Citations

EXECUTIVE SUMMARY We sought to determine emergency medicine physicians’ accuracy in designating patients’ disposition status as “inpatient” or “observation” at the time of hospital admission in the context of Medicare’s Two-Midnight rule and to identify characteristics that may improve the providers’ predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians’ disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers’ awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

Abstract Background: Awareness of burnout has led residency programs to seek interventions to promote well-being, resiliency, camaraderie and social network development. Limited evidence exists on the efficacy of specific interventions. This study evaluated the efficacy of an emergency medicine residency program’s semi-annual retreat using serial administration of the Maslach burnout index and resident well-being survey.Methods: Surveys were administered to all emergency medicine residents (n=25) in July 2018 and before and after fall 2018 and winter 2019 retreats. Retreats included a meal, team building, and social networking opportunities (bowling, softball, snow tubing, and sledding). Comparisons of responses between baseline, pre-retreat, and post-retreat were evaluated using two-sample t, Wilcoxon rank sum, and Fisher exact tests. Results: Sixteen emergency medicine residents (64%) responded at baseline. Response rates on subsequent surveys ranged from 14 (56%) to 21 (84%). Nineteen percent of residents exhibited burnout at baseline. This peaked at 36% pre-winter retreat. Burnout decreased after each retreat (fall: 29% to 6%, winter: 36% to 13%). Mean Maslach burnout index subscores for emotional exhaustion (13 to 9) and depersonalization (7 to 5) decreased from baseline to post-fall retreat, but neither changed significantly over the entire study period (emotional exhaustion: 13 to 12, depersonalization: 7 to 6). Resident well-being survey pre- and post-retreat responses were similar on all items.Conclusion: Meaningful, but not statistically significant differences were detected on the Maslach burnout index and resident well-being survey in association with a retreat. Mean emotional exhaustion, depersonalization and burnout decreased after retreats. Larger studies would provide further insight into the significance of these trends.

Abstract Background Awareness of burnout has led residency programs to seek interventions to promote well-being, resiliency, camaraderie and social network development. Limited evidence exists on the efficacy of specific interventions. This study evaluated the efficacy of an emergency medicine residency program’s semi-annual retreat using serial administration of the Maslach burnout index and resident well-being survey. Methods Surveys were administered to all emergency medicine residents (n = 25) in July 2018 and before and after fall 2018 and winter 2019 retreats. Retreats included a meal, team building, and social networking opportunities (bowling, softball, snow tubing, and sledding). Comparisons of responses between baseline, pre-retreat, and post-retreat were evaluated using two-sample t, Wilcoxon rank sum, and Fisher exact tests. Results Sixteen emergency medicine residents (64%) responded at baseline. Response rates on subsequent surveys ranged from 14 (56%) to 21 (84%). Nineteen percent of residents exhibited burnout at baseline. This peaked at 36% pre-winter retreat. Burnout decreased after each retreat (fall: 29–6%, winter: 36–13%). Mean Maslach burnout index subscores for emotional exhaustion (13 to 9) and depersonalization (7 to 5) decreased from baseline to post-fall retreat, but neither changed significantly over the entire study period (emotional exhaustion: 13 to 12, depersonalization: 7 to 6). Resident well-being survey pre- and post-retreat responses were similar on all items. Conclusion Meaningful, but not statistically significant differences were detected on the Maslach burnout index and resident well-being survey in association with a retreat. Mean emotional exhaustion, depersonalization and burnout decreased after retreats. Larger studies would provide further insight into the significance of these trends.

Background and objectives Dialysis is a preference-sensitive decision where prognosis may play an important role. Although patients desire risk prediction, nephrologists are wary of sharing this information. We reviewed the performance of prognostic indices for patients starting dialysis to facilitate bedside translation. Design, setting, participants, & measurements Systematic review and meta-analysis following the PRISMA guidelines. We searched Ovid MEDLINE, Ovid Embase, Ovid Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus for eligible studies of patients starting dialysis published from inception to December 31, 2018. Selection Criteria: Articles describing validated prognostic indices predicting mortality at the start of dialysis. We excluded studies limited to prevalent dialysis patients, AKI and studies excluding mortality in the first 1–3 months. Two reviewers independently screened abstracts, performed full text assessment of inclusion criteria and extracted: study design, setting, population demographics, index performance and risk of bias. Pre-planned random effects meta-analysis was performed stratified by index and predictive window to reduce heterogeneity. Results Of 12,132 articles screened and 214 reviewed in full text, 36 studies were included describing 32 prognostic indices. Predictive windows ranged from 3 months to 10 years, cohort sizes from 46 to 52,796. Meta-analysis showed discrimination area under the curve (AUC) of 0.71 (95% confidence interval, 0.69 to 073) with high heterogeneity ( I 2 =99.12). Meta-analysis by index showed highest AUC for The Obi, Ivory, and Charlson comorbidity index (CCI)=0.74, also CCI was the most commonly used (ten studies). Other commonly used indices were Kahn-Wright index (eight studies, AUC 0.68), Hemmelgarn modification of the CCI (six studies, AUC 0.66) and REIN index (five studies, AUC 0.69). Of the indices, ten have been validated externally, 16 internally and nine were pre-existing validated indices. Limitations include heterogeneity and exclusion of large cohort studies in prevalent patients. Conclusions Several well validated indices with good discrimination are available for predicting survival at dialysis start.

AbstractObjectivesNeurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time‐window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents.MethodsA panel of 13 board‐certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications—three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed‐methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro‐IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty.ResultsThirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro‐IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive.ConclusionsVariability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.

Background: Patient satisfaction surveys are vital to measuring a patient’s experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known. Objectives: To evaluate whether EM residents’ patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement. Methods: A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 “physician questions” and the “overall” score. Results: We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [ P = .72], courtesy [ P = .55], informative about treatment [ P = .46], and listening [ P = .91]) and overall assessment of emergency department care ( P = .51) were not significantly improved over the course of resident. Conclusion: We did not observe a difference in EM residents’ patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.

AbstractBackgroundShared decision making in the emergency department (ED) can increase patient engagement for patients presenting with chest pain. However, little is known regarding which factors are associated with actual patient involvement in decision making or patients’ desired involvement in emergency care decisions. We examined which factors were associated with patients’ actual and desired involvement in decision making among ED chest pain patients.MethodsThis is a secondary analysis of data from a randomized trial of a shared decision‐making intervention in ED patients with low‐risk chest pain. We evaluated the degree to which patients were involved in decision making using the OPTION‐12 (observing patient involvement) scale and patients’ reported desire for involvement in decision making using the Control Preferences Scale (CPS). We measured the associations of patient factors with OPTION‐12 and CPS scores using multivariable regression.ResultsOf the 898 patients enrolled, mean (±SD) age was 51.5 (±11.4) years and 59% were female. Multivariable analysis revealed that only two factors were significantly associated with OPTION‐12 scores: study site and use of the decision aid. OPTION‐12 scores were 10.3 (standard error = 0.6) points higher for patients randomized to the decision aid compared to usual care (p < 0.001). Higher health literacy was associated with lower scores on the CPS, indicating greater desire for involvement (odds ratio = 0.91, p < 0.001).ConclusionsPatients’ reported desire for involvement in decision making was higher among those with higher health literacy. After study site and other potential confounding factors were adjusted for, only use of the decision aid was associated with observed patient involvement in decision making. As the science and practice of shared decision making in the ED moves toward implementation, high‐fidelity integration of the decision aid into the flow of care will be necessary to realize desired outcomes.

AbstractBackgroundFood is the leading cause of anaphylaxis in children seen in emergency departments in the United States, yet data on emergency department visits and hospitalizations related to food‐induced anaphylaxis are limited. The objective of our study was to examine national time trends of pediatric food‐induced anaphylaxis‐related emergency department visits and hospitalizations.MethodsWe conducted an observational study using a national administrative claims database from 2005 through 2014. Participants were younger than 18 years with an emergency department visit or hospitalization for food‐induced anaphylaxis. Outcome measures of our study included time trends of pediatric food‐induced anaphylaxis‐related emergency department visits and hospitalizations, including observations (in an emergency department or a hospital unit), inpatient admissions, and intensive care unit admissions.ResultsDuring the study period, participants had 7310 food‐induced anaphylaxis‐related emergency department visits. Emergency department visits for food‐induced anaphylaxis increased by 214% (P < .001); the highest rates were in infants and toddlers (age 0‐2 years). Rates of emergency department visits significantly increased in all age‐groups, with the highest increase in adolescents (age 13‐17 years: 413%; P < .001). Peanuts accounted for the highest rates (5.85 per 100 000 in 2014) followed by tree nuts/seeds (4.62 per 100 000 in 2014). The greatest increase in rates of emergency department visits for food‐induced anaphylaxis occurred with tree nuts/seeds (373.0% increase during the study period).ConclusionsThe incidence of food‐induced anaphylaxis has significantly increased over time in children of all ages. Food‐induced anaphylaxis in children is an important national public health concern.

Policy and financial pressures have driven up use of observation stays for patients in traditional Medicare and the Veterans’ Affairs Healthcare System. Using claims data (2004-2014) from OptumLabs™ Data Warehouse, we examined whether people in private Medicare Advantage (MA) and commercial plans experienced similar changes. We found that use of observation increased rapidly for patients in MA plans—even though MA plans were not subject to the same pressures as government-run programs. In contrast, use of observation remained constant for people in commercial plans—except for enrollees 65 and older, for whom it increased somewhat. Privately insured patients returning to the hospital after an inpatient stay were increasingly likely to be placed under observation. Our results suggest that observation is rapidly replacing inpatient admissions and readmissions for many older patients in MA and commercial plans, while younger patients continue to be admitted as inpatients at relatively constant rates.