Impact on an Urgent Care Clinic of a New Freestanding Emergency Department in a Resource-Scarce Area.

Background: Convenience clinics-such as urgent care centers (UCCs), retail clinics, and freestanding emergency departments (FSEDs)-where patients can receive treatment for a variety of medical conditions have increased in number and popularity. We quantify the impact an FSED had on UCC visits in an underserved area in North Baton Rouge, Louisiana. Methods: All FSED and UCC visits were abstracted from 2015 to 2020. Visits were classified using International Classification of Diseases, Tenth Revision codes. We used a time series analysis to evaluate the association of nonemergent and emergent visits to the UCC after the opening of the FSED. Visits were also aggregated at the census block group (neighborhood) level. Demographic characteristics and the neighborhood Area Deprivation Index were used to compare UCC utilization before and after the FSED opened and to describe the visits to the UCC and the FSED. Results: We found a difference in the demographic composition of patients presenting to the UCC after the FSED opened. Emergent visits decreased at the UCC, but nonemergent visits did not change after the FSED opened. The majority of visits to the FSED were nonemergent, and the proportion of nonemergent visits to the FSED increased during the hours that the UCC was closed. The majority of visits to the FSED came from neighborhoods with a high Area Deprivation Index. Conclusion: The opening of an FSED resulted in a reduction of emergent visits to the UCC without impacting the number of nonemergent visits. The opening of an FSED in a poor, healthcare-resource-scarce area resulted in significantly more patients from deprived neighborhoods being treated at the FSED and UCC.

Pilot Study for Assessing Nontechnical Skills in Emergency Medicine Residents: Why We Should C.A.R.E.

Background: The growing regulatory and hospital focus on patient experience and patient satisfaction is evidenced by the Centers for Medicare and Medicaid Services implementation of Hospital Value-Based Purchasing and by the Accreditation Council for Graduate Medical Education milestones. However, there is a paucity of data examining the education and evaluation of emergency medicine residents' nontechnical skills (eg, communication and situational awareness) as they relate to patient interactions. The purpose of the current study was to evaluate a nontechnical skills rating tool with emergency medicine residents during their interactions with patients. Methods: As part of the educational initiative, the authors consulted with a hospitality training and measurement company, the Freeman Group, that developed and trained faculty on the use of an observational tool to assess physicians' nontechnical skills. Nontechnical skills were assessed in 4 domains designated by the acronym C.A.R.E.: connect with the patient, adjust the interaction to meet patient needs, resolve patient requests, and empathize with the patient. Faculty observed emergency medicine residents as they interacted clinically with patients in the emergency department and rated them on a binary scale: acceptable or unacceptable. Results: Thirty-four of 36 residents were observed. Our study demonstrates that the residents performed very well on domains of empathy, adjusting to patients' knowledge, and resolving requests. However, residents' abilities to customize conversations to patients (eg, addressing patients appropriately and establishing and maintaining rapport) were rated as unacceptable 31% of the time. Conclusion: Overall, residents performed well on most aspects of nontechnical skills observed during their interactions with patients. However, even when residents were mindful of faculty observing nontechnical skills, they performed unacceptably in their communication with patients in approximately one-third of the interactions. This study provides important insight into nontechnical skill areas that may be influenced with intervention to improve patient interactions, and ultimately, influence patient satisfaction.

Assessment of a cellular host response test to risk-stratify suspected COVID-19 patients in the Emergency Department setting.

OBJECTIVE: Assess the IntelliSep Index (ISI) for risk stratification of patients presenting to the Emergency Department (ED) with respiratory symptoms suspected of COVID-19 during the pandemic. METHODS: An observational single-center study of prospective cohort of patients presenting to the ED during the early COVID-19 pandemic with respiratory symptoms and a CBC drawn within 4.5 hours of initial vital signs. A sample of this blood was aliquoted for performance of the ISI, and patients were followed for clinical outcomes. The study required no patient-centered activity beyond standard of care and treating clinicians were unaware of study enrollment and ISI test results. MAIN FINDINGS: 282 patients were included. The ISI ranges 0.1 to 10.0, with three interpretation bands indicating risk of adverse outcome: low (green), 0.1-4.9; intermediate (yellow), 5.0-6.2; and high (red), 6.3-10.0. Of 193 (68.4%) tested for SARS-CoV-2, 96 (49.7%) were positive. The ISI resulted in 182 (64.5%) green, 54 (18.1%) yellow, and 46 (15.6%) red band patients. Green band patients had a 1.1% (n = 2) 3-day mortality, while yellow and red band had 3.7% (n = 2, p > .05) and 10.9% (n = 5, p < .05) 3-day mortalities, respectively. Fewer green band patients required admission (96 [52.7%]) vs yellow (44 [81.5%]) and red (43 [93.5%]). Green band patients had more hospital free days (median 23 (Q1-Q3 20-25) than yellow (median 22 [Q1-Q3 0-23], p < 0.05) and red (median 21 [Q1-Q3 0-24], p < 0.01). SOFA increased with interpretation band: green (2, [Q1-Q3 0-4]) vs yellow (4, [Q1-Q3 2-5], p < 0.001) and red (5, [Q1-Q3 3-6]) p < 0.001). CONCLUSIONS: The ISI rapidly risk-stratifies patients presenting to the ED during the early COVID-19 pandemic with signs or suspicion of respiratory infection.

Retrospective identification of infection in the emergency department: A significant challenge in sepsis clinical trials.

BACKGROUND: This study examined three methods for retrospectively identifying infection in emergency department (ED) patients: modified objective definitions of infection (MODI) from the CDC/NHSN, physician adjudication determination of infection, and ED treating physician behavior. METHODS: This study used a subset of data from a prospective sepsis trial. We used Fleiss's Kappa to compare agreement between two physicians retrospectively adjudicating infection based on the patient's medical record, modified infection definition from the CDC/NHSN, and ED treating physician behavior. RESULTS: Overall, there was similar agreement between physician adjudication of infection and MODI criteria (Kappa=0.59) compared to having two physicians independently identify infection through retrospective chart review (Kappa=0.58). ED treating physician behavior was a poorer proxy for infection when compared to the MODI criteria (0.41) and physician adjudication (Kappa = 0.50). CONCLUSIONS: Retrospective identification of infection poses a significant challenge in sepsis clinical trials. Using modified definitions of infection provides a standardized, less time consuming, and equally effective means of identifying infection compared to having multiple physicians adjudicate a patient's chart.

Assessment of a Cellular Host Response Test as a Sepsis Diagnostic for Those With Suspected Infection in the Emergency Department.

OBJECTIVES: Sepsis is a common cause of morbidity and mortality. A reliable, rapid, and early indicator can help improve efficiency of care and outcomes. To assess the IntelliSep test, a novel in vitro diagnostic that quantifies the state of immune activation by measuring the biophysical properties of leukocytes, as a rapid diagnostic for sepsis and a measure of severity of illness, as defined by Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation-II scores and the need for hospitalization. DESIGN SETTING SUBJECTS: Adult patients presenting to two emergency departments in Baton Rouge, LA, with signs of infection (two of four systemic inflammatory response syndrome criteria, with at least one being aberration of temperature or WBC count) or suspicion of infection (a clinician order for culture of a body fluid), were prospectively enrolled. Sepsis status, per Sepsis-3 criteria, was determined through a 3-tiered retrospective and blinded adjudication process consisting of objective review, site-level clinician review, and final determination by independent physician adjudicators. MEASUREMENTS AND MAIN RESULTS: Of 266 patients in the final analysis, those with sepsis had higher IntelliSep Index (median = 6.9; interquartile range, 6.1-7.6) than those adjudicated as not septic (median = 4.7; interquartile range, 3.7-5.9; p < 0.001), with an area under the receiver operating characteristic curve of 0.89 and 0.83 when compared with unanimous and forced adjudication standards, respectively. Patients with higher IntelliSep Index had higher Sequential Organ Failure Assessment (3 [interquartile range, 1-5] vs 1 [interquartile range, 0-2]; p < 0.001) and Acute Physiology and Chronic Health Evaluation-II (7 [interquartile range, 3.5-11.5] vs 5 [interquartile range, 2-9]; p < 0.05) and were more likely to be admitted to the hospital (83.6% vs 48.3%; p < 0.001) compared with those with lower IntelliSep Index. CONCLUSIONS: In patients presenting to the emergency department with signs or suspicion of infection, the IntelliSep Index is a promising tool for the rapid diagnosis and risk stratification for sepsis.

The impact of the COVID-19 pandemic and governor mandated stay at home order on emergency department super utilizers.

BACKGROUND: Despite the trend of rising Emergency Department (ED) visits over the past decade, researchers have observed drastic declines in number of ED visits due to the COVID-19 pandemic. The purpose of the current study was to examine the impact of the COVID-19 pandemic and governor mandated Stay at Home Order on ED super utilizers. METHODS: This was a retrospective chart review of patients presenting to the 12 emergency departments of the Franciscan Mission of Our Lady Hospital System in Louisiana between January 1, 2018 and December 31, 2020. Patients who were 18 years of age or older and had four ED visits within a one-year period (2018, 2019, or 2020) were classified as super-utilizers. We examined number and category of visits for the baseline period (January 2018 - March 2020), the governor's Stay at Home Order, and the subsequent Reopening Phases through December 31, 2020. RESULTS: The number of visits by super utilizers decreased by over 16% when the Stay at Home Order was issued. The average number of visits per week rose from 1010.63 during the Stay at Home Order to 1198.09 after the Stay at Home Order was lifted, but they did not return to Pre-COVID levels of approximately 1400 visits per week in 2018 and 2019. When categories of visits were examined, this trend was found for emergent visits (p < 0.001) and visits related to injuries (p < 0.001). Non-emergent visits declined during the Stay at Home Order compared to the baseline period (p < 0.001), and did not increase significantly during reopening compared to the Stay at Home Order (p = 0.87). There were no changes in number of visits for psychiatric purposes, alcohol use, or drug use during the pandemic. CONCLUSIONS: Significant declines in emergent visits raise concerns that individuals who needed ED treatment did not seek it due to COVID-19. However, the finding that super utilizers with non-emergent visits continued to visit the ED less after the Stay at Home Order was lifted raises questions for future research that may inform policy and interventions for inappropriate ED use.

Challenges in the Diagnosis of Euglycemic Diabetic Ketoacidosis in a Patient With Multiple Sclerosis Taking a Sodium-Glucose Cotransporter 2 Inhibitor.

BACKGROUND: Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been reported to cause euglycemic diabetic ketoacidosis (eDKA), a diagnosis that may be challenging to establish in the emergency department (ED). CASE REPORT: This is a case report of missed eDKA in a 47-year-old male taking empagliflozin (a SGLT2 inhibitor) that presented to the ED with generalized weakness. His past medical history included multiple sclerosis (MS) diagnosed 4 years ago and type 2 diabetes mellitus. The patient attributed his weakness to MS. His neurologist was consulted and agreed with the plan to discharge the patient with diagnoses of asthenia and dehydration and a prescription of prednisone. The patient returned to the ED the next day with similar symptoms and was admitted to the hospital for treatment of eDKA. He was eventually treated per the hospital diabetic ketoacidosis (DKA) protocol and discharged home with instructions to discontinue empagliflozin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The increasing utilization of SGLT2 inhibitor in patients with type 2 diabetes mellitus will inevitably lead to more cases of eDKA seen in the ED. Emergency physicians need to consider this diagnosis in patients taking these medications that present with symptoms including weakness, nausea, vomiting, abdominal pain, and dehydration. Patients taking these medications should be warned about these symptoms, especially because they may be falsely reassured by relatively low plasma glucose levels on home glucometer readings.

Predicting American Board of Emergency Medicine Qualifying Examination Passage Using United States Medical Licensing Examination Step Scores.

BACKGROUND: The objective of the current study was to determine whether emergency medicine residents' United States Medical Licensing Examination (USMLE) scores are significantly associated with first-attempt passage of the American Board of Emergency Medicine (ABEM) qualifying (written) examination. We hypothesized that USMLE Step 2 Clinical Knowledge (CK) scores would be useful in predicting students who passed the ABEM qualifying examination on their first attempt. METHODS: For this retrospective cohort study, we examined the data of residents who successfully completed training at two emergency medicine residency programs between the years 2002-2013. Because scores on the USMLE Step examinations varied greatly across years, we obtained means and standard deviations from the National Board of Medical Examiners. We subtracted the mean score for the year each resident took the examination from the resident's examination score, creating centered Step 1 and centered Step 2 CK scores. RESULTS: A multivariate logistic regression analysis indicated that centered Step 2 CK scores could be used to predict the odds of passing the ABEM qualifying examination (odds ratio = 1.05 [95% confidence interval 1.02 to 1.08, P < 0.001]). Using a Step 2 CK score cutoff of 7 points lower than the mean yielded 64% sensitivity and 81% specificity for predicting passage of the ABEM written examination on the first attempt. CONCLUSION: Program directors and selection committees may wish to consider whether applicants' Step 2 CK scores are near the national average when making ranking decisions, as this variable is highly predictive of passing the ABEM qualifying examination on the initial attempt.

Residents' Preferences and Performance of Three Techniques for Ultrasound-Guided Central Venous Cannulation After Simulation Training.

BACKGROUND: Obtaining central venous cannulation of the internal jugular vein is an important skill for physicians to master. To our knowledge, no studies to date have examined residents' preferences or the safety of the oblique approach compared to other approaches. This study compared medical residents' preferences for and performance of ultrasound-guided central venous access using the transverse, longitudinal, and oblique approaches. METHODS: Emergency medicine and internal medicine residents (n = 72) at an urban community hospital participated in a central venous access course. To assess the residents' preferences, residents were asked to rank the transverse, longitudinal, and oblique approaches as first, second, or third. In addition to preference, skin-to-vein time, carotid artery puncture, and successful completion on the first attempt during a final skills analysis were measured. RESULTS: During the final skills analysis, the majority (87.5%) of residents preferred the transverse approach. The oblique approach had a significantly larger proportion of failures of technique than the transverse approach (P = 0.02). No significant differences in successful cannulation on the first attempt, skin-to-vein time, or carotid artery puncture among the 3 approaches were found during the final skills assessment. CONCLUSION: The majority of residents preferred the transverse approach to the longitudinal and oblique approaches. Although no significant differences among the 3 approaches were found in performance measures, more failures of technique occurred with the oblique approach. This study suggests that novices may require in-depth training and supervision to become proficient with the oblique approach.

Variability in Management of Patients With SJS/TEN: A Survey of Burn Unit Directors.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, type IV hypersensitivity reactions of the skin and mucosa. These reactions (SJS/TEN) are frequently managed in burn units; however, no standardized guidelines exist for the treatment and management of SJS/TEN. To gain insight into current SJS/TEN management practices, a survey on admission, diagnosis, and management, was conducted across accredited burn units in the United States. A 28-item question survey on SJS/TEN management, diagnosis, and treatment practices was distributed among medical directors and co-directors of American Burn Association-verified burn centers. Responses were collected over a 6-week period. In total, 31 (48% response rate) burn unit medical directors/co-directors participated in the survey. The majority of responders indicate that acceptance to their burn unit is based on clinical suspicion of SJS/TEN (74%), and biopsy or dermatological evaluation is not required (67 and 87%, respectively). More than half (61%) of the burn units have their own SJS/TEN protocol in place. No consensus was observed on different treatment aspects, such as infection control, systemic treatment, and wound care. Most directors reported their burn units to consult ophthalmology (77%) and dermatology (54%) for the management of patients with SJS/TEN. Large variability in procedures of admission, treatment, and management of SJS/TEN was identified across burn centers. This study demonstrates the urgent need for SJS/TEN standardized guidelines in the United States.

Factor structure and clinical correlates of the 61-item Wender Utah Rating Scale (WURS).

The objective of this study was to assess the factor structure and clinical correlates of a 61-item version of the Wender Utah Rating Scale (WURS), a self-report retrospective measure of childhood problems, experiences, and behavior used in ADHD assessment. Given the currently mostly widely used form of the WURS was derived via a criterion-keyed approach, the study aimed to use latent variable modeling of the 61-item WURS to potentially identify more and more homogeneous set of items reflecting current conceptualizations of ADHD symptoms. Exploratory structural equation modeling was used to generate factor scores which were then correlated with neuropsychological measures of intelligence and executive attention as well as a broad measure of personality and emotional functioning. Support for a modified five-factor model was found: ADHD, disruptive mood and behavior, negative affectivity, social confidence, and academic problems. The ADHD factor differed somewhat from the traditional 25-item WURS short form largely through weaker associations with several measures of personality and psychopathology. This study identified a factor more aligned with DSM-5 conceptualization of ADHD as well as measures of other types of childhood characteristics and symptoms which may prove useful for both research and clinical practice.

Problems screening for HAND among the educationally disadvantaged.

Neurocognitive screeners are used to detect symptoms of HIV-Associated Neurocognitive Disorders (HAND). However, the degree to which education and socioeconomic status affect these screeners remains unclear. Neurocognitive screeners were administered to 187 socioeconomically disadvantaged HIV+ individuals upon entering treatment who had no other risk factors for HAND. The false positive rates were: 84% for the Montreal Cognitive Assessment, 59% for the International HIV Dementia Scale, and 28.3% for the Modified HIV Dementia Scale. Given these high false positive rates, the screeners may be more useful for establishing baseline functioning and sequential testing to detect deterioration.

Utility of the Personality Assessment Inventory in detecting feigned Attention-Deficit/Hyperactivity Disorder (ADHD): The Feigned Adult ADHD index.

OBJECTIVE: The high potential for secondary gain among college students presenting for Attention-Deficit/Hyperactivity Disorder (ADHD) evaluations highlights the need for psychometrically sound embedded validity indicators. The purpose of this study was to develop new validity indicators specific to feigned ADHD for the Personality Assessment Inventory (PAI) and compare them to preexisting imbedded PAI validity measures. METHOD: PAI scales that were theoretically related to feigned ADHD were evaluated. A binomial (ADHD simulators, n = 138, and genuine ADHD, n = 142) logistic regression was conducted with selected PAI scales and subscales. Classification rates were compared between the new and existing validity scales. A similar approach was used for item-level data in a second study in a subgroup of the original sample. RESULTS: The derived PAI scale-based logistic regression had a sensitivity of 54% and specificity of 92%. This algorithm accurately identified 97% of healthy controls as not feigning ADHD and correctly identified 98% of a no diagnosis group and 75% of a mood/anxiety disorders group. Classification accuracy of the new index was superior to the majority of existing PAI validity scales across groups. An item-level PAI algorithm had a sensitivity of 85% and specificity of 97% for identifying feigned ADHD. CONCLUSIONS: New validity measures were compared to existing PAI validity indicators and performed better than many of them in this study. The algorithms developed in this study of ADHD simulators and genuine ADHD cases have adequate sensitivity and good specificity and appear to function differently than other PAI symptom validity scales.

Improving Patient Safety Communication in Residency Programs by Incorporating Patient Safety Discussions Into Rounds.

BACKGROUND: Engaging residents in patient safety and quality improvement initiatives is sometimes difficult. The primary goal of the current study was to develop a standardized learning experience designed to facilitate patient safety discussions during rounds. METHODS: Residents who were on inpatient rotations during a 2-month period in 2014 were exposed to patient safety discussions on rounds. Residents who were not on inpatient rotations served as a control group. Faculty received weekly text reminders with 3 questions designed to engage residents in patient safety discussions. Before and after the intervention, residents were asked to complete a modified Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. Faculty members were asked to complete a brief survey designed by the study investigators. RESULTS: Of the 160 residents who participated in the study, 49 responded to both the preintervention and postintervention surveys (31%). Residents who participated in patient safety discussions during rounds reported higher frequencies of safety events reported compared to the control group (P<0.05). Both groups of residents reported better communication (P<0.01) and an increased number of safety events reported (P<0.01) at the end of the intervention. Twenty-two faculty were surveyed, and 19 responded (86%). Most faculty felt incorporating patient safety discussions on rounds was constructive and that the residents were responsive. Few faculty members felt the patient safety discussions were burdensome. CONCLUSION: Using weekly text reminders with 3 prompts to incorporate patient safety discussions into rounds was well received by faculty and residents and had an impact on communication and error reporting.

Clinical and financial implications of emergency department visits for synthetic marijuana.

BACKGROUND: Many users believe that synthetic cannabinoids offer a safe and legal means of getting high. However, spikes in emergency department visits have been associated with use of synthetic cannabinoids. The purpose of the current study was to document emergency department visits from three large hospitals in one metropolitan area over a two month period. METHOD: This was a retrospective chart review examining 218 patients presenting to three inner city emergency departments between March and April 2014. Data collected included demographic information, information regarding ED diagnosis and treatment, signs and symptoms, ancillary testing, ED disposition, and cost of the medical treatment. RESULTS: The majority of patients (75.7%) were discharged after ED workup, but 12.4% were admitted for medical treatment and 11.5% were admitted for psychiatric treatment. Ten patients (4.6%) were admitted to the ICU. Symptoms experienced most frequently include: hypertension, tachycardia, agitation, drowsiness, nausea, and confusion. Cluster analysis revealed four symptom clusters of individuals presenting after using synthetic cannabinoids: 1) confusion, hostility, agitation, 2) nausea, vomiting, abdominal pain, 3) drowsiness, and 4) the absence of these symptoms. CONCLUSION: This study has three important findings. First, significant ED resources are being used to treat individuals presenting due to effects of synthetic cannabis. Second, synthetic cannabis is not a benign substance. Third, while the hostile and agitated user is generally presented in the media, this study finds significant heterogeneity in presentation. Further research is needed to fully understand the implications of synthetic cannabinoid use.

Suicide attempts presenting to trauma centers: trends across age groups using the National Trauma Data Bank.

BACKGROUND: This study sought to examine the epidemiology and mortality of violent suicide attempts presenting to trauma centers and to describe differences in male and female suicide attempters presenting to trauma centers by decade of age. METHOD: Data from the National Trauma Data Bank (American College of Surgeons) years 2010-2012 were used for this study. E-codes indicative of self-inflicted injury (e950-e959) were used to identify violent suicide attempts. Incidents were categorized by decade of age at admission. We examined the effects of age and sex on rates of violent suicide attempts, mechanism used, and mortality. RESULTS: In all, 36035 violent suicide attempts were identified in the National Trauma Data Bank. Proportion of in-hospital mortality differed significantly with age (P< .001). Individuals aged 20 to 29 years had a significantly higher number of attempts with 15.6% mortality, whereas individuals aged 80 plus year had fewer attempts but with 45.9% mortality. There were significant interactions between sex and age on lethality of suicide attempts (P< .01) and mechanism chosen (P< .01), with men being more likely to use firearms across age groups. CONCLUSION: This study highlights the importance of examining the epidemiology of suicide attempts across sex and age. There are significant differences in rate of attempts, lethality of mechanism, and in-hospital mortality. Future studies should continue to investigate violent suicide attempts to design and implement effective treatment strategies targeted toward specific populations.

Graduate Medical Education as a Lever for Collaborative Change: One Institution's Experience with a Campuswide Patient Safety Initiative.

BACKGROUND: The 2013 closure of a public hospital in Baton Rouge, LA transformed graduate medical education (GME) at Our Lady of the Lake Regional Medical Center (OLOL). Administrators were tasked with incorporating residents into patient safety and quality improvement initiatives to fulfill regulatory obligations. This report outlines our experiences as we built these patient safety and quality improvement initiatives in a rapidly expanding independent academic medical center. METHODS: We joined the Alliance of Independent Academic Medical Centers (AIAMC) to meet and learn from national peers. To fulfill the scholarly activity requirement of the AIAMC's National Initiative IV, we formed a multidisciplinary team to develop a patient safety education project. Prioritized monthly team meetings allowed for project successes to be celebrated and circulated within the organization. RESULTS: The public-private partnership that more than quadrupled the historic size of GME at OLOL has, in the past 2 years, led to the development of an interdisciplinary team. This team has expanded to accommodate residency program leadership from across the campus. Our National Initiative IV project won a national award and inspired several follow-up initiatives. In addition, this work led to the formation of a Patient Safety and Clinical Quality Improvement fellowship that matched its first fellow in 2015. CONCLUSION: Through the commitment and support of hospital and medical education leaders, as well as a focus on promoting cultural change through scholarly activity, we were able to greatly expand patient safety and quality improvement efforts in our institution.

Utility of the Personality Assessment Inventory for Detecting Malingered ADHD in College Students.

OBJECTIVE: The purpose of the current study is to examine the utility of the Personality Assessment Inventory (PAI) for detecting feigned ADHD in college students. METHOD: A sample of 238 undergraduate students was recruited and asked to simulate ADHD (ADHD simulators) or respond honestly (controls) on the PAI. Archival data (n = 541) from individuals diagnosed with clinical ADHD, no diagnosis, learning disorder, mood/anxiety, comorbid ADHD-mood/anxiety, or suspect effort were used. RESULTS: Few individuals scored above the cutoffs on PAI validity scales. When alternative cutoff scores were examined, cutoffs of ≥77 on the Negative Impression Management (NIM) scale, ≥3 on the Malingering Index (MAL), and ≥1 on the Rogers Discriminant Function (RDF) yielded excellent specificity in all groups and sensitivities of .33, .30, and .20, respectively. CONCLUSION: Individuals who were asked to simulate ADHD easily manipulate the PAI; however, alternative cutoff scores proposed for PAI validity indices may improve the detection of feigned ADHD symptoms.