Search

Introduction The evaluation of peer‐reviewed cases for error is key to quality assurance (QA) in emergency medicine, but defining error to ensure reviewer agreement and reproducibility remains elusive. The objective of this study was to create a consensus‐based set of rules to systematically identify medical errors. Methods This is a prospective, observational study of all cases presented for peer review at an urban, tertiary care, academic medical center emergency department (ED) quality assurance (QA) committee between October 13, 2015, and September 14, 2016. Our hospital uses an electronic system enabling staff to self‐identify QA issues for subsequent review. In addition, physician or patient complaints, 72‐hour returns with admission, death within 24 hours, floor transfers to ICU

BACKGROUND The Society for Academic Emergency Medicine Board of Directors convened a Task Force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The Task Force surveyed academic emergency department (ED) Chairs and Residency Program Directors. METHODS The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member Chairs and their respective Residency Program Directors (PDs) in 2021. We surveyed 125 Chairs with their self-identified PDs. The survey sampled hiring, state independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS Of the AACEM-member Chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast track settings, 80% work in the main ED and 54% in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents report that APPs manage high-acuity patients without attending involvement. Two-thirds of Chairs believe that APPs contribute positively to the quality of patient care, while 44% believe APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic emergency department within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

Study Objectives: Altered mental status (AMS) is frequently associated with poor outcomes across a wide spectrum of conditions including infections. This study aims to identify whether AMS in emergency department (ED) patients with COVID-19 is independently associated with in-hospital mortality. Methods: This was a retrospective multicenter cohort study. We included all patients with a positive SARS-CoV-2 PCR within 2 weeks of presentation, who were admitted from the ED of three hospitals in the greater Boston area between March and August 2020. The primary covariate of interest was ED AMS at ED arrival and the primary outcome was in-hospital mortality. The ED charts were abstracted for demographics, comorbid conditions, symptoms, laboratory testing, and radiology testing along with in-hospital outcomes. AMS was defined by documentation of changes in mental status from baseline. We used logistic regression modeling with backwards elimination to determine an adjusted estimate for the independent association of AMS with mortality. Results: We included 824 visits with 51% male, a mean age was 67.1 (SD 17.0) and 153 (18.6%) had AMS. There were 132 deaths for an overall mortality rate of 16.1%. Patients with AMS had in-hospital mortality of 38.2% (95% CI 30.4%-46.4%), compared to 11.1% (8.8%-13.7%) for patients without AMS (p

Recent news stories have explicitly stated that patients with symptoms of COVID‐19 were “turned away” from emergency departments. This commentary addresses these serious allegations, with an attempt to provide the perspective of academic emergency departments (EDs) around the Nation. The overarching point we wish to make is that academic EDs never deny emergency care to any person.

Postgraduate training in emergency medicine (EM) varies in length among different programs. This fact creates a dilemma for applicants to the specialty of EM and prevents EM educators from reaching a consensus regarding the optimal length of training. Historically, EM training existed in the postgraduate year (PGY) 1-3, 2-4, and 1-4 formats, until the PGY 2-4 program became obsolete in 2011-2012. Currently, three-quarters of EM programs follow the PGY 1-3 format. In this article, we clarify for the applicants the main differences between the PGY 1-3 and PGY 1-4 formats. We also discuss the institutional, personal, and graduate considerations that explain why an institution or an individual would choose one format over the other.

Background: The value of systematic evaluation of both patient and physician identified QA issues in emergency medicine remains poorly characterized as a marker for Emergency Department (ED) quality assurance. Objective: The objective of this study was to determine whether systematic screening and evaluation of patient and physician concerns is useful for identifying physician errors resulting in either an adverse event or a near miss event. Methods: Retrospective, observational cohort study of consecutive patients presenting to an urban, tertiary care academic medical center ED with an annual volume of 57,000 patients between January 2008 and December 2014. Our hospital has an electronic system that easily allows physicians to register a concern or self-identify a potential QA issue for subsequent review. In our system, both patient and physician concerns are then assigned for review by physician evaluators not involved with the patients’ care. Patient complaints were initially prescreened by an experienced evaluator and those not pertaining to possible physician error, such as complaints related to billing, creature comfort, communication, nursing related complaints and waiting times were eliminated unless the reviewer identified a possible physician error. If in addition to these other factors, a potential QA issue was present, the case was referred to the QA committee Reviewers are prompted to use a structured 8-point Likert scale to assess for the presence of error and adverse events. If a reviewer assessed that the case involved a possible error or adverse event that resulted in the need for intervention, additional treatment, or caused patient harm, it was referred to a 20-member quality assurance (QA) committee of ED physicians and nurses who made a final determination as to whether or not an error or adverse event occurred. Results: We identified 570 concerns within a data-base of 383,419 ED presentations, of which 33 were patient-generated and 537 were physician-generated. In the subset of cases where there was a complaint by either patient or physician, physician errors that led to a preventable adverse event were detected in 2.9% of cases (95%CI 1.52% to 4.28%). Further analysis revealed that 9.1% (95%CI 2-24%) of patient complaints correlated to preventable errors leading to an adverse event. In contrast, 2.6% (2-4%) of QA concerns made by a physician alone were found to be preventable physician errors leading to an adverse event. Near miss events (errors without adverse outcome) were more accurately reported by physicians, with physician error found in 12.1% of reported cases (95%CI 10-15%) and in 9.1% of those reported by patients (95%CI 2-24%). Adverse events in general that were not deemed to be due to preventable physician error were found in 12.1% of patient complaints (95%CI 3-28%) and in 5.8% of physician QA concerns (95%CI 4-8%). Conclusion: Screening and systemized evaluation of emergency department patient and physician complaints may be an underutilized and efficient quality assurance tool. Patient complaints may more accurately identify physician errors that result in preventable adverse events, while physician QA concerns may be more likely to uncover a near miss that did not lead to an adverse event.

Introduction Differentiating shock etiologies is a challenging task in the Emergency Department (ED); even the strongest clinical predictors leave some diagnostic uncertainty. This study sought to establish an evidence base for using clinical covariates in the diagnostic evaluation of septic shock. Methods We conducted a prospective, observational study of consecutive ED patients with shock from November 11, 2012 to September 23, 2013. We included all patients at least 18 years old with shock, defined as new vasopressor requirement, systolic blood pressure less than 90 mmHg after at least 1 L of crystalloid or 2 units packed red blood cells, or systolic blood pressure less than 90 mmHg and fluids withheld due to concern for fluid overload. Multivariate logistic regression and recursive partitioning models were constructed, predicting septic cause of shock. The logistic regression model was derived using first 500 patients, and validated with the subsequent 200 patients. Results In the derivation cohort, 55.6% (95% confidence interval: 51.2%-60.0%) were septic, and 20.8% (17.2%-24.4%) died during hospitalization. The multivariate model (derivation area under the curve = 0.88, validation area under the curve = 0.89) identified predictors of septic shock, including temperature more than 100.4°F (odds ratio 4.6, 2.3-9.2) and history of fever (odds ratio 9.2, 4.4-19.2); however, only 153 of 277 (55.3%, 49.5%-61.2%) patients with septic shock had either of these findings. In the recursive partitioning model, if all predictors were absent, the probability of sepsis causing shock was 21% (16.6%-25.6%). Conclusions Clinical data can predict the presence of sepsis causing shock in the ED in most patients. The remaining diagnostic uncertainty provides an opportunity for adding novel diagnostic testing.

INTRODUCTION: The pyruvate dehydrogenase complex (PDH) is an essential enzyme in aerobic metabolism;. Ketones are known to inhibit PDH activity, but the extent of this inhibition is unknown in patients with diabetic ketoacidosis (DKA).RESEARCH DESIGN AND METHODS: We enrolled adult patients presenting to the emergency department in hyperglycemic crisis. Patients were classified as DKA or hyperglycemia without ketoacidosis based on laboratory criteria. Healthy controls were also enrolled. PDH activity and quantity were measured in isolated peripheral blood mononuclear cells. We compared PDH values between groups and measured the relationship of PDH values to measures of acid-base status.RESULTS: 27 patients (17 with DKA) and 31 controls were enrolled. Patients with DKA had lower PDH activity and quantity as compared to the two other groups. PDH activity was significantly correlated with serum bicarbonate and pH, and inversely correlated with the anion gap.CONCLUSION: DKA is associated with greater suppression of PDH activity than hyperglycemia without ketoacidosis, and this is correlated with measures of acid-base status. Future studies may determine whether PDH depression plays a role in the pathophysiology of DKA and whether modification of PDH could decrease time to DKA resolution. This article is protected by copyright. All rights reserved.

Author(s): Henning, Daniel J.; Oedorf, Kimie; Day, Danielle E.; Redfield, Colby S.; Huguenel, Colin J.; Roberts, Jonathan C.; Sanchez, Leon D.; Wolfe, Richard E.; Shapiro, Nathan I. | Abstract: Introduction: Strategies to identify high-risk emergency department (ED) patients often use markedly abnormal vital signs and serum lactate levels. Risk stratifying such patients without using the presence of shock is challenging. The objective of the study is to identify independent predictors of in-hospital adverse outcomes in ED patients with abnormal vital signs or lactate levels, but who are not in shock.Methods: We performed a prospective observational study of patients with abnormal vital signs or lactate level defined as heart rate ≥130 beats/min, respiratory rate ≥24 breaths/min, shock index ≥1, systolic blood pressure l90mm/Hg, or lactate ≥4mmole/L. We excluded patients with isolated atrial tachycardia, seizure, intoxication, psychiatric agitation, or tachycardia due to pain (ie: extremity fracture). The primary outcome was deterioration, defined as development of acute renal failure (creatinine 2x baseline), non-elective intubation, vasopressor requirement, or mortality. Independent predictors of deterioration after hospitalization were determined using logistic regression.Results: Of 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were excluded, leaving 532 for analysis. Of these, 53/532 (9.9±2.5%) deteriorated after hospital admission. Independent predictors of in-hospital deterioration were: lactate g4.0mmol/L (OR 5.1, 95% CI [2.1–12.2]), age ≥80 yrs (OR 1.9, CI [1.0–3.7]), bicarbonate l21mEq/L (OR 2.5, CI [1.3–4.9]), and initial HR≥130 (OR 3.1, CI [1.5–6.1]).Conclusion: Patients exhibiting abnormal vital signs or elevated lactate levels without shock had significant rates of deterioration after hospitalization. ED clinical data predicted patients who suffered adverse outcomes with reasonable reliability.

Variceal hemorrhage is associated with high morbidity and mortality. A balloon tamponade device (BTD), such as the Sengstaken-Blakemore or Minnesota tube, may be used in cases of variceal hemorrhage. While these devices may be effective at controlling acute bleeding, the effect on patient outcomes remains less clear. We sought to describe the number of patients with variceal hemorrhage and a BTD who survive to discharge, survive to one-year, and develop complications related to a BTD.In this retrospective study, we identified patients at a single, tertiary care center who underwent placement of a BTD for upper gastrointestinal hemorrhage between 2003 and 2014. Patient characteristics and outcomes were summarized using descriptive statistics.34 patients with a BTD were identified. Median age was 57.5 (IQR 47-63) and 76% (26/34) were male. Approximately 59% (20/34) of patients survived to discharge, and 41% (13/32) were alive after one year. Two patients were lost to follow-up. Of those surviving to discharge, 95% (19/20) had undergone transjugular intrahepatic portosystemic shunt (TIPS), while 36% (5/14) of patients who did not survive to discharge had TIPS (p0.01). One complication, an esophageal perforation, was identified and managed conservatively.In this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy.

Objectives To create a risk prediction rule for delirium in elderly adults in the emergency department (ED) and to compare mortality and resource use of elderly adults in the ED with and without delirium. Design Prospective observational study. Setting Urban tertiary care ED. Participants Individuals aged 65 and older presenting for ED care (N = 700). Measurements A trained research assistant performed a structured mental status assessment and attention tests, after which delirium was determined using the Confusion Assessment Method. Data were collected on participant demographics, comorbidities, medications, ED course, hospital and intensive care unit (ICU) admission, length of stay, hospital charges, 30-day rehospitalization, and mortality. Results Nine percent of elderly study participants had delirium. Using logistic regression, a delirium prediction rule consisting of older age, prior stroke or transient ischemic attack, dementia, suspected infection, and acute intracranial hemorrhage was created had good predictive accuracy (area under the receiver operating characteristic curve = 0.77). Admitted participants with ED delirium had longer median lengths of stay (4 vs 2 days) and were more likely to require ICU admission (13% vs 6%) and to be discharged to a new long-term care facility (37% vs 9%) than those without. In all participants, ED delirium was associated with higher 30-day mortality (6% vs 1%) and 30-day readmission (27% vs 13%). Conclusion This risk prediction rule may help identify a group of individuals in the ED at high risk of developing delirium who should undergo screening, but it requires external validation. Identification of delirium in the ED may enable physicians to implement strategies to decrease delirium duration and avoid inappropriate discharge of individuals with acute delirium, improving outcomes.

Background: Prior studies show that lactate is a useful prognostic marker in sepsis. Objective: To study the feasibility and accuracy of a point-of-care (POC) analyzer capable of performing bedside serum lactate measurements; and to determine if other measurements (pH, base excess) are predictive of mortality. Methods: Design: prospective cohort study of adult (age 18 years or older) Emergency Department (ED) patients with suspected infection during the study period of May 2006 through March 2007. Setting: A 55,000-annual-visit urban tertiary care ED. Intervention: A point-of-care device (i-STAT, Abbott Point of Care Inc., Princeton, NJ) was deployed using a standardized training and quality assurance process. Using POC testing, we measured serum lactate, pH, and base excess, as well as concomitant lactate measurement via a central laboratory. Statistics: Area under the curve (AUC) for receiver operator characteristic curve, Bland-Altman statistics along with a correlation coefficient, and relative risk with 95% confidence intervals reported. Results: There were 699 patients enrolled, of whom 34 (4.9%) died. The AUCs for mortality prediction were: POC lactate 0.72, laboratory lactate 0.70, pH measurement 0.60, and base excess 0.60. Bland-Altman showed that POC lactate was, on average, 0.32 (95% confidence interval −0.35–0.98) lower than laboratory lactate, with agreement kappa = 0.97. Conclusions: A point-of-care testing device provides a reliable and feasible way to measure serum lactate at the bedside. The pH and base excess were less helpful.

Dr. Daniel McGillicuddy: The patient is a 50-year-oldwoman who was involved in a single car, high-speed motorvehicle collision. The patient was an unrestrained driver ina car without air bags who sustained severe blunt forcefacial trauma secondary to the steering wheel, and wasbrought in as a non-trauma to this community hospital. Shewas also intoxicated and agitated. The patient was unableto provide a past medical history, social history or anyinformation with respect to the accident. The pre-hospitalfingerstick glucose level was normal. The patient’s vitalsigns were a heart rate of 88 beats/min, a blood pressure of160/palpation mmHg, a respiratory rate of 24 breaths/minand an oxygen saturation of 96% on room air. The patientdid not have a temperature recorded. The physical exami-nation revealed a patient who was awake, but agitated. Shewas in cervical spine immobilization as well as immobi-lized on a spine board. The head examination revealedblunt trauma to the left orbit and mid face. She had peri-orbital edema on the left, bilateral massive epistaxis, andshe was actively vomiting blood. The midface was stable,the trachea was midline, and she had normal bilateralbreath sounds. The heart sounds were regular, there was nojugular venous distention, and the pulses were fullthroughout. The abdomen was obese, soft and non-tender.The FAST examination was without free fluid. The pelviswas stable. The Glasgow Coma Score was 12 due toaltered speech. The back and extremity examinations werenormal.Dr. Peter Rosen: Dr. Ban, what is your assessment ofthis patient?Dr. Kevin Ban: The intoxicated, combative traumapatient presents unique challenges for the EmergencyPhysician (EP). The combative behavior may be secondaryto any number of underlying causes, including intoxication(drug or alcohol), head injury, hypoxemia, hypovolemicshock or underlying medical conditions (diabetes withhypoglycemia). The most important priority for the EP is toobtain immediate and definitive control of the patient’sairway to facilitate treatment and diagnosis of the severelyinjured patient. There is controversy as to whether or not toparalyze these patients or to sedate them without additionalneuromuscular blockade as is usually done in a rapidsequence intubation (RSI).Dr. Rosen: Dr. Davis, what is your opinion regardingintubation with sedation alone versus a RSI with neuro-muscular blockade?Dr. Daniel Davis: This is going to be a tough airway,and I’m a bit reluctant to paralyze someone like this. Shehas multiple features that raise concerns about being able tointubate her successfully: obesity, c-collar, facial trauma,blood in the airway. It is reasonable to consider ketamine inthis patient, which might allow an attempt to inspect the

OBJECTIVES: To identify independent risk factors for death in elderly emergency department (ED) patients admitted for infection and to derive and validate a mortality-prediction rule for such patients. DESIGN: Prospective cohort study. SETTING: Tertiary hospital ED with 55,000 annual visits. PARTICIPANTS: ED patients aged 65 and older admitted for infection between December 2003 and September 2004 in the derivation cohort and October 2005 and October 2006 in the validation cohort. MEASUREMENTS: Primary outcome: 28-day in-hospital mortality. Data were extracted from charts, and multivariate logistic regression were performed to identify independent mortality predictors. A prediction model was constructed and then validated in a second cohort. RESULTS: Nine hundred thirty-five patients were included in the derivation cohort and 2,015 in the validation cohort. Mortality was 6% in the derivation cohort and 7% in the validation cohort. In the derivation cohort, logistic regression revealed five independent mortality predictors: respiratory compromise (respiratory rate >20 breaths per minute or hypoxemia) (odds ratio (OR)=4.0, 95% confidence interval (CI)=1.7–9.4), tachycardia (heart rate ≥120 betas per minute; OR=3.2, 95% CI=1.6–6.3), cardiovascular failure (systolic blood pressure

Dr. Carlo Rosen: The patient was a 67-year-old manwho just got off an airplane from Florida complaining ofanterior neck swelling that developed either late the nightprior or early that morning. He was concerned enough inFlorida that he wanted to come to Boston, where all hisdoctors were, so he obtained a flight to Boston with hiswife. He said over the past few hours, the swelling hadgotten worse, and that he had developed a little bit of ahoarse voice. Initially he got put into one of our resusci-tation rooms, and a quick history revealed that he was oncoumadin for atrial fibrillation. He also denied fevers,denied any history of anything like this happening in thepast, denied rash or any pain or discomfort anywhere else,and was able to give a full history by himself. Other pastmedical history was significant for a previous carotid stentand asthma. He did say he had allergies to shellfish,associated with a rash, and took no other medications butthe coumadin. Are there any questions?Dr. Richard Wolfe: How many hours passed from theonset of his symptoms to the point he presented?Dr. C. Rosen: He was vague about the exact timing. Heprobably had symptoms the night before starting with theswelling, and the voice change happened over the past fewhours.Dr. Wolfe: You saw him roughly at what time?Dr. C. Rosen: Probably early afternoon. He took a taxifrom the airport to the Emergency Department (ED).Dr. C. Rosen: Tomethereweretwoworrisomepartsto the history. One was the swelling which had gone onfor probably 18 h. The second, and more concerning,was the voice change, which hesaidhadoccurredover2–3 h.Dr. Wolfe: I am not clear why he was taking coumadin.There was absolutely no history of any trauma, correct?Dr. C. Rosen: There was no history of trauma. He wason coumadin for atrial fibrillation, and said he had beentaking his usual dose. On physical examination the vitalswere: temperature of 36.5 C (97.7 F,) pulse 117 beats perminute, blood pressure 156/88 torr., respirations 25 breathsper minute, and oxygen saturation 99% on room air. Helooked very comfortable. The only alarming thing aboutthe examination was he had a slightly hoarse voice. I thinkwe picked up the voice changes more than he himself or hiswife did. He clearly had anterior submandibular neckswelling from the whole anterior mid to upper part of theneck. He had some tongue elevation and some sublingualecchymosis; it was not woody, but it was definitely feelingfull. The rest of the examination was normal. He wastotally appropriate and wide awake and not in a whole lotof distress.

BACKGROUND: Current data suggest that 30%-50% of patients with syncope leave the hospital without a defined etiology of their syncopal event. Recent studies have shown significant differences in both presentation and therapy in women with coronary disease and congestive heart failure. METHODS: To assess the impact of sex on the frequency of syncope and the rate of identifying a specific etiology among elderly patients who present to the emergency department (ED), a retrospective chart review was performed during a 1-year period. Consecutive patients older than 65 years presenting with syncope to a large urban teaching hospital were enrolled. Inclusion criterion was documented loss of consciousness with no other obvious etiology of loss of consciousness such as stroke or seizure. Charts were screened for presenting history, ethnicity, sex, comorbid conditions, living circumstances, outpatient medication, and cardiac risk factors and outcomes including acute coronary syndromes, myocardial infarction, and death. RESULTS: During 1 year of observation, 7496 women (60%) of 12,401 patients over the age of 65 presented to our ED, and 219 (2.9%) of these met inclusion criteria for syncope. In comparison, 4905 (40%) men presented to the ED, 104 (2.1%) of whom had syncope (relative risk of syncope for women vs men, 1.38; 95% confidence interval, 1.09-1.74). Men were more likely to have comorbid conditions including coronary artery disease (p < or =.01), prior myocardial infarction (p < or =.03), and diabetes mellitus (p < or =.03) than were women. No sex differences were noted in living circumstances, such as living alone, with assistance, or in an institution. Forty-two percent of patients received no diagnosis on discharge from the hospital. Sixty-nine of 147 women admitted (47%) had no etiology of their syncope as compared to 27 (32%) of men. The relative risk for no diagnosis in women versus men was 1.67 (95% confidence interval, 1.07-2.61). CONCLUSIONS: Considerable numbers of patients presenting to EDs with syncope remain without a diagnosis. Women, despite being less likely to have concomitant coronary artery disease or diabetes, are significantly more likely to present to an ED with syncope, yet less likely to be discharged with a defined etiology.

Introduction: The Centers for Medicare and Medicaid Services (CMS) requires reporting of multiple time-sensitive metrics. Most facilities use triage time as the time of arrival. Little is known about how long patients wait prior to triage. As reimbursement to the hospital may be tied to these metrics, it is essential to accurately record the time of arrival. Our objective was to quantify the time spent waiting to be triaged for patients arriving to the emergency department (ED). Methods: We conducted this study in an urban, academic, tertiary care center with approximately 54,000 annual ED visits. All patients arriving to the ED from November 1, 2012, to October 1, 2013, were enrolled. If patients didn’t go directly to a bed or triage, an observer greeted patients as they entered the ED and recorded the time of arrival. The triage time was recorded as normal. We calculated the difference between the arrival time and triage time. Results: There were 50,576 patient visits during the study period. Of these, 7,795 (15.4%) patients did not go directly to a bed or triage. For patients who waited for triage, median time from arrival to triage was 11 minutes (IQR 5-19, range 1-105). When stratified by the number of new patients who arrived in the ED in the previous hour, the percentage of greeted patients who waited more than 10 minutes for triage was: 0-5 new patients – 12.4%; 6-10 new patients – 48.8%; 11-15 new patients – 64.4%; 16+ new patients – 68%. Conclusion: Patients often waited more than 10 minutes to be triaged. As the number of patients registered in the previous hour increased, the percentage of patients who waited more than 10 minutes for triage increased significantly. During times of peak volume, 8.5% of all patients arriving to the ED waited more than 10 minutes for triage. This wait is not accounted for in the normal reporting of ED throughput times and metrics. [West J Emerg Med. 2015;16(1):–0.]

Objective: To ascertain the status of journal club within emergency medicine (EM) residency programs and to describe 3 currently used formats. Methods: The directors of U.S. Residency Review Committee for Emergency Medicine (RRC-EM)-approved residency programs were surveyed to determine the features of their programs' journal clubs. Responses to 3 questions assessing the degree of satisfaction (5-item scales from very good to very poor) with the “current format,” “resident participation,” and “faculty participation” from the survey were grouped according to the program director's impressions of resident and faculty “enjoyment” (2 3-item scales) and whether the journal club is a “success” (3-item scale) to develop an overall satisfaction index. Three journal club formats currently in use at EM residencies are described in detail. Results: Of the 101 directors surveyed, 91 (90%) responded. The respondents' overall satisfaction index was highest when the journal club was held in the evening (p < 0.008) or at a faculty member's home (p < 0.0004). The format of the journal club (e.g., by topic, with a statistical focus, with a research design focus, or as a clinical practice update) was not associated with the overall satisfaction index. Conclusion: Journal clubs associated with EM residencies vary in format and perceived success. The 3 representative journal clubs illustrate different format options.

Background: Academic emergency physicians have expressed concern that increased clinical workloadand overcrowding adversely affect clinical teaching.Objectives: To evaluate the influence of clinical workload and attending physicians’ teaching characteris-tics on clinical teaching in the emergency department (ED).Methods: This was a prospective observational study using learner satisfaction assessment tools to evalu-ate bedside teaching. On days when a research assistant was available, all ED residents and attending phy-sicians were queried. A total of 335 resident surveys were administered over nine months (89% response).Clinical workload was measured by perception and patient volume. Teaching quality and characteristicswere rated on ten-point scales. A linear mixed-effects model was used to obtain adjusted impact estimatesof clinical workload and teaching attributes on teaching scores while controlling for individual attendingphysicians’ teaching ability and residents’ grading tendencies.Results: No clinical workload parameter had a significant effect on teaching scores: residents’ workloadperception (b estimate, 0.024; p = 0.55), attending physicians’ workload perception (b estimate, 0.05; p =0.28), patient volume in patients per hour (b estimate, 0.010; p = 0.36), and shift type (b estimate, 0.19;p = 0.28). The individual attending physician effect was significant (p < 0.001) and adjusted in each case.In another model, the attending physicians’ learning environment established (b estimate, 0.12; p =0.005), clinical teaching skills (b estimate, 0.36; p < 0.001), willingness to teach (b estimate, 0.25; p

Dr. Peter Rosen: Today’s case concerns a 29-year-old man who was riding his motorcycle down a quiet neighbourhood street. Someone had attached a chain from a tree on one side of the street to the other, because of an impending block party. The cyclist neither knew about the party, nor saw the chain. He collided with it at about 40 miles per hour. Someone saw him lying on the side of the road and activated the pre-hospital system by calling 911.

Background Most patients admitted to the hospital from the emergency department (ED) with syncope do not have a myocardial infarction (MI), yet a common practice is to draw serial cardiac enzymes. Methods To assess the value of serial cardiac enzymes in elderly patients who present to the ED with syncope, a retrospective chart review was performed on consecutive patients aged 65 and older with syncope in an urban teaching hospital ED between July 1, 1998 and June 30, 1999. Charts were screened for presenting history, cardiac risk factors, testing, and outcomes including acute coronary syndromes, MI, death, and patients returning to the ED or admitted within 72 hours of discharge. Results 319 patients met the study criteria of syncope with confirmed loss of consciousness in the absence of seizure or stroke. 141 of 228 admitted patients (62%) had creatine phosphokinase (CPK) drawn and 5% of these had Troponin I (TnI). 3 of 141 patients, or 2.1% (95% CI [confidence interval]: 0.04%-6.09%), had positive cardiac enzymes during their hospitalization. CPK was positive in all 3, and TnI, drawn in 1 patient, was also positive. Two of these patients had chest discomfort and ST segment and T-wave abnormalities on electrocardiogram (ECG) in addition to a syncopal event. The third patient had dementia and could not recall the details surrounding her syncopal event. In addition, her baseline ECG demonstrated a left bundle branch block, limiting ECG interpretation. Conclusions Cardiac enzymes may be of little additional value if drawn routinely on elderly patients with syncope who are admitted to the hospital from the ED, unless they have other signs or symptoms suggestive of myocardial ischemia.

The objective was to determine whether the administration of thiamine mitigates elevated lactate levels in patients with septic shock. Thiamine is essential for aerobic metabolism and we have found that thiamine levels are low and inversely correlated with lactate levels in patients with sepsis.