Precision emergency medicine.

BACKGROUND: Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. METHODS: In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. RESULTS: Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. CONCLUSIONS: Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.

Computed tomography rates in pediatric trauma patients among emergency medicine and pediatric emergency medicine physicians.

BACKGROUND: Pediatric trauma patients undergo fewer computed tomography (CT) scans when evaluated at pediatric trauma centers (PTC) versus adult trauma centers (ATC) with no change in clinical outcome. Factors contributing to this difference are unclear. We sought to identify whether the training background of physicians, specifically emergency medicine (EM) versus pediatric emergency medicine (PEM), affected the CT rate of pediatric trauma patients within one institution. METHODS: A single-center retrospective study of CT utilization based on attending physicians' training in trauma patients <18 years between November 2018 and November 2020. Attendings were categorized into two groups: EM residency with no PEM fellowship, or pediatrics/EM residency with PEM fellowship. Primary outcomes measured were the proportion of patients receiving a CT and CT positivity rate. RESULTS: Of 463 study patients, CTs were obtained in 145/228 (64%) patients by EM, and 130/235 (55%) by PEM (p=.07). CT positivity rate was 21% and 19% in EM and PEM, respectively (p=.46). The mean number of CTs per patient in EM was 2.8 compared to 2.1 in PEM (p<.01), and for patients with an injury severity score (ISS) >15, mean number of CTs per patient increased to 4.9 in EM versus 2.4 in PEM (p=.01). CONCLUSIONS: The mean number of CTs ordered per patient was statistically higher for EM attendings. The differences between CT rates highlight future opportunities for ongoing development of pediatric trauma imaging guidelines and radiation exposure reduction. LEVELS OF EVIDENCE: Retrospective Study, Level III.

Emergency department implementation of abbreviated magnetic resonance imaging for pediatric traumatic brain injury.

Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

Magnetic Resonance Imaging Versus Ultrasound as the Initial Imaging Modality for Pediatric and Young Adult Patients With Suspected Appendicitis.

BACKGROUND: While ultrasound (US), given its lack of ionizing radiation, is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time-intensive and operator dependent and results in frequent inconclusive studies, thus necessitating further imaging and admission for observation or repeat clinical visits. A rapid focused magnetic resonance imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to computed tomography but without radiation and offers a potential alternative to US. OBJECTIVE: In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the emergency department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost-effective than US as the initial imaging modality in the ED diagnosis of appendicitis. METHODS: A prospective randomized cohort study of consecutive patients was conducted in patients 2 to 30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the predetermined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (minutes) between triage, order placement, start of imaging, end of imaging, image result, and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging, and repeat ED visits) were recorded. RESULTS: Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45 of 82 (55%) of patients were in the US-first group, and 37 of 82 (45%) patients were in the rapid MRI-first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. Eleven of 45 (24%) of US-first patients had inconclusive studies, resulting in follow-up rapid MRI and five return ED visits contrasted with no inconclusive studies or return visits (p < 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference = 100 minutes; 95% confidence interval [CI] = 35-169 minutes) and increased ED charges (mean difference = $4,887; 95% CI = $1,821-$8,513). CONCLUSIONS: In the diagnosis of appendicitis, US-first imaging is more time-efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first-line imaging modality for appendicitis in patients 2 to 30 years of age.

Predictors of Nondiagnostic Ultrasound for Appendicitis.

BACKGROUND: Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US. OBJECTIVES: We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies. METHODS: A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed. RESULTS: Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients. CONCLUSION: Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

Development of DASH Mobile: a mHealth lifestyle change intervention for the management of hypertension.

Several landmark studies based on the DASH diet have established the effectiveness of a lifestyle approach to blood pressure control that emphasizes a diet rich in fruits and vegetables with moderate portions of low-fat dairy and lean protein along with increased physical activity and reduced sodium intake. However, this evidence base remains underused due feasibility limitations of implementing these intense in-person interventions and poor engagement with desktop computer based versions. Mobile technologies such as smartphones and wireless sensors have the ability to deliver behavioral interventions in-the-moment and with reduced user burden. DASH Mobile is a new mHealth system being developed to deliver this evidence-based lifestyle intervention to hypertensive patients. The system consists of an Android based "app" that facilitates easy tracking of DASH food portions, integrated Bluetooth blood pressure, weight and pedometer monitoring, goal setting, simple data visualizations and multimedia video clips to train patients in the basic concepts of the lifestyle change plan. At present, the system is undergoing usability testing with a pilot clinical trial planned for Spring 2013.

Improved physician work flow after integrating sign-out notes into the electronic medical record.

BACKGROUND: In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed. METHODS: A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey. RESULTS: The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process. DISCUSSION: EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.