Use and diagnostic value of liver enzyme tests in the emergency department and subsequent heart failure diagnosis: a retrospective cohort study.

OBJECTIVES: To determine (1) if liver function tests (LFTs) are ordered in the emergency department (ED) in patients with suspected acute decompensated heart failure (ADHF) and (2) if the pattern of LFT abnormalities are meaningfully associated with a discharge diagnosis of ADHF among patients for whom these tests were ordered. SETTING: We conducted a single-centre retrospective cohort study of patients with suspected ADHF who were seen in an academic tertiary ED using electronic medical records. PARTICIPANTS: All ED patients admitted with suspected ADHF from January 2017 to May 2018, defined as any patient who had a brain natriuretic peptide (BNP) ordered. PRIMARY OUTCOME: The primary outcome was ADHF diagnosis at discharge. RESULTS: In 5323 ED patients with suspected ADHF, 60% (n=3184) had LFTs ordered; 34.6% were abnormal. Men comprised 56% of patients with abnormal LFTs and the average age was 67 years. The odds of a final diagnosis of ADHF in the univariate analysis was 59% higher in patients with abnormal LFTs (OR=1.59, (95% CI 1.35 to 1.87) p<0.001) and remained significant though attenuated after adjusting for BNP, race and ethnicity and age (ORadj=1.31 (95% CI 1.09 to 1.57), p=0.004). Likelihood ratios for abnormal and normal LFTs were 1.2 (95% CI 1.21 to 1.28) and 0.76 (95% CI 0.68 to 0.84), respectively. CONCLUSIONS: A significant proportion (40%) of patients with suspected ADHF was missing LFTs in their ED workup. Among patients with LFTs, abnormal LFTs are associated with discharge diagnosis of ADHF after accounting for potential confounders, but their diagnostic value was relatively low. Future prospective studies are warranted to explore the role of LFTs in the workup of ADHF.

Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach.

PROBLEM: Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners. APPROACH: The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS. OUTCOMES: Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS. NEXT STEPS: Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.

The differential diagnosis of wide QRS complex tachycardia.

Wide complex tachycardia is defined as a cardiac rhythm with a rate greater than 100 beats/min (bpm) and a QRS complex duration greater than 0.10 to 0.12seconds (s) in the adult patient; wide complex tachycardia (WCT) in children is defined according to age-related metrics. The differential diagnosis of the WCT includes ventricular tachycardia and supraventricular tachycardia with aberrant intraventricular conduction, including both relatively benign and life-threatening dysrhythmias. This review focuses on the differential diagnosis of WCT with a discussion of strategies useful in making the appropriate diagnosis, when possible.

What's in It for Me? Maintenance of Certification as an Incentive for Faculty Supervision of Resident Quality Improvement Projects.

PROBLEM: Residents are required to engage in quality improvement (QI) activities, which requires faculty engagement. Because of increasing program requirements and clinical demands, faculty may be resistant to taking on additional teaching and supervisory responsibilities without incentives. The authors sought to create an authentic benefit for University of California, San Francisco (UCSF) Pediatrics Residency Training Program faculty who supervise pediatrics residents' QI projects by offering maintenance of certification (MOC) Part 4 (Performance in Practice) credit. APPROACH: The authors identified MOC as an ideal framework to both more actively engage faculty who were supervising QI projects and provide incentives for doing so. To this end, in 2011, the authors designed an MOC portfolio program which included faculty development, active supervision of residents, and QI projects designed to improve patient care. OUTCOMES: The UCSF Pediatrics Residency Training Program's Portfolio Sponsor application was approved by the American Board of Pediatrics (ABP) in 2012, and faculty whose projects were included in the application were granted MOC Part 4 credit. As of December 2013, six faculty had received MOC Part 4 credit for their supervision of residents' QI projects. NEXT STEPS: Based largely on the success of this program, UCSF has transitioned to the MOC portfolio program administered through the American Board of Medical Specialties, which allows the organization to offer MOC Part 4 credit from multiple specialty boards including the ABP. This may require refinements to screening, over sight, and reporting structures to ensure the MOC standards are met. Ongoing faculty development will be essential.