Impact of an Institutional Clinical Pathway on Emergency Physicians' Stated Preferences in Treating Patients with Low-Risk Pulmonary Embolism.

BACKGROUND: Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool. METHODS: We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway. RESULTS: Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE. CONCLUSION: Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

"Going through the motions": A qualitative exploration of the impact of emergency medicine resident burnout on patient care.

Objectives: Burnout occurs frequently in emergency medicine (EM) residents and has been shown to have a negative impact on patient care. The specific effects of burnout on patient care are less well understood. This study qualitatively explores how burnout may change the way EM residents provide patient care. Methods: Qualitative data were obtained from a sample of 29 EM residents in four semistructured focus groups across four institutions in the United States in early 2019. Transcripts were coded and organized into major patient care themes. Results: Residents described many ways in which feelings of burnout negatively impacted patient care. These detrimental effects most often fit into one of four main themes: reduced motivation to care for patients, poor communication with patients, difficult interactions with health care colleagues, and impaired decision making. Conclusions: According to EM residents, burnout negatively impacts several important aspects of patient care. Resident engagement with clinical care, communication with patients and colleagues, and clinical care may suffer as a result of burnout.

Assessing lactate concentration as a predictor of 28-day in-hospital mortality in the presence of ethanol: A retrospective study of emergency department patients.

BACKGROUND: Presence of ethanol (EtOH) may alter the relationship between blood lactate concentrations and mortality. This study compares lactate-associated mortality risk in the presence and absence of EtOH. METHODS: We performed a retrospective cohort study including all patients, age >17 years, presenting from January 2012-December 2018, to an urban, academic emergency department, with a clinically measured lactate. Data were electronically abstracted from the medical record. The primary outcome was 28-day in-hospital mortality. Patients were grouped by EtOH test results as follows: 1) present (any EtOH detected), 2) absent (EtOH concentration measured and not detected), or 3) not ordered. Marginal analysis was used to calculated probability of mortality for fixed values of lactate and model covariates. RESULTS: Of 40,956 adult emergency department patients with measured lactate, we excluded 768 (1.89%) for lactate >10.0 mmol/L, leaving 40,240 for analysis: 4,066 (10.1%) EtOH present, 10,819 (26.9%) EtOH absent, 25,355 (63%) EtOH not ordered. Of these, 1790 (4.4%) had 28-day in-hospital mortality. Marginal probability of mortality calculated for specific lactate values found less risk for EtOH Present patients versus EtOH absent patients at lactate 0.0 mmol/L (0.8% [95%CI: 0.5-1.2%] vs 3.2% [2.8-3.6%]), 2.0 mmol/L (1.5% [1.1-1.9%] vs 4.0% [3.7-4.3%]), 4.0 mmol/L (2.6% [2.2-3.1%] vs 5.0% [4.6-5.4%]), until 6.0 mmol/L (4.5% [3.7-5.4%] vs 6.2% [5.4-7.0%]). CONCLUSION: EtOH presence significantly alters lactate-associated mortality risk when lactate <6.0 mmol/L. Emergency department clinicians should interpret these lactate values with caution and consider other data for risk stratification when EtOH is present.

Pediatric Toxidrome Simulation Curriculum: Liquid Nicotine Overdose.

Introduction: Liquid nicotine exposure is becoming more common in the pediatric population. Toxicity may occur with exposure to small quantities given the high concentrations in solutions available commercially. Effects can include altered mental status, seizure, and death. Methods: This simulation-based case involves the identification and management of a toddler presenting with acute liquid nicotine exposure, with emphasis on the general approach to the acutely ill pediatric patient, consideration in toxic exposures, and the presentation of nicotine exposure. Providers should assess airway, breathing, and circulation while concurrently providing supportive care for an actively seizing simulated patient, necessitating appropriate selection of medications and acute airway management. Additionally, providers must maintain a broad differential diagnosis and obtain a focused history to narrow that differential and identify toxic exposure as a cause of the patient's presentation. Preparatory and didactic material is provided to help the instructor prepare the simulation environment, guide learners through the case, and debrief with learners afterward. Results: We implemented this curriculum with four pediatric emergency medicine fellows and 15 pediatric residents during two sessions. Feedback was overwhelmingly positive; participants who completed evaluations reported high levels of confidence with knowledge and skills directly related to the educational objectives after participation (mean Likert scores of 4.9 out of 5 in response to effectiveness of the case in teaching evaluation and management of nicotine toxicity). Discussion: This comprehensive resource will aid in offering continuing education for providers and specifically in educating learners with regard to acute liquid nicotine exposure in a child.