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Objective: This study determined if the caregivers of children in the emergency department (ED) have the same COVID-19 vaccination status as the child, the reasons they chose to not vaccinate the child, and self-identified barriers to vaccination to determine if the ED is appropriate for vaccination intervention.Methods: A survey was administered to caregivers of pediatric ED patients at four Children’s Hospitals in: Augusta, GA, Buffalo, NY, Madison, WI, and Sacramento, CA. Participants were asked about their and the child’s demographics, vaccination status, and barriers to vaccination. We used descriptive statistics, Cohen's kappa, and logistic regression to analyze responses.Results: 941 caregivers were considered for enrollment, and 800 consented to participation. Participants were 75% women with a mean age of 40.9 ± 8.9 years. 51% (409) of the pediatric ED patients were COVID-19 vaccinated, as were 74% (591) of the caregivers. There was variation across sites, but overall, 15% of caregivers of unvaccinated children wanted the child tobe vaccinated with the most common barriers to vaccination identified as safety data (25%), time availability (20%), and ability to obtain an appointment (13%). The most common reason for not wanting the child COVID-19 vaccinated was concern the vaccine didn’t work or had too many side effects.Conclusion: A small but clinically important group of pediatric ED patients are not COVID-19 vaccinated but their caregivers want them to be vaccinated, indicating that consideration should be given to offering vaccination in the ED. Reasons for avoiding COVID-19 vaccination were primarily concerns with efficacy and side effects.

Introduction: Providing appropriate healthcare for transgender, intersexual and non-binary (TIN) individuals remains a significant challenge, as this group experiences higher rates of health inequalities, discrimination, and barriers to accessing care. Emergency physicians (EP) often lack formal training and knowledge about caring for TIN patients, while comparatively less evidence is available for other healthcare professionals, including emergency nurses (EN). Therefore, our goal in this study was to explore the experiences, knowledge, and attitudes as well as education/training needs of both ENs and EPs in Germany regarding the care of TIN patients.Methods: In February 2023, we electronically surveyed EPs and ENs from emergency departments (ED) across Germany. The survey, developed through literature review and collaboration with experts and members of the TIN community, consisted of 15 closed-ended items divided into three sections: experiences and knowledge; attitudes; and education/training needs. We used standard descriptive statistics and tested for group differences using the chi-square test.Results: Of the approximately 1,665 EPs and ENs contacted, 502 completed the survey and were eligible for further analysis (30% response rate). Of the respondents, 233 (46%) were EPs and 269 (54%) were ENs, with ENs being significantly younger and with fewer years in practice. More than half reported experience caring for TIN patients (71% of ENs vs 61% of EPs; P = 0.002), but there were significant gaps in medical and non-medical knowledge. Attitudes toward TIN patients were generally positive, but differences in communication approaches were noted, with ENs significantly more likely than EPs to limit their communication with TIN patients to what was necessary (25% of ENs vs 17% of EPs; P = 0.006). Most respondents (55% of ENs and 58% of EPs) had no training in the management of TIN patients, with only 8% of EPs and 17% of ENs having received such training during their medical/nursing school education (P = 0.01). Both groups agreed that there is an urgent need to increase awareness of emergency medical care for TIN patients among ED staff.Conclusion: Both emergency physicians and nurses in Germany demonstrated deficits in knowledge of and clinical preparedness to care for patients in the ED who identify as transgender, intersexual and non-binary, indicating a clear need for enhanced education, training, and institutional support to improve emergency care for this vulnerable patient population. [West J Emerg Med. 2024;25(6)1–9.]

BACKGROUND: Patients presenting to the emergency department with recent palpitations are a diagnostic challenge when the arrhythmia and its symptoms have resolved prior to arrival. Newer smart watch technology, adept at detecting atrial fibrillation, can assist in the diagnostic evaluation of transitory palpitations. We report a case of cold drink-triggered atrial fibrillation whose diagnosis would not have been possible without the assistance of the patients smart watch. CASE PRESENTATION: A middle-aged man without cardiac history developed sudden rapid, irregular palpitations with shortness of breath while drinking a glass of cold juice. He activated his smart watch with 1-lead electrocardiography technology which detected rapid atrial fibrillation. He sought medical care, but while waiting, his symptoms-then 90 min in duration-spontaneously resolved. His initial diagnostic evaluation documented only sinus rhythm, as did several follow-up evaluations with cardiology the next several weeks. Had it not been for his smart watch, the etiology of his transitory palpitations would have remained undiagnosed. His physicians encouraged trigger avoidance. In the following months, he avoided rapid ingestion of cold drink, taking instead small sips. The atrial fibrillation has not recurred. CONCLUSIONS: The case illustrates the valuable contribution of smart watch technology in the diagnostic evaluation of patients with short-lived palpitations. The case also educates clinicians about cold drink and food as a trigger of paroxysmal atrial fibrillation. This trigger, like alcohol, can be modified. Cold drink trigger avoidance has been reported by patients to reduce atrial fibrillation recurrence and is a low-risk, cost-effective strategy that is often successful.

Child maltreatment remains a concerning source of morbidity and mortality in the United States, where more than 600,000 children are victims of abuse each year, with well-described, long-term consequences for physical and mental health. However, the US child welfare system is characterized by systemic racism and inequity. Black and Native American children are more likely to be evaluated and reported for suspected abuse despite evidence that race does not independently change their risk of being abused. Once reported to child protective services (CPS), these children are more likely to be removed from their homes and less likely to be reunited with their families than White children. Much of the inequity in this system starts at the front door, where a growing body of research demonstrates that bias regularly infiltrates decision-making in the initial clinical evaluation and management of suspected abuse. Minority children presenting to emergency departments (ED) are more likely to receive diagnostic testing and are more likely to be referred to CPS.In this editorial, we argue for the application of an equity lens to child protection in the ED. We discuss how emergency physicians can balance efforts to protect children from abuse with the imperative to protect children and families from the harms of an inequitable child welfare system. Our discussion concludes with concrete recommendations for emergency clinicians to participate in active bias mitigation and thoughtfully navigate their responsibilities as mandated reporters.

Introduction: Clinician burnout represents a significant occupational hazard among physicians, with a notably high prevalence among emergency physicians. The Stanford Professional Fulfillment Index (PFI) was developed to comprehensively assess various aspects of doctors’ work experiences, including professional fulfillment. In this study we aimed to validate the Turkish version of the PFI (T-PFI), a 16-item instrument designed to measure physicians’ professional fulfillment and burnout.Methods: In this cross-sectional study, we validated the T-PFI in two phases. The initial phase involved translating and culturally adapting the original PFI into Turkish. We evaluated the content validity of the translated version using item and scale content validity indices (I-CVI and S-CVI, respectively). The validated T-PFI was then distributed among a broad cohort of emergency physicians via an online survey to further assess its reliability and validity. The assessment tools included Cronbach α, confirmatory factor analysis, and content validity indices.Results: Of 1,434 physicians who were sent the survey, 425 fully completed it (29.6%). There was an almost equal distribution of 215 females and 210 males. Only 9.6% of the participants reported high levels of professional fulfillment, whereas a significant majority (79.1%) were susceptible to burnout. The Cronbach α values for the professional fulfillment and overall burnout scales were 0.87 and 0.90, respectively. The content validity was confirmed by I-CVI values exceeding 0.80 and an S-CVI/average relevance of 0.92. The confirmatory factor analysis demonstrated an acceptable model fit after adjustments.Conclusion: The T-PFI is a reliable and valid tool for assessing professional fulfillment and burnout among emergency physicians in Turkey. Effective interventions to mitigate burnout are essential to improve physician well-being in Turkish healthcare settings.

Introduction: The United States lacks a national interfacility patient transfer coordination system. During the coronavirus 2019 (COVID-19) pandemic, many hospitals were overwhelmed and faced difficulties transferring sick patients, leading some states and cities to form transfer centers intended to assist sending facilities. In this study we aimed to explore clinician experiences with newly implemented transfer coordination centers.Methods: This mixed-methods study used a brief national survey along with in-depth interviews. The American College of Emergency Physicians Emergency Medicine Practice Research Network (EMPRN) administered the national survey in March 2021. From September–December 2021, semi-structured qualitative interviews were conducted with administrators and rural emergency clinicians in Arizona and New Mexico, two states that started transfer centers during COVID-19.Results: Among 141 respondents (of 765, 18.4% response rate) to the national EMPRN survey, only 30% reported implementation or expansion of a transfer coordination center during COVID-19. Those with new transfer centers reported no change in difficulty of patient transfers during COVID-19 while those without had increased difficulty. The 17 qualitative interviews expanded upon this, revealing four major themes: 1) limited resources for facilitating transfers even before COVID-19; 2) increased number of and distance to transfer partners during the COVID-19 pandemic; 3) generally positive impacts of transfer centers on workflow, and 4) the potential for continued use of centers to facilitate transfers.Conclusion: Transfer centers may have offset pandemic-related transfer challenges brought on by the COVID-19 pandemic. Clinicians who frequently need to transfer patients may particularly benefit from ongoing access to such transfer coordination services.

Introduction: We aimed to assess antibiotic stewardship by quantifying the use of first-dose intravenous (IV) vs oral-only antibiotics and the frequency with which antibiotic class was changed for discharged patients. Secondary aims included the following: evaluation of the relative length of stay (LOS); differences in prescribing patterns between clinician types; differences between academic and community settings; assessment of prescribing patterns among emergency department (ED) diagnoses; and frequency of return visits for patients in each group.Methods: This was a retrospective cohort study including patients presenting to EDs with infections who were discharged from our Midwest healthcare system consisting of 17 community hospitals and one academic center. We included infection type, antibiotic class and route of administration, type of infection, LOS, return visit within two weeks, clinician type, and demographics. Data were collected between June 1, 2018–December 31, 2021 and analyzed using descriptive statistics.Results: We had 77,204 ED visits for patients with infections during the study period, of whom 3,812 received IV antibiotics during their visit. There were more women (62.4%) than men included. Of the 3,812 patients who received IV antibiotics, 1,026 (34.3%) were discharged on a different class of antibiotics than they received. The most common changes were from IV cephalosporin to oral quinolone or penicillin. Patients treated with IV antibiotics prior to discharge had a longer LOS in the ED (median difference of 102 minutes longer for those who received IV antibiotics). There was not a significant difference in the use of IV antibiotics between the academic center and community sites included in the study.Conclusion: Administering IV antibiotics as a first dose prior to oral prescriptions upon discharge is common, as is shifting classes from the IV dose to the oral prescription. This offers an opportunity for intervention to improve antibiotic stewardship for ED patients as well as reduce cost and length of stay.

BackgroundGlobal surgery research efforts have been criticized for failure to transition from problem identification to intervention implementation. We developed a context-appropriate trauma quality improvement (TQI) bundle to ameliorate care gaps at a regional referral hospital in Cameroon. We determined associations between bundle implementation and improvement in trauma resuscitation practices.MethodsWe implemented a TQI bundle consisting of a hospital-specific trauma protocol, staff training, a trauma checklist, provision of essential emergency trauma supplies in the resuscitation area, and monthly quality improvement meetings. We compared trends in target process measures (e.g., frequency and timing of vital sign collection and primary survey interventions) in the six-month period pre- and post-bundle implementation using Wilcoxon rank-sum and Fisher's exact tests.ResultsWe compared 246 pre-bundle patients with 203 post-bundle patients. Post-bundle patients experienced a greater proportion of all vital signs collected compared to the pre-intervention cohort (0 % pre-bundle vs. 69 % post-bundle, p < 0.001); specifically, the proportion of respiratory rate (0.8 % pre-bundle vs. 76 % post-bundle, p < 0.001) and temperature (7 % pre-bundle vs. 91 % post-bundle, p < 0.001) vital sign collection significantly increased. The post-bundle cohort had vital signs measured sooner (74 % vital signs measured within 15 min of arrival pre-bundle vs. 90 % post-bundle, p < 0.001) and more frequently per patient (7 % repeated vitals pre-bundle vs 52 % post-bundle, p < 0.001). Key primary survey interventions such as respiratory interventions (1 % pre-bundle vs. 8 % post-bundle, p < 0.001) and cervical collar placement (0 % pre-bundle vs. 7 % post-bundle, p < 0.001) also increased in the post-bundle cohort.ConclusionsThe implementation of a context-appropriate TQI bundle was associated with significant improvements in previously identified trauma care deficits at a single regional hospital. Data-derived interventions targeting frontline capacity at the local level can bridge the gap between identifying care limitations and improvement in resource-limited settings.

To assess the actual presence of underlying depressed skull fractures and traumatic brain injuries (TBI) on computed tomography (CT) in children with and without palpable skull fractures on physical examination following minor head trauma. This was a secondary analysis of a prospective, observational multicenter study enrolling 42,412 children

Background: Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers.Methods: This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality.Results: The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019–September 10, 2020) and the post-implementation period (September 11, 2020–December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45–2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as “good.”Conclusion: In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as “good.”

Introduction: Eye emergencies make up nearly 3% of US emergency department (ED) visits. While emergency physicians (EP) should diagnose and treat these ophthalmologic emergencies, many trainees report limited ocular exposure and insufficient training throughout their residency to confidently conduct a thorough slit-lamp exam.Methods: We created an interdisciplinary, simulation-based mastery learning (SBML) curriculum to teach emergency attending physicians how to operate the slit lamp with multimodal learning methodology at a tertiary academic center. The EPs first demonstrate their initial slit-lamp competency with a 20-item checklist, and they then review the necessary curricular content to pass their independent readiness test before completing their in-person teaching and demonstration session with an ophthalmology attending to demonstrate procedural mastery (minimal passing score >90%).Results: Fifteen EPs were enrolled; all completed the final exam of the curriculum. The pre- and post-curriculum checklist scores increased by an average of seven points (P = .002); 86.7% of EPs felt confident in completing a slit-lamp exam after the curriculum, compared to 20% at the beginning. Five of 15 reported teaching learners within the two-month post-curricular period, ranging from 5–30 students. The hands-on teaching was the most positively reviewed element of the curriculum.Conclusion: The SBML program successfully trained EPs on performing a comprehensive slit-lamp exam with promising results of downstream education to junior learners. We encourage other institutions to leverage SBML as a teaching modality for procedural-based training and advocate cross-discipline education initiatives.

Providing appropriate patient education during a medical encounter remains an important area for improvement across healthcare settings. Personalized resources can offer an impactful way to improve patient understanding and satisfaction during or after a healthcare visit. ChatGPT is a novel chatbot—computer program designed to simulate conversation with humans— that has the potential to assist with care-related questions, clarify discharge instructions, help triage medical problem urgency, and could potentially be used to improve patient-clinician communication. However, due to its training methodology, ChatGPT has inherent limitations, including technical restrictions, risk of misinformation, lack of input standardization, and privacy concerns. Medicolegal liability also remains an open question for physicians interacting with this technology. Nonetheless, careful utilization of ChatGPT in clinical medicine has the potential to supplement patient education in important ways.

OBJECTIVES: Precision medicine is data-driven health care tailored to individual patients based on their unique attributes, including biologic profiles, disease expressions, local environments, and socioeconomic conditions. Emergency medicine (EM) has been peripheral to the precision medicine discourse, lacking both a unified definition of precision medicine and a clear research agenda. We convened a national consensus conference to build a shared mental model and develop a research agenda for precision EM. METHODS: We held a conference to (1) define precision EM, (2) develop an evidence-based research agenda, and (3) identify educational gaps for current and future EM clinicians. Nine preconference workgroups (biomedical ethics, data science, health professions education, health care delivery and access, informatics, omics, population health, sex and gender, and technology and digital tools), comprising 84 individuals, garnered expert opinion, reviewed relevant literature, engaged with patients, and developed key research questions. During the conference, each workgroup shared how they defined precision EM within their domain, presented relevant conceptual frameworks, and engaged a broad set of stakeholders to refine precision EM research questions using a multistage consensus-building process. RESULTS: A total of 217 individuals participated in this initiative, of whom 115 were conference-day attendees. Consensus-building activities yielded a definition of precision EM and key research questions that comprised a new 10-year precision EM research agenda. The consensus process revealed three themes: (1) preeminence of data, (2) interconnectedness of research questions across domains, and (3) promises and pitfalls of advances in health technology and data science/artificial intelligence. The Health Professions Education Workgroup identified educational gaps in precision EM and discussed a training roadmap for the specialty. CONCLUSIONS: A research agenda for precision EM, developed with extensive stakeholder input, recognizes the potential and challenges of precision EM. Comprehensive clinician training in this field is essential to advance EM in this domain.

Introduction: Emergency department (ED) patients requiring immediate treatment often bypass a triage process that includes HIV screening. In this study we aimed to investigate the potential missed opportunity to screen these patients for HIV.Methods: We conducted this cross-sectional study in a municipal ED over a six-week period between June–August 2019. The patient population in this study arrived in the ED as a pre-notification from prehospital services or designated by the ambulance or walk-in triage nurse as requiring immediate medical attention. Medical student researchers collected demographic data and categorized patients into three clinical groups (trauma, medical, psychiatric). They documented the patient’s eligibility for HIV screening as determined by a physician and confirmed that the patient met criteria of clear mental status, controlled pain, stable vital signs, and ability to contribute to a medical history and physical examination. The student researchers did this at initial presentation and then again during the patient’s ED stay of up to eight hours. The study outcomes measured the percentage of total patients within each clinical group (trauma, medical, psychiatric) able to engage in the HIV screening process upon arrival and during an eight-hour ED stay.Results: On average, 700 patients per month are announced on arrival via overhead page, indicating that they require immediate medical attention. During the six-week study, 205 patients (approximately 20% of total) were enrolled: 114 trauma; 56 medical; and 35 psychiatric presentations. The average patient age was 53; 60% of patients were male. Niney-eight (48%) patients were eligible for HIV screening within an eight-hour ED stay; 63 (31%) were able to be screened upon initial presentation and 35 (17%) in the first eight hours of their ED visit. Within medical and trauma subgroups, there was no significant difference in the proportion (36%) of patients that could be screened upon presentation. Among the psychiatric presentations, only five (14%) were able to be screened during their hospital stay.Conclusion: Triage protocols for high-acuity medico-surgical patients resulted in a missed opportunity to screen 48% of patients for HIV. Acute psychiatric patients represented a particular missed opportunity. We advocate for universal HIV screening, facilitated through electronic best practice advisories and a modified triage tailored to higher acuity patients. Implementing these changes would ensure that HIV screening is not overlooked in high-acuity ED patients, leading to early detection and timely interventions.

Introduction: In this study we aimed to investigate the effects of incorporating Swedish-style fika (coffee) breaks into the didactic schedule of emergency medicine residents on their sleepiness levels during didactic sessions. Fika is a Swedish tradition that involves a deliberate decision to take a break during the workday and usually involves pastries and coffee. We used the Karolinska Sleepiness Scale to assess changes in sleepiness levels before and after the implementation of fika breaks.Methods: The study design involved a randomized crossover trial approach, with data collected from emergency medicine residents over a specific period. This approach was done to minimize confounding and to be statistically efficient.Results: Results revealed the average sleepiness scale was 4.6 and 5.5 on fika and control days, respectively (P = 0.004).Conclusion: Integration of fika breaks positively influenced sleepiness levels, thus potentially enhancing the educational experience during residency didactics.

Introduction: Hundreds of children suffer burn injuries each day, yet care guidelines regarding the need for acute inpatient treatment vs outpatient follow-up vs no required follow-up remain nebulous. This gap in the literature is particularly salient for the emergency clinician, who must be able to rapidly determine appropriate disposition.Methods: This was a retrospective review of patients presenting to a Level II pediatric trauma center, January 1, 2017–December 31, 2019, and discharged with an International Classification of Diseases, Rev 10, burn diagnosis. We obtained and analyzed demographics, burn characteristics, and follow-up data using univariate and bivariate analysis as well as logistic regression modeling. Patients were stratified into three outcome groups: group 1—patients who underwent emergent evaluation at a burn center or were admitted at their first follow-up appointment; group 2—patients who followed up at a burn center (as an outpatient) or at the emergency department (and were discharged home); and group 3—patients with no known follow-up.Results: A total of 572 patients were included in this study; 58.9% of patients were 1–5 years of age. Sixty-five patients met group 1 criteria, 189 patients met group 2 criteria, and 318 patients met group 3 criteria. Sixty-five percent of patients met at least one American Burn Association criteria, and 79% of all burns were second-degree burns. Flame and scald burns were associated with increased odds (odds ratio [OR] 1.21,O1.12) of group 1 vs group 2 + group 3 (P = 0.02, P < 0.001). Second/third-degree burns and concern for non-accidental trauma were also associated with increased odds of group 1 vs 2 or 3 (OR = 1.11, 1.35, P ≤ 0.001, 0.001, respectively). Scald burns were associated with increased odds of group 2 compared to group 3 (OR 1.11, P = 0.04). Second/third degree burns were also associated with increased odds of group 2 vs 3 (OR 1.19, P ≤ 0.001).Conclusion: There were few statistically significant variables strongly associated with group 1 (emergent treatment/admission) vs group 2 (follow-up/outpatient treatment) vs group 3 (no follow- up). However, one notable finding in this study was the association of scald burns with treatment (admission or follow-up) suggesting that the presence of a scald burn in a child may signify to clinicians that a burn center consult is warranted.

Introduction: Emergency medicine (EM) was recognized as a specialty in Israel in 1999. Fifty-nine of the 234 (25%) attending physicians working in emergency departments (ED) nationwide in 2002 were board-certified emergency physicians (EP). A 2012 study revealed that 123/270 (45%) of ED attendings were EPs, and that there were 71 EM residents. The EPs primarily worked midweek morning shifts, leaving the EDs mostly staffed by other specialties. Our objective in this study was to re-evaluate the EP workforce in Israeli EDs and their employment status and satisfaction 10 years after the last study, which was conducted in 2012.Methods: We performed a three-part, prospective cross-sectional study: 1) a survey, sent to all EDs in Israel, to assess the numbers, level of training, and specialties of physicians working in EDs; 2) an anonymous questionnaire, sent to EPs in Israel, to assess their demographics, training, employment, and work satisfaction; and 3) interviews of a convenience sample of EPs analyzed by a thematic approach.Results: There were 266 board-certified EPs, 141 (53%) of whom were employed in EDs full-time or part-time. Sixty-two non-EPs also worked in EDs. The EPs were present in the EDs primarily during weekday morning shifts. There were 273 EM residents nationwide. A total of 101 questionnaires were completed and revealed that EPs working part-time in the ED worked fewer hours, received higher salaries, and had more years of experience compared to EPs working full time or not working in the ED. Satisfaction correlated only with working part time. Meaningful work, diversity, and rewarding relationships with patients and colleagues were major positive reasons for working in the ED. Feeling undervalued, carrying a heavy caseload, and having complicated relationships with other hospital departments were reasons against working in the ED.Conclusion: Our study findings showed an increase in the number of trained and in-training EPs, and a decrease in the percentage of board-certified EPs who persevere in the EDs. Emergency medicine in Israel is at a crossroads: more physicians are choosing EM than a decade ago, but retention of board-certified EPs is a major concern, as it is worldwide. We recommend taking measures to maintain trained and experienced EPs working in the ED by allowing part-time ED positions, introducing dedicated academic time, and diversifying EP roles, functioning, and work routine.

There is recognition in the field of emergency medicine (EM) that social determinants of health (SDoH) are key drivers of patient care outcomes. Leaders in EM are calling for curricula integrating SDoH assessment and intervention, public health, and multidisciplinary approaches to EM care throughout medical school and residency. This intersection of SDoH and the emergency care system is known as social emergency medicine (SEM). Currently, there are few resources available for EM training programs to integrate this content; as a result, few EM trainees receive adequate education in SEM. To address this gap, we developed a four-part training in SEM tailored to EM residency programs and medical schools.This curriculum, known as RISE-EM (Resident Instruction in Social Emergency Medicine), uses video lectures, case examples, and group discussions to engage trainees and develop competency in providing sound care that is grounded in evidence-based principles of SEM. In the current study, we tested RISE-EM by delivering the video lectures to residents and medical students in two training programs. We administered pre- and post-course knowledge tests and a post-course participant attitudes survey to assess the acceptability and potential efficacy of the program for improving SEM knowledge and attitudes among EM learners.We found it to be both feasible and acceptable to introduce SEM content in residency conferences, with preliminary data showing statistically significant improvement in knowledge of the content and self-efficacy to apply it to their clinical practice. In summary, RISE-EM has been highly valued by EM learners and viewed as a strong supplement to their existing training, and it has been shown to successfully improve SEM knowledge and attitudes.

In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patients STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.

Introduction: We sought to determine the difference between Canadian CT Head Rule (CCHR) indicated imaging rates and actual imaging rates for patients with mild traumatic brain injuries (mTBIs) at a rural emergency department (ED) without in-house computed tomography (CT). In addition, we compared CCHR adherence at a hospital without CT to previous publications from centres with CT to determine if rural populations receive less CT imaging for minor head traumas when indicated by the CCHR. Methods: This retrospective chart review explored individuals who presented to a rural ED (no in-house CT scanner) with a primary diagnosis of mild head injury or concussion between 1 January 2017 and 31 December 2021. Information regarding CCHR criteria, transfer status and patient demographics was collected. Descriptive analyses were completed to determine the percentage of patients who received appropriate transfer for imaging, did not receive transfer for imaging when indicated and received unnecessary transfer. Results: A total of 124 charts met our inclusion criteria (17 [12.1] charts excluded), with 25.8 transferred to the nearest hospital for CT imaging. After applying the CCHR criteria to our charts, 62.1 were indicated for CT. Of the 62.1, only 35.1 were transferred for imaging (51.2 of high-risk and 16.7 of medium-risk). Conclusion: By exploring CT rates for mTBIs in a rural Canadian ED, we found low transfer rates (35.1) of CCHR-indicated patients for imaging needed to guide further healthcare decisions. This work highlights a discrepancy within the Canadian healthcare system between rural and urban centres and allows for opportunities to help narrow the gap in health care. Introduction: Nous avons cherché à déterminer la différence entre les taux d'imagerie indiqués par le Canadian CT Head Rule (CCHR, règlement canadien relatif à la tomodensitométrie de la tête) et les taux d'imagerie réels pour les patients souffrant de traumatismes craniocérébraux légers (TCCL) dans un service d'urgence rural ne disposant pas d'une tomographie par ordinateur interne. En outre, nous avons comparé l'adhésion au CCHR dans un hôpital sans tomographie par ordinateur à des publications antérieures provenant de centres avec tomographie par ordinateur afin de déterminer si les populations rurales reçoivent moins d'imagerie par tomodensitométrie pour les traumatismes crâniens mineurs lorsque le CCHR l'indique. Méthodes: Cette étude rétrospective des dossiers a exploré les personnes qui SE sont présentées à une urgence rurale (sans tomodensitomètre interne) avec un diagnostic primaire de traumatisme crânien léger ou de commotion cérébrale entre le 1[sup.er] janvier 2017 et le 31 décembre 2021. Les informations concernant les critères du CCHR, l'état de transfert et les données démographiques des patients ont été recueillies. Des analyses descriptives ont été réalisées pour déterminer le pourcentage de patients ayant reçu un transfert approprié pour l'imagerie, n'ayant pas reçu de transfert pour l'imagerie quand c'était indiqué et ayant reçu un transfert inutile. Résultats: Au total, 124 dossiers répondaient à nos critères d'inclusion [17 (12,1) dossiers exclus], dont 25,8 ont été transférés à l'hôpital le plus proche pour une imagerie par tomodensitométrie. Après avoir appliqué les critères du CCHR à nos dossiers, 62,1 d'entre eux étaient indiqués pour une tomodensitométrie. Sur ces 62,1, seuls 35,1 ont été transférés pour imagerie (51,2 de haut risque, 16,7 de risque moyen). Conclusion: En explorant les taux de tomodensitométrie pour les TCCL dans un service d'urgence rural canadien, nous avons constaté de faibles taux de transfert (35,1) des patients recommandés par le CCRH pour une imagerie nécessaire dans le but de guider les décisions de soins de santé ultérieures. Ce travail met en évidence un écart dans le système de santé canadien entre les centres ruraux et urbains et offre des opportunités pour aider à réduire l'écart dans les soins de santé. Keywords: Emergency imaging, emergency medicine, head injury, rural medicine, Author(s): Matthew D. Lavery (corresponding author) [1]; Rylen A. Williamson [1]; Jason Curran [2,3]; July Wilkey [4]; Kirk McCarroll [4] INTRODUCTION Between 2002 and 2018, more than 5 million emergency [...]

Introduction: Patients who stay in the emergency department (ED) for prolonged periods of time require verification of home medications, a process known as medication reconciliation. The complex nature of medication reconciliation can lead to adverse events and staff dissatisfaction. A multidisciplinary team was formed to improve accuracy, timing, and staff satisfaction with the medication reconciliation process.Methods: Between November 2021–January 2022, stakeholders were surveyed to identify gaps in the medication reconciliation process. This project implemented education on role-specific tasks, as well as a “Let’s chat!” huddle, bringing together the entire care team to perform medication reconciliation. We used real-time evaluations by frontline staff to evaluate effectiveness during plan- do-study-act cycles and obtain feedback. Following the implementation period, stakeholders completed the post-intervention survey between June-July 2022, using a 4-point Likert scale (0 = very dissatisfied to 3 = very satisfied). We calculated the change in staff satisfaction from pre-intervention to post-intervention. Differences in proportions and 95% confidence intervals are reported. This study adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) and followed the Lean Six Sigma rapid cycle process improvement (define-measure-analyze-improve-control).Results: A total of 111 front-line ED staff (physicians, nurse practitioners, physician assistants, pharmacists, nurses) completed the pre-intervention survey (of 350 ED staff, corresponding to a 31.7%response rate), and 89 stakeholders completed the post-intervention survey (a 25.4% response rate). Subjective feedback from staff identifying causes of low satisfaction with the initial process included the following: complexity of process; unclear delineation of staff roles; time burden to completion; high patient volume; and lack of standardized communication of task completion. Overall satisfaction improved after the intervention. The greatest improvement was seen in the correct medication (difference 20.7%, confidence interval [CI] 6.3–33.9%, P < 0.01), correct dose (25.6%, CI 11.4–38.6%, P < 0.001) and time last taken (24.5%, CI 11.4–37.0%, P < 0.001).Conclusion: There is a steep learning curve to educate multidisciplinary staff on a new process and implement the associated changes. With goals to impact the safety of our patients and reduce negative outcomes, engagement and awareness of the team involved in the medication reconciliation process is critical to improve staff satisfaction.

Introduction: The opioid epidemic is a major cause of morbidity and mortality in the United States. Prior work has shown that emergency department (ED) opioid prescribing can increase the incidence of opioid use disorder in a dose-dependent manner, and systemic changes that decrease default quantity of discharge opioid tablets in the electronic health record (EHR) can impact prescribing practices. However, ED leadership may be interested in the impact of communication around the intervention as well as whether the intervention may differentially impact different types of clinicians (physicians, physician assistants [PA], and nurse practitioners). We implemented and evaluated a quality improvement intervention of an announced decrease in EHR default quantities of commonly prescribed opioids at a large, academic, urban, tertiary-care ED.Methods: We gathered EHR data on all ED discharges with opioid prescriptions from January 1, 2019–December 6, 2021, including chief complaint, clinician, and opioid prescription details. Data was captured and analyzed on a monthly basis throughout this time period. On March 29, 2021, we implemented an announced decrease in EHR default dispense quantities from 20 tablets to 12 tablets for commonly prescribed opioids. We measured pre- and post-intervention quantities of opioid tablets prescribed per discharge receiving opioids, distribution by patient demographics, and inter-clinician variability in prescribing behavior.Results: The EHR change was associated with a 14% decrease in quantity of opioid tablets per discharge receiving opioids, from 14 to 12 tablets (P =

Case Presentation: A 60-year-old female presented to the emergency department with unilateral eye pain and vision loss. Point-of-care ultrasound (POCUS) was performed, which demonstrated ocular metastatic lesions of breast cancer.Discussion: Ocular metastasis is rare, clinically challenging, and may present with a wide range of ophthalmic symptoms. However, POCUS may safely and rapidly identify metastatic lesions to direct further care.

Introduction: Bacterial urinary tract infections (UTI) and some sexually transmitted infections (STI) can have overlapping signs and symptoms or nonspecific findings, such as pyuria on urinalysis. Furthermore, results from the urine culture and the nucleic acid amplification test for an STI may not be available during the clinical encounter. We sought to determine whether gonorrhea, chlamydia, and trichomoniasis are associated with bacteriuria, information that might aid in the differentiation of STIs and UTIs.Methods: We used multinomial logistic regression to analyze 9,650 encounters of female patients whowere aged ≥18 years and who underwent testing for STIs. The ED encounters took place from April 18, 2014–March 7, 2017. We used a multivariable regression analysis to account for patient demographics, urinalysis findings, vaginal wet-mount results, and positive or negative (or no) findings from the urine culture and testing for Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis.Results: In multivariable analysis, infection with T vaginalis, N gonorrhoeae, or C trachomatis was not associated with having a urine culture yielding 10,000 or more colony-forming units per mililiter (CFU/mL) of bacteria compared with a urine culture yielding less than 10,000 CFU/mL or no urine culture obtained. The diagnosis of a UTI in the ED was not associated with having a urine culture yielding 10,000 or more CFU/mL compared with a urine culture yielding less than 10,000 CFU/mL.Conclusion: After adjusting for covariates, no association was observed between urine culture results and testing positive for trichomoniasis, gonorrhea, or chlamydia. Our results suggest that having a concurrent STI and bacterial UTI is unlikely.

Introduction: Ectopic pregnancies are a significant cause of morbidity and mortality in the first trimester of pregnancy. Hospital protocols requiring a specific beta-human chorionic gonadotropin (β-hCG) level to qualify for diagnostic testing (pelvic ultrasound) can delay diagnosis and treatment. In this study we sought to determine the relationship between β-hCG level and the size of ectopic pregnancy withassociated outcomes.Methods: We performed a retrospective case review of patients diagnosed with ectopic pregnancy in an urban, academic emergency department specializing in obstetrical care, from January 1, 2015–December 31, 2017. Variables extracted included presentation, treatment, adverse outcomes, and rates of rupture.Results: Weidentified 519 unique ectopic pregnancies. Of those ectopic pregnancies, 22.9% presented with evidence of rupture on ultrasound, and 14.4% showed evidence of hemodynamic instability (pulse >100 beats per minute; systolic blood pressure

Background: Patients with coronavirus 2019 (COVID-19) are at high risk for respiratory dysfunction. The pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratio is a non-invasive assessment of respiratory dysfunction substituted for the PaO2:FiO2 ratio in Sequential Organ Failure Assessment scoring. We hypothesized that emergency department (ED) SpO2/FiO2 ratios correlate with requirement for mechanical ventilation in COVID-19 patients. Our objective was to identify COVID-19 patients at greatest risk of requiring mechanical ventilation, using SpO2/FiO2 ratios.Methods: We performed a retrospective review of patients admitted with COVID-19 at two hospitals. Highest and lowest SpO2/FiO2 ratios (percent saturation/fraction of inspired O2) were calculated on admission. We performed chi-square, univariate, and multiple regression analysis to evaluate the relationship of admission SpO2/FiO2 ratios with requirement for mechanical ventilation and intensive care unit (ICU) care.Results: A total of 539 patients (46% female; 84% White), with a mean age 67.6 ± 18.6 years, met inclusion criteria. Patients who required mechanical ventilation during their hospital stay were statistically younger in age (P = 0.001), had a higher body mass index (P < .001), and there was a higher percentage of patients who were obese (P = 0.03) and morbidly obese (P < .001). Shortness of breath, cough, and fever were the most common presenting symptoms with a median temperature of 99°F. Average white blood count was higher in patients who required ventilation (P =300 and mechanical ventilation or intensive care unit (ICU) requirement.Conclusion: The ED SpO2/FiO2 ratios correlated with mechanical ventilation and ICU requirements during hospitalization for COVID-19. These results support ED SpO2/FiO2 as a possible triage tool and predictor of hospital resource requirements for patients admitted with COVID-19. Further investigation is warranted.

Introduction: Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions.Methods: This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians’ buprenorphine experience.Results: Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend

Background and Objectives: Greater lifetime exposure to psychological trauma correlates with a higher number of health comorbidities and negative health outcomes. However, physicians often are not specifically trained in how to care for patients with trauma, especially in acute care settings. Our objective was to identify implemented trauma-informed care (TIC) training protocols for emergency and/or trauma service physicians that have both sufficient detail that they can be adapted and outcome data indicating positive impact.Methods: We conducted a comprehensive literature search in MEDLINE (Ovid), Scopus, PsycInfo, Web of Science, Cochrane Library, Ebsco’s Academic Search Premier, and MedEdPORTAL. Inclusion criteria were EM and trauma service clinicians (medical doctors, physician assistants and nurse practitioners, residents), adult and/or pediatric patients, and training evaluation. Evaluation was based on the Kirkpatrick Model.Results: We screened 2,280 unique articles and identified two different training protocols. Results demonstrated the training included patient-centered communication and interprofessional collaboration. One curriculum demonstrated that targeted outcomes were due to the training (Level 4). Both curricula received overall positive reactions (Level 1) and illustrated behavioral change (Level 3). Neither were found to specifically illustrate learning due to the training (Level 2).Conclusion: Study findings from our review show a paucity of published TIC training protocols that demonstrate positive impact and are described sufficiently to be adopted broadly. Current training protocols demonstrated an increasing comfort level with the TIC approach, integration into current practices, and referrals to trauma intervention specialists.

Introduction: The number and characteristics of pregnant patients presenting to the emergency department (ED) has not been well described. Our objective in this study was to determine the prevalence and characteristics of pregnant patients presenting to EDs in the US between 2010–2020. Methods: We completed a retrospective, cross-sectional study of patient encounters at hospital-based EDs in the US from 2010–2020. Using the ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS) we identified ED visits for female patients aged 15–44 years. We defined a subsample of these as visits for pregnant patients using discharge diagnosis codes specificto pregnancy. We compared this population of pregnant patient visits to those for non-pregnant patients and computed point estimates for nationally weighted values. Multivariable linear regression was used to determine factors independently associated with pregnant patient visits. Results: The 2010–2020 NHAMCS dataset included 255,963 ED visits. Of these visits 59,080 were for female patients 15–44 years old, and 6,068 of those visits were for pregnant patients. Pregnant patients accounted for 3% (95% confidence interval [CI] 2.7–3.2) of all ED visits and 8.6% (95% CI 8–9.3) of all visits among female patients 15–44 years. Weighting to a national sample, this equates to 2.77 million pregnant patients presenting for ED visits annually. Pregnant patients were more likely to be Black, Hispanic, or to use public insurance. Conclusion: Pregnant patients make up a significant number of ED visits annually and are more likely to be people of color or publicly insured. Interventions to address the effects of changing abortion legislation on emergency medicine practice may benefit from consideration that certain populations of pregnant people are more likely to present to the ED for care.

OBJECTIVE: Recent clinical guidelines for sepsis management emphasize immediate antibiotic initiation for suspected septic shock. Though hypotension is a high-risk marker of sepsis severity, prior studies have not considered the precise timing of hypotension in relation to antibiotic initiation and how clinical characteristics and outcomes may differ. Our objective was to evaluate antibiotic initiation in relation to hypotension to characterize differences in sepsis presentation and outcomes in patients with suspected septic shock. METHODS: Adults presenting to the emergency department (ED) June 2012-December 2018 diagnosed with sepsis (Sepsis-III electronic health record [EHR] criteria) and hypotension (non-resolving for ≥30 min, systolic blood pressure 60 min after (late) treatment. RESULTS: Among 2219 patients, 55% received early treatment, 13% immediate, and 32% late. The late subgroup often presented to the ED with hypotension (median 0 min) but received antibiotics a median of 191 min post-ED presentation. Clinical characteristics notable for this subgroup included higher prevalence of heart failure and liver disease (p

Emergency departments (ED) in the United States serve a dual role in public health: a portal of entry to the health system and a safety net for the community at large. Public health officials often target the ED for public health interventions due to the perception that it is uniquely able to reach underserved populations. However, under time and resource constraints, emergency physicians and public health officials must make calculated decisions in choosing which interventions in their local context could provide maximal impact to achieve public health benefit. We identify how decisions regarding public health interventions are affected by considerations of cost, time, and available personnel, and further consider the role of local community needs, health department goals, and political environment. We describe a sample of ED-based public health interventions and demonstrate how to use a proposed framework to assess interventions. We posit a series of questions and variables to consider: local disease prevalence; ability of the ED to perform the intervention; relative efficacy of the ED vs community partnerships as the primary intervention location; and expected outcomes. In using this framework, clinicians should be empowered to improve the public health in their communities.

Introduction: In the 2023 National Resident Matching Program (NRMP) match, there were 554 unfilled emergency medicine (EM) positions before the Supplemental Offer and Acceptance Program (SOAP). We sought to describe features of EM programs that participated in the match and the association between select program characteristics and unfilled positions. Methods: The primary outcome measures included the proportion of positions filled in relation to state and population density, hospital ownership type, and physician employment model. Secondary outcome measures included comparing program-specific attributes between filled and unfilled programs, including original accreditation type, year of original accreditation, the total number of approved training positions, length of training, urban-rural designation, hospital size by number of beds, resident-to-bed ratio, and the percentage of disproportionate share patients seen. Results: The NRMP Match had 276 unique participating EM programs with 554 unfilled positions. Six states offered 52% of the total NRMP positions available. Five states were associated with two-thirds of the unfilled positions. Public hospitals had a statistically significant higher match rate (88%) when compared to non-profit and for-profit hospitals, which had match rates of 80% and 75%, respectively (P < 0.001). Programs with faculty employed by a health system had the highest match rate of 87%, followed by clinician partnerships at 79% and private equity groups at 68% (P < 0.001 overall and between all subgroups). Conclusion: The 2023 match in EM saw increased rates in the number of residency positions and programs that did not fill before the SOAP. Public hospitals had higher match rates than for-profit or non-profit hospitals. Residency programs that employed academic faculty through the hospital or health system were associated with higher match rates.

Chest pain is a common presentation to the emergency department (ED) that can be caused by a multitude of etiologies. It can be challenging to differentiate life-threatening conditions from more benign causes. A 54-year-old woman presented to the ED complaining of chest pain with dyspnea in the setting of recent blunt trauma. This case offers a thorough yet practical approach to the diagnostic workup of chest pain with dyspnea in the ED setting. The surprising final diagnosis and case outcome are then revealed.

Introduction: Learners frequently benefit from modalities such as small-group, case-based teaching and interactive didactic experiences rather than passive learning methods. These contemporary techniques are features of Foundations of Emergency Medicine (FoEM) curricula, and particularly the Foundations I (F1) course, which targets first-year resident (PGY-1) learners. The American Board of Emergency Medicine administers the in-training exam (ITE) that provides an annual assessment of EM-specific medical knowledge. We sought to assess the effect of F1 implementation on ITE scores.Methods: We retrospectively analyzed data from interns at four EM residency programs accredited by the Accreditation Council for Graduate Medical Education. We collected data in 2021. Participating sites were geographically diverse and included three- and four-year training formats. We collected data from interns two years before (control group) and two years after (intervention group) implementation of F1 at each site. Year of F1 implementation ranged from 2015–2018 at participating sites. We abstracted data using a standard form including program, ITE raw score, year of ITE administration, US Medical Licensing Exam Step 1 score, Step 2 Clinical Knowledge (CK) score, and gender. We performed univariable and multivariable linear regression to explore differences between intervention and control groups.Results: We collected data for 180 PGY-1s. Step 1 and Step 2 CK scores were significant predictors of ITE in univariable analyses (both with P < 0.001). After accounting for Step 1 and Step 2 CK scores, we did not find F1 implementation to be a significant predictor of ITE score, P = 0.83.Conclusion: Implementation of F1 curricula did not show significant changes in performance on the ITE after controlling for important variables.

Background: Hospice and palliative medicine (HPM) is a board-certified subspecialty within emergency medicine (EM), but prior studies have shown that EM residents do not receive sufficient training in HPM. Experts in HPM-EM created a consensus list of competencies for HPM training in EM residency. We evaluated how the HPM competencies integrate within the American Board of Emergency Medicine Milestones, which include the Model of the Clinical Practice of Emergency Medicine (EM Model) and the knowledge, skills, and abilities (KSA) list.Methods: Three emergency physicians independently mapped the HPM-EM competencies onto the 2019 EM Model items and the 2021 KSAs. Discrepancies were resolved by a fourth independent reviewer, and the final mapping was reviewed by all team members.Results: The EM Model included 78% (18/23) of the HPM competencies as a direct match, and we identified recommended areas for incorporating the other five. The KSAs included 43% (10/23). Most HPM competencies included in the KSAs mapped onto at least one level B (minimal necessary for competency) KSA. Three HPM competencies were not clearly included in the EM Model or in the KSAs (treating end-of-life symptoms, caring for the imminently dying, and caring for patients under hospice care).Conclusion: The majority of HPM-EM competencies are included in the current EM Model and KSAs and correspond to knowledge needed to be competent in EM. Programs relying on the EM Milestones to plan their curriculums may miss training in symptom management and care for patients at the end of life or who are on hospice.

BackgroundAchilles tendinopathy can be a devastating condition in ballet dancers. Initial medical evaluation is frequently conducted by generalist physicians, who may lack the perspective of dance and sports medicine focused training and often prescribe complete rest for chronic overuse injuries. In order to provide targeted information about Achilles tendinopathy and the unique needs of elite athletes, such as ballet dancers, we designed an educational intervention that covers relevant anatomy, physiology, biomechanics, clinical presentation and evaluation, and recommendations for initial treatment and sub-specialty referral. The objectives of this study were to determine baseline understanding of Achilles tendinopathy by generalist physicians and to evaluate the efficacy of an educational intervention on their knowledge.MethodsThis was a prospective pre- post-test study, to measure improvement in knowledge about Achilles tendinopathy. Emergency Medicine and Primary Care physicians participated in an educational intervention with didactic and hands-on components. Data were analyzed using a two-tailed t-test.ResultsTwenty generalist physicians participated. There was significant improvement in their knowledge of Achilles tendinopathy for all our educational objectives (Pre-test: 59% correct answers; post-test: 79% correct answers; P

Space travel has transformed in the past several years. Given the burgeoning market for space tourism, in-flight medical emergencies are likely to be expected. Ultrasound is one of the few diagnostic and therapeutic modalities available for astronauts in space. However, while point-of-care ultrasound (POCUS) is available, there is no current standard of training for astronaut preparation. We suggest an organized and structured methodology by which astronauts should best prepare for space with the medical equipment available on board. As technology continues to evolve, the assistance of other artificial intelligence and augmented reality systems are likely to facilitate training and dynamic real-time needs during space emergencies.Summary: As space tourism continues to evolve, an organized methodology for POCUS use is advised to best prepare astronauts for space.

Purpose: Using point-of-care ultrasound (POCUS) to diagnose abdominal aortic aneurysm (AAA) is an essential skill in emergency medicine (EM). While simulation-based POCUS education is commonly used, the translation to performance in the emergency department (ED) is unknown. We investigated whether adding case-based simulation to an EM residency curriculum was associated with changes in the quantity and quality of aorta POCUS performed by residents in the ED.Methods: A case-based simulation was introduced to resident didactics at our academic, Level I trauma center. A case of undifferentiated abdominal pain was presented, which required examination of an ultrasound phantom to diagnose an AAA, with a hands-on didactic. We compared the quantity, quality, and descriptive analyses of aorta POCUS performed in the ED during the four months before and after the simulation.Results: For participating residents (17/32), there was an 86% increase in total studies and an 80%increase in clinical studies. On an opportunity-adjusted, per-resident basis, there was no significant difference in median total scans per 100 shifts (4.4 [interquartile range (IQR) 0–15.8 vs 8.3 [IQR] 3.3–23.6, P = 0.21) or average total quality scores (3.2 ± 0.6 vs 3.2 ± 0.5, P = 0.92). The total number of limited or inadequate studies decreased (43% vs 19%, P = 0.02), and the proportion of scans submitted by interns increased (7% vs 54%, P =

Background: Academic emergency medicine (EM) communities have viewed anonymous online communities (AOC) such as Reddit or specialty-specific “applicant spreadsheets” as poor advising resources. Despite this, robust EM AOCs exist, with large user bases and heavy readership. Insights about applicants’ authentic experiences can be critical for applicants and program leadership decision-making. To date, there are no EM studies to qualitatively assess EM AOC narratives during the application cycle. Our goal was to perform a qualitative analysis of students’ EM program experiences through a publicly available AOC.Methods: This was a qualitative analysis of a publicly available, time-stamped, user-locked AOC dataset: “Official 2020–2021 Emergency Medicine Applicant Spreadsheet.” We extracted and then de-identified all data from selected sub-sheets entitled “Virtual Interview Impressions” and “Rotation Impressions.” Four investigators used constant comparative method to analyze the data inductively, and they subsequently met to generate common themes discussed by students. Preliminary thematic analysis was conducted on a random sample of 37/183 (20%) independent narratives to create the initial codebook. This was used and updated iteratively to analyze the entire narrative set consisting of 841 discrete statements. Finally, two unique codes were created to distinguish whether the identified sub-themes, or program attributes, were likely “modifiable” or “non-modifiable.”Results: We identified six major themes: living and working conditions; interpersonal relationships; learning experiences, postgraduate readiness, and online/virtual supplements. Common sub-themes included patient population (13%); resident personality (7%); program leadership personality (7%); relationship with faculty/leadership (6%); geography (4%); practice setting (4%); program reputation (4%), and postgraduate year-3 experiences (4%). Modifiable sub-themes outnumbered non-modifiable sub-themes, 60.7% to 39.3%.Conclusion: In this analysis of selected medical students’ narratives in an AOC, the majority of identified themes represented topics that may serve as external feedback for EM residency programs and their clerkships. Selective use of AOCs may set a precedent for future program assessments by applicants and inform program leadership of important programmatic elements in the eyes of applicants. It elucidates important themes in their interactions or learning experiences with programs and creates opportunities for learner-centric program improvement.

Introduction: Seizures are a common presenting complaint and account for approximately 1% of total emergency department (ED) visits. Seizures are especially common in children less than five years old as they have a lower seizure threshold as compared to adults. One potentially dangerous etiology that is far less common, especially in children, is thyroid storm, the extreme manifestationof hyperthyroidism.Case Report: We describe the case of a 3-year-old girl who presented to the ED with an afebrile seizure but was found to be in thyroid storm. This case should serve as a reminder for emergency physicians to consider thyroid disease when evaluating patients presenting with seizures.Conclusion: Although most pediatric seizures are self-limited and frequently benign, it is imperative that the emergency physician evaluate for and rule out any potentially associated dangerous conditions such as thyroid storm.

ImportanceProcedural proficiency is a core competency for graduate medical education; however, procedural reporting often relies on manual workflows that are duplicative and generate data whose validity and accuracy are difficult to assess. Failure to accurately gather these data can impede learner progression, delay procedures, and negatively impact patient safety.ObjectiveTo examine accuracy and procedure logging completeness of a system that extracts procedural data from an electronic health record system and uploads these data securely to an application used by many residency programs for accreditation.Design, setting, and participantsThis quality improvement study of all emergency medicine resident physicians at University of California, San Diego Health was performed from May 23, 2023, to June 25, 2023.ExposuresAutomated system for procedure data extraction and upload to a residency management software application.Main outcomes and measuresThe number of procedures captured by the automated system when running silently compared with manually logged procedures in the same timeframe, as well as accuracy of the data upload.ResultsForty-seven residents participated in the initial silent assessment of the extraction component of the system. During a 1-year period (May 23, 2022, to May 7, 2023), 4291 procedures were manually logged by residents, compared with 7617 procedures captured by the automated system during the same period, representing a 78% increase. During assessment of the upload component of the system (May 8, 2023, to June 25, 2023), a total of 1353 procedures and patient encounters were evaluated, with the system operating with a sensitivity of 97.4%, specificity of 100%, and overall accuracy of 99.5%.Conclusions and relevanceIn this quality improvement study of emergency medicine resident physicians, an automated system demonstrated that reliance on self-reported procedure logging resulted in significant procedural underreporting compared with the use of data obtained at the point of performance. Additionally, this system afforded a degree of reliability and validity heretofore absent from the usual after-the-fact procedure logging workflows while using a novel application programming interface-based approach. To our knowledge, this system constitutes the first generalizable implementation of an automated solution to a problem that has existed in graduate medical education for decades.

BackgroundPrediction-based strategies for physiologic deterioration offer the potential for earlier clinical interventions that improve patient outcomes. Current strategies are limited because they operate on inconsistent definitions of deterioration, attempt to dichotomize a dynamic and progressive phenomenon, and offer poor performance.ObjectiveCan a deep learning deterioration prediction model (Deep Learning Enhanced Triage and Emergency Response for Inpatient Optimization [DETERIO]) based on a consensus definition of deterioration (the Adult Inpatient Decompensation Event [AIDE] criteria) and that approaches deterioration as a state "value-estimation" problem outperform a commercially available deterioration score?Derivation cohortThe derivation cohort contained retrospective patient data collected from both inpatient services (inpatient) and emergency departments (EDs) of two hospitals within the University of California San Diego Health System. There were 330,729 total patients; 71,735 were inpatient and 258,994 were ED. Of these data, 20% were randomly sampled as a retrospective "testing set."Validation cohortThe validation cohort contained temporal patient data. There were 65,898 total patients; 13,750 were inpatient and 52,148 were ED.Prediction modelDETERIO was developed and validated on these data, using the AIDE criteria to generate a composite score. DETERIO's architecture builds upon previous work. DETERIO's prediction performance up to 12 hours before T0 was compared against Epic Deterioration Index (EDI).ResultsIn the retrospective testing set, DETERIO's area under the receiver operating characteristic curve (AUC) was 0.797 and 0.874 for inpatient and ED subsets, respectively. In the temporal validation cohort, the corresponding AUC were 0.775 and 0.856, respectively. DETERIO outperformed EDI in the inpatient validation cohort (AUC, 0.775 vs. 0.721; p < 0.01) while maintaining superior sensitivity and a comparable rate of false alarms (sensitivity, 45.50% vs. 30.00%; positive predictive value, 20.50% vs. 16.11%).ConclusionsDETERIO demonstrates promise in the viability of a state value-estimation approach for predicting adult physiologic deterioration. It may outperform EDI while offering additional clinical utility in triage and clinician interaction with prediction confidence and explanations. Additional studies are needed to assess generalizability and real-world clinical impact.

INTRODUCTION: Human trafficking (HT) is a public health issue that adversely affects patients well-being. Despite the prevalence of trafficked persons in health care settings, a lack of educational modules exists for use in clinical contexts. We developed a 50-minute train-the-trainer module on HT. METHODS: After piloting the workshop for faculty, fellows, and residents (n = 19) at the Society for Academic Emergency Medicine (SAEM) national conference, we implemented it in medical students curricula during their emergency medicine clerkship at the University of Iowa (n = 162). We evaluated the worskhop by (a) a retrospective pre-post survey of self-reported ability to (1) define HT, (2) recognize high-risk signs, (3) manage situations with trafficked persons, and (4) teach others about HT, and (b) a 3-month follow-up survey to assess longitudinal behavior change. RESULTS: In both contexts, results demonstrated improvement across all learning outcomes (pre-post differences of 1.5, 1.3, 1.9, and 1.7 on a 4-point Likert-type scale for each learning objective above, respectively, at the SAEM conference and 1.2, 1.0, 1.3, and 1.3 at the University of Iowa; p < .001 for all). In the 3-month follow-up, we observed statistically significant changes in self-reported consideration of and teaching about HT during clinical encounters among learners who had previously never done either (p < .001 and p = .006, respectively). DISCUSSION: This train-the-trainer module is a brief and effective clinical tool for bedside teaching about HT, especially among people who have never previously considered HT in a clinical context.

Syndromic surveillance is an effective tool for enabling the timely detection of infectious disease outbreaks and facilitating the implementation of effective mitigation strategies by public health authorities. While various information sources are currently utilized to collect syndromic signal data for analysis, the aggregated measurement of cough, an important symptom for many illnesses, is not widely employed as a syndromic signal. With recent advancements in ubiquitous sensing technologies, it becomes feasible to continuously measure population-level cough incidence in a contactless, unobtrusive, and automated manner. In this work, we demonstrate the utility of monitoring aggregated cough count as a syndromic indicator to estimate COVID-19 cases. In our study, we deployed a sensor-based platform (Syndromic Logger) in the emergency room of a large hospital. The platform captured syndromic signals from audio, thermal imaging, and radar, while the ground truth data were collected from the hospitals electronic health record. Our analysis revealed a significant correlation between the aggregated cough count and positive COVID-19 cases in the hospital (Pearson correlation of 0.40, p-value < 0.001). Notably, this correlation was higher than that observed with the number of individuals presenting with fever (ρ = 0.22, p = 0.04), a widely used syndromic signal and screening tool for such diseases. Furthermore, we demonstrate how the data obtained from our Syndromic Logger platform could be leveraged to estimate various COVID-19-related statistics using multiple modeling approaches. Aggregated cough counts and other data, such as people density collected from our platform, can be utilized to predict COVID-19 patient visits related metrics in a hospital waiting room, and SHAP and Gini feature importance-based metrics showed cough count as the important feature for these prediction models. Furthermore, we have shown that predictions based on cough counting outperform models based on fever detection (e.g., temperatures over 39°C), which require more intrusive engagement with the population. Our findings highlight that incorporating cough-counting based signals into syndromic surveillance systems can significantly enhance overall resilience against future public health challenges, such as emerging disease outbreaks or pandemics.

BACKGROUND: During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS: We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale (very unlikely to very likely) was used to assess the likelihood of asking about medical procedures (procedure based) and patients values (value based) during code status conversations, followed by semistructured interviews. RESULTS: Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patients acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS: Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

Background: Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula.Methods: Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members.Results: The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A).Conclusion: All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.

Introduction: Identification of patients not meeting catheterization laboratory activation criteria by electrocardiogram (ECG) but who would benefit from early coronary intervention remains challenging in the emergency department (ED). The purpose of this study was to evaluate whether emergency physician (EP)-performed point-of-care transthoracic echocardiography (POC TTE) could help identify patients who required coronary intervention within this population.Methods: This was a retrospective observational cohort study of adult patients who presented to two EDs between 2018–2020. Patients were included if they received a POC TTE and underwent diagnostic coronary angiography within 72 hours of ED presentation. We excluded patients meeting catheterization laboratory activation criteria on initial ED ECG. Ultrasound studies were independently reviewed for presence of regional wall motion abnormalities (RWMA) by two blinded ultrasound fellowship-trained EPs. We then calculated test characteristics for coronary intervention.Results: Of the 221 patient encounters meeting inclusion criteria, 104 (47%) received coronary intervention or coronary artery bypass grafting (CABG) referral. Overall prevalence of RWMA on POC TTE was 35% (95% confidence interval [CI] 29–42%). Presence of RWMA had 38% (95% CI 29–49%) sensitivity and 68% (95% CI 58–76%) specificity for coronary intervention/CABG referral. Presence of “new” RWMA (presence on EP-performed POC TTE and prior normal echocardiogram) had 43% (95%CI 10–82%) sensitivity and 93% (95% CI 66–100%) specificity for coronary intervention/CABG referral. The EP-performed POC TTE interpretation of RWMA had 57% (95% CI 47–67%) sensitivity and 96%(95% CI 87–100%) specificity for presence of RWMA on subsequent cardiology echocardiogram during the same admission.Conclusion: Presence of RWMA on EP-performed POC TTE had limited sensitivity or specificity for coronary intervention or referral to CABG. The observed specificity appeared to trend higher in subjects with a prior echocardiogram demonstrating absence of RWMA, although a larger sample size will be required to confirm this finding. The EP-performed POC TTE RWMA had high specificity for presence of RWMA on subsequent cardiology echocardiogram. Further evaluation of the diagnostic performance of new RWMA on EP-performed POC TTE with a dedicated cohort is warranted.

Introduction: Interruptions that occur during sign-out in the emergency department (ED) may affect workflow, quality of care, patient safety, errors in documentation, and resident education. Our objective in this study was to determine the frequency and classification (emergent vs non-emergent, in-person vs phone call) of interruptions that occur during emergency medicine (EM) resident sign-out before and after the institution of a group sign-out process involving residents and attending physicians.Methods: A convenience sample of sign-out observations between EM residents were observed and coded between April–December 2021. We excluded sign-out observations of pediatric patients (

Introduction: We conducted this systematic review to identify emergency department (ED) relevant recommendations in current guidelines for care of transgender and gender-diverse (TGD)people internationally.Methods: Using PRISMA criteria, we did a systematic search of Ovid Medline, EMBASE, and CINAHL and a hand search of gray literature for clinical practice guidelines (CPG) or best practice statements (BPS) published until June 31, 2021. Articles were included if they were in English, included medical or paramedical care of TGD populations of any age, in any setting, region or nation, and were national or international in scope. Exclusion criteria included primary research studies, review articles, narrative reviews or otherwise non-CPG or BPS, editorials, or letters to the editor, articles of regional or individual hospital scope, non-medical articles, articles not in English, or if a more recent version of the guideline existed. Recommendations relevant to ED care were identified, recorded, and assessed for quality using the AGREE-II and AGREE-REX criteria. We performed interclass correlation coefficient for interrater reliability. Recommendations were coded for the relevant point of care while in the ED (triage, registration, rooming, investigations, etc.).Results: We screened 1,658 unique articles, and 1,555 were excluded. Of the remaining 103 articles included, seven had recommendations relevant to care in the ED, comprising a total of 10 recommendations. Four guidelines and eight recommendations were of high quality. They included recommendations for testing, prevention, referral, and provision of post-exposure prophylaxis for HIV, and culturally competent care of TGD people.Conclusions: This is the most comprehensive review to date of guidelines and best practices statements offering recommendations for care of ED TGD patients, and several are immediately actionable. There are also many opportunities to build community-led research programs to synthesize and inform a comprehensive dedicated guideline for care of TGD people in emergency settings.