE from inception to July 2, 2020. We assessed the risk of bias using Quality Assessment of Diagnostic Accuracy Studies–2, calculated likelihood ratios (LRs), and applied a random‐effects model for meta‐analysis. Results Among 7641 references screened, 76 were included in the systematic review and 53 were included in the meta‐analyis. The overall pooled prevalence for ureteral stones was 63% (95% confidence interval [CI], 58%–67%). No individual demographic feature, symptom, or sign when present had an LR+ ≥2.0 for identifying ureterolithiasis. A (Sex, Timing and Origin of pain, race, presence or absence of Nausea, and Erythrocytes) STONE score ≥10 increased (sensitivity 0.49, specificity 0.91, LR 5.3 [95% CI, 4.1–6.7]) and a STONE score

Abstract Burnout, a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job, remains a substantial problem for emergency physicians, leading to decreased quality of care and attrition from the workforce. The majority of prior work on burnout in emergency medicine has focused on individualized solutions, which have demonstrated modest efficacy for ameliorating burnout. However, recent studies suggest that burnout in medicine is primarily caused by workplace factors (eg, unmanageable workloads, unreasonable time pressures) and therefore requires solutions at an organizational level. In her decades of research across industries, Christina Maslach identified 6 domains of organizations that can either promote engagement or lead to burnout. In this article, we apply Maslach's 6 domains to emergency medicine to provide a systematic framework for alleviating burnout and promoting engagement among emergency physicians. By considering the domains of workload, reward, control, fairness, community, and value congruence, emergency medicine leaders can develop and deploy more effective interventions aimed at improving the experience and longevity of physicians across our specialty.

Study objective Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations. Methods This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them. Results Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks “all of the time” and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%). Conclusions Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.

Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as “very low risk” by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal “very low risk” subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on “very low risk” patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all “very low risk” cases. Trial registration: Clinicaltrials.gov trial registration number: NCT04937868.

Problem As of 2020, less than 5% of physicians in the United States have a drug enforcement administration-X waiver to prescribe buprenorphine. The coronavirus-2019 pandemic restricted in-person gatherings, including traditional drug enforcement administration-X waiver courses. As a result, in-person conferences have needed to adopt remote formats. Many programs identified a gap between educational delivery and the faculty skills required to deliver content remotely. Approach To address the need for high-quality remote learning, Get Waivered designed and implemented a novel experience for clinicians, called Get Waivered Remote. An educational session was live-streamed via Zoom™. To foster interactivity, like in-person didactic conferences, participants were polled to facilitate discussion among presenters, learners, and facilitators during the broadcast Outcomes The RE-AIM framework was used for evaluation. Our program had a Reach encompassing 814 users that participated during the live-streamed event; Effectiveness with 73.79% reporting being somewhat familiar or very familiar with the practice of opioid dependency treatment with approved buprenorphine medications; Adoption with 95.15% reporting a favorable experience and 92.23% reporting it was similar or more enjoyable than their usual teaching; Implementation with 450 messages sent by 281 users to engage with presenters and other learners via Zoom chat in real time. Next steps Get Waivered Remote provides a proof-of-concept that a broadcast with a concurrent, interactive remote learning platform is feasible, low cost, and simple to execute. Further study is required to assess the ability of our group to maintain this innovation and also to measure its impact on the treatment of opioid use disorder.

Introduction: Although emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge. Methods: We conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified. Results: PubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs. Conclusion: Numerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients’ needs upon ED discharge.

Introduction: Burnout is a major threat to patient care quality and physician career longevity in emergency medicine. We sought to develop and implement a quality improvement process to engage emergency department (ED) faculty in identifying sources of burnout and generating interventions targeted at improving the work environment. Methods: In this prospective interventional study conducted at a large, urban, academic medical center, we surveyed a 60-person faculty group using the Professional Fulfilment Index (PFI), as well as burnout-relevant questions from the American Medical Association’s Mini-Z survey and the Maslach-Leiter framework for organizational burnout, in order to identify organizational sources of burnout. We assessed the relationship between burnout scores and responses to the Maslach-Leiter framework using univariate regression analysis. In a two-hour facilitated session, we shared survey results and led the group in a process using the six Maslach-Leiter domains to develop a rank-ordered list of interventions to reduce burnout in each domain. Results: In total, 47 of 60 faculty (78.3%) completed the survey and 45 faculty (75%) attended the discussion session. Of the 47 survey respondents, 14 (30%) met criteria for moderate to severe burnout. The respondents’ answers to the Maslach-Leiter organizational burnout domain questions were significantly correlated with their burnout scores (P

Objectives: Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED). Methods: We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations. Results: Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: “in-series”; “in-parallel modeling”; and “in-parallel supervision.” Conclusions: Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study.

Introduction: Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic. Methods: ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales. Results: We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were “to enhance my sense of community and connection” (81%) followed by “to support colleagues” (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/− 17.6) interquartile range: 73–89), NPPs were less comfortable speaking up (58.5 +/− 23.6) than attending physicians (77.8 +/− 25.0) (p = < 0.008). Conclusion: Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce.

Introduction: Adverse effects of administrative burden on emergency physicians have been described previously, but the impact of electronic health record documentation by academic emergency attendings on resident education is not known. In this observational study of a quaternary care, academic emergency department, we sought to assess whether the amount of time attending physicians spent on documentation affected the amount of time they spent teaching. Methods: A fourth-year emergency medicine (EM) resident observed 10 attending physicians over 42 hours during 11 shifts, recording their activities every 30 seconds. Activity categories were developed iteratively by the study team and validated through co-observation by an EM education fellow with a kappa of 0.89. We used regression analysis to assess the relationship between time spent documenting and time spent teaching, as well as the relationship between these two activities and all other attending activity categories. Results: Results demonstrate that time spent documenting was significantly and specifically associated with less time spent teaching, controlling for patient arrivals per hour; every minute spent on documentation was associated with 0.48 fewer minutes spent teaching (p

Introduction: In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations.” However, it is unknown whether New England emergency departments (ED) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013. Our objective was to determine this, as well as whether provider-specific audit and feedback for imaging had been implemented in these EDs. Methods: This survey study was exempt from institutional review board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and we followed up twice with repeat mailings to nonresponders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test. Results: A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway and 28% reported implementing a computerized decision support system. The most common interventions were for chest computed tomography (CT) in patients at low risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit and feedback, without significant interstate variation (range: 29-55%). Conclusion: One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority of them were using provider-specific audit and feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care. [West J Emerg Med.2017;18(3)454-458.]

Introduction: Emergency department (ED) crowding is widespread, and can result in care delays, medical errors, increased costs, and decreased patient satisfaction. Simultaneously, while capacity constraints on EDs are worsening, contributing factors such as patient volume and inpatient bed capacity are often outside the influence of ED administrators. Therefore, systems engineering approaches that improve throughput and reduce waste may hold the most readily available gains. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays and determine the most effective techniques. Methods: This prospective, before-and-after analysis of radiology process flow improvements in an academic hospital ED was exempt from institutional review board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely using Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013- 3/2016 and requiring plain film imaging were included. We analyzed electronic medical record data using Microsoft Excel and SAS version 9.4, and we used a two-sample t-test to compare data from the pre- and post-intervention periods. Results: Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.7 ± 4.2 minutes during the three months pre-intervention. It was reduced by 15% in the first three months (4.4 minutes [95% confidence interval [CI] 1.5-7.3]; to 24.3 ± 3.3 min, P=0.021), 19% in the following six months (5.4 minutes, 95% CI [2.7-8.2]; to 23.3 ± 3.5 min, P=0.003), and 26% one year following the intervention (7.4 minutes, 95% CI [4.8-9.9]; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in ED radiology processes. Conclusion: In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use. [West J Emerg Med. 2017;18(3)410-418.]

Introduction: While only 15-20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury. Methods: We obtained institutional review board approval for this randomized controlled study performed April 18, 2012—December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order-entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups. Results: Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p

Background Variability in the management of atrial fibrillation (AF) in the emergency department (ED) leads to avoidable hospital admissions and prolonged length of stay (LOS). In a retrospective single‐center study, a multidisciplinary AF treatment pathway was associated with a reduced hospital admission rate and reduced LOS. To assess the applicability of the AF pathway across institutions, we conducted a 2‐center study. Methods and Results We performed a prospective, 2‐stage study at 2 tertiary care hospitals. During the first stage, AF patients in the ED received routine care. During the second stage, AF patients received care according to the AF pathway. The primary study outcome was hospital admission rate. Secondary outcomes included ED LOS and inpatient LOS. We enrolled 104 consecutive patients in each stage. Patients treated using the AF pathway were admitted to the hospital less frequently than patients who received routine care (15% versus 55%; P

Introduction: Under regulations established by the Affordable Care Act, insurance plans must meet minimum standards in order to be sold through the federal Marketplace. These standards to become a qualified health plan (QHP) include maintaining a provider network sufficient to assure access to services. However, the complexity of emergency physician (EP) employment practices – in which the EPs frequently serve as independent contractors of emergency departments, independently establish insurance contracts, etc... – and regulations governing insurance repayment may hinder the application of network adequacy standards to emergency medicine. As such, we hypothesized the existence of QHPs without in-network access to EPs. The objective is to identify whether there are QHPs without in-network access to EPs using information available through the federal Marketplace and publicly available provider directories. Results: In a national sample of Marketplace plans, we found that one in five provider networks lacks identifiable in-network EPs. QHPs lacking EPs spanned nearly half (44%) of the 34 states using the federal Marketplace. Conclusion: Our data suggest that the present regulatory framework governing network adequacy is not generalizable to emergency care, representing a missed opportunity to protect patient access to in-network physicians. These findings and the current regulations governing insurance payment to EPs dis-incentivize the creation of adequate physician networks, incentivize the practice of balance billing, and shift the cost burden to patients.

Introduction: Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU). Methods: We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results: During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion: The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.

Introduction: Growing evidence supports emergency physician (EP)-performed point-of-care ultrasound (PoC US). However, there is a utilization gap between academic emergency departments (ED) and other emergency settings. We elucidated barriers to PoC US use in a multistate sample of predominantly non-academic EDs to inform future strategies to increase PoC US utilization, particularly in non-academic centers. Methods: In 2010, we surveyed ED directors in five states (Arkansas, Hawaii, Minnesota, Vermont, and Wyoming; n=242 EDs) about general ED characteristics. In four states we determined barriers to PoC US use, proportion of EPs using PoC US, use privileges, and whether EPs can bill for PoC US. Results: Response rates were >80% in each state. Overall, 47% of EDs reported PoC US availability. Availability varied by state, from 34% of EDs in Arkansas to 85% in Vermont. Availability was associated with higher ED visit volume, and percent of EPs who were board certified/board eligible in emergency medicine. The greatest barriers to use were limited training (70%), expense (39%), and limited need (perceived or real) (32%). When PoC US was used by EPs, 50% used it daily, 44% had privileges not requiring radiology confirmation, and 34% could bill separately for PoC US. Only 12% of EPs used it ≥80% of the time when placing central venous lines. Conclusion: Only 47% of EDs in our five-state sample of predominantly non-academic EDs had PoC US immediately available. When available, the greatest barriers to use were limited training, expense, and limited need. Recent educational and technical advancements may help overcome these barriers.

Introduction: Telemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use. Methods: We analyzed data from the National Emergency Department Inventory-New England survey, which assessed basic ED characteristics in 2014. The survey queried directors of every ED (n=195) in the six New England states (excluding federal hospitals and college infirmaries). Descriptive statistics characterized ED telemedicine use; multivariable logistic regression identified independent predictors of use. Results: Of the 169 responding EDs (87% response rate), 82 (49%) reported using telemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of non-users, p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); and less likely to have 24/7 access to neurology (p

Introduction: Emergency department observation units (EDOUs) are a valuable alternative to inpatient admissions for ED patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU. Methods: This institutional review board-approved, retrospective study was performed at a 999-bed quaternary care academic Level I adult and pediatric trauma center, with approximately 114,000 ED visits annually and a 32-bed adult EDOU. We retrospectively reviewed the EDOU patient database for all MRI examinations done from October 1, 2013, to September 30, 2015. We sought to describe the most frequent uses for MRI during EDOU admissions and reviewed EDOU length of stay (LOS) to determine whether the use of MRI was associated with any change in LOS. Results: A total of 22,840 EDOU admissions were recorded during the two-year study period, and 4,437 (19%) of these patients had a least one MRI examination during their stay; 2,730 (62%) of these studies were of the brain, head, or neck, and an additional 1,392 (31%) were of the spine. There was no significant difference between the median LOS of admissions in which an MRI study was performed (17.5 hours) and the median LOS (17.7 hours) of admissions in which an MRI study was not performed [p=0.33]. Conclusion: Neuroimaging makes up the clear majority of MRI examinations from our EDOU, and the use of MRI does not appear to prolong EDOU LOS. Future work should focus on the appropriateness of these MRI examinations to determine potential resource and cost savings.

Abstract Introduction Effective health care delivery provided by trauma teams can be enhanced through teaching and training multidisciplinary team members the essential elements of crisis resource management (CRM). The authors originally implemented a trauma team exercise focused on the resident learners and supported the central elements of advanced trauma life support. In 2009 this program was put on hold and a needs assessment was conducted. As a result the curriculum was rewritten to focus on the entire team training and CRM principles. The materials presented and the simulation scenarios enclosed are to highlight and teach role clarity, effective communication, resource management and utilization, and global assessment. Methods This resource takes approximately 4 hours to complete with the first hour consisting of introductions, orientation to the simulations, and a review of the institution's trauma system. The remaining 3 hours are comprised of three simulation scenarios (i.e., a 70-year-old man who is injured in a single-car collision, a 20-year-old woman who is 32 weeks pregnant and sustains injuries following intimate partner violence, and a multiple-case scenario). This is followed by a debriefing and sharing of lessons learned. Results To date, seven teams with 34 learners have been trained with this module. Discussion This educational unit successfully brings together multidisciplinary teams consisting of emergency medicine and surgery residents, nurses, patient care assistants, and medical students, to learn about CRM.

Emergency department (ED) crowding continues to be a major challenge and has important ramifications for patient care quality. One strategy to decrease ED crowding has been to implement alternative pathways to traditional hospital admission. Through a survey-based retrospective cohort study, we aimed to assess the patient experience for those who agreed to transfer and admission to an affiliated community hospital from a large, academic center’s ED. In all, 85% of participants rated their overall experience as either great or good, 92% did not find it hard to make the decision to be transferred, and 95% found the transfer process itself to be easy.

COVID-19 has highlighted an opportunity for medical professionals to engage in online Public Engagement with Science (PES). Currently a popular platform for PES is Reddit. Reddit provides an Ask Me Anything (AMA) format for subject matter experts to answer questions asked by the public. On March 11, 2020, from 2:00 to 4:00pm EST, two Emergency Department physicians from Massachusetts General Hospital hosted an AMA session on coronavirus. We retroactively conducted an analysis of the questions and answers from this AMA session in order to better understand the public's concerns around coronavirus and identify future opportunities for medical experts to leverage the Reddit AMA format in communicating with the general public. Results suggested that participants sought not only to obtain information, but to engage in discussion, and did so with each other in the absence of expert responses. The majority of bi-directional discussion occurred between participants. Due to the volume of questions and ratio of experts to participants, not all questions were answered. More posts provided facts or opinions, than posts that providing resources or requesting resources.

Background: Patient-centered approaches in the evaluation of patient experience are increasingly important priorities for quality improvement in health-care delivery. Our objective was to investigate common themes in patient-reported data to better understand areas for improvement in the emergency department (ED) experience. Methods: A large urban, tertiary-care ED conducted phone interviews with 2607 patients who visited the ED during 2015. Patients were asked to identify one area that would have significantly improved their visit. Transcripts were analyzed using content analysis, and the results were summarized with descriptive statistics. Results: The most commonly cited themes for improvement in the patient experience were wait time (49.4%) and communication (14.6%). Related, but more nuanced, themes emerged around the perception of ED crowding and compassionate care as additional important contributors to the patient experience. Other frequently cited factors contributing to a negative experience were the discharge process and inability to complete follow-up plan (8.0%), environmental factors (7.9%), perceived competency of providers in the evaluation or treatment (7.4%), and pain management (7.4%). Conclusions: Wait times and perceptions of ED crowding, as well as provider communication and compassionate care, are significant factors identified by patients that affect their ED experience.

Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients.From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection.We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.