Development and Implementation of an Alternate Care Site During the COVID-19 Pandemic.

Introduction With the rampant spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent pandemic of coronavirus disease 2019 (COVID-19), the need for medical resources has never been greater. In recent history, the deployment of surge medical facilities and their importance in improving the provision of crisis care became relevant. The primary objective of this study was to describe the development and implementation of an alternate care site (ACS) during the COVID-19 pandemic. Methods This was a retrospective, single-center study that was conducted between April 7, 2020, and May 26, 2020, of adult patients from a primary facility admitted to an ACS, labeled Staten Island University Hospital East (SIUH-E). These select patients met specific inclusion criteria for SIUH-E before transfer. Results During the operational course of SIUH-E, 813 patients were screened and 203 patients were accepted for transfer. Of the patients admitted to SIUH-E, 120 (59%) were male. The mean age was 63 years (SD = 13.91). The mean length of stay was 3.93 days (SD = 3.94). Among discharged patients, 179 (88%) were discharged to home or another long-term facility, whereas 24 (12%) patients required a transfer back to the main campus. Conclusions In this study, we describe the development and implementation of an alternate care surge facility during the COVID-19 pandemic. SIUH-E played a vital role in effectively caring for select COVID-19 patients, which allowed the primary facilities to treat a greater volume of higher acuity patients. The combined efforts of the state and hospital were able to create and sustain a safe, practical alternative care facility.

How Well Does the Standardized Video Interview Score Correlate with Traditional Interview Performance?

INTRODUCTION: In 2017, all medical students applying for residency in emergency medicine (EM) were required to participate in the Standardized Video Interview (SVI). The SVI is a video-recorded, uni-directional interview consisting of six questions designed to assess interpersonal and communication skills and professionalism. It is unclear whether this simulated interview is an accurate representation of an applicant's competencies that are often evaluated during the in-person interview. OBJECTIVE: The goal of this study was to determine whether the SVI score correlates with a traditional in-person interview score. METHODS: Six geographically and demographically diverse EM residency programs accredited by the Accreditation Council for Graduate Medical Education participated in this prospective observational study. Common demographic data for each applicant were obtained through an Electronic Residency Application Service export function prior to the start of any scheduled traditional interviews (TI). On each TI day, one interviewer blinded to all applicant data, including SVI score, rated the applicant on a five-point scale. A convenience sample of applicants was enrolled based on random assignment to the blinded interviewer. We studied the correlation between SVI score and TI score. RESULTS: We included 321 unique applicants in the final analysis. Linear regression analysis of the SVI score against the TI score demonstrated a small positive linear correlation with an r coefficient of +0.13 (p=0.02). This correlation remained across all SVI score subgroups (p = 0.03). CONCLUSION: Our study suggests that there is a small positive linear correlation between the SVI score and performance during the TI.

Effect of New York State Electronic Prescribing Mandate on Opioid Prescribing Patterns.

BACKGROUND: Drug overdose was the leading cause of injury and death in 2013, with drug misuse and abuse causing approximately 2.5 million emergency department (ED) visits in 2011. The Electronic Prescriptions for Controlled Substances (EPCS) program was created with the goal of decreasing rates of prescription opioid addiction, abuse, diversion, and death by making it more difficult to "doctor-shop" and alter prescriptions. OBJECTIVE: In this study, we describe the opioid-prescribing patterns of emergency physicians after the introduction of the New York State EPCS mandate. METHODS: We conducted a retrospective, single-center, descriptive study with a pre-/post-test design. The pre-implementation period used for comparison was April 1-July 31, 2015 and the post-implementation period was April 1-July 31, 2016. All ED discharge prescriptions for opioid medications prior to and after the initiation of New York State EPCS were identified. RESULTS: During the pre-implementation study period, 22,221 patient visits were identified with 1366 patients receiving an opioid prescription. During the post-implementation study period, 22,405 patient visits were identified with 642 patients receiving an opioid prescription. This represented an absolute decrease of 724 (53%) opioid prescriptions (p < 0.0001), which is an absolute difference of 2.3% (95% confidence interval 2.0-2.6%). CONCLUSIONS: There was a significant decline in the overall number of opioid prescriptions after implementation of the New York EPCS mandate.

The Standardized Video Interview: How Does It Affect the Likelihood to Invite for a Residency Interview?

BACKGROUND: The Association of American Medical Colleges instituted a standardized video interview (SVI) for all applicants to emergency medicine (EM). It is unclear how the SVI affects a faculty reviewer's decision on likelihood to invite an applicant (LTI) for an interview. OBJECTIVES: The objective was to determine whether the SVI affects the LTI. METHODS: Nine Accreditation Council of Graduate Medication Education (ACGME)-accredited EM residency programs participated in this prospective, observational study. LTI was defined on a 5-point Likert scale as follows: 1 = definitely not invite, 2 = likely not invite, 3 = might invite, 4 = probably invite, 5 = definitely invite. LTI was recorded at three instances during each review: 1) after typical screening (blinded to the SVI), 2) after unblinding to the SVI score, and 3) after viewing the SVI video. RESULTS: Seventeen reviewers at nine ACGME-accredited residency programs participated. We reviewed 2,219 applications representing 1,424 unique applicants. After unblinding the SVI score, LTI did not change in 2,065 (93.1%), increased in 85 (3.8%) and decreased in 69 (3.1%; p = 0.22). In subgroup analyses, the effect of the SVI on LTI was unchanged by United States Medical Licensing Examination score. However, when examining subgroups of SVI scores, the percentage of applicants in whom the SVI score changed the LTI was significantly different in those that scored in the lower and upper subgroups (p < 0.0001). The SVI video was viewed in 816 (36.8%) applications. Watching the video did not change the LTI in 631 (77.3%); LTI increased in 106 (13.0%) and decreased in 79 (9.7%) applications (p = 0.04). CONCLUSIONS: The SVI score changed the LTI in 7% of applications. In this group, the score was equally likely to increase or decrease the LTI. Lower SVI scores were more likely to decrease the LTI than higher scores were to increase the LTI. Watching the SVI video was more likely to increase the LTI than to decrease it.

Standardized Video Interviews Do Not Correlate to United States Medical Licensing Examination Step 1 and Step 2 Scores.

INTRODUCTION: In 2017, the Standardized Video Interview (SVI) was required for applicants to emergency medicine (EM). The SVI contains six questions highlighting professionalism and interpersonal communication skills. The responses were scored (6-30). As it is a new metric, no information is available on correlation between SVI scores and other application data. This study was to determine if a correlation exists between applicants' United States Medical Licensing Examination (USMLE) and SVI scores. We hypothesized that numeric USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores would not correlate with the SVI score, but that performance on the Step 2 Clinical Skills (CS) portion may correlate with the SVI since both test communication skills. METHODS: Nine EM residency sites participated in the study with data exported from an Electronic Residency Application Service (ERAS®) report. All applicants with both SVI and USMLE scores were included. We studied the correlation between SVI scores and USMLE scores. Predetermined subgroup analysis was performed based on applicants' USMLE Step 1 and Step 2 CK scores as follows: (≥ 200, 201-220, 221-240, 241-260, >260). We used linear regression, the Kruskal-Wallis test and Mann-Whitney U test for statistical analyses. RESULTS: 1,325 applicants had both Step 1 and SVI scores available, with no correlation between the overall scores (p=0.58) and no correlation between the scores across all Step 1 score ranges, (p=0.29). Both Step 2 CK and SVI scores were available for 1,275 applicants, with no correlation between the overall scores (p=0.56) and no correlation across all ranges, (p=0.10). The USMLE Step 2 CS and SVI scores were available for 1,000 applicants. Four applicants failed the CS test without any correlation to the SVI score (p=0.08). CONCLUSION: We found no correlation between the scores on any portion of the USMLE and the SVI; therefore, the SVI provides new information to application screeners.

The effect of practice settings on individual Doctor Press Ganey scores: A retrospective cohort review.

OBJECTIVE: The Press Ganey (PG) survey is a patient experience survey mailed to patients upon discharge from the emergency department (ED). It is a nationally recognized survey that is commonly used to measure patient's perception of the healthcare delivered. Emergency medicine physicians at Staten Island University Hospital staff two distinct sites: a tertiary-care setting (SIUH-N) and a community setting (SIUH-S). The goal of our study was to compare the effect of different ED practice settings, within the same hospital and healthcare system, on individual attending physician PG scores. METHODS: This was a retrospective, observational study of EM physicians, conducted at Staten Island University Hospital between January 1, 2015 and December 31, 2016. Physicians with PG survey responses from both sites were included. The number of responses and mean scores for the four doctor specific survey questions and the doctor overall score were extracted from PG surveys. RESULTS: Mean PG scores at SIUH-N were significantly lower than the mean scores at SIUH-S in each of the four doctor-specific questions, as well as the doctor overall score (p < 0.05). 16 out of 18 doctors demonstrated higher doctor overall scores at SIUH-S. CONCLUSION: Variables other than the individual doctor may be influencing the PG survey responses and perceptions of care. The PG survey may underestimate the impact of different practice settings on individual doctor PG scores.

Characteristics of prior emergency departments visits associated with subsequent opioid overdose.

OBJECTIVES: In this study, we aim to identify and discuss the clinical and demographic characteristics of previous emergency department (ED) patient visits, at one of the only two medical centers in Staten Island, the epicenter of the opioid epidemic within Staten Island, who subsequently present to the ED with an opioid overdose. DESIGN: This was a retrospective, observational study of all patients presenting to the emergency ED between July 1, 2010 and December 31, 2015. SETTING: The study was conducted at Staten Island University Hospital. The ED has a census of 120,000 patient visits per year. PATIENTS: All adult patients ≥ 18 years of age, with an ICD-9 code consistent with opioid intoxication and a history of intentional or unintentional overdose were included. MAIN OUTCOME MEASURE: Clinical and demographic characteristics of previous ED patient visits who subsequently presented to the ED with an opioid overdose. RESULTS: One hundred and twenty-four subjects with a median age of 30 years [interquartile range, 24-40] were reviewed. Eighty-seven (70 percent) were males. Fifty-five subjects were admitted, 68 discharged, and one death. Patients were not more likely to present at any specific time of day. The most common past medical history was anxiety (21 percent), depression (20 percent), back pain (15 percent), hypertension (14 percent), and seizure disorder (11 percent). The most common past surgical history was a prior orthopedic procedure (11 percent). CONCLUSIONS: This study identified clinical and demographic characteristics of previous ED patient visits who subsequently present to the ED with an opioid overdose. These characteristics will be vital toward an increased understanding of subjects who subsequently experience an opioid overdose.

Effects of eliminating routine use of oral contrast for computed tomography of the abdomen and pelvis: A pilot study.

INTRODUCTION: Computed tomography (CT) of the abdomen and pelvis using only intravenous contrast has been shown to have a high degree of accuracy in evaluating abdominal pain. The aim of this study was to determine the effect on time to completion of study, time to radiologist read, and length of stay in the emergency department (ED) of implementing a protocol that stopped the routine use of oral contrast for CT of the abdomen and pelvis. METHODS: This was a single-center, retrospective cohort study. All patients ≥18 years of age who presented to the ED and required a CT of the abdomen and pelvis during the hours 0700-1500 were included. There were two one-month study periods, before and after implementing a protocol that specified oral contrast should only be used for CT scans of the abdomen and pelvis if body mass index <25 kg/m2 or age < 30 years, or if there was history of inflammatory bowel disease, gastrointestinal surgery, or suspected bowel malignancy. RESULTS: During the pre- and post-implementation periods, there were 93 and 83 patients, respectively, with mean times to CT completion of 158 min and 135 min, representing a reduction of 23 min (15%). The mean lengths of stay in the pre- and post-implementation periods were 365 min and 336 min, a decrease of 29 min (8%). CONCLUSION: A protocol without the routine use of oral contrast for CT of the abdomen and pelvis can result in improved time to completion and ED length of stay.

A Novel Approach to Addressing an Unintended Consequence of Direct to Room: The Delay of Initial Vital Signs.

INTRODUCTION: The concept of "direct to room" (DTR) and "immediate bedding" has been described in the literature as a mechanism to improve front-end, emergency department (ED) processing. The process allows for an expedited clinician-patient encounter. An unintended consequence of DTR was a time delay in obtaining the initial set of vital signs upon patient arrival. METHODS: This retrospective cohort study was conducted at a single, academic, tertiary-care facility with an annual census of 94,000 patient visits. Inclusion criteria were all patients who entered the ED from 11/1/15 to 5/1/16 and between the hours of 7 am to 11 pm. During the implementation period, a vital signs station was created and a personal care assistant was assigned to the waiting area with the designated job of obtaining vital signs on all patients upon arrival to the ED and prior to leaving the waiting area. Time to first vital sign documented (TTVS) was defined as the time from quick registration to first vital sign documented. RESULTS: The pre-implementation period, mean TTVS was 15.3 minutes (N= 37,900). The post-implementation period, mean TTVS was 9.8 minutes (N= 39,392). The implementation yielded a 35% decrease and an absolute reduction in the average TTVS of 5.5 minutes (p<0.0001). CONCLUSION: This study demonstrated that the coupling of registration and a vital signs station was successful at overcoming delays in obtaining the time to initial vital signs.

Effect of an emergency department opioid prescription policy on prescribing patterns.

BACKGROUND: Staten Island University Hospital is located in NYC, where the opioid epidemic has resulted in significant mortalities from unintentional overdoses. In 2013 as a response to the rising threat to our community, our Emergency Department (ED) administration adopted a clinical practice policy focused on decreasing the prescription of controlled substances. The effects of this policy on our provider prescription patterns are presented here. METHODS: A retrospective chart review of patients prescribed opioids from the ED before and after policy implementation was performed. Dates chosen for analysis was November 1, 2012 through January 31, 2013 and November 1, 2013 through January 31, 2014; these time periods were used to serve as a seasonally comparative group pre and post clinical practice policy implementation. Opioids written for the treatment of cough, and for children under eighteen were excluded from analysis. Patient age, sex, diagnoses, and prescription formulation, strength, and pill number was recorded for each patient receiving an opioid prescription. RESULTS: There was a drop in the total prescriptions from 1756 to 1128 without a change in the average number of pills (12.78 vs 12.44) or average total dose prescribed (69.39 vs 68.98) mg of morphine equivalent per prescription. Additionally, there were sizable reductions in opioid prescriptions written for arthralgias/myalgias, dental pain, soft tissue injuries, and headaches. CONCLUSION: The opioid clinical policy had a clear effect in decreasing the number of patients prescribed opioids. Such policies may be the key to reducing the epidemic and saving lives from unintentional opioid overdoses.

Impact of Hurricane Sandy on the Staten Island University Hospital Emergency Department.

UNLABELLED: Introduction On October 29, 2012, Hurricane Sandy touched down in New York City (NYC; New York USA) causing massive destruction, paralyzing the city, and destroying lives. Research has shown that considerable damage and loss of life can be averted in at-risk areas from advanced preparation in communication procedures, evacuation planning, and resource allocation. However, research is limited in describing how natural disasters of this magnitude affect emergency departments (EDs). Hypothesis/Problem The aim of this study was to identify and describe trends in patient volume and demographics, and types of conditions treated, as a result of Hurricane Sandy at Staten Island University Hospital North (SIUH-N; Staten Island, New York USA) site ED. METHODS: A retrospective chart review of patients presenting to SIUH-N in the days surrounding the storm, October 26, 2012 through November 2, 2012, was completed. Data were compared to the same week of the year prior, October 28, 2011 through November 4, 2011. Daily census, patient age, gender, admission rates, mode of arrival, and diagnoses in the days surrounding the storm were observed. RESULTS: A significant decline in patient volume was found in all age ranges on the day of landfall (Day 0) with a census of 114; -55% compared to 2011. The daily volume exhibited a precipitous drop on the days preceding the storm followed by a return to usual volumes shortly after. A notably larger percentage of patients were seen for medication refills in 2012; 5.8% versus 0.4% (P<.05). Lacerations and cold exposure also were increased substantially in 2012 at 7.6% versus 2.8% (P<.05) and 3.8% versus 0.0% (P<.05) of patient visits, respectively. A large decline in admissions was observed in the days prior to the storm, with a nadir on Day +1 at five percent (-22%). Review of admitted patients revealed atypical admissions for home care service such as need for supplemental oxygen or ventilator. In addition, a drop in Emergency Medical Services (EMS) utilization was seen on Days 0 and +1. The SIUH-N typically sees 18% of patients arriving via EMS. On Day +1, only two percent of patients arrived by ambulance. CONCLUSION: The daily ED census saw a significant decline in the days preceding the storm. In addition, the type of conditions treated varied from baseline, and a considerable drop in hospital admissions was seen. Data such as these presented here can help make predictions for future scenarios. Greenstein J , Chacko J , Ardolic B , Berwald N . Impact of Hurricane Sandy on the Staten Island University Hospital emergency department. Prehosp Disaster Med. 2016;31(3):335-339.

A survey of academic emergency medicine department chairs on hiring new attending physicians.

BACKGROUND: For graduating emergency medicine (EM) residents, little information exists as to what attributes department chairs are seeking in hiring new attendings. STUDY OBJECTIVES: To determine which qualities academic EM department chairs are looking for when hiring a new physician directly out of residency or fellowship. METHODS: An anonymous 15-item Web-based survey was sent to the department chairs of all accredited civilian EM residency programs in March of 2011. The questions assessed the desirability of different candidate attributes and the difficulty in recruiting EM-trained physicians. Respondents were also asked to give the current number of available job openings. RESULTS: Fifty-five percent of eligible department chairs responded. On a 5-point scale, the most important parts of a candidate's application were the interview (4.8 ± 0.4), another employee's recommendation (4.7 ± 0.5), and the program director's recommendation (4.5 ± 0.7). The single most important attribute possessed by a candidate was identified as "Ability to work in a team," with 58% of respondents listing it as their top choice. Advanced training in ultrasound was listed as the most sought-after fellowship by 55% of the chairs. Overall, department chairs did not have a difficult time in recruiting EM-trained physicians, with 56% of respondents stating that they had no current job openings. CONCLUSION: How a physician relates to others was consistently rated as the most important part of the candidate's application. However, finding a job in academic EM is difficult, with graduates having limited job prospects.

Pilot study on documentation skills: is there adequate training in emergency medicine residency?

BACKGROUND: Thorough and accurate documentation in the medical record is important, and documentation skills should be an integral component of emergency medicine (EM) residency training. STUDY OBJECTIVE: We sought to study the documentation skills of EM residents as they relate to emergency department (ED) reimbursement. METHODS: This was a retrospective, cross-sectional study. We reviewed all charts of patients presenting to the adult ED during a 2-week period. We compared three groups: patients seen primarily by an EM resident, patients seen primarily by a physician assistant (PA), and patients seen primarily by an attending emergency physician. Outcome measures were the incidence of downcodes and dollars lost to downcodes in all groups. RESULTS: There were 212 patients in the resident group, 683 patients in the PA group, and 437 patients in the attending group. There were 12 downcodes (5.7%, 95% confidence interval [CI] 2.96-9.70) in the resident group, 10 downcodes (1.5%, 95% CI 0.70-2.68) in the PA group, and 17 downcodes (3.9%, 95% CI 2.28-6.14) in the attending group (p = 0.002). The mean dollar lost per patient seen in the resident group was $3.21 (95% CI 1.41-5.00); $0.91 (95% CI 0.33-1.49) in the PA group; and $2.23 (95% CI 1.17-3.28) in the attending group (p = 0.002). CONCLUSION: Charts documented primarily by EM residents were more likely to be downcoded than charts documented primarily by PAs or ED attendings. This downcode rate resulted in a greater loss of revenue in the resident group. We believe this represents an area for improvement in EM residency education.

A STEMI code protocol improves door-to-balloon time on weekdays and weekends.

Primary percutaneous coronary intervention (PCI) has emerged as the standard of care for the management of ST-elevation myocardial infarctions (STEMI). Only 32% of patients with STEMI receive this procedure within the recommended 90 min for door-to-balloon time (DTB). We reviewed all STEMI cases that presented to our institution before and after the implementation of a STEMI Code protocol. Before the STEMI Code protocol, 27.1% of weekday cases and 6.3% of weekend cases were performed within 90 min. After the STEMI Code protocol, there was a threefold increase in the number of patients who received PCI within 90 min (p<.0001). A STEMI Code protocol dramatically improves DTB and equalizes disparities between weekday and weekend care.