Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area.

BACKGROUND: The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. OBJECTIVE: This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. METHODS: The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. RESULTS: The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. CONCLUSIONS: Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Defensive Medicine: A Case and Review of Its Status and Possible Solutions.

Malpractice liability systems exist, in part, to provide compensation for medical malpractice, corrective justice for those injured by it, and to incentivize quality care by punishing substandard care. Defensive medicine is loosely defined as practice based primarily on the fear of litigation rather than on expected patient outcomes. It is largely motivated by a physician's belief that the malpractice system is unfair, slow, and ineffective; these perceptions make malpractice concerns one of the largest physician stressors. A physician's perception of malpractice rarely correlates with the stringency of their state's tort system, overestimates their own risk, and overestimates the cost of defensive practices. While estimates are difficult to make, defensive medicine likely only accounts for 2.8% of total healthcare expenses. The phrase "tort reform" has been frequently used to suggest fixes to the malpractice system and to defensive practices. Safe harbors, clinical practice guidelines, comparative fault reform, reducing plaintiff attorney fees, and apology laws have each been evaluated as potential remedies to defensive practice, although most are unproven and all must be deployed in a state-by-state approach.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices.

OBJECTIVE: To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician. METHODS: Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R2 value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate. RESULTS: There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates. CONCLUSIONS: In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

A National Evaluation of the Scholarly Activity Requirement in Residency Programs: A Survey of Emergency Medicine Program Directors.

OBJECTIVES: The Review Committee for Emergency Medicine (RC-EM) requirement for scholarly activity, which programs may define as an original research project or some other form of scholarly activity, applies to all EM residents. The objectives of this study were to: 1) describe the percentage of residency programs that require an original research project to meet the RC-EM requirement for scholarly activity, 2) describe specific challenges and resources for residents completing the RC-EM scholarly activity requirement, and 3) identify associations between the interpretation of the requirement and early career outcomes. METHODS: This was a cross-sectional online survey of program or research directors from all U.S. allopathic EM residency programs. Respondents were queried about key demographics and domains relating to research curriculum, resources, expectations, outcomes, challenges, and future opportunities. Data were analyzed using descriptive statistics. RESULTS: The overall response rate was 113 of 156 (72%) EM residency programs. Respondents were more likely to represent university-based programs, but otherwise did not differ from nonrespondents across key demographic criteria. An original research project was required by 39% of responding programs, with a minimum deliverable in 93% of these programs. Program directors listed data collection and study design as the principle challenges residents face while completing their scholarly activities. Faculty mentorship, biostatistical support, and travel support were common resources reportedly available to residents. Comparison of programs with an original research requirement to those without revealed many differences in outcomes. Programs with a research requirement were more likely to have residents with oral or poster presentations (46% vs. 25%, mean difference = 21%, 95% confidence interval [CI] = 16% to 28%), published manuscripts (25% vs. 18%, mean difference = 7%, 95% CI = 2% to 10%), entering fellowship training after residency (27% vs. 20%, mean difference = 7%, 95% CI = 4% to 10%), and using a biostatistician (64% vs. 28%, median difference = 26%, 95% CI = 24% to 28%). There were no statistically significant differences in other evaluations of resources or outcome measures, including resident choice of academic career after leaving residency. CONCLUSIONS: There is no consistent interpretation and implementation of the RC-EM requirement for scholarly activity among EM residency programs. Residency programs requiring an original research project were more likely to have residents with accepted oral or poster presentations, published manuscripts, and entering fellowships after residency training.

A novel concept in residency education: case-based remediation.

BACKGROUND: Resident remediation is required for all residents who do not meet minimum standards in one or more of the Accreditation Council for Graduate Medical Education core competencies. The Council of Residency Directors in Emergency Medicine Remediation Taskforce identified the need for case-based examples of remediation efforts. OBJECTIVES: 1) To describe a complicated resident remediation case and employ consensus panel evaluation of the process. 2) To discuss the available assessment tools (including neuropsychologic/medical testing), due process, documentation, reassessment, and relevant barriers to implementation for this and other resident remediations. DISCUSSION: Details of a remediation case were altered to protect resident confidentiality, and then presented to a multidisciplinary group of program directors. The case details, action plan, and course were submitted and the remediation process, action plan, and course are assessed based on a standardized remediation approach. The resident entered remediation for poor organizational skills and an inability to make or follow through with patient care plans. Opportunities for improvement in the applied remediation process are identified and discussed. Legal concerns and utility of neuropsychological assessment of residents are reviewed. CONCLUSIONS: Remediation requires a complicated and detailed effort. This case demonstrates issues that program directors may face when working with residents and provides suggestions for use of specific remediation tools.

Emergency medicine directors' perceptions on professionalism: a Council of Emergency Medicine Residency Directors survey.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires residency training programs to teach and assess professionalism in residents; however, programs may struggle to successfully remediate residents not meeting professionalism standards. To assist programs with this complex issue, a Professionalism Remediation Task Force was formed by the Council of Emergency Medicine Residency Directors (CORD-EM), which surveyed program directors (PDs) concerning their experiences. The purpose of this study is to report survey results regarding the identification and rating of unprofessional behaviors and challenges in the evaluation and remediation of professionalism. METHODS: In June 2010, the task force sent an anonymous survey via the CORD-EM listserv to PDs with active EM programs. RESULTS: Fifty percent (77/154) of eligible PDs responded to the survey. Most PDs rated the unprofessional behaviors of interpersonal/communication conflicts, lack of responsibility during patient care, lack of respect of coworkers, and reports of impairment as "critical"; repeated tardiness, incomplete work, poor ability to accept feedback, poor attitude, and repetitive unresponsiveness to aid colleagues were rated as "very serious"; frequent missed deadlines were "serious"; and repetitive failure to complete medical records was rated as "mildly serious." A resident with "less serious" professionalism issues was also felt to be likely to have "serious" or "critical" issues "often" (33.8% of respondents) or "always" (6.5%). The most common methods of assessment were clinical/advisor evaluations. However, existing assessment methods were described as inadequate in identifying serious professionalism issues by 50.7% of responding PDs. Unprofessionalism was most commonly discovered by unofficial faculty complaint (54.5%). Eighty percent report that professionalism is more difficult to remediate than other core competencies. Resident ownership of the problem was reported as most critical to remediation success (84.4%). PDs perceived the greatest challenges in residency remediation to be lack of resident insight or responsibility for the problem (45.2%) and personality/behavioral issues (32.9%). CONCLUSIONS: Identification and remediation of professionalism in EM residents is challenging. A future goal is to create a system by which PDs can use standardized pathways as a guide to identify and remediate unprofessional conduct.

Guiding principles for resident remediation: recommendations of the CORD remediation task force.

Remediation of residents is a common problem and requires organized, goal-directed efforts to solve. The Council of Emergency Medicine Residency Directors (CORD) has created a task force to identify best practices for remediation and to develop guidelines for resident remediation. Faculty members of CORD volunteered to participate in periodic meetings, organized discussions and literature reviews to develop overall guidelines for resident remediation and in a collaborative authorship of this article identifying best practices for remediation. The task force recommends that residency programs: 1. Make efforts to understand the challenges of remediation, and recognize that the goal is successful correction of deficits, but that some deficits are not remediable. 2. Make efforts aimed at early identification of residents requiring remediation. 3. Create objective, achievable goals for remediation and maintain strict adherence to the terms of those plans, including planning for resolution when setting goals for remediation. 4. Involve the institution's Graduate Medical Education Committee (GMEC) early in remediation to assist with planning, obtaining resources, and documentation. 5. Involve appropriate faculty and educate those faculty into the role and terms of the specific remediation plan. 6. Ensure appropriate documentation of all stages of remediation. Resident remediation is frequently necessary and specific steps may be taken to justify, document, facilitate, and objectify the remediation process. Best practices for each step are identified and reported by the task force.

Rapidly fatal infections.

Emergency physicians are trained to separate "sick" from "not sick" patients during their training. Nevertheless, every emergency physician will face situations in which early intervention is critical to their patient's outcome. Infectious diseases are responsible for many of these potentially poor outcomes. This article discusses early identification and treatment for several rapidly fatal infections, including two newly identified travel-related illnesses.

Depression among emergency medicine residents over an academic year.

OBJECTIVES: To describe the frequency of depression among emergency medicine (EM) residents by month, gender, rotation type, postgraduate year (PGY), and number of hours worked. METHODS: This was a prospective, nonblinded, cohort study of consenting EM residents in a four-year, 51-resident EM residency program from July 2003 to June 2004. Participants received an anonymous monthly survey via Web site that consisted of the Center for Epidemiologic Studies Depression Scale (CESD) and the resident's gender, PGY, number of hours worked in the previous week (< or =40, 41-60, 61-80 and >80), and rotation type (EM, intensive care unit, non-EM clinical, or other). Residents were excluded from analysis if they did not complete at least one survey during each season. For each resident, the peak score for each three-month period was recorded and analyzed with a mixed-model analysis of variance to account for a repeated-measures effect. RESULTS: Fifty of 51 (98.0%) residents consented for participation. Nineteen (38%) were excluded because of incomplete data. The prevalence of depression was 12.1% (95% confidence interval [95% CI] = 7.5% to 19.0%; 15 of 124 scores). The women had numerically, but not statistically, significantly lower mean +/- standard deviation CESD scores than the men (6.4 +/- 6.8 vs. 8.7 +/- 8.6, p = 1.0). There was no significant difference in mean CESD score by month, PGY, rotation type, or number of hours worked. CONCLUSIONS: Season, number of hours worked, rotation type, PGY, and gender all failed to predict depression among EM residents in this single-center trial. The prevalence of depression was comparable to that of the general population.

Identifying inaccuracies on emergency medicine residency applications.

BACKGROUND: Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. METHODS: This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. RESULTS: Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6-14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2-12.4%), contained at least one error. 41% (95% CI 35.0-47.0%) of all publications contained an error. All AOA membership claims were verified, but 13.7% (95%CI 4.4-23.1%) of claimed advanced degrees were inaccurate. Inter-rater reliability of evaluations was good. Investigators were reluctant to notify applicants' dean's offices and the NRMP. CONCLUSION: This is the largest study to date of accuracy on application for residency and the first such multi-centered trial. High rates of incorrect data were found on applications. This data will serve as a baseline for future years of the project, with emphasis on reporting inaccuracies and warning applicants of the project's goals.

Inaccuracies on applications for emergency medicine residency training.

OBJECTIVES: Studies have shown erroneous claims of authorship by medical students applying for residency. Authors have hypothesized that investigation of advanced degrees, Alpha Omega Alpha (AOA) status, and peer-reviewed publications all show important rates of inaccuracy. METHODS: A retrospective review of all applicants offered an interview for the authors' emergency medicine (EM) residency (entering class of 2002), excluding foreign medical graduates and current residents, was conducted. After verifying peer-reviewed publications by MEDLINE search and journal review, errors were tabulated as follows: reference not found, not referenced as an abstract, incorrect author list, or clerical error. AOA status was verified by the AOA organization. Advanced degrees were verified by the awarding institutions. RESULTS: Of 194 applications screened (58.3% of applications), 21 (10.8%) were excluded (9 foreign medical graduates, 12 current residents). Multiple inaccuracies on a single application were counted separately. Of the 173 remaining applications, 23 (13.3%; 95% confidence interval [95% CI] = 8.8% to 19.5%) had at least one misrepresentation and seven of 173 (4.0%; 95% CI = 1.8% to 8.5%) had two or more. Authorship of at least one peer-reviewed article was claimed by 47 of 173 (27.2%), with ten of 47 (21.3%; 95% CI = 11.2% to 36.1%) having one inaccuracy and six of 47 (12.8%, 95% CI = 5.3% to 26.4%) having two or more. AOA membership was claimed by 14 applicants (8.1%), but five claims (35.7%, 95% CI = 14.0% to 64.4%) were inaccurate. Advanced degrees were claimed by 15 (8.7%); four (26.7%, 95% CI = 8.9% to 55.2%) were in error. CONCLUSIONS: Applications for EM residency contain frequent inaccuracies in publications listed, AOA status, and advanced degrees. Careful review of applications is necessary to ensure appropriate credit is given for claims of these types.

Predictors of outcome in geriatric patients with urinary tract infections.

A study was conducted to determine the prognosis of geriatric patients with urinary tract infections (UTIs) and identify clinical factors associated with adverse outcomes. This retrospective, cohort study identified elderly patients (age > or =65 years) presenting to an academic, urban Emergency Department (ED) during a 16-week period with UTI, suggested by urinalysis and pertinent symptoms. There were 37 demographic and clinical variables analyzed as potential predictors of outcome. Morbidity was defined as in-hospital death, Intensive Care Unit (ICU) admission, hospital length of stay (LOS) >2 days, or hospital intravenous (i.v.) antibiotics >2 days. Factors identified by univariate analysis were combined using multiple logistic regression to identify independent predictors of morbidity. There were 284 patients who met selection criteria. Thirteen patients (4.6%) died during hospitalization and 27 (9.5%) had ICU admission, 139 (48.9%) had LOS >2 days, and 75 (26.4%) had i.v. antibiotics >2 days. Multivariate analysis identified the following variables as independent predictors of adverse outcomes: mental status change, frequent UTIs, other nonurinary infections, abnormal temperature, tachycardia, hypotension, elevated BUN, hyperglycemia, elevated WBC, and relative neutrophilia. Regression models for adverse outcomes had sensitivities from 74.8% to 96.2% and specificities from 31.1% to 69.0%. In conclusion, this study defines high rates of morbidity for geriatric patients with UTIs and describes predictive variables that may help identify low-risk patients. These data may lay the foundation for determining specific guidelines for disposition of this high-risk patient population.

Careers of graduates of combined emergency medicine/internal medicine programs.

UNLABELLED: In 1991, the American Boards of Internal Medicine and Emergency Medicine changed their credentialing requirements to recognize training common to both disciplines. This allowed the formation of a five-year track for dual board eligibility. From 1995 to 1998, 28 physicians graduated from eight emergency medicine/internal medicine (EM/IM) programs. This study was an analysis of career outcomes of these graduates. OBJECTIVES: To document career outcomes of EM/IM program graduates, establish a baseline for future studies of EM/IM graduates, and elucidate the role of EM/IM graduates in medicine. METHODS: The 28 EM/IM graduates were mailed a written questionnaire. Endpoints assessed included practice fields, practice environments, ongoing research, publications, academic appointments, board examination scores, career satisfaction, and career goals. RESULTS: Surveys were obtained from 23 of 28 (82.1%) graduates. Seven (30.4%) practice EM and IM, 15 (65.2%) practice EM exclusively, and one (4.3%) practices IM exclusively. Twelve (52.2%) are involved in research. The graduates authored a total of 30 papers or chapters. Ten (43.5%) currently work in administrative positions, but many more aspire to. The most common reasons for having chosen an EM/IM program are to be a better physician (22/23, 95.7%), to practice in both fields (15/23, 65.2%), and to become better prepared for an academic career (15/23, 65.2%). The EM/IM graduates reported high career satisfaction. CONCLUSIONS: Although the majority of EM/IM graduates do not practice both IM and EM, many would prefer to. The graduates are highly satisfied with their choice of residency and career. Early in career development, the graduates appear to gravitate toward academic and leadership positions.