The impact of emergency department crowding and patient boarding on resident point-of-care ultrasound education.

Objectives: Emergency department (ED) crowding negatively affects patient care, but the effect on resident education has been difficult to quantify. We aimed to describe the relationship between ED crowding and residents' ability to meet point-of-care ultrasound (POCUS) education goals. Methods: We retrospectively reviewed medical records from November 2021 to June 2023 at an academic level 1 trauma center, where emergency medicine residents complete longitudinal POCUS scanning shifts throughout 3 years of training. Residents are expected to complete ≥14 scans per scanning shift. We assessed whether completing the goal POCUS scans on a scanning shift (success: ≥14 scans, near-success: 10‒13, failure: <10) was associated with the average National Emergency Department Overcrowding Scale (NEDOCS) score or patient boarding hours during each scanning shift. Ordinal logistic regression was performed, controlling for the type of POCUS device available and the presence of medical students, interns, ultrasound faculty, and multiple residents. Results: Over 125 scanning shifts, 1340 scans were performed. Residents met the expected number of POCUS scans for 26.4% of scanning shifts, with 34.4% near-success and 39.2% failure. The average NEDOCS was 157.4 ± 31.9. POCUS success was associated with a lower mean NEDOCS (142 vs. 169, p < 0.001). After controlling for covariates, every 10-point increase in NEDOCS was associated with 17% lower odds of achieving the goal (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.73‒0.94, p = 0.003). Other significant factors were having only one resident on a scanning shift, which was associated with lower odds of success (OR = 0.41, 95% CI 0.18‒0.97, p = 0.043), and having a cart-based POCUS device available in addition to a handheld POCUS device, which was associated with higher odds of success (OR = 13.58, 95% CI 5.53‒33.38, p < 0.001). Conclusion: As ED crowding increased, residents were increasingly likely to fail to meet their POCUS education goals.

Improving Outcomes in Patients Sent to the Emergency Department from Outpatient Providers: A Receiver-Driven Handoff Process Improvement.

BACKGROUND: Outpatient providers refer to emergency departments (EDs) due to findings requiring assessment beyond existing capabilities. However, poor communication surrounding these transitions may hinder safety and timeliness of emergency care. Receiver-driven handoff (RDH) is a process that helps ensure that all pertinent information is shared. This quality improvement project aimed to (1) improve knowledge of RDH, (2) increase satisfaction and perceptions surrounding RDH, (3) modify behaviors in relation to RDH, and (4) decrease referred patients leaving without being seen (LWBS). METHODS: The Iowa Model and Implementation Framework guided this evidence-based quality improvement project. A multidisciplinary team developed and implemented a standardized RDH process consisting of screening to determine whether a patient was referred to the ED, review of electronic health record (EHR), and use of EHR documentation. Process measures were collected via questionnaire pre- and postimplementation and were analyzed quantitatively. Outcome measures were trended by a statistical process control p-chart, which was developed to demonstrate changes in the percentage of patients who were referred to the ED from the outpatient setting and LWBS. RESULTS: The average response for the question "How satisfied are you with the handoff of patient information from referring clinic providers to the ED?" increased from 1.51 preintervention to 2.04 postintervention (p = 0.005). Respondents rated the information received during handoff higher postintervention (2.12 vs. 2.52, p = 0.04). Compliance with screening for referral to the ED was 84.0%. The proportion of patients LWBS after referral decreased by 6.2 percentage points (p < 0.001). CONCLUSION: Using RDH in conjunction with a standardized triage screening may improve quality of information shared during this vulnerable transition and may assist in reduction of referred patients LWBS. The RDH process should be adapted into everyday workflow to ensure sustainability and effectiveness.

Inpatient boarding definitions and mitigation strategies: A cross-sectional survey of academic emergency departments in the United States.

OBJECTIVE: Conceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management. METHODS: This was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated. RESULTS: Of the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%). CONCLUSIONS: We found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

Cepheid Xpert Xpress Flu/RSV evaluation performed by minimally trained non-laboratory operators in a CLIA-waived environment.

The COVID-19 pandemic highlighted the significance of readily available and easily performed viral testing for surveillance during future infectious pandemics. The objectives of this study were: to assess the performance of the Xpert Xpress Flu and/or RSV test, a multiplex PCR assay for detecting influenza A and B virus and respiratory syncytial virus nucleic acids in respiratory tract specimens, relative to the Quidel Lyra Influenza A+B assay and the Prodesse ProFlu+ assay, and the system's ease of use by minimally trained operators. Overall, the Xpert Xpress Flu/RSV test demonstrated a high positive and negative percent agreement with the comparator assays, and was easy to use and interpret results, based on the operators' feedback. We concluded that the Xpert Xpress Flu/RSV test is sensitive, specific, and easy to use for the diagnosis of influenza and RSV by minimally trained operators and can be a valuable tool in future infectious clusters or pandemics.

Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America.

OBJECTIVES: The objective was to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit in the emergency department (ED) on hospital admissions, ED length of stay, and 30-day follow-up for patients presenting with suicidal ideation or attempt. METHODS: This study was a before-and-after analysis of introducing the EmPATH unit within a Midwestern academic medical center on outcomes of adult patients (≥18 years) presenting with suicidal ideation or suicidal attempt. The primary outcome in this study was the change in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED before and after implementation of the EmPATH unit. Secondary outcomes compared were changes in proportion of any admission, incomplete admission defined as discharge from the ED after admission request placed, outpatient follow-up, return ED visits within 30 days of admission, and ED boarding time. Association between the EmPATH unit implementation and categorical outcomes were determined using log-binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). Continuous outcomes were log-transformed and generalized estimating equations were used to examine as the mean difference by time period. RESULTS: There were 962 patients presenting with suicidal ideation (n = 435 before EmPATH unit, n = 527 after EmPATH unit). Compared to the pre-EmPATH-unit period, there was a reduction in psychiatric admission (RR = 0.48, 95% CI = 0.40 to 0.56), any admission (RR = 0.65, 95% CI = 0.58 to 0.73), incomplete admission (RR = 0.22, 95% CI = 0.11 to 0.43), and 30-day return to the ED (RR = 0.74, 95% CI = 0.56 to 0.98). ED boarding time among admitted patients was reduced by approximately two-thirds both in admitted patients (RR = 0.34, 95% CI = 0.30 to 0.39) and among those with incomplete admissions (RR = 0.37, 95% CI = 0.23 to 0.61). There was a 60% increase in a 30-day follow-up care established at the time of discharge (RR = 1.60, 95% CI = 1.40 to 1.82). CONCLUSIONS: The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care.

The "double eights mask brace" improves the fit and protection of a basic surgical mask amidst COVID-19 pandemic.

STUDY OBJECTIVE: The COVID-19 pandemic has resulted in widespread shortages of personal protective equipment, including N95 respirators. Although basic surgical facemasks are more commonly available, their efficacy is limited due primarily to their poor face seal. This pilot study examined the impact of a rubber band mask brace on a basic surgical mask, as determined by quantitative fit testing. METHODS: Subjects wearing a basic surgical facemask and the rubber band mask brace underwent quantitative fit testing using machinery designed to certify N95 mask fit. Subjects were tested with the brace anchored behind their ears, with a paperclip behind the head, and on the side knobs of their face shields. The primary outcome measure was whether the subject passed the quantitative fit test at or above the Occupational Safety and Health Administration (OSHA)-verified standard for N95 masks. RESULTS: Subjects (n = 11) were 54.5% female, with a median height of 70 inches (interquartile range [IQR] = 68-74), weight of 170 pounds (IQR = 145-215), and body mass index (BMI) of 24.6 (IQR = 22.2-27.2), and encompassing 5 distinct N95 mask fit types. We found that 45%, 100%, and 100% of subjects passed the quantitative fit test when the brace was anchored behind the ears, with a paperclip and on a face shield, respectively. CONCLUSION: Of the 11 subjects included in the analysis, across a range of body habitus and N95 mask fit types, all passed the quantitative fit test when the mask brace was anchored on either face shield or with a paperclip. This data suggests that although the brace does not create an N95 equivalent in terms of filtration, it would offer improved protection from airborne viruses when worn with a basic surgical mask.

Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit.

OBJECTIVES: We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). METHODS: We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. RESULTS: There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes). CONCLUSION: The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.

Telemedicine Physical Examination Utilizing a Consumer Device Demonstrates Poor Concordance with In-Person Physical Examination in Emergency Department Patients with Sore Throat: A Prospective Blinded Study.

BACKGROUND: Telemedicine allows patients to connect with healthcare providers remotely. It has recently expanded to evaluate low-acuity illnesses such as pharyngitis by using patients' personal communication devices. The purpose of our study was to compare the telemedicine-facilitated physical examination with an in-person examination in emergency department (ED) patients with sore throat. MATERIALS AND METHODS: This was a prospective, observational, blinded diagnostic concordance study of patients being seen for sore throat in a 60,000-visit Midwestern academic ED. A telemedicine and a face-to-face examination were performed independently by two advanced practice providers (APP), blinded to the results of the other evaluator. The primary outcome was agreement on pharyngeal redness between the evaluators, with secondary outcomes of agreement and inter-rater reliability on 14 other aspects of the pharyngeal physical examination. We also conducted a survey of patients and providers to evaluate perceptions and preferences for sore throat evaluation using telemedicine. RESULTS: Sixty-two patients were enrolled, with a median tonsil size of 1.0. Inter-rater agreement (kappa) for tonsil size was 0.394, which was worse than our predetermined concordance threshold. Other kappa values ranged from 0 to 0.434, and telemedicine was best for detecting abnormal coloration of the palate and tender superficial cervical lymph nodes (anterior structures), but poor for detecting abnormal submandibular lymph nodes or asymmetry of the posterior pharynx (posterior structures). In survey responses, telemedicine was judged easier to use and more comfortable for providers than patients; however, neither patients nor providers preferred in-person to telemedicine evaluation. CONCLUSION: Telemedicine exhibited poor agreement with the in-person physical examination on the primary outcome of tonsil size, but exhibited moderate agreement on coloration of the palate and cervical lymphadenopathy. Future work should better characterize the importance of the physical examination in treatment decisions for patients with sore throat and the use of telemedicine in avoiding in-person healthcare visits.

Key High-efficiency Practices of Emergency Department Providers: A Mixed-methods Study.

OBJECTIVE: The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs). METHODS: A mixed-methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety-nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000- to 55,000-visit) community EDs during two 4-hour periods and recorded in minute-by-minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site. RESULTS: Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, "inefficiency practices," demonstrated significant negative correlations: non-work-related tasks and documentation on patients no longer in the ED. CONCLUSIONS: Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.

Telemedicine Provides Noninferior Research Informed Consent for Remote Study Enrollment: A Randomized Controlled Trial.

OBJECTIVE: Telemedicine networks are beginning to provide an avenue for conducting emergency medicine research, but using telemedicine to recruit participants for clinical trials has not been validated. The goal of this consent study was to determine whether patient comprehension of telemedicine-enabled research informed consent is noninferior to standard face-to-face (F2F) research informed consent. METHODS: A prospective, open-label randomized controlled trial was performed in a 60,000-visit Midwestern academic emergency department (ED) to test whether telemedicine-enabled research informed consent provided noninferior comprehension compared with standard consent. This study was conducted as part of a parent clinical trial evaluating the effectiveness of 0.12% oral chlorhexidine gluconate in preventing hospital-acquired pneumonia among adult ED patients with expected hospital admission. Prior to being recruited into the study, potential participants were randomized in a 1:1 allocation ratio to consent by telemedicine versus standard F2F consent. Telemedicine connectivity was provided using a commercially available interface (REACH platform, Vidyo Inc.) to an emergency physician located in another part of the ED. Comprehension of research consent (primary outcome) was measured using the modified quality of informed consent (QuIC) instrument, a validated tool for measuring research informed consent comprehension. Parent trial accrual rate and qualitative survey data were secondary outcomes. RESULTS: A total of 131 patients were randomized (n = 64, telemedicine), and 101 QuIC surveys were completed. Comprehension of research informed consent using telemedicine was not inferior to F2F consent (QuIC scores 74.4 ± 8.1 vs. 74.4 ± 6.9 on a 100-point scale, p = 0.999). Subjective understanding of consent (p = 0.194) and parent trial study accrual rates (56% vs. 69%, p = 0.142) were similar. CONCLUSION: Telemedicine is noninferior to F2F consent for delivering research informed consent, with no detected differences in comprehension and patient-reported understanding. This consent study will inform design of future telemedicine-enabled clinical trials.

Characterizing demographics, injury severity, and intubation status for patients transported by air or ground ambulance to a rural burn center.

Our study was designed to characterize intubation status among patients transported by air or ground ambulance to a rural burn center. A retrospective chart review of patients arriving at our burn center from January 1, 2005 to December 31, 2009 was completed. Descriptive and multivariate analyses were performed. During the study period, 259 air and 590 ground ambulance patients met inclusion criteria. Air ambulance patients were older and had higher total body surface area burned, lower Glasgow Coma scores, longer lengths of stay, and more frequent inhalation injuries. Approximately 10% of patients arriving by air were intubated after burn center admission, and 49% of intubated patients were extubated within 24 hours of admission. These values were 2% and 40%, respectively, for patients transported by ground. Increasing age and air ambulance transport increased the overall likelihood of change in intubation status. The likelihood of intubation by burn center providers increased with age, with suspicion of inhalation injury, and for patients transported by air. The likelihood of extubation within 24 hours of burn center admission increased with age, decreased with suspected inhalation injury, and was independent of transport mode. Among our patient population, more severely injured patients were being transported by air ambulance. However, age, suspicion of inhalation injury, and mode of transport showed a complex pattern of associations with changes in intubation status, and illustrate the need to develop better prehospital guidelines for intubation in burn patients.