Integrating Choosing Wisely, Value-Based Care Principles, Into Undergraduate Medical Education: A Pilot Study.

BACKGROUND: Healthcare spending represents a large portion of the GDP of the United States. Value-based care (VBC) seeks to decrease waste in health care spending, yet this concept is insufficiently taught to medical students. The Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) campaign promotes initiatives that integrate knowledge of VBC into undergraduate medical education (UME). This study sought to determine the most effective strategy to educate medical students on key principles of VBC as taught by the STARS campaign. METHODS: Choosing Wisely principles were incorporated into the UME curriculum of an academic medical institution via the creation of eight new learning objectives (LOs) for case-based learning (CBL) sessions and lectures. Medical students completed an annual 10-question survey from 2019 to 2022 and 10 formal examination questions during the preclinical (years 1 and 2) curriculum after exposure to varying quantities of LOs. Pearson correlation, chi-square, and logistic regression were employed to determine the association between increased LOs in the curriculum and (1) campaign awareness and (2) knowledge of VBC principles. RESULTS: A total of 700 survey responses over a four-year period (2019 to 2022) were analyzed. Student awareness of the campaign and knowledge of VBC principles increased year over year during the survey period (39% to 92% and 64% to 74%, respectively). There were significant associations between increased LOs in the curriculum and (1) campaign awareness (0.828, p<0.0001) and (2) knowledge of VBC principles (0.934, p<0.001). Students also performed well on formal examination questions related to VBC principles (mean: 81.5% and mean discrimination index: 0.18). CONCLUSION: Integration of VBC-focused LOs is significantly associated with awareness of the Choosing Wisely STARS campaign and knowledge of VBC principles taught by the campaign. Collaborative initiatives to increase exposure to VBC education may improve students' knowledge of these principles during medical school.

Co-designing Diabetes Care With Patients.

More than 537 million adults worldwide are living with diabetes and navigating its health and lifestyle impact. People living with diabetes face unique challenges in managing their diet and exercise, monitoring their blood glucose, self-administering medications, and effectively integrating their disease into their social activities. In addition to diabetes being a challenging multifactorial disease, these challenges arise in part from patients having to navigate a complex ecosystem where sectors are siloed and its services, products, and environments are not designed with the patient in mind. To address these challenges, the ecosystem of diabetes care, including researchers, healthcare professionals, product and service developers, and policymakers, can adopt co-design methodologies providing patients and caregivers a seat at the table when creating solutions. Co-design in healthcare is an approach to problem-solving where patients are viewed as equal partners providing their own unique perspective and expertise, to design and develop devices, services, and environments. Co-design emphasizes the value of the user's insights and expertise. Incorporating patient perspective has been shown to increase patient empowerment and satisfaction, enhance healthcare technology value, and strengthen the collaboration between the patient and their interprofessional ecosystem. We describe opportunity spaces, successful examples, and strategies to better engage patients in research, policymaking, and healthcare product, service, and environment development through co-design methods. By incorporating co-design, the ecosystem of diabetes care can deliver more effective, high-quality patient-centered care, products, and services.

Curriculum Development by Design Thinking: Analyzing a Program for Social Determinants of Health Screening by Pre-Clerkship Medical Students.

PROBLEM: Health systems science (HSS) curricula in medical schools facilitate an understanding of social determinants of health (SDOH) and their impact on health outcomes. After implementation of an experiential, patient-centered program based around SDOH screening, however, our medical college noted poor student receptivity and engagement. In order to improve the program, we chose a design thinking approach based on the perceived value of actively engaging learners in the design of education. The role of design thinking in curricular quality improvement, however, remains unclear. INTERVENTION: We sought to determine if a current educational model for SDOH screening could be improved by reforming the curriculum using a design thinking workshop involving student and faculty stakeholders. CONTEXT: The current study is a retrospective analysis of first-year medical student, end-of-year evaluations of the Clinical Experience (CE) program at the Sidney Kimmel Medical College before (2018-19) and after (2019-20) implementation of the design thinking workshop and subsequent curriculum changes. IMPACT: Overall positive results significantly increased across all survey questions after the curricular intervention (p < 0.01), indicating increased student satisfaction with the revised curriculum. LESSONS LEARNED: Few studies assess outcomes of design thinking-driven curricular changes. The current study of an SDOH screening program details the implementation of initiatives that originated from a design thinking sprint and assesses program evaluations following these curricular changes. Most of the well-received curricular changes concerned improvements in student training, patient screening and follow-up, and the leveraging of existing technology. The study reinforces the importance of co-creation among stakeholders when redesigning medical curricula.

Virtual Community Health Workers: Approaches to Patient Outreach During the COVID-19 Pandemic.

BACKGROUND: Prior to the COVID-19 pandemic, community health workers (CHWs) in our health system screened patients in-person for social determinants of health and connected them to community resources. However, when our CHWs were required to work remotely from home due to the pandemic, the best platform to optimize contacting these patients was unknown. This study sought to evaluate the effectiveness of three outgoing phone call approaches (*67, Google Voice®, and Doximity Dialer®) in successfully contacting patients. METHODS: We performed a retrospective analysis comparing reach rates across the three outgoing call approaches. RESULTS: Reach rates were highest when Doximity Dialer was used (64.0%, 95% CI: 58.8-69.0) compared with *67 (40.8%, 95% CI: 30.8-51.6) or Google Voice (53.2%, 95% CI: 48.4-57.8) in this analysis of 1,144 outreach calls. CONCLUSION: Due to higher reach rates, we recommend Doximity Dialer for phone-based outreach to patients. Additional research to improve the efficacy of remote outreach is warranted.

Relationship of the Built Environment on Nursing Communication Patterns in the Emergency Department: A Task Performance and Analysis Time Study.

INTRODUCTION: The physical layout of the emergency department affects the way in which patients and providers move within the space and can cause substantial changes in workflow and, therefore, affect communication patterns between providers. There is no 1 ED design that enables the best patient care, and quantitative studies looking at ED design are limited. The goal of this study was to examine how different ED designs, centralized and decentralized, are associated with communication patterns among health care professionals. METHODS: A task performance, direct observation time study was used. By developing a novel tablet-based digital mapping tool using a cloud-based mapping platform (ArcGIS), data on provider actions and interactions were collected and mapped to a precise location within the emergency department throughout an entire nursing shift. RESULTS: The difference in the duration of nurse-physician interactions between the 2 ED designs was statistically significant. Within the centralized design, nurse-physician interactions totaled 14 minutes and 38 seconds compared with 30 minutes and 11 seconds in the decentralized design (t = 2.31, P = 0.02). More conversations between nurses and physicians occurred inside the patient's room in the decentralized design. DISCUSSION: Our findings suggest that the ED design affects communication patterns among health care providers and that the design has the potential to affect the quality of patient care.

Development of a Novel Emergency Department Mapping Tool.

OBJECTIVES: Develop a built environment mapping workflow. Implement the workflow in the emergency department (ED). Demonstrate the actionable representations of the data that can be collected using this workflow. BACKGROUND: The design of the healthcare built environment impacts the delivery of patient care and operational efficiency. Studying this environment presents a series of challenges due to the limitations associated with existing technology such as radio-frequency identification. The authors designed a customized mapping workflow to collect high-resolution spatial, temporal, and activity data to improve healthcare environments, with emphasis on patient safety and operational efficiency. METHOD: A large, urban, academic medical center ED collaborated with an architecture firm to create a data collection, and mapping workflow using ArcGIS tools and data collectors. The authors developed tools to collect data on the entire ED, as well as individual patients, physicians, and nurses. Advanced visual representations were created from the master data set. RESULTS: In 48 consecutive hourly snapshots, 5,113 data points were collected on patients, physicians, nurses, and other staff reflecting the operations of the ED. Separately, 84 patients, 10 attending physicians, 10 resident physicians, and 17 nurses were tracked. CONCLUSIONS: The data obtained from this pilot study were used to create advanced visual representations of the ED environment. This cost-effective ED mapping workflow may be applied to other healthcare settings. Further investigation to evaluate the benefits of this high-resolution data is required.

Outpatient Treatment of Uncomplicated Urinary Tract Infections in the Emergency Department.

One of the most commonly treated infections in the emergency department (ED) is an uncomplicated urinary tract infection. Multiple classes of antibiotics are frequently used to treat this condition, but not all have equivalent efficacy, and many may confer risks to not only the patient but society as a whole if used on a large scale. These antibiotic selections should also be guided by local antimicrobial susceptibility patterns, and general multidisciplinary recommendations for therapy should be developed on a local scale to assist prescribing patterns. The proactive development of a routine approach to reviewing and addressing positive cultures following discharge from the ED should also be developed and implemented in order to ensure that optimal patient care is provided. The objective of this review is to assess the available literature to isolate which antibiotics and approaches to care are the most appropriate options for treating uncomplicated outpatient urinary tract infections in the ED.

Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

BACKGROUND: Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. OBJECTIVES: We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. METHODS: We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. RESULTS: There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. CONCLUSIONS: An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

Ultrasound-Guided Diagnosis of Femoral Osteomyelitis and Abscess.

Skin and soft tissue infections are common disease presentations to the pediatric emergency department, and rapid and accurate identification of potentially serious skin and soft tissue infections is critical. In cases of atraumatic musculoskeletal pain with systemic complaints, a bacterial etiology must be ruled out. Point-of-care ultrasonography is increasingly common in the pediatric emergency department and assists in rapid and accurate identification of a variety of disease processes. We present a case of a 14-year-old adolescent boy with atraumatic right knee pain to illustrate the benefits of point-of-care ultrasonography in the timely diagnosis of musculoskeletal and soft tissue pathology. Moreover, we describe the use of ultrasound in procedural guidance of deep-space fluid aspiration, with an eventual diagnosis of femoral osteomyelitis. Ultrasonographic techniques and the emergent work-up and management of osteomyelitis are reviewed.

Point-of-Care Ultrasound for Pediatric Shock.

The evaluation of critically ill children in the emergency department is oftentimes challenging. Point-of-care ultrasound is an essential tool in the rapid identification of reversible pathology and provides unique insight into the appropriate treatment approach. In this article, we discuss a straightforward sonographic approach to pediatric patients who present in shock.

Ketamine Saves the Day: Priapism in a Pediatric Psychiatric Patient.

Priapism is an adverse effect of medications used to treat psychiatric disorders. Often, this condition is self-limiting but may require urologic intervention involving aspiration and injection to induce detumescence. A case of a 15-year-old patient with priapism secondary to a long-acting stimulant is presented to describe the effectiveness of ketamine treatment for priapism.

Pulmonary embolism in the pediatric emergency department: a case demonstrating the application of point-of-care cardiac ultrasound in a pediatric patient with pulmonary embolism.

Although pulmonary embolism in children is rare, it is important for the pediatric emergency medicine provider to be aware of its presentation and emergent management. We present a case of bilateral pulmonary embolisms in an adolescent patient to illustrate the benefits from the timely diagnosis of right ventricular dysfunction by point-of-care echocardiography performed by emergency medicine physicians. Ultrasonographic techniques and the emergent management of pulmonary embolism are reviewed.

Ultrasound-guided diagnosis of occult mandibular osteomyelitis.

BACKGROUND: Skin and soft-tissue infections (SSTIs) are common disease presentations to the emergency department (ED), with the majority of the infections attributed to community-acquired methicillin-resistant Staphylococcus aureus. Rapid and accurate identification of potentially serious SSTIs is critical. Clinician-performed ultrasonography (CPUS) is increasingly common in the ED, and assists in rapid and accurate identification of a variety of disease processes. CASE REPORT: A 21-year-old female presented to the ED with chin swelling and "boils." Although her visual examination was benign, CPUS of her facial swelling quickly established a more concerning disease process, which was eventually confirmed by aspiration and bone biopsy to be mandibular osteomyelitis. The causative organism, Serratia odorifera, is rarely associated with infections, and we are aware of no previously reported cases of osteomyelitis due to this species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case of mandibular osteomyelitis, CPUS rapidly and accurately identified abnormal bony cortex of the mandible and an associated fluid collection. CPUS of an otherwise benign presentation of a facial infection led to a maxillofacial computed tomography scan, aspiration and biopsy, and then elective debridement of the bone infection. Emergency physicians should be aware of the utility of CPUS and the need to carefully investigate SSTIs presenting to the ED.

SonoGames: an innovative approach to emergency medicine resident ultrasound education.

SonoGames was created by the Academy of Emergency Ultrasound for the 2012 annual meeting of the Society for Academic Emergency Medicine. The assessment of resident knowledge and of the performance of point-of-care ultrasound examinations is an integral component of ultrasound education and is required in emergency medicine residency training. With that in mind, game organizers sought to assess and improve emergency medicine residents' point-of-care ultrasound knowledge, hands-on skills, and integration of knowledge into clinical decision making. SonoGames is an annual 4-hour competition consisting of 3 rounds. In this article, we provide a description of SonoGames and provide a blueprint for an effective and successful educational event.

HLA incompatible combined liver-kidney transplantation: dynamics of antibody modulation revealed by a novel approach to HLA antibody characterisation.

This case report confirms the utility of simultaneous liver transplantation in allowing successful kidney transplantation in the face of preformed, high levels of DSA, which would under normal circumstances be associated with hyperacute rejection and kidney graft failure. Antibody characterisation in terms of epitope specificity is more accurate and informative than antibodies described as "antigen-specific" and we suggest a method for identifying and tracking these antibodies; i.e. follow the epitope reaction not the antigen reactions. We consider that this will give a better insight into the behaviour and pathogenicity of HLA-specific sera. In the case presented here this approach has revealed some novel features of the post transplant antibody response in a sensitised recipient. These illustrate three phenomena which challenge current dogmas; an early resynthesis of DSA does not necessarily cause AMR, high levels of DSA can spontaneously modulate, and measurement of antibodies in terms of antigen specificity can give misleading results.

Bowel obstruction and hernia.

Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.