Transfer Patient Imaging: Assessment of the Impact of Discrepancies Identified by Emergency Radiologists.

PURPOSE: Advanced imaging examinations of emergently transferred patients (ETPs) are overread to various degrees by receiving institutions. The practical clinical impact of these second opinions has not been studied in the past. The purpose of this study is to determine if emergency radiology overreads change emergency medicine decision making on ETPs in the emergency department (ED). METHODS: All CT and MRI examinations on patients transferred to a level I trauma center during calendar year 2018 were routinely overread by emergency radiologists and discrepancies with the outside report electronically flagged. All discrepant reports compared with the outside interpretations were reviewed by one of four emergency medicine physicians. Comparing the original and final reports, reviewers identified changes in patient management that could be attributed to the additional information contained in the final report. Changes in patient care were categorized as affecting ED management, disposition, follow-up, or consulting services. RESULTS: Over a 12-month period, 5,834 patients were accepted in transfer. Among 5,631 CT or MRI examinations with outside reports available, 669 examinations (12%) had at least one discrepancy in the corresponding outside report. In 219 examinations (33%), ED management was changed by discrepancies noted on the final report; patient disposition was affected in 84 (13%), outpatient follow-up in 54 (8%), and selection of consulting services in 411 (61%), and ED stay was extended in 544 (81%). Discrepant findings affected decision making in 613 of 669 of examinations (92%). CONCLUSION: Emergency radiology overreading of transferred patients' advanced imaging examinations provided actionable additional information to emergency medicine physicians in the care of 613 of 669 (92%) examinations with discrepant findings. This added value is worth the effort to design workflows to routinely overread CT and MRI examinations of ETPs.

Leveraging a health information exchange to examine the accuracy of self-report emergency department utilization data among hospitalized injury survivors.

BACKGROUND: Accurate acute care medical utilization history is an important outcome for clinicians and investigators concerned with improving trauma center care. The objective of this study was to examine the accuracy of self-report emergency department (ED) utilization compared with utilization obtained from the Emergency Department Information Exchange (EDIE) in admitted trauma surgery patients with comorbid mental health and substance use problems. METHODS: This is a retrospective cohort study of 169 injured patients admitted to the University of Washington's Harborview Level I Trauma Center. Patients had high levels of post-traumatic stress disorder and depressive symptoms, suicidal ideation and alcohol comorbidity. The investigation used EDIE, a novel health technology tool that collects information at the time a patient checks into any ED in Washington and other US states. Patterns of EDIE-documented visits were described, and the accuracy of injured patients' self-report visits was compared with EDIE-recorded visits during the course of the 12 months prior to the index trauma center admission. RESULTS: Overall, 45% of the sample (n=76) inaccurately recalled their ED visits during the past year, with 36 participants (21%) reporting less ED visits than EDIE indicated and 40 (24%) reporting more ED visits than EDIE indicated. Patients with histories of alcohol use problems and major psychiatric illness were more likely to either under-report or over-report ED health service use. DISCUSSION: Nearly half of all patients were unable to accurately recall ED visits in the previous 12 months compared with EDIE, with almost one-quarter of patients demonstrating high levels of disagreement. The improved accuracy and ease of use when compared with self-report make EDIE an important tool for both clinical and pragmatic trial longitudinal outcome assessments. Orchestrated investigative and policy efforts could further examine the benefits of introducing EDIE and other information exchanges into routine acute care clinical workflows. LEVEL OF EVIDENCE: II/III. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02274688.

Does team leader gender matter? A Bayesian reconciliation of leadership and patient care during trauma resuscitations.

OBJECTIVE: Team leadership facilitates teamwork and is important to patient care. It is unknown whether physician gender-based differences in team leadership exist. The objective of this study was to assess and compare team leadership and patient care in trauma resuscitations led by male and female physicians. METHODS: We performed a secondary analysis of data from a larger randomized controlled trial using video recordings of emergency department trauma resuscitations at a Level 1 trauma center from April 2016 to December 2017. Subjects included emergency medicine and surgery residents functioning as trauma team leaders. Eligible resuscitations included adult patients meeting institutional trauma activation criteria. Two video-recorded observations for each participant were coded for team leadership quality and patient care by 2 sets of raters. Raters were balanced with regard to gender and were blinded to study hypotheses. We used Bayesian regression to determine whether our data supported gender-based advantages in team leadership. RESULTS: A total of 60 participants and 120 video recorded observations were included. The modal relationship between gender and team leadership (ß = 0.94, 95% highest density interval [HDI], -.68 to 2.52) and gender and patient care (ß = 2.42, 95% HDI, -2.03 to 6.78) revealed a weak positive effect for female leaders on both outcomes. Gender-based advantages to team leadership and clinical care were not conclusively supported or refuted, with the exception of rejecting a strong male advantage to team leadership. CONCLUSIONS: We prospectively measured team leadership and clinical care during patient care. Our findings do not support differences in trauma resuscitation team leadership or clinical care based on the gender of the team leader.

Predicting 30-day return hospital admissions in patients with COVID-19 discharged from the emergency department: A national retrospective cohort study.

OBJECTIVES: Identification of patients with coronavirus disease 2019 (COVID-19) at risk for deterioration after discharge from the emergency department (ED) remains a clinical challenge. Our objective was to develop a prediction model that identifies patients with COVID-19 at risk for return and hospital admission within 30 days of ED discharge. METHODS: We performed a retrospective cohort study of discharged adult ED patients (n = 7529) with SARS-CoV-2 infection from 116 unique hospitals contributing to the National Registry of Suspected COVID-19 in Emergency Care. The primary outcome was return hospital admission within 30 days. Models were developed using classification and regression tree (CART), gradient boosted machine (GBM), random forest (RF), and least absolute shrinkage and selection (LASSO) approaches. RESULTS: Among patients with COVID-19 discharged from the ED on their index encounter, 571 (7.6%) returned for hospital admission within 30 days. The machine-learning (ML) models (GBM, RF, and LASSO) performed similarly. The RF model yielded a test area under the receiver operating characteristic curve of 0.74 (95% confidence interval [CI], 0.71-0.78), with a sensitivity of 0.46 (95% CI, 0.39-0.54) and a specificity of 0.84 (95% CI, 0.82-0.85). Predictive variables, including lowest oxygen saturation, temperature, or history of hypertension, diabetes, hyperlipidemia, or obesity, were common to all ML models. CONCLUSIONS: A predictive model identifying adult ED patients with COVID-19 at risk for return for return hospital admission within 30 days is feasible. Ensemble/boot-strapped classification methods (eg, GBM, RF, and LASSO) outperform the single-tree CART method. Future efforts may focus on the application of ML models in the hospital setting to optimize the allocation of follow-up resources.

Multicenter Test of an Emergency Department Trigger Tool for Detecting Adverse Events.

OBJECTIVES: Traditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED trigger tool using a multidisciplinary, multicenter approach. We conducted a multicenter test of this tool and assess its performance. METHODS: In design and participants, we studied the ED trigger tool for a 13-month period at four EDs. All patients 18 years and older with Emergency Severity Index acuity levels of 1 to 3 seen by a provider were eligible. Reviewers completed standardized training modules. Each site reviewed 50 randomly selected visits per month. A first-level reviewer screened for presence of predefined triggers (findings that increase the probability of an AE). If no trigger is present, the review is deemed complete. When present, a trigger prompts an in-depth review for an AE. Any event identified is assigned a level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). Events are noted as present on arrival or in the ED, an act of commission or omission, and are assigned one of four event categories. A second-level physician performs a confirmatory review of all AEs and independently reviews 10% of cases to estimate the false-negative rate. All AEs or potential AEs were reviewed in monthly group calls for consensus on findings. The primary outcome is the proportion of visits in which an AE is identified, overall and by site. Secondary outcomes include categories of events, distribution of harm ratings, and association of AEs with sociodemographic and clinical factors and triggers. We present sociodemographic data and details about AEs and results of logistic regression for associations of AEs with of triggers, sociodemographics, and clinical variables. RESULTS: We captured 2594 visits that are representative, within site, of their patient population. Overall, the sample is 64% white, 54% female, and with a mean age of 51. Variability is observed between sites for age, race, and insurance, but not sex. A total of 240 events were identified in 228 visits (8.8%) of which 53.3% were present on arrival, 19.7% were acts of omission, and 44.6% were medication-related, with some variability across sites. A MERP F score (contributing to need for admission, higher level of care, or prolonged hospitalization) was the most common severity level (35.4% of events). Overall, 185 (77.1%) of 240 events involved patient harm (MERP level ≥ E), affecting 175 visits (6.7%). Triggers were present in 951 visits (36.6%). Presence of any trigger was strongly associated with an AE (adjusted odds ratio = 4.6, 95% confidence interval = 3.2-6.6). Ten triggers were individually associated with AEs (adjusted odds ratio = 2.1-7.7). Variability was observed across sites in individual trigger associations, event rates, and categories, but not in severity ratings of events. The overall false-negative rate was 6.1%. CONCLUSIONS: The trigger tool approach was successful in identifying meaningful events. The ED trigger tool seems to be a promising approach for identifying all-cause harm in the ED.

Addressing Workplace Safety in the Emergency Department: A Multi-Institutional Qualitative Investigation of Health Worker Assault Experiences.

OBJECTIVE: This study aims to identify interventions to address workplace violence in the emergency department based on direct evidence from experiences of patient assault. METHODS: We performed de novo coding and thematic analysis of datasets from two geographically distinct institutions and five different sites that contained interviews with 80 health workers. RESULTS: We identified concepts that corresponded to the micro (workers and patients), meso (organizations and clinical units), and macro (society at large, worldviews, and values) levels of the healthcare system. Within each level, potential interventions fell into the prevention, response, and recovery phases of emergency preparedness. CONCLUSION: Efforts to address workplace violence should consider interconnected influences from individual workers, organizations, and society at large. Comprehensive approaches at multiple phases of preparedness are needed to have sustained impact on safety.

An Event-based Approach to Measurement: Facilitating Observational Measurement in Highly Variable Clinical Settings.

BACKGROUND: Translational research in medical education requires the ability to rigorously measure learner performance in actual clinical settings; however, current measurement systems cannot accommodate the variability inherent in many patient care  environments. This is especially problematic in emergency medicine, where patients represent a wide spectrum of severity for a single clinical presentation. Our objective is to describe and implement EBAM, an event-based approach to measurement that can be applied to actual emergency medicine clinical events. METHODS: We used a four-step event-based approach to create an emergency department trauma resuscitation patient care measure. We applied the measure to a database of 360 actual trauma resuscitations recorded in a Level I trauma center using trained raters. A subset (n = 50) of videos was independently rated in duplicate to determine inter-rater reliability. Descriptive analyses were performed to describe characteristics of resuscitation events and Cohen's kappa was used to calculate reliability. RESULTS: The methodology created a metric containing both universal items that are applied to all trauma resuscitation events and conditional items that only apply in certain situations. For clinical trauma events, injury severity scores ranged from 1 to 75 with a mean (±SD) of 21 (±15) and included both blunt (254/360; 74%) and penetrating (86/360; 25%) traumatic injuries, demonstrating the diverse nature of the clinical encounters. The mean (±SD) Cohen's kappa for patient care items was 0.7 (±0.3). CONCLUSION: We present an event-based approach to performance assessment that may address a major gap in translational education research. Our work centered on assessment of patient care behaviors during trauma resuscitation. More work is needed to evaluate this approach across a diverse array of clinical events.

Development of an Emergency Department Trigger Tool Using a Systematic Search and Modified Delphi Process.

OBJECTIVE: This study aimed to develop an emergency department (ED) trigger tool to improve the identification of adverse events in the ED and that can be used to direct patient safety and quality improvement. This work describes the first step toward the development of an ED all-cause harm measurement tool by experts in the field. METHODS: We identified a multidisciplinary group of emergency medicine safety experts from whom we solicited candidate triggers. We then conducted a modified Delphi process consisting of 4 stages as follows: (1) a systematic literature search and review, including an independent oversampling of review for inclusion, (2) solicitation of empiric triggers from participants, (3) a Web-based survey ranking triggers on specific performance constructs, and (4) a final in-person meeting to arrive at consensus triggers for testing. Results of each step were shared with participants between each stage. RESULTS: Among an initial 804 unique articles found using our search criteria, we identified 94 that were suitable for further review. Interrater reliability was high (κ = 0.80). Review of these articles yielded 56 candidate triggers. These were supplemented by 58 participant-submitted triggers yielding a total of 114 candidate triggers that were shared with team members electronically along with their definitions. Team members then voted on each measure via a Web-based survey, ranking triggers on their face validity, utility for quality improvement, and fidelity (sensitivity/specificity). Participants were also provided the ability to flag any trigger about which they had questions or they felt merited further discussion at the in-person meeting. Triggers were ranked by combining the first 2 categories (face validity and utility), and information on fidelity was reviewed for decision making at the in-person meeting. Seven redundant triggers were eliminated. At an in-person meeting including representatives from all facilities, we presented the 50 top-ranked triggers as well as those that were flagged on the survey by 2 or more participants. We reviewed each trigger individually, identifying 41 triggers about which there was a clear agreement for inclusion. Of the seven additional triggers that required subsequent voting via e-mail, 5 were adopted, arriving at a total of 46 consensus-derived triggers. CONCLUSIONS: Our modified Delphi process resulted in the identification of 46 final triggers for the detection of adverse events among ED patients. These triggers should be pilot field tested to quantify their individual and collective performance in detecting all-cause harm to ED patients.

Simulation-Based Team Leadership Training Improves Team Leadership During Actual Trauma Resuscitations: A Randomized Controlled Trial.

OBJECTIVES: Trauma resuscitations are complex critical care events that present patient safety-related risk. Simulation-based leadership training is thought to improve trauma care; however, there is no robust evidence supporting the impact of leadership training on clinical performance. The objective of this study was to assess the clinical impact of simulation-based leadership training on team leadership and patient care during actual trauma resuscitations. DESIGN: Randomized controlled trial. SETTING: Harborview Medical Center (level 1 trauma center). SUBJECTS: Seventy-nine second- and third-year residents were randomized and 360 resuscitations were analyzed. INTERVENTIONS: Subjects were randomized to a 4-hour simulation-based leadership training (intervention) or standard orientation (control) condition. MEASUREMENTS AND MAIN RESULTS: Participant-led actual trauma resuscitations were video recorded and coded for leadership behaviors and patient care. We used random coefficient modeling to account for the nesting effect of multiple observations within residents and to test for post-training group differences in leadership behaviors while controlling for pre-training behaviors, Injury Severity Score, postgraduate training year, and days since training occurred. Sixty participants completed the study. There was a significant difference in post-training leadership behaviors between the intervention and control conditions (b1 = 4.06, t (55) = 6.11, p < 0.001; intervention M = 11.29, SE = 0.66, 95% CI, 9.99-12.59 vs control M = 7.23, SE = 0.46, 95% CI, 6.33-8.13, d = 0.92). Although patient care was similar between conditions (b = 2.00, t (55) = 0.99, p = 0.325; predicted means intervention M = 62.38, SE = 2.01, 95% CI, 58.43-66.33 vs control M = 60.38, SE = 1.37, 95% CI, 57.69-63.07, d = 0.15), a test of the mediation effect between training and patient care suggests leadership behaviors mediate an effect of training on patient care with a significant indirect effect (b = 3.44, 95% CI, 1.43-5.80). Across all trauma resuscitations leadership was significantly related to patient care (b1 = 0.61, SE = 0.15, t (273) = 3.64, p < 0.001). CONCLUSIONS: Leadership training resulted in the transfer of complex skills to the clinical environment and may have an indirect effect on patient care through better team leadership.

Wound Care Follow-Up From the Emergency Department Using a Mobile Application: A Pilot Study.

BACKGROUND: Many patients presenting to emergency departments (EDs) do not have primary care and risk being lost to follow-up. Technology has been used successfully in surgical populations for wound care follow-up yet this is not well studied in ED populations. OBJECTIVE: We aimed to conduct a pilot study demonstrating "smartphone" application-based follow-up after wound care in the ED. METHODS: We enrolled participants in 2 urban EDs using a smartphone application called Mobile Post-Operative Wound Evaluator (mPOWEr) and defined participation as photographic submission at any time during the study period. We collected demographic data, frequency of use of mPOWEr, number of photographs uploaded, and timing of uploads. RESULTS: We approached patients for study enrollment, and 67 patients (28%) were not enrolled because they had no access to a smartphone. Seventy-one patients (30%) declined to enroll, leaving 100 (42%) successfully enrolled. Smartphone ownership was more common among patients <40 years of age (81% vs. 64%, p = 0.004), more common among white patients than nonwhite patients (75% vs. 15%, p = 0.046), more common among patients approached at the university medical center than the trauma center (84% vs. 66%, p = 0.003), and among patients with commercial or other insurance than those with Medicare or Medicaid (92% vs. 54%, p < 0.001). Of those enrolled, 58% submitted a photograph. CONCLUSIONS: Patients presenting for wound care to the ED will participate in smartphone-based app communication for wound care follow-up and are satisfied with this option. Disparities in smartphone access must be considered when using this follow-up method.

Identification of processes that mediate the impact of workplace violence on emergency department healthcare workers in the USA: results from a qualitative study.

OBJECTIVES: Violence towards emergency department healthcare workers is pervasive and directly linked to provider wellness, productivity and job satisfaction. This qualitative study aimed to identify the cognitive and behavioural processes impacted by workplace violence to further understand why workplace violence has a variable impact on individual healthcare workers. DESIGN: Qualitative interview study using a phenomenological approach to initial content analysis and secondary thematic analysis. SETTING: Three different emergency departments. PARTICIPANTS: We recruited 23 emergency department healthcare workers who experienced a workplace violence event to participate in an interview conducted within 24 hours of the event. Participants included nurses (n=9; 39%), medical assistants (n=5; 22%), security guards (n=5; 22%), attending physicians (n=2; 9%), advanced practitioners (n=1; 4%) and social workers (n=1; 4%). RESULTS: Five themes emerged from the data. The first two supported existing reports that workplace violence in healthcare is pervasive and contributes to burn-out in healthcare. Three novel themes emerged from the data related to the objectives of this study: (1) variability in primary cognitive appraisals of workplace violence, (2) variability in secondary cognitive appraisals of workplace violence and (3) reported use of both avoidant and approach coping mechanisms. CONCLUSION: Healthcare workers identified workplace violence as pervasive. Variability in reported cognitive appraisal and coping strategies may partially explain why workplace violence negatively impacts some healthcare workers more than others. These cognitive and behavioural processes could serve as targets for decreasing the negative effect of workplace violence, thereby improving healthcare worker well-being. Further research is needed to develop interventions that mitigate the negative impact of workplace violence.

Targeted Simulation-based Leadership Training for Trauma Team Leaders.

INTRODUCTION: Effective team leadership is linked to better teamwork, which in turn is believed to improve patient care. Simulation-based training provides a mechanism to develop effective leadership behaviors. Traditionally, healthcare curricula have included leadership as a small component of broader teamwork training, with very few examples of leadership-focused curricula. The objective of this work is to describe a novel simulation-based team leadership curriculum that easily adapts to individual learners. METHODS: We created a simulation-based team leadership training for trauma team leaders in graduate medical education. Participants included second- and third-year emergency medicine and surgery residents. Training consisted of a single, four-hour session and included facilitated discussion of trauma leadership skills, a brief didactic session integrating leadership behaviors into Advanced Trauma Life Support®, and a series of simulations and debriefing sessions. The simulations contained adaptable components that facilitated individualized learning while delivering set curricular content. A survey evaluation was administered 7-24 months following the training to assess self-reported implementation of trained material. RESULTS: A total of 36 residents participated in the training and 23 (64%) responded to the survey. The majority of respondents (n = 22, 96%) felt the training was a valuable component of their residency education and all respondents reported ongoing use of at least one behavior learned during the training. The most commonly cited skills for ongoing use included the pre-arrival brief (n = 21, 91%) and prioritization (n = 21, 91%). CONCLUSION: We delivered a leadership-focused, simulation-based training that 1) adapted to learners' individual needs, and 2) was perceived to impact practice up to 24 months post-training. More work is needed to understand the impact of this training on learner knowledge and behavior, as well as patient outcomes.

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine.

BACKGROUND: Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation. METHODS: This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts. RESULTS: During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = -2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = -6.8%, 95% CI = -18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = -46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = -33%, 95% CI = -100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001). CONCLUSIONS: Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.

Critical Review, Development, and Testing of a Taxonomy for Adverse Events and Near Misses in the Emergency Department.

OBJECTIVES: An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g., hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g., "communication error"). We set out to create a patient-centered, emergency department (ED)-specific framework for describing AEs and near misses to advance quality and safety in the acute care setting. METHODS: We performed a critical review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified AEs and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our criterion standard. RESULTS: Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems AE taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories, and up to three modifiers to further describe events. On testing, overall reviewer agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55 of 59 scenarios (93%) and all four concurred in 46 of 59 scenarios (78%). At the subcategory level, there was complete agreement in 40 of 59 (68%) scenarios and majority agreement in 55 of 59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level. CONCLUSIONS: We developed a taxonomy of AEs and near misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good inter-rater reliability. This taxonomy can be adapted and modified by EDs seeking to enhance their quality and safety reviews and characterize harm occurring in their EDs for quality improvement purposes.