An ultrashort video can teach residents to perform a fingertip injury repair.

BACKGROUND: Acute fingertip injuries are common. Providers in rural and underserved areas often transfer these patients due to lack of comfort and skill with treating these injuries. Current learners prefer short and high-density educational material. It is unknown if basic hand procedures can be taught using ultrashort training videos. This study investigates whether fingertip repair can be taught using a 60-second educational video viewed immediately prior to performing the procedure. METHODS: A standardized cadaveric fingertip injury model was developed. Twenty-three emergency medicine residents each having minimal experience with fingertip injury repair were randomized into one of three study arms: A) no video, B) standard-length (8-minute) video, and C) ultrashort (60-second) video. Each subject was presented with an injured cadaveric finger and asked to prepare for and perform the repair within a 30-minute time frame. The repair was graded on a 10-point scale following a standard rubric. Time to completion, preparedness, and subjects' confidence were also assessed. Results were analyzed by one-way ANOVA and Kruskal-Wallis tests. RESULTS: Mean repair scores for the standard-length video group (9.5 ± 0.3) and the ultrashort video group (9.2 ± 0.3) were significantly higher than those of the no video group (4.0 ± 0.3, p < 0.05 for both comparisons). Mean time to completion of the exercise was significantly shorter in the ultrashort video group (19 ± 2 minutes) than in the standard-length video group (26 ± 2 minutes). Subject-reported outcomes (median preparedness, median post-repair confidence, and median change in confidence following the procedure) were all significantly higher in the standard-length video group and the ultrashort video group than in the no video group (p < 0.05 for all comparisons). CONCLUSION: A 60-second educational video viewed immediately prior to performing a fingertip injury repair can effectively teach an emergency medicine resident to correctly perform the procedure.

Using a human factors-centric approach to development and testing of a face shield designed for health care workers: A COVID-19 case study for process and outcomes.

BACKGROUND: Face shields are a critical piece of personal protective equipment and their comfort impacts compliant use and thus protectiveness. Optimal design criteria for face shield use in healthcare environments are limited. We attempt to identify factors affecting face shield usability and to test and optimize a face shield for comfort and function in health care settings. METHODS: A broad range of workers in a large health care system were surveyed regarding face shield features and usability. Quantitative and qualitative analysis informed the development of iterative prototypes which were tested against existing shields. Iterative testing and redesign utilized expert insight and feedback from participant focus groups to inform subsequent prototype designs. RESULTS: From 1,648 responses, 6 key elements were identified: ability to adjust tension, shifting load bearing from the temples, anti-fogging, ventilation, freedom of movement, and durability. Iterative prototypes received consistently excellent feedback based on use in the clinical environment, demonstrating incremental improvement. CONCLUSION: We defined elements of face shield design necessary for usability in health care and produced a highly functional face shield that satisfies frontline provider criteria and Emergency Use Authorization standards set by the Food and Drug Administration. Integrating human factors principles into rapid-cycle prototyping for personal protective equipment is feasible and valuable.

Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging.

OBJECTIVE: Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED). METHODS: Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education. RESULTS: We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics. CONCLUSION: Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.

A comparison of the effect of weather and climate on emergency department visitation in Roanoke and Charlottesville, Virginia.

Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.

Eagle Syndrome: A Rare Case of Atraumatic, Painful Cervical Neck Swelling.

INTRODUCTION: Painful neck swelling is a common emergency complaint but can present diagnostic challenges. Eagle syndrome is a rare clinical entity in which a pathologically elongated styloid process or ossified stylohyoid ligament produces a constellation of symptoms in the head and neck region. CASE REPORT: We present the case of a 50-year-old male with a spontaneous, atraumatic fracture of an elongated styloid process associated with hematoma formation and radiological findings of airway impingement. DISCUSSION: The classic triad for Eagle syndrome consists of unilateral cervicofacial pain, globus sensation, and dysphagia. Diagnosis of Eagle syndrome should be made based on a combination of physical examination and radiological findings. Treatment options vary based on severity of symptoms. CONCLUSION: Although more likely to be an indolent and progressive complaint, providers in the acute care setting should be familiar with Eagle syndrome due to the potential for a spontaneous fracture of an elongated styloid process to cause acute, painful neck swelling and life-threatening airway compromise.

Normal saline versus Normosol™-R in sepsis resuscitation: A retrospective cohort study.

OBJECTIVE: To determine the effect of Normosol™-R as compared to normal saline on the outcomes of acute kidney injury and the need for renal replacement therapy in the resuscitation phase of sepsis. DESIGN: Our study is a retrospective before-and-after cohort study. SETTING: The study occurred at a 700-bed tertiary academic level 1-trauma center. PATIENTS: A total of 1218 patients were enrolled through emergency department admissions. The normal saline (before) cohort was defined as the dates between 1 March and 30 September 2014 and the Normosol™-R (after) cohort was assessed from 1 March to 30 September 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intravenous fluid volumes received during the first 24 h, 72 h, and total hospital stays were compared. Sodium, chloride, potassium, and bicarbonate levels at 72 h were also compared. The medical coded diagnosis of acute kidney failure, need for renal replacement therapy, hospital LOS, ICU admission, ICU LOS, in-hospital mortality, and need for mechanical ventilation were all compared. There was no significant difference in intravenous fluid volumes between groups. Regression modelling controlling for baseline characteristics and 24-h fluid intake volume found no differences between groups for the primary outcomes of acute kidney injury (P = 0.99) and renal replacement therapy (P = 0.88). Patients in the Normosol™-R cohort were found to have a lower rate of hyperchloremia at 72 h post-admission (28% vs. 13%, P < 0.0001). There was a trend toward a decrease in the hospital and ICU LOS in the Normosol™-R cohort; however, the data were not statistically significant. CONCLUSIONS: This study was unable to detect any difference in outcomes between sepsis patients who received intravenous fluid resuscitation with either a balanced crystalloid (Normosol™-R) or normal saline, except for a decreased rate of hyperchloremia.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

OBJECTIVE: We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging. METHODS: Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning. RESULTS: We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%). CONCLUSION: The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing. PRACTICE IMPLICATIONS: Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

Hemostatic Matrix (FloSeal) as Treatment for Urethral Crush Injury After Failure of Traditional Hemostatic Technique.

We report a case of traumatic arterial hemorrhage from the posterior urethral artery, refractory to traditional hemostatic technique, and successfully managed with intraurethral thrombin hemostatic matrix (FloSeal [Baxter Healthcare Corporation, Deerfield, Illinois, US]). We believe that this demonstrates a safe, effective therapy for urethral hemorrhage that may be accomplished by Emergency Physicians and may preclude the need for more invasive hemorrhage control strategies.

Advancing the Use of Administrative Data for Emergency Department Diagnostic Imaging Research.

Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions.

Trends in emergency department management of skin abscesses.

BACKGROUND: Abscess is a distinct skin and soft tissue infection (SSTI) requiring incision and drainage (I&D). Previous national surveys combined all SSTIs to estimate abscess and evaluate management. We hypothesized that antibiotic rates are declining in response to evidence that antibiotics are unnecessary for most SSTIs requiring I&D. METHODS: Emergency department (ED) patients included in the National Hospital Ambulatory Medical Care Survey from 2007-2010 with diagnosis codes for cutaneous abscess or SSTI were filtered using a procedure code for I&D available since 2007. The number of patients with SSTI, the percentage of patients receiving I&D, and the percentage of patients receiving antibiotics were determined. Antibiotics were characterized based on efficacy to methicillin-resistant Staphylococcus aureus (MRSA). RESULTS: ED visits for SSTI increased from 3.55 million (95% confidence interval [CI], 3.24 million-3.86 million) in 2007 to 4.21 million (95% CI, 3.89 million-4.55 million) in 2010. Incidences of I&D rose from 736,000 (95% CI, 602,000-869,000) to 1.48 million (95% CI, 1.30 million-1.65 million) and comprised 32.2% of SSTI visits over the 4 years. In 2007, 85.1% (95% CI, 82.6%-87.7%) of patients received antibiotics after I&D with no change over 4 years. In 2010, 15.5% (95% CI, 12.1%-18.7%) received ≥2 antibiotics. Commonly prescribed antibiotics were trimethoprim-sulfamethoxazole (mean, 50.4%) followed by cephalexin (mean, 17.2%) and clindamycin (mean, 16.3%). CONCLUSION: ED visits for SSTIs continue to rise. Despite mounting evidence, antibiotic use in SSTIs requiring I&D is high, and many patients receive multiple antibiotics, including drugs with no efficacy on MRSA.

Variation in use of all types of computed tomography by emergency physicians.

STUDY OBJECTIVES: Variation in computed tomography (CT) use between emergency medicine (EM) physicians may delineate appropriate or inappropriate use. We hypothesize that variation in all types of CT use exists between providers and their use in patients with common chief concerns. We determine EM physicians' variability in CT use of all types and whether high use in one area predicts use of other CT types. METHODS: This was a retrospective study of EM physicians practicing at an 800-bed tertiary level 1 trauma center over a 3.5-year period. Computed tomography rates by type and by patient chief concern were modeled for providers as a function of patient acuity, disposition, age, and time of day using logistic regression. RESULTS: Of 195 801 eligible visits, 44 724 visits resulted in at least 1 CT scan. The adjusted rate of CT ordering by providers was 23.8% of patient visits, ranging from 11.5% to 32.7% The upper quartile of providers was responsible for 78% of the CT scans ordered above the mean. There was a large variation in use of all types of CT and by chief concern. There was an 8-fold variation in use of CT abdomen in discharged patients. High head CT use by providers predicts high use in all other CT types. CONCLUSION: We demonstrate a dramatic variation in CT use among EM physicians in all types of CT and common chief concerns. Greater variation was present in patients who were discharged. Large deviation from the mean by a group of providers may suggest inappropriate use.