Early Cold Stored Platelet Transfusion Following Severe Injury: A Randomized Clinical Trial.

OBJECTIVE: To determine the feasibility, efficacy, and safety of early cold stored platelet transfusion compared to standard care resuscitation in patients with hemorrhagic shock. SUMMARY BACKGROUND DATA: Data demonstrating the safety and efficacy of early cold stored platelet transfusion are lacking following severe injury. METHODS: A phase 2, multicenter, randomized, open label, clinical trial was performed at five U.S. trauma centers. Injured patients at risk of large volume blood transfusion and the need for hemorrhage control procedures were enrolled and randomized. The intervention was the early transfusion of a single apheresis cold stored platelet unit, stored for up to 14 days vs. standard care resuscitation. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was 24-hour mortality. RESULTS: Mortality at 24 hours was 5.9% in patients who were randomized to early cold stored platelet transfusion compared to 10.2% in the standard care arm (difference, -4.3%; 95% CI, -12.8% to 3.5%; P=0.26). No significant differences were found for any of the prespecified ancillary outcomes. Rates of arterial and/or venous thromboembolism and adverse events did not differ across treatment groups. CONCLUSIONS AND RELEVANCE: In severely injured patients, early cold stored platelet transfusion is feasible, safe and did not result in a significant lower rate of 24-hour mortality. Early cold stored platelet transfusion did not result in a higher incidence of arterial and/or venous thrombotic complications or adverse events. The storage age of the cold stored platelet product was not associated with significant outcome differences.

Effect of the Extended Focused Assessment With Sonography for Trauma on the Screening Performance of the National Emergency X-Radiography Utilization Study Chest Decision Instrument.

STUDY OBJECTIVE: Developed to decrease unnecessary thoracic computed tomography use in adult blunt trauma patients, the National Emergency X-Radiography Utilization Study (NEXUS) Chest clinical decision instrument does not include the extended Focused Assessment with Sonography in Trauma (eFAST). We assessed whether eFAST improves the NEXUS Chest clinical decision instrument's diagnostic performance and may replace the chest radiograph (CXR) as a predictor variable. METHODS: We performed a secondary analysis of prospective data from 8 Level I trauma centers from 2011-2014. We compared performance of modified clinical decision instruments that (1) added eFAST as a predictor (eFAST-added clinical decision instrument), and (2) replaced CXR with eFAST (eFAST-replaced clinical decision instrument), in screening for blunt thoracic injuries. RESULTS: One thousand nine hundred fifty-seven patients had documented computed tomography, CXR, clinical NEXUS criteria, and adequate eFAST; 624 (31.9%) patients had blunt thoracic injuries, and 126 (6.4%) had major injuries. Compared to the NEXUS Chest clinical decision instrument, the eFAST-added clinical decision instrument demonstrated unchanged screening performance for major injury (sensitivity 0.98 [0.94 to 1.00], specificity 0.28 [0.26 to 0.30]) or any injury (sensitivity 0.97 [0.95 to 0.98], specificity 0.21 [0.19 to 0.23]). The eFAST-replaced clinical decision instrument demonstrated unchanged sensitivity for major injury (sensitivity 0.93 [0.87 to 0.97], specificity 0.31 [0.29 to 0.34]) and decreased sensitivity for any injury (0.93 [0.91 to 0.951] versus 0.97 [0.953 to 0.98]). CONCLUSION: In our secondary analysis, adding eFAST as a predictor variable did not improve the diagnostic screening performance of the original NEXUS Chest clinical decision instrument; eFAST cannot replace the CXR criterion of the NEXUS Chest clinical decision instrument.

Toxic Exposures Among Young Children One Year into the COVID-19 Pandemic: A Retrospective Review of Three San Francisco Bay Area Emergency Departments.

BACKGROUND: Daycare and school closures prompted by shelter-in-place orders may have increased opportunities for unintentional ingestions among young children. OBJECTIVES: We examined emergency department (ED) presentations for toxic exposures among young children during the COVID-19 pandemic in the San Francisco Bay Area, which had some of the strictest and most prolonged shelter-in-place policies in the United States. METHODS: We performed a retrospective cross-sectional study of children 0 to 5 years of age who presented with an ED International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of toxic exposure within a tertiary care hospital system between March 16, 2016 and March 15, 2021. We considered the period after March 16, 2020 to represent the pandemic. RESULTS: During the pandemic, the absolute number of poisonings among young children remained stable. Overall, ED encounters within this cohort decreased by 55%, which doubled the relative toxic exposure rate per 1000 ED encounters from 4.99 (95% confidence interval [CI] 3.19-5.90) to 9.79 (95% CI 8.09-11.49). Rates of admission, severe medical complications, operating room case requests, and length of stay were not significantly different. Shelter-in-place was associated with significantly higher odds of cannabis ingestion (odds ratio = 2.70, 95% CI 1.60-4.49). CONCLUSION: Despite dramatic decreases in overall ED patient volumes, the absolute number and severity of toxic exposures were similar during the pandemic compared with previous years. © 2022 Elsevier Inc.

Diagnostic accuracy of point-of-care ultrasonography for intussusception in children: A systematic review and meta-analysis.

OBJECTIVES: Ileocolic intussusception can be challenging to diagnose due to vague complaints, but rapid diagnosis and treatment can help prevent morbidity and mortality. Prior research has focused on radiologic ultrasound, with more recent studies focusing on point-of-care ultrasonography (POCUS). This systematic review and meta-analysis assesses the diagnostic accuracy of POCUS for children with suspected ileocolic intussusception. METHODS: PubMed, Embase, CINAHL, LILACS, the Cochrane databases, Google Scholar, conference abstracts, and bibliographies of selected articles were searched for studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children. Data were dual extracted into a predefined worksheet, and quality analysis was performed with the QUADAS-2 tool. Data were summarized, and a meta-analysis was performed. RESULTS: Eleven studies (n = 2400 children) met our inclusion criteria. Overall, 14.4% of children had intussusception. POCUS was 95.1% (95% CI: 90.3% to 97.2%) sensitive and 98.1% (95% CI: 95.8% to 99.2%) specific with a positive likelihood ratio of 50 (95% CI: 23 to 113) and a negative likelihood ratio of 0.05 (95% CI: 0.03 to 0.09). CONCLUSIONS: POCUS has excellent diagnostic accuracy for intussusception in children presenting to the emergency department.

SARS COV-2 anti-nucleocapsid and anti-spike antibodies in an emergency department healthcare worker cohort: September 2020 - April 2021.

BACKGROUND: Emergency department (ED) workers have an increased seroprevalence of SARS-CoV-2 antibodies. However, breakthrough infections in ED workers have led to a reduced workforce within a strained healthcare system. By measuring levels of IgG antibodies to the SARS-CoV-2 nucleocapsid and spike antigens in ED workers, we determined the incidence of infection and described the course of antibody levels. We also measured the antibody response to vaccination and examined factors associated with immunogenicity. METHODS: We conducted a prospective cohort study of ED workers conducted at a single ED from September 2020-April 2021. IgG antibodies to the SARS-CoV-2 nucleocapsid antigen were measured at baseline, 3, and 6 months, and IgG antibodies to the SARS-CoV-2 spike antigen were measured at 6 months. RESULTS: At baseline, we found 5 out of 139 (3.6%) participants with prior infection. At 6 months, 4 of the 5 had antibody results below the test manufacturer's positivity threshold. We identified one incident case of SARS-COV-2 infection out of 130 seronegative participants (0.8%, 95% CI 0.02-4.2%). In 131 vaccinated participants (125 BNT162b2, 6 mRNA-1273), 131 tested positive for anti-spike antibodies. We identified predictors of anti-spike antibody levels: time since vaccination, prior COVID-19 infection, age, and vaccine type. Each additional week since vaccination was associated with an 11.1% decrease in anti-spike antibody levels. (95% CI 6.2-15.8%). CONCLUSION: ED workers experienced a low incidence of SARS-CoV-2 infection and developed antibodies in response to vaccines and prior infection. Antibody levels decreased markedly with time since infection or vaccination.

Development and Validation of a Deep Learning Strategy for Automated View Classification of Pediatric Focused Assessment With Sonography for Trauma.

OBJECTIVE: Pediatric focused assessment with sonography for trauma (FAST) is a sequence of ultrasound views rapidly performed by clinicians to diagnose hemorrhage. A technical limitation of FAST is the lack of expertise to consistently acquire all required views. We sought to develop an accurate deep learning view classifier using a large heterogeneous dataset of clinician-performed pediatric FAST. METHODS: We developed and conducted a retrospective cohort analysis of a deep learning view classifier on real-world FAST studies performed on injured children less than 18 years old in two pediatric emergency departments by 30 different clinicians. FAST was randomly distributed to training, validation, and test datasets, 70:20:10; each child was represented in only one dataset. The primary outcome was view classifier accuracy for video clips and still frames. RESULTS: There were 699 FAST studies, representing 4925 video clips and 1,062,612 still frames, performed by 30 different clinicians. The overall classification accuracy was 97.8% (95% confidence interval [CI]: 96.0-99.0) for video clips and 93.4% (95% CI: 93.3-93.6) for still frames. Per view still frames were classified with an accuracy: 96.0% (95% CI: 95.9-96.1) cardiac, 99.8% (95% CI: 99.8-99.8) pleural, 95.2% (95% CI: 95.0-95.3) abdominal upper quadrants, and 95.9% (95% CI: 95.8-96.0) suprapubic. CONCLUSION: A deep learning classifier can accurately predict pediatric FAST views. Accurate view classification is important for quality assurance and feasibility of a multi-stage deep learning FAST model to enhance the evaluation of injured children.

The P2Network-Advancing Pediatric Emergency Care With Point-of-Care Ultrasound.

ABSTRACT: Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Trends in Use of Diagnostic Imaging for Abdominal Pain in U.S. Emergency Departments.

OBJECTIVE. CT has excellent accuracy for appendicitis but is associated with risks. Research and educational campaigns have been conducted to implement an ultrasound-first strategy for children but not for adults. The purpose of this study was to measure the use of CT and ultrasound in emergency department (ED) visits for abdominal pain and appendicitis to examine the impact of these efforts. MATERIALS AND METHODS. We analyzed data from the National Hospital Ambulatory Medical Care Survey (1997-2016). Use of CT and ultrasound was measured over time in visits for abdominal pain and visits in which appendicitis was diagnosed. Predictors of CT use were identified by means of regression analysis. RESULTS. For children, CT use increased from 1.2% (95% CI, 0.6-2.5%) in 1997, peaked in 2010 at 16.6% (95% CI, 13.8-19.6%), and decreased slightly in 2016. In adults, CT use increased steadily from 3.9% in 1997 (95% CI, 3.1-4.8%) to 37.8% (95% CI, 35.5-41.0%) in 2016. CT use increased for both pediatric and adult ED visits with a diagnosis of appendicitis, from 5.2% (95% CI, 0.7-29.5%) to 71.0% (95% CI, 43.1-88.8%) for children and 7.2% (95% CI, 2.7-17.6%) to 83.3% (95% CI, 64.1-93.3%) for adults. Children with abdominal pain and a diagnosis of appendicitis evaluated in a pediatric ED were at decreased odds (pain odds ratio, 0.6 [95% CI, 0.3-0.9]; appendicitis odds ratio, 0.2 [95% CI, 0.0-0.7]) of receiving CT than were those evaluated in general EDs. CONCLUSION. CT use has decreased in the evaluation of abdominal pain in children, perhaps because of research findings and efforts to implement an ultrasound-first strategy for suspected appendicitis. In contrast, CT use has continued to increase among adults with abdominal pain in EDs.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Meckel Diverticulum Presenting as Abdominal Pain and Subsequent Bowel Perforation.

BACKGROUND: Abdominal pain is a common presenting symptom with a broad array of potential etiologies. Meckel diverticulum (MD), the most common congenital gastrointestinal malformation, classically presents with painless gastrointestinal bleeding. However, it can also lead to diverticulitis, intussusception, or obstruction, manifesting as abdominal pain. CASE REPORT: A 2-year-old boy presented to the emergency department with intermittent abdominal pain, vomiting, and loose stools. Abdominal ultrasound findings were consistent with ileitis and ileocolic intussusception, but no such intussusception was seen during fluoroscopic air enema. The patient was admitted for serial abdominal examinations and subsequently developed an acute abdomen. Emergent laparotomy revealed a perforated MD. Small bowel resection and primary anastomosis were performed and no complications developed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The presence of an MD can lead to diverticulitis, intussusception, or obstruction, putting the patient at risk of bowel perforation. As such, it is important to consider MD in the differential diagnosis of patients with abdominal pain. In cases in which sonographic findings are ambiguous or transient, additional observation or alternative imaging, such as computed tomography, should be strongly considered.

Patient Factors Associated With the Decision to Transfer Adult Patients From a Pediatric Emergency Department for Definitive Care.

OBJECTIVE: Adults presenting to pediatric emergency departments are transferred to general emergency departments in proportions between 20% and 60%. How illness severity is related to the decision to transfer is poorly understood. We compared the proportion of adults with emergent and nonemergent conditions with respect to their final disposition. We also determined characteristics associated with transfer. METHODS: We conducted a retrospective review of the electronic medical record and identified all patients 25 years and older presenting to a large urban freestanding pediatric emergency department from 2008 to 2013. We collected demographic and clinical information and used a preexisting algorithm to classify visits as emergent or nonemergent. We created a multivariate logistical regression model to determine independent variables associated with transfer. RESULTS: Among 246,694 encounters, 1182 (0.5%) patients were older than 25 years. We excluded 402 (34%) because they were not categorized. Of the 780 categorized, 32% had an emergent and 68% had a nonemergent condition. Only 22% were transferred. Compared with nonurgent patients, the proportion transferred was twice as high for emergent patients (36% vs 15%), but even for emergent patients, most (63%) were retained for definitive care and/or disposition. Emergent diagnosis, age 45 to 64 years, and higher triage acuity were independently associated with the decision to transfer. CONCLUSION: Regardless of illness severity, a minority of adult patients were transferred away for definitive care. Factors independently associated with transfer were emergent condition, higher triage acuity, and older age.

Severe Sea Lion Bites in Urban Cold-Water Swimmers.

BACKGROUND: A series of sea lion bites in open-water swimmers recently gained the attention of the national and international media. Pinniped (the clade including seals and sea lions) bites historically have been in people who hunt or handle marine mammals. As populations of humans and pinnipeds continue to grow, interactions with animals by those participating in recreational activities are likely to become more frequent. CASE REPORTS: In December of 2017 and January of 2018, four sea lion (Zalophus californianus) bites in humans occurred at a popular open-water recreational swimming area in San Francisco, California. Three swimmers required treatment at a local trauma center and two required surgery. Two of the wounds were potentially life threatening; one swimmer required a field tourniquet to stop bleeding from the antecubital fossa, and the bite in another narrowly missed the femoral artery. The purpose of this report is to offer an in-depth discussion of antimicrobial use and rabies postexposure prophylaxis in patients with severe pinniped bites. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Information from this report can be used in conjunction with input from local experts to develop a thoughtful therapeutic plan for patients with severe pinniped bites. Doxycycline is the first-line antibiotic therapy, but broader coverage may be needed for severe wounds with the potential for contamination. The likelihood of rabies is low, and rabies postexposure prophylaxis should be reserved for cases that involve unusually aggressive animal behavior or other factors suggestive of rabies.

Computed Tomography Use Plateaus Among Children With Emergency Visits for Abdominal Pain.

OBJECTIVES: Abdominal pain is a common pediatric complaint to emergency departments (EDs), and clinicians often rely on imaging for diagnosis. Studies have demonstrated an increase in computed tomography (CT) in this population. Following emphasis on radiation reduction by researchers and organizations, this study evaluates recent national trends in CT use among pediatric patients presenting to EDs with abdominal pain. METHODS: This is a cross-sectional analysis of ED patients 18 years or younger with chief complaint of abdominal pain in the National Hospital Ambulatory Medical Care Survey from 2008 to 2011. Outcomes include annual proportions of visits with x-ray, ultrasound, or CT, as well as diagnosis of appendicitis and hospital admission. RESULTS: Of 32,304 ED visits, 2120 (6.6%) were for abdominal pain. Proportions of visits using CT, ultrasound, and plain x-ray were 16.0%, 10.5%, and 23.4%, respectively. For all outcome measures, including imaging, hospital admission, and diagnosis of appendicitis, there was no change from 2008 to 2011. Considering previous data, there was a significant rise in ultrasound use from 5.4% (95% confidence interval, 2.4%-8.4%) in 1998 to 12.1% (95% confidence interval, 9.4%-13.7%) in 2011. Multivariate analysis of CT use found the strongest predictor to be increasing age. Females, black children, and those with Medicaid insurance had lower odds of having a CT. CONCLUSIONS: In contrast to the earlier dramatic increase in CT use for pediatric patients with abdominal pain, CT remained constant between 2008 and 2011. There was no associated change in the rate of diagnosis of appendicitis or hospitalization; however, ultrasound is increasing.

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics.

BACKGROUND/OBJECTIVE: Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia. METHODS: We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated. RESULTS: We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90). CONCLUSIONS: For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.

Point-of-Care Ultrasonography for Appendicitis Uncovers Two Alternate Diagnoses.

We present two cases of pediatric patients initially presenting with a clinical suspicion of acute appendicitis. In these cases, point-of-care ultrasonography was performed early in the patient's emergency department course, leading to alternate diagnoses. This article highlights a role for point-of-care ultrasound in the diagnoses of two alternate conditions that clinically mimic appendicitis: Meckel diverticulitis and acute ileocecitis. We offer a brief overview of terminology, relevant literature, and ultrasound scanning technique for the right-lower-quadrant point-of-care ultrasound evaluation.

Useful but not used: pediatric critical care physician views on bedside ultrasound.

OBJECTIVE: The purpose of this study was to assess the learning needs of pediatric critical care (PCC) physicians in bedside ultrasound (BUS) use. METHODS: This was a survey-based study conducted at an academic center with a PCC fellowship program. We surveyed PCC fellows and faculty to elicit their views on BUS and asked them about the frequency of use, their perception of the clinical utility, and their level of confidence in performing different BUS applications. RESULTS: There was no statistical difference in the self-reported use of BUS applications in the faculty and fellows, except for cardiac arrest, which 66.7% of the faculty used but none of the fellows did (P < 0.05). There were no statistically significant differences between perceived usefulness and confidence in the performance of BUS applications between the fellows and faculty. The largest gaps between perceived usefulness and confidence in performing BUS applications were for left ventricle ejection fraction (Δ = 2.72), inferior vena cava collapse (Δ = 2.67), pulmonary edema (Δ = 2.22), and pneumothorax (Δ = 2.11). CONCLUSIONS: Pediatric critical care providers report limited confidence in several applications that they perceive as useful and are therefore likely motivated to learn BUS applications. Concentrating curricula on those applications with the greatest differences between usefulness and confidence and building on the confidence of those applications the PCC providers are already using will serve to expand availability and increase use of this high-impact technology.

Evaluating Large Language Models for Drafting Emergency Department Discharge Summaries.

Importance: Large language models (LLMs) possess a range of capabilities which may be applied to the clinical domain, including text summarization. As ambient artificial intelligence scribes and other LLM-based tools begin to be deployed within healthcare settings, rigorous evaluations of the accuracy of these technologies are urgently needed. Objective: To investigate the performance of GPT-4 and GPT-3.5-turbo in generating Emergency Department (ED) discharge summaries and evaluate the prevalence and type of errors across each section of the discharge summary. Design: Cross-sectional study. Setting: University of California, San Francisco ED. Participants: We identified all adult ED visits from 2012 to 2023 with an ED clinician note. We randomly selected a sample of 100 ED visits for GPT-summarization. Exposure: We investigate the potential of two state-of-the-art LLMs, GPT-4 and GPT-3.5-turbo, to summarize the full ED clinician note into a discharge summary. Main Outcomes and Measures: GPT-3.5-turbo and GPT-4-generated discharge summaries were evaluated by two independent Emergency Medicine physician reviewers across three evaluation criteria: 1) Inaccuracy of GPT-summarized information; 2) Hallucination of information; 3) Omission of relevant clinical information. On identifying each error, reviewers were additionally asked to provide a brief explanation for their reasoning, which was manually classified into subgroups of errors. Results: From 202,059 eligible ED visits, we randomly sampled 100 for GPT-generated summarization and then expert-driven evaluation. In total, 33% of summaries generated by GPT-4 and 10% of those generated by GPT-3.5-turbo were entirely error-free across all evaluated domains. Summaries generated by GPT-4 were mostly accurate, with inaccuracies found in only 10% of cases, however, 42% of the summaries exhibited hallucinations and 47% omitted clinically relevant information. Inaccuracies and hallucinations were most commonly found in the Plan sections of GPT-generated summaries, while clinical omissions were concentrated in text describing patients' Physical Examination findings or History of Presenting Complaint. Conclusions and Relevance: In this cross-sectional study of 100 ED encounters, we found that LLMs could generate accurate discharge summaries, but were liable to hallucination and omission of clinically relevant information. A comprehensive understanding of the location and type of errors found in GPT-generated clinical text is important to facilitate clinician review of such content and prevent patient harm.

Use of a Large Language Model to Assess Clinical Acuity of Adults in the Emergency Department.

Importance: The introduction of large language models (LLMs), such as Generative Pre-trained Transformer 4 (GPT-4; OpenAI), has generated significant interest in health care, yet studies evaluating their performance in a clinical setting are lacking. Determination of clinical acuity, a measure of a patient's illness severity and level of required medical attention, is one of the foundational elements of medical reasoning in emergency medicine. Objective: To determine whether an LLM can accurately assess clinical acuity in the emergency department (ED). Design, Setting, and Participants: This cross-sectional study identified all adult ED visits from January 1, 2012, to January 17, 2023, at the University of California, San Francisco, with a documented Emergency Severity Index (ESI) acuity level (immediate, emergent, urgent, less urgent, or nonurgent) and with a corresponding ED physician note. A sample of 10 000 pairs of ED visits with nonequivalent ESI scores, balanced for each of the 10 possible pairs of 5 ESI scores, was selected at random. Exposure: The potential of the LLM to classify acuity levels of patients in the ED based on the ESI across 10 000 patient pairs. Using deidentified clinical text, the LLM was queried to identify the patient with a higher-acuity presentation within each pair based on the patients' clinical history. An earlier LLM was queried to allow comparison with this model. Main Outcomes and Measures: Accuracy score was calculated to evaluate the performance of both LLMs across the 10 000-pair sample. A 500-pair subsample was manually classified by a physician reviewer to compare performance between the LLMs and human classification. Results: From a total of 251 401 adult ED visits, a balanced sample of 10 000 patient pairs was created wherein each pair comprised patients with disparate ESI acuity scores. Across this sample, the LLM correctly inferred the patient with higher acuity for 8940 of 10 000 pairs (accuracy, 0.89 [95% CI, 0.89-0.90]). Performance of the comparator LLM (accuracy, 0.84 [95% CI, 0.83-0.84]) was below that of its successor. Among the 500-pair subsample that was also manually classified, LLM performance (accuracy, 0.88 [95% CI, 0.86-0.91]) was comparable with that of the physician reviewer (accuracy, 0.86 [95% CI, 0.83-0.89]). Conclusions and Relevance: In this cross-sectional study of 10 000 pairs of ED visits, the LLM accurately identified the patient with higher acuity when given pairs of presenting histories extracted from patients' first ED documentation. These findings suggest that the integration of an LLM into ED workflows could enhance triage processes while maintaining triage quality and warrants further investigation.