Evaluating Large Language Models for Drafting Emergency Department Discharge Summaries.

Importance: Large language models (LLMs) possess a range of capabilities which may be applied to the clinical domain, including text summarization. As ambient artificial intelligence scribes and other LLM-based tools begin to be deployed within healthcare settings, rigorous evaluations of the accuracy of these technologies are urgently needed. Objective: To investigate the performance of GPT-4 and GPT-3.5-turbo in generating Emergency Department (ED) discharge summaries and evaluate the prevalence and type of errors across each section of the discharge summary. Design: Cross-sectional study. Setting: University of California, San Francisco ED. Participants: We identified all adult ED visits from 2012 to 2023 with an ED clinician note. We randomly selected a sample of 100 ED visits for GPT-summarization. Exposure: We investigate the potential of two state-of-the-art LLMs, GPT-4 and GPT-3.5-turbo, to summarize the full ED clinician note into a discharge summary. Main Outcomes and Measures: GPT-3.5-turbo and GPT-4-generated discharge summaries were evaluated by two independent Emergency Medicine physician reviewers across three evaluation criteria: 1) Inaccuracy of GPT-summarized information; 2) Hallucination of information; 3) Omission of relevant clinical information. On identifying each error, reviewers were additionally asked to provide a brief explanation for their reasoning, which was manually classified into subgroups of errors. Results: From 202,059 eligible ED visits, we randomly sampled 100 for GPT-generated summarization and then expert-driven evaluation. In total, 33% of summaries generated by GPT-4 and 10% of those generated by GPT-3.5-turbo were entirely error-free across all evaluated domains. Summaries generated by GPT-4 were mostly accurate, with inaccuracies found in only 10% of cases, however, 42% of the summaries exhibited hallucinations and 47% omitted clinically relevant information. Inaccuracies and hallucinations were most commonly found in the Plan sections of GPT-generated summaries, while clinical omissions were concentrated in text describing patients' Physical Examination findings or History of Presenting Complaint. Conclusions and Relevance: In this cross-sectional study of 100 ED encounters, we found that LLMs could generate accurate discharge summaries, but were liable to hallucination and omission of clinically relevant information. A comprehensive understanding of the location and type of errors found in GPT-generated clinical text is important to facilitate clinician review of such content and prevent patient harm.

Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department.

BACKGROUND: Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline. METHODS: Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment. RESULTS: Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)). CONCLUSION: Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.

Pathophysiological and Pharmaceutical Considerations for Enhancing the Control of Sarcoptes scabiei in Wombats Through Improved Transdermal Drug Delivery.

Sarcoptic scabiei is an invasive parasitic mite that negatively impacts wombats, causing sarcoptic mange disease, characterized by alopecia, intense pruritus, hyperkeratosis, and eventual mortality. Evidence suggests that wombats may be unable to recovery from infection without the assistance of treatments. Transdermal drug delivery is considered the most ideal route of administration for in situ treatment in free-ranging wombats, as it is non-invasive and avoids the need to capture affected individuals. Although there are effective antiparasitic drugs available, an essential challenge is adequate administration of drugs and sufficient drug retention and absorption when delivered. This review will describe the implications of sarcoptic mange on the physiology of wombats as well as discuss the most widely used antiparasitic drugs to treat S. scabiei (ivermectin, moxidectin, and fluralaner). The prospects for improved absorption of these drugs will be addressed in the context of pathophysiological and pharmaceutical considerations influencing transdermal drug delivery in wombats with sarcoptic mange.

Utilizing Telemedicine in a Novel Approach to COVID-19 Management and Patient Experience in the Emergency Department.

Background: The COVID-19 crisis has highlighted telemedicine as a care delivery tool uniquely suited for a disaster pandemic. Introduction: With support from emergency department (ED) leadership, our institution rapidly deployed telemedicine in a novel approach to large-scale ED infectious disease management at NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCMC) and NewYork-Presbyterian/Lower Manhattan Hospital (NYP/LMH). Materials and Methods: Nineteen telemedicine carts were placed in COVID-19 isolation rooms to conserve personal protective equipment (PPE) and mitigate infectious risk for patients and providers by decreasing in-person exposures. Results: The teleisolation carts were used for 261 COVID-19 patient interactions from March to May 2020, with 79% of overall use in March. Our urban academic site (NYP/WCMC) had 173 of these cases, and the urban community hospital (NYP/LMH) had 88. This initiative increased provider/patient communication and attention to staff safety, improved palliative care and patient support services, lowered PPE consumption, and streamlined clinical workflows. The carts also increased patient comfort and reduced the psychological toll of isolation. Discussion: Deploying customized placement strategies in these two EDs maximized cart availability for isolation patients and demonstrates the utility of telemedicine in various ED settings. Conclusions: The successful introduction of this program in both academic and urban community hospitals suggests that widespread adoption of similar initiatives could improve safe ED evaluation of potentially infectious patients. In the longer term, our experience underscores the critical role of telemedicine in disaster preparedness planning, as building these capabilities in advance allows for the agile scaling needed to manage unforeseen catastrophic scenarios.

Health Insurance Surcharges For Tobacco Use Declined Among Small Employers In 2018.

Use of increased premiums for tobacco users in the small-group market fell to 4.1 percent in 2018 from 17.8 percent in 2017 and 16.2 percent in 2016. This decline, possibly due to increased government oversight, occurred without any significant change in the prevalence of tobacco cessation programs. Thus, fewer workers are subject to tobacco surcharges without being provided cessation resources.

A Multicenter Observational Cohort Study to Evaluate the Effects of Bisphosphonate Exposure on Bone Mineral Density and Other Health Outcomes in Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is characterized by low bone mass and bone fragility. Using data from a large cohort of individuals with OI from the Osteogenesis Imperfecta Foundation's linked clinical research centers, we examined the association between exposure to bisphosphonate (BPN) treatment (past or present) and lumbar spine (LS) areal bone mineral density (aBMD), fractures, scoliosis, and mobility. From 466 individuals, we obtained 1394 participant-age LS aBMD data points. Though all OI subtypes were examined, primary analyses were restricted to type I OI (OI-1). Using linear regression, we constructed expected OI-1 LS aBMD-for-age curves from the data from individuals who had never received BPN. LS aBMD in those who had been exposed to BPN was then compared with the computed expected aBMD. BPN exposure in preadolescent years (age <14 years) was associated with a LS aBMD that was 9% more than the expected computed values in BPN-naïve individuals (p < 0.01); however, such association was not observed across all ages. Exposure to i.v. BPN and treatment duration >2 years correlated with LS aBMD in preadolescent individuals. BPN exposure also had a significant association with non-aBMD clinical outcome variables. Logistic regression modeling predicted that with BPN exposure, a 1-year increase in age would be associated with an 8.2% decrease in fracture probability for preadolescent individuals with OI-1, compared with no decrease in individuals who had never received any BPN (p < 0.05). In preadolescent individuals with OI-1, a 0.1 g/cm2 increase in LS aBMD was associated with a 10.6% decrease in scoliosis probability, compared with a 46.8% increase in the BPN-naïve group (p < 0.01). For the same changes in age and LS aBMD in preadolescent individuals, BPN exposure was also associated with higher mobility scores (p < 0.01), demonstrating that BPN treatment may be associated with daily function. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs.

The Affordable Care Act (ACA) allowed employer plans in the small-group marketplace to charge tobacco users up to 50 percent more for premiums-known as tobacco surcharges-but only if the employer offered a tobacco cessation program and the employee in question failed to participate in it. Using 2016 survey data collected by the Henry J. Kaiser Family Foundation and Health Research and Educational Trust on 278 employers eligible for Small Business Health Options Program, we examined the prevalence of tobacco surcharges and tobacco cessation programs in the small-group market under this policy and found that 16.2 percent of small employers used tobacco surcharges. Overall, 47 percent of employers used tobacco surcharges but failed to offer tobacco cessation counseling. Wellness program prevalence was lower in states that allowed tobacco surcharges, and 10.8 percent of employers in these states were noncompliant with the ACA by charging tobacco users higher premiums without offering cessation programs. Efforts should be undertaken to improve the monitoring and enforcement of ACA tobacco rating rules.