Harnessing the Power of Generative AI for Clinical Summaries: Perspectives From Emergency Physicians.

STUDY OBJECTIVE: The workload of clinical documentation contributes to health care costs and professional burnout. The advent of generative artificial intelligence language models presents a promising solution. The perspective of clinicians may contribute to effective and responsible implementation of such tools. This study sought to evaluate 3 uses for generative artificial intelligence for clinical documentation in pediatric emergency medicine, measuring time savings, effort reduction, and physician attitudes and identifying potential risks and barriers. METHODS: This mixed-methods study was performed with 10 pediatric emergency medicine attending physicians from a single pediatric emergency department. Participants were asked to write a supervisory note for 4 clinical scenarios, with varying levels of complexity, twice without any assistance and twice with the assistance of ChatGPT Version 4.0. Participants evaluated 2 additional ChatGPT-generated clinical summaries: a structured handoff and a visit summary for a family written at an 8th grade reading level. Finally, a semistructured interview was performed to assess physicians' perspective on the use of ChatGPT in pediatric emergency medicine. Main outcomes and measures included between subjects' comparisons of the effort and time taken to complete the supervisory note with and without ChatGPT assistance. Effort was measured using a self-reported Likert scale of 0 to 10. Physicians' scoring of and attitude toward the ChatGPT-generated summaries were measured using a 0 to 10 Likert scale and open-ended questions. Summaries were scored for completeness, accuracy, efficiency, readability, and overall satisfaction. A thematic analysis was performed to analyze the content of the open-ended questions and to identify key themes. RESULTS: ChatGPT yielded a 40% reduction in time and a 33% decrease in effort for supervisory notes in intricate cases, with no discernible effect on simpler notes. ChatGPT-generated summaries for structured handoffs and family letters were highly rated, ranging from 7.0 to 9.0 out of 10, and most participants favored their inclusion in clinical practice. However, there were several critical reservations, out of which a set of general recommendations for applying ChatGPT to clinical summaries was formulated. CONCLUSION: Pediatric emergency medicine attendings in our study perceived that ChatGPT can deliver high-quality summaries while saving time and effort in many scenarios, but not all.

Clinical Nurse Specialist Role Advocacy: Quantifying the Financial Contributions Via Development of a Scorecard.

PURPOSE/OBJECTIVES: The purpose of this article is to guide the clinical nurse specialist in constructing a scorecard to track clinical outcomes and identify the associated financial impact. DESCRIPTION OF THE PROJECT/PROGRAM: Creation of a scorecard highlighting the financial impact of the clinical nurse specialist team was used to disseminate financial outcomes to hospital executive stakeholders, allowing the clinical nurse specialist team to demonstrate its clinical and financial value. OUTCOME: During development and ongoing maintenance of the scorecard, the clinical nurse specialist team cultivated skills to identify the financial impact of projects. The team also utilized financial implications of individual and group projects to prioritize work. At the end of fiscal year 2022, the clinical nurse specialist team demonstrated revenue generation of $29 890 and cost avoidance of $2 854 807.30. The clinical nurse specialist scorecard was presented quarterly to the chief nursing officer, who shared with executive leadership. CONCLUSION: Clinical nurse specialists are positioned to make significant and positive financial impact to organizations. A scorecard presented to executive leadership offers a clinical nurse specialist team a tool to capture and disseminate a clinical nurse specialist team's unique financial contribution at the system level.

Near Complete Response to Platinum-based Systemic Chemotherapy in High-risk Upper Tract Urothelial Carcinoma With an ERBB2 Gene Mutation: A Case Report.

In bladder urothelial carcinoma, ERBB2 mutations have been associated with favorable response to platinum-based neoadjuvant chemotherapy. However, this association has not been reported in upper tract urothelial carcinoma (UTUC). We describe an excellent response to cisplatin-based chemotherapy in metastatic UTUC with an ERBB2 mutation. Our patient is a 54-year-old female with metastatic UTUC who received systemic cisplatin and gemcitabine. Postchemotherapy imaging demonstrated decreased size of pyelocaliceal mass and decreased retroperitoneal adenopathy compared to initial imaging. Surgical pathology from consolidative resection showed 3 mm residual renal tumor and no viable lymph node disease. Genomic testing demonstrated an ERBB2 gain of function mutation.

Embedding Interprofessional Education in Clinical Settings: Medical and Dental Student Perceptions of a Patient Interview-Storytelling Experience.

PROBLEM: Interprofessional education (IPE) is valued but difficult to deliver, given logistical and other barriers. Centering IPE around patients and grounding it in authentic practice settings are challenging within early undergraduate medical education. APPROACH: This intervention facilitated student-patient conversations to elicit patient reflections on the health care professionals who keep them healthy and care for them when they are unwell. After being introduced to the Interprofessional Education Collaborative (IPEC) core competencies, first-year medical (n = 127) and dental (n = 34) students conducted a brief semistructured patient interview, using an interview card with guiding questions, during a precepted outpatient clinic session in March-May 2021. Students transcribed patients' stories and wrote their own reflections on the interview card. These reflections were used as a stimulus for a class IPE discussion. The authors employed a pragmatic qualitative research approach to explore what students learned about interprofessional collaboration from reflecting on patients' stories. OUTCOMES: Of the 161 students, 158 (98%) completed an interview card. Sixteen health professions were represented in patients' stories. The patients' stories prompted students to recognize and expand their understanding of the IPEC competencies. Students' responses reflected synthesis of the competencies into 3 themes: students value patient-centered holistic care as the goal of interprofessional collaboration; students reflect emerging professional and interprofessional identities in relating to patients, teams, and systems; and students appreciate interprofessional care is complex and challenging, requiring sustained effort and commitment. NEXT STEPS: Next steps include continuing to integrate patient voices through structured conversations across the undergraduate and graduate medical education spectrum and adapting the model to support conversations with other health professionals engaged in shared patient care. These experiences could foster ongoing deliberate reflection by students on their professional and interprofessional identity development but would require investments in student time and faculty development.

Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where.

Objectives: Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions. Methods: This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods. Results: Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods. Conclusions: Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.

It Takes a Village: Optimal Graduate Medical Education Requires a Deliberately Developmental Organization.

Coaching is proposed as a means of improving the learning culture of medicine. By fostering trusting teacher-learner relationships, learners are encouraged to embrace feedback and make the most of failure. This paper posits that a cultural shift is necessary to fully harness the potential of coaching in graduate medical education. We introduce the deliberately developmental organization framework, a conceptual model focusing on three core dimensions: developmental communities, developmental aspirations, and developmental practices. These dimensions broaden the scope of coaching interactions. Implementing this organizational change within graduate medical education might be challenging, yet we argue that embracing deliberately developmental principles can embed coaching into everyday interactions and foster a culture in which discussing failure to maximize learning becomes acceptable. By applying the dimensions of developmental communities, aspirations, and practices, we present a six-principle roadmap towards transforming graduate medical education training programs into deliberately developmental organizations.

High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence.

BACKGROUND: Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS: We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS: Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS: In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.

Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation.

Background: Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods: Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results: Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions: This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.

Management of the Difficult Airway.

ABSTRACT: Airway management is a fundamental component of care during resuscitation of critically ill and injured children. In addition to predicted anatomic and physiologic differences in children compared with adults, certain conditions can predict potential difficulty during pediatric airway management. This review presents approaches to identifying pediatric patients in whom airway management is more likely to be difficult, and discusses strategies to address such challenges. These strategies include optimization of effective bag-mask ventilation, alternative approaches to laryngoscopy, use of adjunct airway devices, modifications to rapid sequence intubation, and performance of surgical airways in children. The importance of considering systems of care in preparing for potentially difficult pediatric airways is also discussed.

Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach.

BACKGROUND: Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking. METHODS: A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation. RESULTS: All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist. CONCLUSIONS: Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.

Symptomatic and Histological Tissue Reaction to Upper Eyelid Platinum Weight.

OBJECTIVES: To present a case of non-infectious platinum eyelid weight rejection, the first reported case in otolaryngology literature. METHODS: A case of a non-infectious tissue reaction to a platinum eyelid weight was identified. RESULTS: A platinum eyelid weight was placed in a 72-year-old female for paralytic lagophthalmos. The patient presented with persistent edema and skin discoloration on post-operative day 8, though no drainage, tenderness, or other signs of infection were present. The weight was eventually explanted with rapid resolution of symptoms. Pathology demonstrated granulomatous inflammation with histiocytosis and foreign-body giant cells, consistent with tissue reaction to the platinum weight. CONCLUSIONS: Platinum eyelid weights are commonly used to treat paralytic lagophthalmos. While non-infectious tissue reactions to platinum are less common than with gold weights, they are still possible and should be treated with weight removal.

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes.

STUDY OBJECTIVE: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.

Childbearing and Family Leave Policies for Physicians at US Children's Hospitals.

The objective of this study was to examine the childbirth and parental leave policies for physicians at children's hospitals. We obtained institutional policies from 15 hospitals in 2021. The median duration of full salaried leave was 8 weeks (range, 2-12 weeks). Leave policies vary widely among US children's hospitals.

Two-dimensional liquid chromatography-mass spectrometry for lipidomics using off-line coupling of hydrophilic interaction liquid chromatography with 50 cm long reversed phase capillary columns.

Comprehensive characterization of the lipidome remains a challenge requiring development of new analytical approaches to expand lipid coverage in complex samples. In this work, offline two-dimensional liquid chromatography-mass spectrometry was investigated for lipidomics from human plasma. Hydrophilic interaction liquid chromatography was implemented in the first dimension to fractionate lipid classes. Nine fractions were collected and subjected to a second-dimension separation utilizing 50 cm capillary columns packed with 1.7 µm C18 particles operated on custom-built instrumentation at 35 kpsi. Online coupling with time-of-flight mass spectrometry allowed putative lipid identification from precursor-mass based library searching. The method had good orthogonality (fractional coverage of ∼40%), achieved a peak capacity of approximately 1900 in 600 min, and detected over 1000 lipids from a 5 µL injection of a human plasma extract while consuming less than 3 mL of solvent. The results demonstrate the expected gains in peak capacity when employing long columns and two-dimensional separations and illustrate practical approaches for improving lipidome coverage from complex biological samples.

Marine heat waves drive bleaching and necrosis of temperate sponges.

Marine heat waves (MHWs) are extended periods of excessively warm water1 that are increasing in frequency, duration, intensity, and impact, and they likely represent a greater threat to marine ecosystems than the more gradual increases in sea surface temperature.2,3,4 Sponges are major and important components of global benthic marine communities,5,6,7 with earlier studies identifying tropical sponges as potential climate change "winners."8,9,10,11 In contrast, cold-water sponges may be less tolerant to predicted ocean warming and concurrent MHWs. Here, we report how a series of unprecedented MHWs in New Zealand have impacted millions of sponges at a spatial scale far greater than previously reported anywhere in the world. We reported sponge tissue necrosis12 and bleaching (symbiont loss/dysfunction),13 which have been previously associated with temperature stress,6,12,14 for three common sponge species across multiple biogeographical regions, with the severity of impact being correlated with MHW intensity. Given the ecological importance of sponges,15 their loss from these rocky temperate reefs will likely have important ecosystem-level consequences.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine.

Background: Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. Methods: This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. Results: There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. Conclusions: The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Improved Tandem Mass Spectrometry Detection and Resolution of Low Molecular Weight Perfluoroalkyl Ether Carboxylic Acid Isomers.

Per- and polyfluoroalkyl substances (PFAS) are emerging contaminants widely used in a variety of industrial and consumer applications. Due to phasing out legacy PFAS, some manufacturers developed short-chain alternatives like perfluoroalkyl ether carboxylic acids (PFECA). Published liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods cover a wide range of these replacement chemicals including PFMPA (perfluoro-3-methoxypropanoic acid) and PFMBA (perfluoro-4-methoxybutanoic acid). However, many methods do not monitor for their branched isomers, PMPA (perfluoro-2-methoxypropanoic acid) and PEPA (perfluoro-2-ethoxypropanoic acid), respectively. Although these isomers are chromatographically separable under certain conditions, using the common MS/MS transitions for PFMPA (m/z 229 → 85) and PFMBA (m/z 279 → 85) can yield low or no detection signals for PMPA and PEPA, thus leading to underestimated values or nondetects. We compared various MS/MS transitions for these isomers and determined the optimal transitions for PMPA (m/z 185 → 85) and PEPA (m/z 235 → 135). We applied the developed method to water sampled near two chemical manufacturing plants and observed these analytes, plus a suspected third isomer. Using these MS/MS transitions will ensure all isomers are detected and will lead to better monitoring and exposure estimates of PFECA in humans and the environment.

Hydrolytically Stable Ionic Fluorogels for High-Performance Remediation of Per- and Polyfluoroalkyl Substances (PFAS) from Natural Water.

PFAS are known bioaccumulative and persistent chemicals which pollute natural waters globally. There exists a lack of granular sorbents to efficiently remove both legacy and emerging PFAS at environmentally relevant concentrations. Herein, we report a class of polymer networks with a synergistic combination of ionic and fluorous components that serve as granular materials for the removal of anionic PFAS from water. A library of Ionic Fluorogels (IFs) with systematic variation in charge density and polymer network architecture was synthesized from hydrolytically stable fluorous building blocks. The IFs were demonstrated as effective sorbents for the removal of 21 legacy and emerging PFAS from a natural water and were regenerable over multiple cycles of reuse. Comparison of one IF to a commercial ion exchange resin in mini-rapid small-scale column tests demonstrated superior performance for the removal of short-chain PFAS from natural water under operationally relevant conditions.