Defining well-being: A case-study among emergency medicine residents at an academic center: A qualitative study.

BACKGROUND: Healthcare-associated burnout is linked to reduced quality of care, decreased patient experience, and higher cost. The National Academy of Medicine has emphasized the importance of supporting clinician well-being across healthcare; however, well-being is poorly defined, especially early in emergency medicine training. OBJECTIVES: The primary objective of this study was to explore and understand the attitudes, beliefs, and perspectives of emergency medicine (EM) resident physicians surrounding well-being. A secondary objective was to identify priority areas of focus to promote a culture of well-being for EM trainees. APPROACH: We conducted semi-structured focus groups of EM resident physicians at an urban, academic institution with a 4-year training curriculum. Focus group interviews were transcribed and constructivist aggregated themes were identified using content analysis with a constant comparative coding approach. RESULTS: Seventeen EM residents participated in semi-structured qualitative focus groups (PGY1 = 6, PGY2 = 6, PGY3 = 2, PGY4 = 3). Six key themes related to well-being emerged spanning clinical and nonclinical areas: (1) a focus on basic needs being met, (2) on-shift operational structure, (3) individual feedback, (4) feeling valued for clinical contributions, (5) a sense of community within the clinical environment, and (6) a sense of personal ownership over time. CONCLUSIONS: Shifting the focus for medical trainees away from mitigating burnout and toward proactively promoting well-being is important. Understanding the perspectives and key themes in how EM residents define well-being can help support trainees early in their careers. Using qualitative methods, this study identified six key themes that can guide trainees, educational leaders, and academic hospital systems as they work toward building a culture of well-being early in graduate medical education.

The Impact of the Parenteral Opioid Medication Shortages on Opioid Utilization Practices in the Emergency Department of Two University Hospitals.

INTRODUCTION: Both opioid and non-opioid analgesics are commonly utilized in treating acute and chronic pain in the emergency department (ED). Opioid stewardship efforts have focused on judicious opioid use and opioid alternatives as first-line analgesics. Parenteral opioid formulations have been impacted by periodic shortages creating the opportunity for a natural experiment to observe how emergency clinician prescribing behavior may be impacted. We investigated the change in analgesic practice related to a period of parenteral opioid shortage at two large urban, academic medical centers. METHODS: A retrospective review of pharmacy administration data from two academic urban EDs was performed looking at time periods before, during, and after resolution of the parenteral opioid shortage. The data were analyzed by medication, dose, time, number of doses, and oral morphine milligram equivalents (MME) administered per patient. RESULTS: The percentage of patients who received any opioid among ED visits decreased during the shortage period and did not return to pre-shortage levels after the shortage ended: 11.5% pre, 8.5% during (p=0.01), 7.2% post (NS; p=0.18). The number of doses of either oral or IV opioid doses administered during the shortage decreased significantly: 8.7% pre, 5.6% during (p=0.02) for PO, and 13.7% pre, 9.0% during (p=0.004) for IV, and neither changed during recovery from the shortage. The percentage of patients receiving non-opioid analgesics rose from 30.5% before to 45.8% (p=0.004) after the shortage. Among patients who received opioids, the MME per patient did not change across the time periods: 11.5% before, 11.2% during, 12.7% post. CONCLUSIONS: A period of restricted opioid use due to parenteral opioid shortages led to less opioid use overall and fewer patients treated with opioids, yet no significant change in opioid MME administered per patient requiring opioids. Overall, the shift in opioid prescribing during the parenteral opioid shortage appeared to be sustained in the post-shortage period.

Good agreement between endoscopic findings and biopsy reports supports limited tissue sampling during pediatric colonoscopy.

OBJECTIVES: Colonoscopy in children routinely includes the practice of obtaining multiple biopsy samples even in the absence of gross mucosal abnormalities. The aim of our investigation was to examine the level of agreement between endoscopic and histological findings during pediatric colonoscopy. We also investigated the predictors of agreement and abnormal histology. METHODS: We performed an institutionally approved retrospective review of consecutive patients who underwent diagnostic colonoscopy during a 6-month period. Descriptive analyses and regression models were used to determine agreement rates, as well as potential predictors of both agreement and abnormal histology. RESULTS: Of 390 included colonoscopies, endoscopists (n = 26) reported abnormal gross findings in 218 (56%) and pathologists (n = 4) found histopathology in 195 (50%). Considering histology as the criterion standard, endoscopy had a sensitivity of 90% and a specificity of 78%. Reports of grossly normal endoscopic findings were highly associated with agreement (odds ratio [OR] 1.9, P = 0.001). A known diagnosis of inflammatory bowel disease was a strong predictor of abnormal histology (OR 6.4, P < 0.0001). Abdominal pain as a procedural indication was a strong predictor for normal histology (OR 0.4, P < 0.0001). CONCLUSIONS: The results of our study suggest good agreement between endoscopic and histological findings, especially when an endoscopist reports normal-appearing colonic mucosa. We identified predictors of abnormal histology to include known inflammatory bowel disease, whereas abdominal pain was found to be a negative predictor. Future studies are needed to determine evidence-based protocols for obtaining biopsies during colonoscopy in children.

Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement.

OBJECTIVES: Little is known about long-term outcomes of patients undergoing percutaneous endoscopic gastrostomy (PEG) placement. The purpose of this study was to examine tube-related major complications in pediatric patients undergoing PEG placement during a 10-year follow-up period. METHODS: A retrospective chart review of patients undergoing PEG placement from April 1999 through December 2000 at Boston Children's Hospital was performed. Cumulative incident rates of major complications (defined by additional hospitalization, surgical or interventional radiology procedures) as well as time between PEG placement and major complications were evaluated using Kaplan-Meier survival analysis. Time to elective tube removal and patient mortality was also assessed. RESULTS: One hundred thirty-eight patients (59% [n = 82] boys [median age 22.5 months] [interquartile range, IQR 9-72.5], weight 9.2 kg [IQR 6.1-15.8]), underwent PEG placement during the study period and were followed at our hospital for a median of 4.98 years (IQR 1.5-8.7) years. Median time to elective tube removal was 10.2 years, with approximately half of the patients estimated to still have an indwelling enteral tube 10 years after placement. Fifteen patients (11%) had at least 1 major complication related to their gastrostomy tubes during the examined time period. The cumulative incidence of patients having a major complication was 15% (95% confidence interval 8.9-24.5) by 5.4 years. CONCLUSIONS: Children undergoing PEG placement have a long-term high risk of morbidity related to enteral tubes. Major complications can occur many years after PEG placement. Larger prospective studies may be useful to assess risk factors for PEG-related complications in pediatrics.