Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System.

BACKGROUND AND OBJECTIVE: Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system. METHODS: This was a retrospective study before and after the implementation of a standardized ED note template. A multi-disciplinary group consensus was built around standardized note elements, provider note workflows within the electronic health record (EHR), and how to incorporate newly required medical decision-making elements. The primary outcomes measured included the proportion of ED visits using standardized note templates, and the distribution of billing codes in the 6 months before and after implementation. RESULTS: In the preimplementation period, a total of six legacy ED note templates were being used across nine EDs, with the most used template accounting for approximately 36% of ED visits. Marked variations in documentation elements were noted across six legacy templates. After the implementation, 82% of ED visits system-wide used a single standardized note template. Following implementation, we observed a 1% increase in the proportion of ED visits coded as highest acuity and an unchanged proportion coded as second highest acuity. CONCLUSION: We observed a greater than twofold increase in the use of a standardized ED note template across a nine-hospital health system in anticipation of the new 2023 coding guidelines. The development and utilization of a standardized note template format relied heavily on multi-disciplinary stakeholder engagement to inform design that worked for varied documentation practices within the EHR. After the implementation of a standardized note template, we observed better-than-anticipated coding performance.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects.

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

An Innovative Use of Twitter to Disseminate and Promote Medical Student Scholarship During the COVID-19 Pandemic: Usability Study.

BACKGROUND: Due to the emergence of the COVID-19 pandemic in March 2020, the cancellation of in-person learning activities forced every aspect of medical education and student engagement to pivot to a web-based format, including activities supporting the performance and dissemination of scholarly work. At that time, social media had been used to augment in-person conference learning, but it had not been used as the sole platform for scholarly abstract presentations. OBJECTIVE: Our aim was to assess the feasibility of using Twitter to provide a completely web-based forum for real-time dissemination of and engagement with student scholarly work as an alternative to a traditional in-person poster presentation session. METHODS: The Brody School of Medicine at East Carolina University launched an online Medical Student Scholarship Forum, using Twitter as a platform for students to present scholarly work and prepare for future web-based presentations. A single student forum participant created posts using a standardized template that incorporated student research descriptions, uniform promotional hashtags, and individual poster presentations. Tweets were released over 5 days and analytic data were collected from the Twitter platform. Outcome measures included impressions, engagements, retweets, likes, media engagements, and average daily engagement rate. RESULTS: During the conference, the student leader published 63 tweets promoting the work of 58 students (55 medical and 3 dental students) over 5 days. During the forum and the following week, tweets from the @BrodyDistinctly Twitter account received 63,142 impressions and 7487 engagements, including 187 retweets, 1427 likes, and 2082 media engagements. During the 5 days of the forum, the average daily engagement rate was 12.72%. CONCLUSIONS: Using Twitter as a means of scholarly dissemination resulted in a larger viewing community compared to a traditional in-person event. Early evidence suggests that social media platforms may be an alternative to traditional scholarly presentations. Presenting via Twitter allowed students to receive instantaneous feedback and effectively network with wider academic communities. Additional research is needed to evaluate the effectiveness of knowledge uptake, feedback, and networking.

Dissemination of Quality Improvement Project Results After Local Presentation.

Among quality improvement (QI) projects submitted for local presentation, the authors sought to understand how often project results were eventually disseminated through national/international presentation or peer-reviewed journal publication. Projects submitted for local presentation from 2016 to 2019 were linked to resulting publications or national/international conference presentations. Submitting authors were surveyed about their intentions, experience, and satisfaction with the process of disseminating their project results. Of 83 projects, 5 were published and another 10 were presented nationally/internationally. External dissemination was more likely with fewer project cycles and cost-focused outcomes. Survey responses indicated that most project leaders wanted to see their results published but held mixed opinions about resources and encouragement available to reach this goal. Few QI projects submitted for local presentation resulted in wider dissemination of project results. Sharing results and lessons learned beyond the local institution requires long-term planning, education, and support beginning early in the QI process.

Developing Tomorrow's Leaders: A Medical Student Distinction Track in Health System Transformation and Leadership.

PROBLEM: Calls for medical education reform focus on preparing physicians to meet the challenges of today's complex health care system. Despite implementing curricula focused on health systems science (HSS), including quality improvement (QI), patient safety, team-based care, and population health, a significant gap remains in training students to meet the system's evolving needs. APPROACH: Brody School of Medicine redesigned its curriculum to prepare leaders to effect health system change. This included development of a distinction track in health system transformation and leadership, known as the Leaders in INnovative Care (LINC) Scholars Program. Selected LINC scholars spend eight weeks in a summer immersion experience designed to provide foundational knowledge and practical application. OUTCOMES: Two cohorts (15 LINC scholars) completed the summer immersion in 2015 and 2016. Participants demonstrated significant improvement in knowledge and confidence and continue to be engaged in ongoing QI projects throughout the health system. All scholars have presented their work at local, regional, or national meetings. Students rated patient navigation experiences, health system leader interviews, QI project application, and interprofessional experiences as most valuable and recommended adoption in the curriculum for all students. NEXT STEPS: A distinction track with an immersion component can be an effective method to pilot innovative HSS components for the entire curriculum while preparing a cadre of learners with advanced expertise. To longitudinally measure HSS knowledge change, behavioral impact, and organization-level outcomes, next steps must focus on development of workplace-based assessments, establishment of learner portfolios, and longitudinal tracking of student outcomes, including career trajectory.

Trends in Eye Injuries and Associated Medical Costs among Children in the United States, 2002-2014.

PURPOSE: To describe the trends in eye injuries and associated medical costs among children in the United States. METHODS: Data were from the 2002-2014 Medical Expenditure Panel Survey (MEPS). Eye injuries in children aged <18 years were identified by the International Classification of Diseases-9 (ICD-9) codes. The trends of cumulative incidence of eye injury, total costs, and average costs were estimated from 2002-2014 MEPS data. All costs were adjusted to 2014 US dollars. Analyses accounted for the complex stratified multistage survey design of the MEPS. We used MarketScan data (2010-2013) to validate outpatient cost estimates. RESULTS: The 3-year average cumulative incidence of eye injuries declined from 0.56% in 2002-2004 to 0.31% in 2012-2014 (Trend p < 0.001). The average annual total costs decreased from $193 million during 2002-2004 to $66 million during 2012-2014 (p < 0.001). CONCLUSION: The MEPS data showed that among children aged <18 years, the incidence of eye injuries and associated financial burden substantially declined during 2002-2014, highlighting the progress in preventing children eye injuries. Continuing efforts are needed to further reduce the burden in this population.

Sustained oxygenation without ventilation in paralyzed pigs with high-flow tracheal oxygen.

OBJECTIVES: It is generally assumed that ventilation is necessary for oxygenation. This study tested if paralyzed animals without respirations can maintain arterial oxygenation when administered high-flow oxygen delivered by a catheter in the trachea. DESIGN: Prospective observational study. SETTING: University research laboratory. PARTICIPANTS: 3 anesthetized/paralyzed swine weighing 29.5 +/- 4.2 kg. INTERVENTIONS/OBSERVATIONS: Pigs were intubated, anesthetized with intravenous tiletamine and a pentobarbital drip. A femoral arterial line was placed to record arterial blood gases and vital signs every 5 minutes. Respiratory paralysis was obtained with vecuronium 150 microg/kg and repeated at any sign of movement. A catheter was placed in the trachea to deliver oxygen at 15 L/min. Outflow gas from the endotracheal tube was analyzed for O2 and CO2. O2 was discontinued at 75 minutes. The institutional animal care and use committee approved the protocol. RESULTS: All pigs survived to 75 minutes. PaO2 was more than 100 mm Hg throughout the study period. Mean PaCO2 was 37.4 +/- 2.8 mm Hg at baseline, 146 +/- 59 at 30 minutes, then rose above 200 mm Hg in all pigs by 45 minutes. Mean arterial pH fell from 7.47 +/- 0.04 at onset to 6.75 +/- 0.06 at 75 minutes. When oxygen was terminated at 75 minutes, PaO2 fell to 16.5 +/- 7.6 mm Hg within 5 minutes, and all pigs were sacrificed within 10 minutes. For outflow gas, O2 was more than 98% and expired CO2 less than 1% throughout the study period. CONCLUSIONS: Paralyzed, unventilated pigs receiving high-flow oxygen via a tracheal catheter remained alive after 75 minutes, although a profound respiratory acidosis developed.

Managing the difficult airway: a survey of residency directors and a call for change.

This study examines airway management issues in Emergency Medicine residency programs (EMRP) including; airway adjunct availability and frequency of use, number of pediatric intubations, approach to trauma airways, and teaching methods. Surveys were distributed to all accredited EM program directors, who were asked about these issues. Availability of airway adjuncts among respondents included: cricothyrotomy kits (94.9%), fiberoptic scopes (76.3%), Bougies (69.5%), LMAs (66.1%), intubating LMAs (61.0%), lighted stylets (54.2%), retrograde intubation kits (49.2%), Combitube (45.8%), and esophageal obturator airways (15.3%). Responses indicated that 93.6% of airways were orotracheal intubations. A small percentage of intubations used airway adjuncts. Programs use didactics, mannequins, cadavers, direct care and operating rooms for airway training. Emergency Physicians (EPs) are responsible for trauma airways in 89.9% of programs. Most programs have multiple airway adjuncts available, but they are rarely utilized. EPs must become proficient with airway adjuncts. EMRPs must increase resident exposure by using airway adjuncts during routine intubations.

The overcrowded emergency department: a comparison of staff perceptions.

OBJECTIVES: To study perceptions of physicians and nursing staff about real-time demands and capacity of an emergency department (ED). To use ED data to calculate proposed demand ratios called Real-time Emergency Analysis of Demand Indicators (READI) scores. To compare the READI scores with ED staff perceptions of demand and capacity. METHODS: This prospective study used a computerized clinical management system to provide data about ED demand and capacity. Physicians and staff charge nurses were surveyed about perceptions of ED demand and capacity. Results were compared with mathematical READI scores, which are proposed to objectively assess ED demand. Kappa scores were used to measure intrarater reliability between the physicians' and charge nurses' assessment of demand and between the staff assessments and the READI scores. RESULTS: Kappa scores of the perception of excess demand were as follows: between two physician groups, kappa = 0.392; between one physician group and charge nurses, kappa = 0.453; and between a second physician group and charge nurses, kappa = 0.243. Comparing respondents who indicated that demand had or had not exceeded capacity, one of the READI ratios, the Bed Ratio, showed a significant difference in mean, 0.245 (95% confidence interval = 0.153 to 0.336), between groups. CONCLUSIONS: Real-time data may be used to predict ED demand and resource needs. Subjective assessment of excess ED demand did not correlate between physician groups or between physicians and charge nurses. Although there was a trend toward predicting excess demand with one of the READI scores, these scores did not correlate to staff perceptions.

ED utilization: the effect of changing demographics from 1992 to 2000.

To explore factors contributing to increased emergency department (ED) utilization, this retrospective chart review compared ED visits for a 2-week period in both 1992 and 2000 at a rural, tertiary medical center. Total ED visits increased 455 between the periods (% increase = 28.6%), whereas county population increased 18,253 (% increase = 16.1%) (P < 0.005). Average age increased from 35.2 +/- 23.8 years to 40.1 +/- 23.6 years (95% confidence interval, difference of means, 3.34 to 6.45). Patients over 80 years increased by 83%, whereas those over 90 years increased 138%. The admission rate, increased from 21.9% to 25.6% (P < 0.005). Patients with Medicare as primary insurance increased from 17.9% to 23.6% (P < 0.005). Increased age of the population, increased acuity as shown by 4 different measurements, and limited access to primary care physicians all contributed to increased ED demand in this study.