Flexible-Interval High-Sensitivity Troponin Velocity for the Detection of Acute Coronary Syndromes.

Many algorithms for emergency department (ED) evaluation of acute coronary syndrome (ACS) using high-sensitivity troponin assays rely on the detection of a "delta," the difference in concentration over a predetermined interval, but collecting specimens at specific times can be difficult in the ED. We evaluate the use of troponin "velocity," the rate of change of troponin concentration over a flexible short interval for the prediction of major adverse cardiac events (MACEs) at 30 days. We conducted a prospective, observational study on a convenience sample of 821 patients who underwent ACS evaluation at a high-volume, urban ED. We determined the diagnostic performance of a novel velocity-based algorithm and compared the performance of 1- and 2-hour algorithms adapted from the European Society of Cardiology (ESC) using delta versus velocity. A total of 7 of 332 patients (2.1%) classified as low risk by the velocity-based algorithm experienced a MACE by 30 days compared with 35 of 221 (13.8%) of patients classified as greater than low risk, yielding a sensitivity of 83.3% (95% confidence interval [CI] 68.6% to 93.0%) and negative predictive value (NPV) of 97.9% (95% CI 95.9% to 98.9%). The ESC-derived algorithms using delta or velocity had NPVs ranging from 98.4% (95% CI 96.4% to 99.3%) to 99.6% (95% CI 97.0% to 99.9%) for 30-day MACEs. The NPV of the novel velocity-based algorithm for MACE at 30 days was borderline, but the substitution of troponin velocity for delta in the framework of the ESC algorithms performed well. In conclusion, specimen collection within strict time intervals may not be necessary for rapid evaluation of ACS with high-sensitivity troponin.

Strategies for recruiting underrepresented in medicine and sexual and gender minority students to emergency medicine.

Background: Despite having well-described benefits, diversifying the physician workforce has been an ongoing challenge. Within emergency medicine (EM), multiple professional organizations have identified expanding diversity and inclusion as top priorities. The following is a description of an interactive session held at the SAEM annual meeting addressing recruitment strategies for underrepresented in medicine (URiM) and sexual and gender minority (SGM) students into EM. Methods: During the session, the authors provided an overview of the current state of diversity in EM. In the small-group portion of the session, a facilitator helped characterize the challenges programs face in recruiting URiM and SGM students. These challenges were described during three distinct phases of the recruitment process: (1) preinterview, (2) interview day, and (3) postinterview. Results: Our facilitated small-group session allowed for discussing the challenges faced by various programs in recruiting a diverse group of trainees. Common challenges in the preinterview and interview day included messaging and visibility as well as funding and support. Postinterview challenges included communication and the ranking process. Through this exercise, we were able to collaboratively share ideas on tangible solutions that programs may use to overcome their specific challenges. Conclusions: Given the importance of intentionality in diversifying the physician workforce, the authors describe successful strategies implemented within one residency program and those shared by session participants to overcome recruitment challenges.

"I'd rather see action": Application and recruitment experiences of underrepresented in emergency medicine trainees.

Objectives: The emergency medicine (EM) physician workforce is largely composed of white men. Despite recruitment efforts over the past decade, there has not been a significant increase of trainees with underrepresented racial and ethnic identities in EM (URM). Prior studies have focused on institutional strategies to improve diversity, equity, and inclusion (DEI) in EM residency recruitment but have been limited in describing URM trainees' perspectives. We sought to assess URM trainees' perspectives on DEI in the EM residency application and selection process. Methods: This study was conducted at an urban academic medical center in the United States from November 2021 to March 2022. Junior residents were invited to participate in individual semistructured interviews. We used a combined deductive-inductive approach to categorize responses in predetermined areas of interest then elicit dominant themes within each category through consensus discussions. Thematic saturation was reached after eight interviews, indicating adequate sample size. Results: Ten residents participated in semistructured interviews. All identified as racial or ethnic minorities. Three dominant themes emerged relating to authenticity, representation, and being treated as a learner first. Participants assessed the authenticity of a program's DEI efforts by evaluating the time frame and scope of DEI efforts. Participants reported a desire for representation of other URM colleagues in a residency program and training environment. While participants wanted their lived experience as URM trainees acknowledged, they were wary of being viewed solely through the lens of future DEI leaders rather than as learners first. Conclusions: URM residents value multifaceted commitment to DEI efforts, representation, and being seen as learners first when assessing residency programs. Programs seeking to recruit URM residents should develop a department-wide, multipronged, comprehensive DEI plan and showcase how their program will contribute to an applicant's professional development.

Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis.

Importance: In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs. Objective: To assess the use and safety of outpatient management of acute appendicitis. Design, Setting, and Participants: This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020. Exposures: Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively. Main Outcomes and Measures: Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared. Results: Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores. Conclusions and Relevance: These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Impact of a rapid high-sensitivity troponin pathway on patient flow in an urban emergency department.

Study Objective: To evaluate whether the introduction of a 1-hour high-sensitivity cardiac troponin-T (hs-TnT) pathway for patients who present to the emergency department (ED) with suspected acute coronary syndrome (ACS) improves ED patient flow without changing the rate of "missed" major adverse cardiac events (MACE), compared to use of conventional cardiac troponin with an associated 3-hour pathway. Methods: This was a prospective, uncontrolled observational study conducted before and after implementation of a 1-hour hs-TnT pathway at a high-volume urban ED. Patients undergoing evaluation for ACS in the ED were enrolled during their initial visit and clinical outcomes were assessed at 30 and 90 days. Throughput markers were extracted from the electronic medical record and compared. The primary outcome was provider-to-disposition decision time. Results: A total of 1892 patients were enrolled, 1071 patients while using conventional troponin and 821 after introduction of hs-TnT. With the new assay and pathway, median interval between troponin tests decreased from 4.7 hours (interquartile range [IQR] 3.9-5.7 hours) to 2.3 hours (IQR 1.5-3.4 hours) (P < 0.001). However, there was no difference in median provider-to-disposition decision time, which measured 4.7 hours (IQR 2.9-7.2) and 4.8 hours (IQR 3.1-7.1) (P = 0.428) respectively. Total 30-day MACE rate in discharged patients was low in both groups, occurring in only 4/472 (0.85%) encounters in the first cohort and 4/381 (1.0%) encounters in the second. Conclusion: Introduction of a 1-hour hs-TnT ACS evaluation pathway reduced the troponin collection interval but did not reduce provider to disposition time. There was no difference in rate of 30-day MACE in patients discharged from the ED.

Stages of Milestones Implementation: A Template Analysis of 16 Programs Across 4 Specialties.

BACKGROUND: Since 2013, US residency programs have used the competency-based framework of the Milestones to report resident progress and to provide feedback to residents. The implementation of Milestones-based assessments, clinical competency committee (CCC) meetings, and processes for providing feedback varies among programs and warrants systematic examination across specialties. OBJECTIVE: We sought to determine how varying assessment, CCC, and feedback implementation strategies result in different outcomes in resource expenditure and stakeholder engagement, and to explore the contextual forces that moderate these outcomes. METHODS: From 2017 to 2018, interviews were conducted of program directors, CCC chairs, and residents in emergency medicine (EM), internal medicine (IM), pediatrics, and family medicine (FM), querying their experiences with Milestone processes in their respective programs. Interview transcripts were coded using template analysis, with the initial template derived from previous research. The research team conducted iterative consensus meetings to ensure that the evolving template accurately represented phenomena described by interviewees. RESULTS: Forty-four individuals were interviewed across 16 programs (5 EM, 4 IM, 5 pediatrics, 3 FM). We identified 3 stages of Milestone-process implementation, including a resource-intensive early stage, an increasingly efficient transition stage, and a final stage for fine-tuning. CONCLUSIONS: Residency program leaders can use these findings to place their programs along an implementation continuum and gain an understanding of the strategies that have enabled their peers to progress to improved efficiency and increased resident and faculty engagement.

Let's Escape Didactics: Virtual Escape Room as a Didactic Modality in Residency.

Audience: The virtual escape room is a didactic activity for emergency medicine residents (interns, junior residents, senior residents). Introduction: Residency programs are employing a wide variety of active learning techniques to engage their learners, including large-group discussion, small-group activities, team-based learning, gamification, problem-based learning, role-playing and case studies. In recent years, educators have drawn their attention to educational escape rooms, a new type of learning activity that utilizes collaborative learning activities to foster creating thinking, communication, teamwork and leadership.1-3 There have been a number of cases in medicine, 4,5 but there have been limited works published on the use of virtual educational escape rooms in residency education.Unfortunately, the COVID pandemic has made participation in an escape room more difficult. In lieu of social distancing during the COVID pandemic, participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote participant satisfaction, competency, learning, and engagement. Educational Objectives: By the end of the activity, learners should be able to:Identify the hazardous chemicals associated with house firesClassify burn injury according to depth, extent and severity based on established standardsRecall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)Recall key laboratory features of cyanide and carbon monoxide poisoningsIdentify appropriate management strategies for smoke inhalation injuriesRecite the treatment for cyanide and carbon monoxide poisoningsDescribe the management of the burn injuriesCommunicate and collaborate as a team to arrive at solutions of problemsDisplay task-switching and leadership skills during exerciseEvaluate virtual escape room experience. Educational Methods: Emergent care of burns, a popular and shared topic in both Emergency Medicine and Family Medicine literature, was chosen and educational objectives were developed. The website Deck.Toys was utilized to formulate the escape room along with puzzles around the educational objectives. Students congregated remotely on Zoom, and after instructions, were separated into teams to solve content-specific puzzles in order to escape the room. Teams which solve all the puzzles in the allotted time were considered to have successfully escaped the room. After the allotted time, the faculty led debriefing, and topic discussion occurred. Research Methods: Sixty-three participants composed of residents (24 emergency [EM], 29 family medicine [FM], 4 combined emergency and family medicine [EM/FM]), advanced practice practitioner trainees (2 EM), and faculty member participants (4 FMP) partook in the virtual escape room experience. At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency in communication, collaboration, task-switching, and leadership skills. Results: Eighteen out of 63 participants filled out the survey. This was the first virtual escape room experience for 94% of the respondents. A majority (88.9%) of respondents enjoyed the virtual escape room, finding it fun, interesting, engaging, and interactive. None of the respondents preferred traditional didactics over the virtual escape room activity, and 72% were either just as or equally as satisfied with virtual compared to in-person escape rooms. Nearly all respondents agreed that the activity encouraged collaboration, communication skills, task-switching, and leadership skills (94.4%, 88.9%, 72.2%, 72.2%, respectively). Discussion: Participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote learner satisfaction and engagement. The escape room also promoted important competencies encouraged during residency, such as interpersonal and communication skills and practice-based learning and improvement, and is an effective addition to virtual learning tools. Topics: Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals.

Emergency department antibiotic use for exacerbations of COPD.

BACKGROUND: COPD is the third leading cause of death, with acute exacerbations accounting for 1.5 million emergency department (ED) visits annually. Guidelines include recommendations for antibiotic therapy, though evidence for benefit is limited, and little is known about ED prescribing patterns. Our objectives were to determine the rate with which ED patients with acute exacerbations of COPD (AECOPD) are treated with antibiotics, compare the proportions of antibiotic classes prescribed, describe trends of antibiotic treatment, and identify predictors of antibiotic therapy. PATIENTS AND METHODS: This was an analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2014. Descriptive statistics were used to summarize the rate of antibiotic therapy and the relative proportions of each antibiotic class prescribed for AECOPD. Logistic regression was used to measure the trend in treatment rate over time and identify the variables associated with antibiotic use. RESULTS: There were an estimated 4.5 million ED visits for AECOPD. Antibiotic treatment occurred at a rate of 39%. Among those treated, macrolides (41%) and quinolones (35%) were prescribed most frequently. Logistic regression did not reveal a trend in antibiotic treatment over time and identified emergent/immediate triage level (OR 2.11, 95% CI 1.09-4.10) and elevated temperature (OR 7.92, 95% CI 2.28-27.50) as being independently associated with antibiotic therapy. CONCLUSION: Less than half of the ED visits for AECOPD resulted in antibiotic therapy, with no upward trend over time. Fever and triage level were predictive of antibiotic therapy, with macrolides and quinolones constituting the agents most commonly prescribed.

Emergency department diagnosis of a quadriceps intramuscular loculated abscess/pyomyositis using dynamic compression bedside ultrasonography.

INTRODUCTION: A 73-year-old man with a past medical history of myelodysplastic syndrome and recent chemotherapy presented to the emergency department with a 1-week history of progressively increasing left thigh pain and swelling. His physical examination revealed left anterolateral diffuse thigh swelling with no erythema or warmth to palpation. The anterolateral quadriceps was markedly tender to palpation. Emergency department bedside dynamic compression ultrasonography that was performed on the left anterolateral thigh revealed a quadriceps intramuscular abscess with loculated yet movable pus. CONCLUSION: Bedside dynamic compression ultrasonography can assist the emergency or critical care physician in the diagnosis of quadriceps intramuscular abscess or pyomyositis.