Individualized throughput metric reports for emergency medicine residents: Impact on time to disposition and resident perceptions.

Background: Research suggests that quantitative metric reports can improve the clinical performance of emergency physicians; however, few studies have examined their effects on physicians in training. The primary study objective was to assess the effects of providing emergency medicine (EM) residents with individualized throughput metrics with regard to emergency department (ED) disposition times. Methods: We performed a single-center, retrospective, observational study from January 2021 to December 2022 examining ED disposition times before and after providing upper-level EM residents individualized throughput metrics. Residents received monthly reports of three specific metrics averaged over the preceding 6 months: (1) median time from room to discharge order (Rm2Dc), (2) median time from return of all results to discharge order (Rlts2Dc), and (3) median time from room and to consult order for hospitalization (Rm2Hosp). Overall mean values of the three metrics before and during metric sharing were compared via independent t-test and stratified by level of training and time of year. Adjusted analysis was performed to control for temporal differences between study periods. Testing was conducted at α = 0.05 level of significance. Results: A total of 35 unique residents were included in the analysis. Overall, mean disposition times were not significantly different before and during reporting of metrics: Rm2Dc (154.8 min vs. 148.9 min, p = 0.109), Rslt2Dc (46.5 min vs. 45.1 min, p = 0.522), and Rm2Hosp (141.7 min vs. 135.7 min, p = 0.257). Subgroup analysis yielded similar results, aside from a significant decrease in mean Rm2Hosp in the postgraduate year-3 (PGY-3) group (145.8 min vs. 124.1 min, p = 0.004). Analysis with adjusted means yielded results similar to those observed with unadjusted data. Conclusions: Overall, individualized throughput metrics were not correlated with decreased average times to ED disposition for upper-level EM residents; however, in the subset of hospitalized patients seen by PGY-3 residents, we observed a mean decrease of 21.7 min to consultation.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis.

OBJECTIVE: The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS: We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS: We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS: POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION: PROSPERO registration number: CRD42022303598.

Utility of serial conventional troponin testing for emergency department patients stratified by HEART score and symptom timing.

BACKGROUND: The HEART score for risk stratifying chest pain patients in the emergency department (ED) has been widely adopted in clinical practice, but is often employed with nonconformant serial troponin measurements. OBJECTIVE: The primary objective of this study was to examine the utility of obtaining a second conventional 3-h troponin I (TnI) level in ED patients presenting with potential acute coronary syndrome (ACS), stratified by HEART score and duration of symptoms. METHODS: This was a retrospective cohort study of consecutive adult ED patients with a complete HEART score. We assessed the utility of repeat TnI measurement by examining the positivity rate of ΔTnI = [Second TnI] - [Initial TnI] stratified by HEART score and time elapsed since onset or resolution of symptoms. Major adverse cardiac events (MACE) within 6 weeks of index visit were assessed. RESULTS: A total of 944 patients were included with 433 (45.9%) assigned a low risk HEART score 0-3. Of the 268 (61.9%) low risk HEART score patients receiving a second TnI, only 3 (1.1%, [0.2-3.2%]) resulted in a positive ΔTnI, one of which occurred in the setting of an elevated initial TnI. Overall, patients presenting within 3 h of symptoms were more likely to experience positive ΔTnI, index MACE and MACE at 6 weeks compared to patients presenting ≥3 h since symptoms onset/resolution and patients with unknown timing of symptoms (15.9% vs 11.0% vs 10.3%, p < 0.001; 10.0% vs 5.3% vs 4.6%, p = 0.021; 12.7% vs 6.6% vs 6.4%, p = 0.047). CONCLUSION: Our data suggest serial measurement of conventional troponin provides limited added benefit in low risk HEART score patients, regardless of duration and timing of symptoms. Conversely, serial troponin measurement may confer utility in moderate/high risk HEART score patients, particularly those presenting within 3 h of symptoms.

A prospective, multicenter evaluation of point-of-care ultrasound for appendicitis in the emergency department.

OBJECTIVE: The main objective of this study was to evaluate the accuracy of point-of-care ultrasound (POCUS) for the diagnosis of appendicitis in a general emergency department (ED) population as performed by emergency physicians with variable ultrasound experience. METHODS: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential appendicitis presenting to the ED between July 2014 and February 2020. Each emergency physician-performed POCUS was interpreted at the bedside and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS and blinded expert interpretation compared to surgical pathology in patients undergoing appendectomy and advanced imaging in patients managed nonoperatively. RESULTS: A total of 256 subjects were included in the primary analysis with an overall appendicitis prevalence of 28.1%. For the diagnosis of appendicitis, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.85 (95% confidence interval [CI] = 0.74 to 0.92), 0.63 (95% CI = 0.56 to 0.70), 2.29 (95% CI = 1.85 to 2.84), and 0.24 (95% CI = 0.14 to 0.42), respectively. Expert review yielded a lower sensitivity (0.74 [95% CI = 0.62 to 0.83]) with a similar specificity (0.63 [95% CI = 0.56 to 0.70]). CONCLUSION: POCUS is moderately accurate for acute appendicitis as performed by emergency physicians with a wide range of ultrasound expertise, but lacks adequate sensitivity and specificity to function as a definitive test in an undifferentiated ED population. Further study is warranted to elucidate the optimal role of integrated POCUS in the general approach to suspected appendicitis.

Atezolizumab-induced Autoimmune Diabetes in a Patient with Metastatic Breast Cancer: A Case Report.

INTRODUCTION: Immune checkpoint inhibitors (ICI) are a class of immunotherapy drugs used increasingly in the treatment of multiple types of cancer. Major side effects include immune-related adverse effects, potentially resulting in damage to normal tissue across multiple different organ systems. CASE REPORT: A 74-year-old woman with a history of triple negative metastatic breast cancer treated with the ICI atezolizumab presented with new-onset autoimmune diabetes in diabetic ketoacidosis. She required fluid resuscitation, insulin infusion, vasopressors, and initial hospitalization in the intensive care unit. The patient was subsequently discharged on bolus dose insulin and remained an insulin-dependent diabetic at three-month follow-up. CONCLUSION: Autoimmune diabetes is a rare, but life-threatening, adverse event associated with ICIs such as atezolizumab. To our knowledge this is the only case report of atezolizumab causing autoimmune diabetes in the setting of metastatic breast cancer. As ICIs become more common in the treatment of cancer, emergency physicians should remain vigilant for the various immune-mediated complications associated with this class of immunotherapy drugs.

Impact of creatinine screening on contrast-induced nephropathy following computerized tomography for stroke.

OBJECTIVE: This study sought to evaluate rates of acute kidney injury in patients undergoing contrast-enhanced computerized tomography for acute stroke in the emergency department (ED) before and after the cessation of creatinine screening. METHODS: This retrospective study compared ED patients receiving contrast-enhanced imaging for suspected acute stroke with and without protocolized creatinine screening. The primary outcome was CIN, defined as an increase in serum creatinine of 0.3 mg/dl within 48 hours or 50% above baseline within 7 days after contrast administration. Secondary outcomes consisted of CIN based on other definitions, renal impairment greater than 30 days from contrast administration, hemodialysis, and mortality. Outcomes were compared using difference of proportions and odds ratios with 95% confidence intervals. RESULTS: This study included 382 subjects, with 186 and 196 in the screening and post-screening cohorts, respectively. No significant differences were observed for CIN (7.0% vs 7.1%, difference 0.1% [95% CI -5.6-5.1%], OR 1.02 [95% CI 0.47-2.24]), renal impairment greater than 30 days post-contrast (8.4% vs 7.5%, OR 0.88 [0.38-2.07]), or mortality (index visit: 4.8% vs 2.6%, OR 0.51 [0.17-1.57], 90-day follow-up: 6.7% vs 4.0%, OR 0.58 [0.22-1.53]). No patients from either group required hemodialysis. CONCLUSIONS: The elimination of creatinine screening prior to obtaining contrast-enhanced computerized tomography in patients with suspected acute stroke did not adversely affect rates of CIN, hemodialysis, or mortality at a comprehensive stroke center.

Gastric Outlet Obstruction Due to Malposition of Replacement Gastrostomy Tube.

A 78-year old male presented to the emergency department after accidental dislodgement of his chronic gastrostomy tube. A replacement gastrostomy tube was passed easily through the existing stoma and flushed without difficulty. Confirmatory abdominal radiography demonstrated contrast in the proximal small bowel, but the patient subsequently developed epigastric pain and refractory vomiting. Computed tomography revealed the tip of the gastrostomy tube terminating in the pylorus or proximal duodenum. This case highlights gastric outlet obstruction complicating the replacement of a gastrostomy tube and the associated radiographic findings.

A Prospective, Multicenter Evaluation of Point-of-care Ultrasound for Small-bowel Obstruction in the Emergency Department.

OBJECTIVE: The main objective of this study was to evaluate the accuracy of emergency physician-performed point-of-care ultrasound (POCUS) for the diagnosis of small-bowel obstruction (SBO) compared to computed tomography (CT). METHODS: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential SBO presenting to the emergency department (ED) between July 2014 and May 2017. Each POCUS was interpreted at the bedside by the performing emergency physician and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS, blinded expert interpretation, and specific POCUS parameters. RESULTS: A total of 217 subjects were included in the primary analysis with an overall SBO prevalence of 42.9%. For the diagnosis of SBO, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.88 (95% confidence interval [CI] = 0.80 to 0.94), 0.54 (95% CI = 0.45 to 0.63), 1.92 (95% CI = 1.56 to 2.35), and 0.22 (95% CI = 0.12 to 0.39), respectively. Expert review yielded a similar sensitivity (0.89 [95% CI = 0.81 to 0.95]) with a significantly higher specificity (0.82 [95% CI = 0.74 to 0.88]). The more sensitive sonographic parameters for both POC sonographers and expert reviewers were small-bowel dilation ≥ 25 mm (0.87 [95% CI = 0.79 to 0.93], 0.87 [95% CI = 0.79 to 0.93]) and abnormal peristalsis (0.82 [95% CI = 0.72 to 0.89], 0.85 [95% CI = 0.76 to 0.87]). The more specific parameters for both groups were transition point (0.82 [95% CI = 0.74 to 0.89], 0.98 [95% CI = 0.94 to 1.00]), intraperitoneal free fluid (0.82 [95% CI = 0.74 to 0.89], 0.93 [95% CI = 0.87 to 0.97]), and bowel wall edema (0.76 [95% CI = 0.67 to 0.83], 0.93 [95% CI = 0.87 to 0.97]). CONCLUSION: POCUS is moderately sensitive for SBO, although less specific, when performed by a diverse group of emergency physicians across multiple EDs. Interpretation of acquired POCUS images is significantly more accurate when performed by physicians with prior emergency ultrasound fellowship training and familiarity with the sonographic appearance of SBO.

Low-level troponin elevations following a reduced troponin I cutoff: Increased resource utilization without improved outcomes.

OBJECTIVE: The study sought to evaluate changes in mortality and resource utilization in patients with low level troponin elevations following a reduction in the cutoff for normal troponin I (TnI) from 0.5 ng/mL to the 99th percentile (0.06 ng/mL). METHODS: This was an interrupted time series comparing emergency department (ED) patients with possible acute coronary syndrome (ACS) and TnI values 0.06-0.5 ng/mL before and after an institutional decrease in the TnI cutoff. The primary outcome was overall mortality at 90 days. Secondary outcomes included rates of rehospitalization, subsequent ACS, and coronary intervention within 90 days, as well as rates of anticoagulation, cardiology consultation, cardiac testing, and coronary intervention during the index visit. Outcomes for the pre-cutoff change group (control) and post-cutoff change group (post) were compared using tests of proportions and odds ratios. RESULTS: The study included a total of 1058 subjects with 529 in each cohort. No significant differences in 90 day outcomes were observed between groups, including mortality (13.2% post vs 14.1% control, OR 0.93 [95% CI: 0.65-1.34], p = 0.705). During the index visit, the post-group demonstrated higher rates of cardiology consultation (55.4% vs 41.2%, OR 1.77 [1.39-2.26], p < 0.0001) and cardiac stress testing (16.4% vs 10.6%, OR 1.66 [1.16-2.38], p = 0.006), but no significant differences in coronary intervention or short-term mortality were observed. CONCLUSION: A reduction in the TnI cutoff to the 99th percentile did not change mortality or rates of coronary intervention in ED patients with low level troponin elevations, but significantly increased the use of cardiology resources.

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study.

BACKGROUND: Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. OBJECTIVE: The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. METHODS: We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. RESULTS: A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. CONCLUSION: Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.

Intraosseous access in the obese patient: assessing the need for extended needle length.

BACKGROUND: Intraosseous (IO) access can be complicated by obesity. Successful placement of a 25 mm IO needle is unlikely when soft tissue depth exceeds 20 mm. OBJECTIVES: The authors examined the relationship between body mass index (BMI), the ability to palpate the tibial tuberosity (TT), and soft tissue depth at recommended IO insertion sites. METHODS: Obese emergency department patients were assessed for a palpable TT and received ultrasound measurement of the soft tissue depth at recommended IO insertion sites. Linear and logistic regression were used to determine cut-off BMI values predicting soft tissue depth >20 mm. RESULTS: Seventy-five patients were enrolled with a mean BMI of 47.2. The mean soft tissue depth at the proximal humerus, proximal tibial, and distal tibial were 29.6 [95% CI 27.5-31.7] mm, 11.0 [8.9-13.0] mm, and 10.7 [9.4-12.1] mm, respectively. In 5 patients without a palpable TT the soft tissue depth exceeded 20 mm at all three anatomic sites. A BMI ≥43 and BMI ≥60 predicted a soft tissue depth >20 mm at the proximal tibia and distal tibia, respectively, while no reliable BMI cut-off was identified at the proximal humerus. CONCLUSIONS: In obese adults with a palpable TT or BMI ≤43 a 25 mm IO needle is likely adequate at the proximal and distal tibial insertion sites. Empiric use of an extended 45 mm IO needle is advisable at the proximal humeral insertion site in obese patients.

Extrabiliary Pathology Identified by Right Upper Quadrant Abdominal Ultrasound in Emergency Department Patients.

BACKGROUND: The effectiveness of point of care (POC) right upper quadrant ultrasound (RUQ US) in the diagnosis of biliary disease has been well studied. Extrabiliary pathology that might remain undetected in the course of typical, focused POC RUQ US has not been directly examined. OBJECTIVES: Our objective was to determine the prevalence and clinical significance of extrabiliary findings (EBFs) seen on radiology-performed, comprehensive RUQ US. METHODS: We conducted a retrospective review of all adult patients undergoing radiology-performed RUQ US in the emergency department (ED) between January 2007 and April 2012. Ultrasound findings and contemporaneous laboratory values were collected. EBFs were identified and further classified by clinical significance. RESULTS: A total of 1579 charts were included, demonstrating a total of 1030 EBFs, with 747 (47.3% [95% confidence interval {CI}, 44.8-49.8%]) patients demonstrating ≥ 1 EBF. Of these EBFs, 184 were classified as clinically significant (CSEBFs) and 150 (9.5% [95% CI, 8.1-11.0%]) patients had ≥ 1 CSEBF. A total of 50 unspecified masses were seen in 47 (3.0% [95% CI, 2.1-3.8%]) patients, with 8 (0.5%) representing a previously undiagnosed malignancy. CONCLUSION: CSEBFs were seen in < 10% of ED patients undergoing comprehensive RUQ US. Nonspecific masses were seen in 3% of patients, but < 1% of patients were found to have a new malignancy.

Focused Cardiac Ultrasound Diagnosis of Cor Triatriatum Sinistrum in Pediatric Cardiac Arrest.

Cardiac arrest in the adolescent population secondary to congenital heart disease (CHD) is rare. Focused cardiac ultrasound (FoCUS) in the emergency department (ED) can yield important clinical information, aid in resuscitative efforts during cardiac arrest and is commonly integrated into the evaluation of patients with pulseless electrical activity (PEA). We report a case of pediatric cardiac arrest in which FoCUS was used to diagnose a critical CHD known as cor triatriatum sinistrum as the likely cause for PEA cardiac arrest and help direct ED resuscitation.

Multi-Institution Validation of an Emergency Ultrasound Image Rating Scale-A Pilot Study.

BACKGROUND: As bedside ultrasound (BUS) is being increasingly taught and incorporated into emergency medicine practice, measurement of BUS competency is becoming more important. The commonly adopted experiential approach to BUS competency has never been validated on a large scale, and has some limitations by design. OBJECTIVE: Our aim was to introduce and report preliminary testing of a novel emergency BUS image rating scale (URS). METHODS: Gallbladder BUS was selected as the test case. Twenty anonymous BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six training sites across the United States. Each reviewer rated the BUS sets using the pilot URS that consisted of three components, with numerical values assigned to each of the following aspects: Landmarks, Image Quality, and Annotations. Reviewers also decided whether or not each BUS set would be "Clinically Useful." Kendall τs were calculated as a measure of concordance among the reviewers. RESULTS: Among the 13 attendings, image review experience ranged from 2-15 years, 5-300 scans per week, and averaged 7.8 years and 60 images. Kendall τs for each aspect of the URS were: Landmarks: 0.55; Image Quality: 0.57; Annotation: 0.26; Total Score: 0.63, and Clinical Usefulness: 0.45. All URS elements correlated significantly with clinical usefulness (p < 0.001). The correlation coefficient between each attending reviewer and the entire group ranged from 0.48-0.69, and was independent of image review experience beyond fellowship training. CONCLUSION: Our novel URS had moderate-to-good inter-rater agreement in this pilot study. Based on these results, the URS will be modified for use in future investigations.

Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis.

BACKGROUND: Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers. OBJECTIVE: To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound. METHODS: We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis. RESULTS: Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values. CONCLUSION: The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.