A National Voter Registration Campaign.

Research suggests that increased voting among adults is associated with improved child health. Despite the benefits of voting, the United States has low voter turnout compared with peer nations. Turnout is especially low among marginalized people in the United States. Voter registration is essential for increasing voter turnout, and registration efforts have been successfully carried out in clinical settings. Working with a nonprofit called Vot-ER, we advocated for nonpartisan voter registration efforts in pediatric settings nationwide preceding the November 2020 US elections. We describe lessons learned from these efforts. Using data obtained from Vot-ER, we also provide the first estimates of participation in a national voter registration campaign in pediatric settings. There was widespread engagement in voter registration efforts among pediatricians in 2020. Many lessons were learned from these efforts, including the benefits of advanced planning because registration deadlines can be up to 1 month in advance of Election Day. Obtaining buy-in from numerous stakeholders (e.g., health center leadership, public relations teams) supports widespread staff participation. Also important is to consider the tradeoffs between active voter registration (in which staff can broach the topic of voting with patients and families) and passive efforts (in which voting is discussed only if patients or families inquire about it). These and other lessons can inform future voter registration efforts in diverse pediatric settings across the country.

The Healthy Democracy Kit: design, implementation, uptake, and impact of a novel voter registration toolkit for healthcare settings.

BACKGROUND: Access to voting is increasingly recognized as a social determinant of health. Health equity could be improved if healthcare workers (HCWs) routinely assessed the voter registration status of patients during clinical encounters and helped direct them towards appropriate resources. However, little consensus exists on how to achieve these tasks efficiently and effectively in healthcare settings. Intuitive and scalable tools that minimize workflow disruptions are needed. The Healthy Democracy Kit (HDK) is a novel voter registration toolkit for healthcare settings, featuring a wearable badge and posters that display quick response (QR) and text codes directing patients to an online hub for voter registration and mail-in ballot requests. The objective of this study was to assess national uptake and impact of the HDK prior to the 2020 United States (US) elections. METHODS: Between 19 May and 3 November 2020, HCWs and institutions could order and use HDKs to help direct patients to resources, free of cost. A descriptive analysis was conducted to summarize the characteristics of participating HCWs and institutions as well as the resultant total persons helped prepare to vote. RESULTS: During the study period, 13,192 HCWs (including 7,554 physicians, 2,209 medical students, and 983 nurses) from 2,407 affiliated institutions across the US ordered 24,031 individual HDKs. Representatives from 604 institutions (including 269 academic medical centers, 111 medical schools, and 141 Federally Qualified Health Centers) ordered 960 institutional HDKs. Collectively, HCWs and institutions from all 50 US states and the District of Columbia used HDKs to help initiate 27,317 voter registrations and 17,216 mail-in ballot requests. CONCLUSIONS: A novel voter registration toolkit had widespread organic uptake and enabled HCWs and institutions to successfully conduct point-of-care civic health advocacy during clinical encounters. This methodology holds promise for future implementation of other types of public health initiatives. Further study is needed to assess downstream voting behaviors from healthcare-based voter registration.

Effect of the Extended Focused Assessment With Sonography for Trauma on the Screening Performance of the National Emergency X-Radiography Utilization Study Chest Decision Instrument.

STUDY OBJECTIVE: Developed to decrease unnecessary thoracic computed tomography use in adult blunt trauma patients, the National Emergency X-Radiography Utilization Study (NEXUS) Chest clinical decision instrument does not include the extended Focused Assessment with Sonography in Trauma (eFAST). We assessed whether eFAST improves the NEXUS Chest clinical decision instrument's diagnostic performance and may replace the chest radiograph (CXR) as a predictor variable. METHODS: We performed a secondary analysis of prospective data from 8 Level I trauma centers from 2011-2014. We compared performance of modified clinical decision instruments that (1) added eFAST as a predictor (eFAST-added clinical decision instrument), and (2) replaced CXR with eFAST (eFAST-replaced clinical decision instrument), in screening for blunt thoracic injuries. RESULTS: One thousand nine hundred fifty-seven patients had documented computed tomography, CXR, clinical NEXUS criteria, and adequate eFAST; 624 (31.9%) patients had blunt thoracic injuries, and 126 (6.4%) had major injuries. Compared to the NEXUS Chest clinical decision instrument, the eFAST-added clinical decision instrument demonstrated unchanged screening performance for major injury (sensitivity 0.98 [0.94 to 1.00], specificity 0.28 [0.26 to 0.30]) or any injury (sensitivity 0.97 [0.95 to 0.98], specificity 0.21 [0.19 to 0.23]). The eFAST-replaced clinical decision instrument demonstrated unchanged sensitivity for major injury (sensitivity 0.93 [0.87 to 0.97], specificity 0.31 [0.29 to 0.34]) and decreased sensitivity for any injury (0.93 [0.91 to 0.951] versus 0.97 [0.953 to 0.98]). CONCLUSION: In our secondary analysis, adding eFAST as a predictor variable did not improve the diagnostic screening performance of the original NEXUS Chest clinical decision instrument; eFAST cannot replace the CXR criterion of the NEXUS Chest clinical decision instrument.

Discharge Navigator: Implementation and Cross-Sectional Evaluation of a Digital Decision Tool for Social Resources upon Emergency Department Discharge.

INTRODUCTION: Many patients have unaddressed social needs that significantly impact their health, yet navigating the landscape of available resources and eligibility requirements is complex for both patients and clinicians. METHODS: Using an iterative design-thinking approach, our multidisciplinary team built, tested, and deployed a digital decision tool called "Discharge Navigator" (edrive.ucsf.edu/dcnav) that helps emergency clinicians identify targeted social resources for patients upon discharge from the acute care setting. The tool uses each patient's clinical and demographic information to tailor recommended community resources, providing the clinician with action items, pandemic restrictions, and patient handouts for relevant resources in five languages. We implemented two modules at our urban, academic, Level I trauma center. RESULTS: Over the 10-week period following product launch, between 4-81 on-shift emergency clinicians used our tool each week. Anonymously surveyed clinicians (n = 53) reported a significant increase in awareness of homelessness resources (33% pre to 70% post, P<0.0001) and substance use resources (17% to 65%, P<0.0001); confidence in accessing resources (22% to 74%, P<0.0001); knowledge of eligibility criteria (13% to 75%, P<0.0001); and ability to refer patients always or most of the time (11% to 43%, P<0.0001). The average likelihood to recommend the tool was 7.8 of 10. CONCLUSION: Our design process and low-cost tool may be replicated at other institutions to improve knowledge and referrals to local community resources.

The Vot-ER Healthy Democracy Campaign: A National Medical Student Competition to Increase Voting Access.

PROBLEM: Voting affords citizens a direct say in the leaders and policies that affect their health. However, less than 20% of eligible U.S. citizens have been offered the chance to register to vote at a government-funded agency like a hospital or clinic that provides Medicaid or Medicare services. Medical students are well positioned to increase voting access due to their interactions with multiple actors in health care settings, including patients, visitors, colleagues, and others. APPROACH: Vot-ER, a nonpartisan, nonprofit organization that aims to promote civic engagement in health care settings, launched the inaugural Healthy Democracy Campaign from July 20 to October 9, 2020. As part of this national, gamification-based competition, medical student captains were recruited to lead teams of health care trainees and professionals that helped eligible adults start the voter registration and/or mail-in ballot request process before the November 2020 elections. Post competition, medical student captains were surveyed about their motivations for participating and skills and knowledge gained. OUTCOMES: In total, 128 medical student captains at 80 medical schools in 31 states and the District of Columbia formed teams that helped 15,692 adults start the voter registration and/or mail-in ballot request process. Eighty-two (64.1%) captains responded to the post competition survey, representing 56 (70.0%) of the participating schools. The top-ranked motivation for participating in the campaign was the desire to address social and racial inequities (37, 45.1%). Respondents reported gaining skills and knowledge in several aspects of civic engagement, including community organizing (67, 81.7%) and voting rights (63, 76.8%). The majority of respondents planned to incorporate voter registration into their future practice (76, 92.7%). NEXT STEPS: Future Healthy Democracy Campaigns will aim to continue closing the voting access gap and promote the long-term inclusion of hands-on civic engagement in medical education and practice.

Physician Wellness Measures and Clinical Performance on a Critically Ill Simulated Patient: Does a Lack of Well-Being Impact Patient Care?

BACKGROUND/OBJECTIVE: Burnout is common among resident physicians, which has the potential to translate into diagnostic and management errors. Our study investigates the relationship between sleepiness, depression, anxiety, burnout, and lack of professional fulfillment with clinical performance during a critically ill patient simulation. Methods/Approach: Emergency medicine residents were recruited to participate in a high-fidelity simulation case of a critically ill patient. A survey with validated wellbeing measures (National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH PROMIS), Linzer burnout measure, and professional fulfillment index) was administered prior to the simulation. Each encounter was video-recorded and analyzed by two blinded raters based on a binary critical-actions checklist. Time-to-intubation, management errors, and misdiagnosis rates were assessed. RESULTS: Twenty residents participated, with most subjects endorsing sleepiness (70%) and less than half reporting depression (40%) and anxiety (45%). Burnout was identified to be in 50% of participants by the Linzer measure and 85% by the professional fulfillment index. No significant difference was found between mean performance scores in sleepy, depressed, and anxious cohorts in comparison to groups without those symptoms. Similarly, burnout and professional fulfillment did not yield any significant difference, nor did comparisons with time to intubation, management errors, and frequency of misdiagnosis. CONCLUSION: Resident burnout, depression, anxiety, sleepiness, and lack of professional fulfillment did not appear to have a measurable impact on clinical performance in managing a critically ill patient. There is no evidence from this study that the lack of resident physician well-being adversely impacts patient care by increasing errors in management or misdiagnoses during this high-fidelity simulation.

Streamlining Care in Crisis: Rapid Creation and Implementation of a Digital Support Tool for COVID-19.

The unprecedented COVID-19 pandemic has resulted in rapidly evolving best practices for transmission reduction, diagnosis, and treatment. A regular influx of new information has upended traditionally static hospital protocols, adding additional stress and potential for error to an already overextended system. To help equip frontline emergency clinicians with up-to-date protocols throughout the evolving COVID-19 crisis, our team set out to create a dynamic digital tool that centralized and standardized resources from a broad range of platforms across our hospital. Using a design thinking approach, we rapidly built, tested, and deployed a solution using simple, out-of-the-box web technology that enables clinicians to access the specific information they seek within moments. This platform has been rapidly adopted throughout the emergency department, with up to 70% of clinicians using the digital tool on any given shift and 78.6% of users reporting that they "agree" or "strongly agree" that the platform has affected their management of COVID-19 patients. The tool has also proven easily adaptable, with multiple protocols being updated nearly 20 times over two months without issue. This paper describes our development process, challenges, and results to enable other institutions to replicate this process to ensure consistent, high-quality care for patients as the COVID-19 pandemic continues its unpredictable course.

Attending Surgeons Differ From Other Team Members in Their Perceptions of Operating Room Communication.

BACKGROUND: The Joint Commission has repeatedly recognized inadequate communication as a top contributing factor to medical error in the operating room (OR). The goal of this qualitative study was to develop a deeper and more nuanced understanding of OR communication dynamics, specifically across different interdisciplinary roles and to recommend specific interventions based on these findings. METHODS: We performed a two-phase qualitative study at one academic institution to explore contributors and barriers to optimal OR communication. The first phase consisted of interviews with OR team members, including surgery and anesthesiology attending faculty and residents, medical students, and OR staff. We qualitatively analyzed the transcripts of these interviews using a deductive approach. We additionally verified the findings through subsequent focus groups. RESULTS: Most OR team members, independent of role, noted that team familiarity, clear role expectations, and formal communication are vital for effective OR communication. There was a disconnect between attending surgeons and the rest of the OR team: Whereas the majority of team members noted the importance of procedural-focused discussions, team hierarchy, and the attending surgeon's mood as major contributors to successful OR communication, the attending surgeons did not recognize their own ability to contribute to optimal OR communication in these regards. CONCLUSIONS: Although team familiarity was important to all participants in the OR, we noted that attending surgeons differed in their perceptions of OR communications from other members of the team, including attending anesthesiologists, residents, medical students, and nurses. Our findings support the need for (1) improved awareness of the impact of a team members's content and character of communication, particularly by attending surgeons; and (2) targeted initiatives to prioritize team familiarity in OR scheduling.

Accelerating Research With Technology: Rapid Recruitment for a Large-Scale Web-Based Sleep Study.

BACKGROUND: Participant recruitment can be a significant bottleneck in carrying out research studies. Connected health and mobile health platforms allow for the development of Web-based studies that can offer improvement in this domain. Sleep is of vital importance to the mental and physical health of all individuals, yet is understudied on a large scale or beyond the focus of sleep disorders. For this reason and owing to the availability of digital sleep tracking tools, sleep is well suited to being studied in a Web-based environment. OBJECTIVE: The aim of this study was to investigate a method for speeding up the recruitment process and maximizing participant engagement using a novel approach, the Achievement Studies platform (Evidation Health, Inc, San Mateo, CA, USA), while carrying out a study that examined the relationship between participant sleep and daytime function. METHODS: Participants could access the Web-based study platform at any time from any computer or Web-enabled device to complete study procedures and track study progress. Achievement community members were invited to the study and assessed for eligibility. Eligible participants completed an electronic informed consent process to enroll in the study and were subsequently invited to complete an electronic baseline questionnaire. Then, they were asked to connect a wearable device account through their study dashboard, which shared their device data with the research team. The data were used to provide objective sleep and activity metrics for the study. Participants who completed the baseline questionnaires were subsequently sent a daily single-item Sleepiness Checker activity for 7 consecutive days at baseline and every 3 months thereafter for 1 year. RESULTS: Overall, 1156 participants enrolled in the study within a 5-day recruitment window. In the 1st hour, the enrollment rate was 6.6 participants per minute (394 per hour). In the first 24 hours, the enrollment rate was 0.8 participants per minute (47 participants per hour). Overall, 1132 participants completed the baseline questionnaires (1132/1156, 97.9%) and 1047 participants completed the initial Sleepiness Checker activity (1047/1156, 90.6%). Furthermore, 1000 participants provided activity-specific wearable data (1000/1156, 86.5%) and 982 provided sleep-specific wearable data (982/1156, 84.9%). CONCLUSIONS: The Achievement Studies platform allowed for rapid recruitment and high study engagement (survey completion and device data sharing). This approach to carrying out research appears promising. However, conducting research in this way requires that participants have internet access and own and use a wearable device. As such, our sample may not be representative of the general population.

Outcomes and Characteristics of Patients Treated with Emergent Palliative Radiation Therapy.

PURPOSE: Emergent palliative radiation therapy (PRT) of symptomatic metastases can significantly increase the quality of life of patients with cancer. In some contexts, this treatment may be underused, but in others PRT may represent an excessively aggressive intervention. The characterization of the current use of emergent PRT is warranted for optimized value and patient-centered care. METHODS AND MATERIALS: This study is a cross-sectional retrospective analysis of all emergent PRT courses at a single academic tertiary institution across 1 year. RESULTS: A total of 214 patients received a total of 238 treatment courses. The most common indications were bone (39%) and brain (14%) metastases. Compared with outpatients, inpatients had lower mean survival rates (2 months vs 6 months; P < .001), higher rates of stopping treatment early (19.1% vs 9.0%; P = .034), and greater involvement of palliative care (44.8% vs 24.1%; P < .001), but the same mean planned fractions (9.10 vs 9.40 fractions; P = .669). In a multiple predictor survival analysis, palliative care involvement (P = .025), male sex (P = .001), ending treatment early (P = .011), and having 1 of 3 serious indications (airway compromise, leptomeningeal disease, and superior/inferior vena cava involvement; P = .007) were significantly associated with worse overall survival. CONCLUSIONS: Survival is particularly poor in patients who receive emergent PRT, and patient characteristics such as functional status and indication should be considered when determining fractionation schedule and dosing. A multi-institutional study of practice patterns and outcomes is warranted.

Renal ultrasound abnormalities in children with syndromic and non-syndromic microtia.

OBJECTIVE: Renal abnormalities are commonly considered in the work up of pediatric patients with external ear malformations. However, there is little consensus regarding an appropriate renal screening protocol for patients with microtia. We sought to characterize renal abnormalities detected on ultrasonography in pediatric patients with microtia. METHODS: We conducted a retrospective cohort study of pediatric patients diagnosed with microtia who underwent renal ultrasound from 1991 to 2014 at a single tertiary academic institution. Renal ultrasound reports and medical records were reviewed to assess for renal abnormalities and to determine whether patients required specialist follow-up or interventions. Audiograms and otolaryngology notes were used to determine patterns of hearing loss. The following additional information was recorded from the electronic medical records: patient sex, microtia grade (I-IV), microtia laterality, and known associated syndromes. Characteristics were compared between those who did and did not have renal ultrasound findings using Fisher's exact test. Univariate logistic regression analysis was performed to determine factors associated with renal ultrasound findings. RESULTS: The majority of patients in this cohort were syndromic (n = 51, 64%) with grade III microtia (n = 46, 58%) and conductive hearing loss (n = 58, 72%). Syndromic children with microtia demonstrated a higher crude rate of renal ultrasound abnormalities (22%) than children with isolated microtia (7%). Of these patients, 69% required specialist follow-up. Univariate logistic regression analysis did not identify predictors that were significantly associated with renal ultrasound findings. CONCLUSION: Fairly high rates of abnormalities in syndromic and non-syndromic patients may warrant screening renal ultrasound in all patients with microtia, especially given the high percentage of findings requiring renal follow-up. A prospective study to formally evaluate screening efficacy is needed.

Impact of primary care provider density on detection and diagnosis of cutaneous melanoma.

INTRODUCTION: Early diagnosis of cutaneous melanoma is critical in preventing melanoma-associated deaths, but the role of primary care providers (PCPs) in diagnosing melanoma is underexplored. We aimed to explore the association of PCP density with melanoma incidence and mortality. METHODS: All cases of cutaneous melanoma diagnosed in the United States from 2008-2012 and reported in the Surveillance, Epidemiology, and End Results (SEER) database were analyzed in 2016. County-level primary care physician density was obtained from the Area Health Resources File (AHRF). We conducted multivariate linear regression using 1) average annual melanoma incidence or 2) average annual melanoma mortality by county as primary outcomes, adjusting for demographic confounders and dermatologist density. Cox proportional hazard regression was conducted using individual outcome data from SEER with the same covariates. RESULTS: Across 611 counties, 167,305 cases of melanoma were analyzed. Per 100,000 people, an additional 10 PCPs per county was associated with 1.62 additional cases of melanoma per year (95% CI 1.06-2.18, p<0.001). This increased incidence occurred disproportionally in early-stage melanoma (Stage 0: 0.69 cases (0.38-1.00), p<0.001; Stage I: 0.63 cases (0.37-0.89), p<0.001; Stage II: 0.11 cases (0.03-0.19), p = 0.005). There was no statistically significant association between PCP density and incidence of stage III or IV melanoma, or with melanoma-specific mortality. Survival analysis demonstrated elimination of 5-year post-diagnosis mortality risk in medically underserved counties after adjusting for stage. CONCLUSIONS: Higher densities of PCPs may be linked to increased diagnosis of early-stage melanoma without corresponding decreases in late-stage diagnoses or melanoma-associated mortality.

Isolated Renal Laceration on Point-of-care Ultrasound.

We report a renal laceration identified on a point-of-care ultrasound (POCUS) performed in the emergency department on a 58-year-old female presenting after blunt trauma. Emergency workup demonstrated a right flank abrasion with tenderness to palpation, hematuria, and decreasing hematocrit. A Focused Assessment with Sonography in Trauma (FAST) exam, performed as part of the intake trauma protocol, identified positive intraperitoneal fluid in the right upper quadrant. A computed tomography (CT) scan established a diagnosis of isolated right renal hematoma arising from a Grade IV laceration, with no collecting duct involvement. This report reviews the sonographic distinction between a renal hematoma and a positive FAST exam, and emphasizes the vital role ultrasound plays in the evaluation of the trauma patient.

Surgical volunteerism or voluntourism - Are we doing more harm than good?

The significant rise in the number of international health electives undertaken by medical students and doctors in the US, Canada and UK reflects acknowledgement of the inter-connected nature of these challenges to health systems and the drive to help solve them. However, the next generation of international volunteers often operate under a conflicting duality: whilst many of their role models have devoted their lives to global health following a similar volunteering experience, there are pervasive ethical problems associated with transient global health work that must be identified and addressed to ensure positive outcomes for all parties involved. The majority of populations served by shortterm surgical volunteer trips are vulnerable communities; this raises ethical questions such as the lack of informed consent, use of unauthorised photos for marketing, and practicing new procedural techniques. 2 Whilst there exist various models that can be used to facilitate effective international health electives, there is a lack of stringent monitoring and enforcement both on the part of healthcare institutions deploying volunteers as well as recipient bodies in LMICS. Well-organised programmes prevent cases of 'poor care given to poor people' as medical students and doctors are expected to act in their patients' best interests as they would do in their home country. As clinician interest in global health projects continue to rise, too-common trainee naivety - while rooted in goodwill - must be supplanted by adequate training, ethical coherence, and cultural fluency. The onus lies on medical schools and healthcare bodies endorsing international electives to ensure that individuals are appropriately prepared and only travel through programmes that are able to demonstrate that they meet the necessary requirements and follow guidelines to avoid doing more harm than good.

Cost-effectiveness of Stereotactic Body Radiation Therapy versus Radiofrequency Ablation for Hepatocellular Carcinoma: A Markov Modeling Study.

Purpose To assess the cost-effectiveness of stereotactic body radiation therapy (SBRT) versus radiofrequency ablation (RFA) for patients with inoperable localized hepatocellular carcinoma (HCC) who are eligible for both SBRT and RFA. Materials and Methods A decision-analytic Markov model was developed for patients with inoperable, localized HCC who were eligible for both RFA and SBRT to evaluate the cost-effectiveness of the following treatment strategies: (a) SBRT as initial treatment followed by SBRT for local progression (SBRT-SBRT), (b) RFA followed by RFA for local progression (RFA-RFA), (c) SBRT followed by RFA for local progression (SBRT-RFA), and (d) RFA followed by SBRT for local progression (RFA-SBRT). Probabilities of disease progression, treatment characteristics, and mortality were derived from published studies. Outcomes included health benefits expressed as discounted quality-adjusted life years (QALYs), costs in U.S. dollars, and cost-effectiveness expressed as an incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analysis was performed to assess the robustness of the findings. Results In the base case, SBRT-SBRT yielded the most QALYs (1.565) and cost $197 557. RFA-SBRT yielded 1.558 QALYs and cost $193 288. SBRT-SBRT was not cost-effective, at $558 679 per QALY gained relative to RFA-SBRT. RFA-SBRT was the preferred strategy, because RFA-RFA and SBRT-RFA were less effective and more costly. In all evaluated scenarios, SBRT was preferred as salvage therapy for local progression after RFA. Probabilistic sensitivity analysis showed that at a willingness-to-pay threshold of $100 000 per QALY gained, RFA-SBRT was preferred in 65.8% of simulations. Conclusion SBRT for initial treatment of localized, inoperable HCC is not cost-effective. However, SBRT is the preferred salvage therapy for local progression after RFA. © RSNA, 2017 Online supplemental material is available for this article.

Confirming psychogenic nonepileptic seizures with video-EEG: sex matters.

The influence of gender on psychogenic nonepileptic seizures (PNES) diagnosis was examined retrospectively in 439 subjects undergoing video-EEG (vEEG) for spell classification, of whom 142 women and 42 men had confirmed PNES. The epileptologist's predicted diagnosis was correct in 72% overall. Confirmed epilepsy was correctly predicted in 94% men and 88% women. In contrast, confirmed PNES was accurately predicted in 86% women versus 61% men (p=0.003). Sex-based differences in likelihood of an indeterminate admission were not observed for predicted epilepsy or physiologic events, but were for predicted PNES (39% men, 12% women, p=0.0002). More frequent failure to record spells in men than women with predicted PNES was not explained by spell frequency, duration of monitoring, age, medication use, or personality profile. PNES are not only less common in men, but also more challenging to recognize in the clinic, and even when suspected more difficult to confirm with vEEG.

Indeterminate EMU admissions: does repeating the admission help?

Epilepsy monitoring unit (EMU) admissions during 2007-2009 at Mayo Clinic Hospital Arizona were reviewed. Of the 106 indeterminate admissions, 13 (12%) went on to have a second admission. During the second admission, 8 (62%) were diagnosed. Five patients went on to have a third or fourth admission, with none of them receiving a diagnosis. Nineteen (18%) patients had ambulatory EEG monitoring after an indeterminate admission, with only one (5%) receiving a diagnosis after ambulatory EEG monitoring. Even in patients who were initially indeterminate, medication management changed 37% of the time. Admission to the EMU was helpful for spell classification, with 80% of the patients receiving a diagnosis after the first admission. Based on this study, a second admission should be considered if no diagnosis is reached after the first admission. If no diagnosis is made after the second EMU admission, subsequent admissions are unlikely to produce a definitive diagnosis.