Pre-endoscopic Rockall and Blatchford scores to identify which emergency department patients with suspected gastrointestinal bleed do not need endoscopic hemostasis.

BACKGROUND: The pre-endoscopic Rockall Score (RS) and the Glasgow-Blatchford Scores (GBS) can help risk stratify patients with upper gastrointestinal bleed who are seen in the Emergency Department (ED). The RS and GBS have yet to be validated in a United States patient population for their ability to discriminate which ED patients with upper gastrointestinal bleed do not need endoscopic hemostasis. OBJECTIVE: We sought to determine whether patients who received a score of zero on either score (the lowest risk) in the ED still required upper endoscopic hemostasis during hospitalization. METHODS: Retrospective electronic medical record chart review was performed during a 3-year period (2007-2009) to identify patients with suspected upper gastrointestinal bleed by ED final diagnosis of gastrointestinal hemorrhage and related terms at a single urban academic ED. The RS and GBS were calculated from ED chart abstraction and the hospital records of admitted patients were queried for subsequent endoscopic hemostasis. RESULTS: Six hundred and ninety patients with gastrointestinal bleed were identified and 86% were admitted to the hospital. One hundred and twenty-two patients had an RS equal to zero; 67 (55%; 95% confidence interval [CI] 46-63%) of these patients were admitted to the hospital and 11 (16%; 95% CI 9-27%) received endoscopic hemostasis. Sixty-three patients had a GBS equal to zero; 15 (24%; 95% CI 15-36%) were admitted to the hospital and 2 (13%; 95% CI 4-38%) received endoscopic hemostasis. CONCLUSIONS: Some patients who were identified as lowest risk by the GBS or RS still received endoscopic hemostasis during hospital admission. These clinical decision rules may be insufficiently sensitive to predict which patients do not require endoscopic hemostasis.

Emergency Medicine Trainee Burnout Is Associated With Lower Patients' Satisfaction With Their Emergency Department Care.

INTRODUCTION: Emergency medicine (EM) physicians and trainees report high levels of burnout. Burnout negatively impacts physician well-being and career satisfaction but it remains unclear how burnout may influence patient care. We examined the degree to which EM trainee burnout at one institution was associated with patients' satisfaction with their emergency department (ED) care. METHODS: In this cross-sectional, pilot study conducted at a single institution, we measured EM trainee burnout using the Maslach Burnout Inventory through a confidential, electronic survey. We subsequently linked individual trainee burnout results with their individual Press Ganey (PG) ED patient satisfaction scores. We compared burnout scores across sex and postgraduate year using chi-square tests and PG results via analysis of variance. RESULTS: Twenty-seven of 53 (50.9%) eligible EM trainees completed the burnout assessment. Trainees reported an overall burnout rate of 77.8% (95% confidence interval = 59.2%-89.4%). There were no significant differences in burnout based on sex (p = 0.888) or postgraduate year (p = 0.671). Trainee burnout was significantly associated with lower trainee-specific PG scores, including patient ratings of resident physician courtesy (p = 0.011), taking the time to listen (p = 0.004), keeping informed of treatment (p = 0.014), and concern for patient comfort (p = 0.006). There was no significant association between trainee burnout and patients' overall likelihood to recommend the ED to others (p = 0.364). CONCLUSION: Emergency medicine trainee burnout is associated with lower trainee-specific PG ED patient satisfaction scores across all four physician domains. In addition to its detrimental impact on physician wellness, burnout may play a significant adverse role in patients' perceptions of their ED providers' interpersonal and communication skills.

Emergency physicians accurately interpret video capsule endoscopy findings in suspected upper gastrointestinal hemorrhage: a video survey.

BACKGROUND: Acute upper gastrointestinal (GI) hemorrhage is a common emergency department (ED) presentation whose severity ranges from benign to life-threatening and the best tool to risk stratify the disease is an upper endoscopy, either by scope or by capsule, a procedure performed almost exclusively by gastroenterologists. Unfortunately, on-call gastroenterology specialists are often unavailable, and emergency physicians (EPs) currently lack an alternative method to endoscopically visualize a suspected acute upper GI hemorrhage. Recent reports have shown that video capsule endoscopy is well tolerated by ED patients and has similar sensitivity and specificity to endoscopy for upper GI hemorrhage. OBJECTIVES: The study objective was to determine if EPs can detect upper GI bleeding on capsule endoscopy after a brief training session. METHODS: A survey study was designed to demonstrate video examples of capsule endoscopy to EPs and determine if they could detect upper GI bleeding after a brief training session. All videos were generated from a prior ED-based study on patients with suspected acute upper GI hemorrhage. The training session consisted of less than 10 minutes of background information and capsule endoscopy video examples. EPs were recruited at the American College of Emergency Physicians Scientific Assembly in Denver, Colorado, from October 8, 2012, to October 10, 2012. Inclusion criteria included being an ED resident or attending physician and the exclusion criteria included any formal endoscopy training. The authors analyzed the agreement between the EPs and expert adjudicated capsule endoscopy readings for each capsule endoscopy video. For the outcome categories of blood (fresh or coffee grounds type) or no blood detected, the sensitivity and specificity were calculated. RESULTS: A total of 126 EPs were enrolled. Compared to expert gastroenterology-adjudicated interpretation, the sensitivity to detect blood was 0.94 (95% confidence interval [CI] = 0.91 to 0.96) and specificity was 0.87 (95% CI = 0.80 to 0.92). CONCLUSIONS: After brief training, EPs can accurately interpret video capsule endoscopy findings of presence of gross blood or no blood with high sensitivity and specificity.