Effect of a split-flow physician in triage model on abdominal CT ordering rate and yield.

OBJECTIVE: The objective of this study was to compare the rate and clinical yield of computed tomography (CT) imaging between patients presenting with abdominal pain initially seen by a physician in triage (PIT) versus those seen only by physicians working in the main emergency department (ED). METHODS: A retrospective study was conducted of all self-arrivals >18 years old presenting to a single ED with abdominal pain. Nine-hundred patients were randomly selected from both the PIT and traditional patient flow groups and rates and yields of CT imaging were compared, both alone and in a model controlling for potential confounders. Predetermined criteria for CT significance included need for admission, consult, or targeted medications. RESULTS: The overall rate of CT imaging (unadjusted) did not differ between the PIT and traditional groups, 48.7% (95% CI 45.4-51.9) vs. 45.1% (95% CI 41.8-48.4), respectively (p = .13). The CT yield for patients seen in in the PIT group was also similar to that of the traditional group: 49.1% (95% CI 44.4-53.8) vs. 50.5% (95% CI 45.6-55.4) (p = .68). In the logistic regression model, when controlling for age, gender, ESI-acuity, race and insurance payor, PIT vs. traditional was not a predictor of CT ordering (OR 1.14, 95% CI 0.94-1.38). CONCLUSIONS: For patients with abdominal pain, we found no significant differences in rates of CT ordering or CT yield for patients seen in a PIT vs. traditional models, suggesting the increased efficiencies offered by PIT models do not come at the cost of increased or decreased imaging utilization.

Training and Interpreting Machine Learning Algorithms to Evaluate Fall Risk After Emergency Department Visits.

BACKGROUND: Machine learning is increasingly used for risk stratification in health care. Achieving accurate predictive models do not improve outcomes if they cannot be translated into efficacious intervention. Here we examine the potential utility of automated risk stratification and referral intervention to screen older adults for fall risk after emergency department (ED) visits. OBJECTIVE: This study evaluated several machine learning methodologies for the creation of a risk stratification algorithm using electronic health record data and estimated the effects of a resultant intervention based on algorithm performance in test data. METHODS: Data available at the time of ED discharge were retrospectively collected and separated into training and test datasets. Algorithms were developed to predict the outcome of a return visit for fall within 6 months of an ED index visit. Models included random forests, AdaBoost, and regression-based methods. We evaluated models both by the area under the receiver operating characteristic (ROC) curve, also referred to as area under the curve (AUC), and by projected clinical impact, estimating number needed to treat (NNT) and referrals per week for a fall risk intervention. RESULTS: The random forest model achieved an AUC of 0.78, with slightly lower performance in regression-based models. Algorithms with similar performance, when evaluated by AUC, differed when placed into a clinical context with the defined task of estimated NNT in a real-world scenario. CONCLUSION: The ability to translate the results of our analysis to the potential tradeoff between referral numbers and NNT offers decisionmakers the ability to envision the effects of a proposed intervention before implementation.

Development and validation of a pragmatic natural language processing approach to identifying falls in older adults in the emergency department.

BACKGROUND: Falls among older adults are both a common reason for presentation to the emergency department, and a major source of morbidity and mortality. It is critical to identify fall patients quickly and reliably during, and immediately after, emergency department encounters in order to deliver appropriate care and referrals. Unfortunately, falls are difficult to identify without manual chart review, a time intensive process infeasible for many applications including surveillance and quality reporting. Here we describe a pragmatic NLP approach to automating fall identification. METHODS: In this single center retrospective review, 500 emergency department provider notes from older adult patients (age 65 and older) were randomly selected for analysis. A simple, rules-based NLP algorithm for fall identification was developed and evaluated on a development set of 1084 notes, then compared with identification by consensus of trained abstractors blinded to NLP results. RESULTS: The NLP pipeline demonstrated a recall (sensitivity) of 95.8%, specificity of 97.4%, precision of 92.0%, and F1 score of 0.939 for identifying fall events within emergency physician visit notes, as compared to gold standard manual abstraction by human coders. CONCLUSIONS: Our pragmatic NLP algorithm was able to identify falls in ED notes with excellent precision and recall, comparable to that of more labor-intensive manual abstraction. This finding offers promise not just for improving research methods, but as a potential for identifying patients for targeted interventions, quality measure development and epidemiologic surveillance.

The Association Between Use of Brain CT for Atraumatic Headache and 30-Day Emergency Department Revisitation.

OBJECTIVE: The purpose of this article is to describe the association between initial CT for atraumatic headache and repeat emergency department (ED) visitation within 30 days of ED discharge. MATERIALS AND METHODS: A retrospective observational study was performed at an academic urban ED with more than 85,000 annual visits. All adult patients with a chief complaint of headache from January through December 2010 who were discharged after ED evaluation were included in the analysis. Patients were excluded if they were transferred, died in the ED, or had a diagnosis indicating a traumatic mechanism. A propensity score-matched logistic regression model was used to determine whether the use of brain CT was associated with the primary outcome of ED revisitation within 30 days, controlling for potential confounding variables. RESULTS: Of 80,619 total patient visits to the ED during the study period, 922 ED discharges with a chief complaint of headache were included. A total of 139 (15.1%) patients revisited within 30 days. The return rate was 11.2% among patients who underwent CT at their initial visit and 21.1% among those who did not. In the adjusted analysis, controlling for age, race, sex, insurance status, triage vital signs, laboratory values, and triage pain level, the odds ratio for revisitation given CT performance was 0.49 (95% CI, 0.27-0.86). CONCLUSION: After adjustment for clinical factors, we found that patients who underwent a brain CT examination for atraumatic headache at an initial ED visit were less likely to return to the ED within 30 days. Future appropriate use quality metrics regarding ED imaging use may need to incorporate downstream health care use.

Safety of a rapid diagnostic protocol with accelerated stress testing.

BACKGROUND: Most patients at low to intermediate risk for an acute coronary syndrome (ACS) receive a 12- to 24-hour "rule out." Recently, trials have found that a coronary computed tomographic angiography-based strategy is more efficient. If stress testing were performed within the same time frame as coronary computed tomographic angiography, the 2 strategies would be more similar. We tested the hypothesis that stress testing can safely be performed within several hours of presentation. METHODS: We performed a retrospective cohort study of patients presenting to a university hospital from January 1, 2009, to December 31, 2011, with potential ACS. Patients placed in a clinical pathway that performed stress testing after 2 negative troponin values 2 hours apart were included. We excluded patients with ST-elevation myocardial infarction or with an elevated initial troponin. The main outcome was safety of immediate stress testing defined as the absence of death or acute myocardial infarction (defined as elevated troponin within 24 hours after the test). RESULTS: A total of 856 patients who presented with potential ACS were enrolled in the clinical pathway and included in this study. Patients had a median age of 55.0 (interquartile range, 48-62) years. Chest pain was the chief concern in 86%, and pain was present on arrival in 73% of the patients. There were no complications observed during the stress test. There were 0 deaths (95% confidence interval, 0%-0.46%) and 4 acute myocardial infarctions within 24 hours (0.5%; 95% confidence interval, 0.14%-1.27%). The peak troponins were small (0.06, 0.07, 0.07, and 0.19 ng/mL). CONCLUSIONS: Patients who present to the ED with potential ACS can safely undergo a rapid diagnostic protocol with stress testing.

Call me Dr Ishmael: trends in electronic health record notes available at emergency department visits and admissions.

Objectives: Numerous studies have identified information overload as a key issue for electronic health records (EHRs). This study describes the amount of text data across all notes available to emergency physicians in the EHR, trended over the time since EHR establishment. Materials and Methods: We conducted a retrospective analysis of EHR data from a large healthcare system, examining the number of notes and a corresponding number of total words and total tokens across all notes available to physicians during patient encounters in the emergency department (ED). We assessed the change in these metrics over a 17-year period between 2006 and 2023. Results: The study cohort included 730 968 ED visits made by 293 559 unique patients and a total note count of 132 574 964. The median note count for all encounters in 2006 was 5 (IQR 1-16), accounting for 1735 (IQR 447-5521) words. By the last full year of the study period, 2022, the median number of notes had grown to 359 (IQR 84-943), representing 359 (IQR 84-943) words. Note and word counts were higher for admitted patients. Discussion: The volume of notes available for review by providers has increased by over 30-fold in the 17 years since the implementation of the EHR at a large health system. The task of reviewing these notes has become commensurately more difficult. These data point to the critical need for new strategies and tools for filtering, synthesizing, and summarizing information to achieve the promise of the medical record.

Effectiveness of MR angiography for the primary diagnosis of acute pulmonary embolism: clinical outcomes at 3 months and 1 year.

PURPOSE: To determine the effectiveness of MR angiography for pulmonary embolism (MRA-PE) in symptomatic patients. MATERIALS AND METHODS: We retrospectively reviewed all patients whom were evaluated for possible pulmonary embolism (PE) using MRA-PE. A 3-month and 1-year from MRA-PE electronic medical record (EMR) review was performed. Evidence for venous thromboembolism (VTE) (or death from PE) within the year of follow-up was the outcome surrogate for this study. RESULTS: There were 190 MRA-PE exams performed with 97.4% (185/190) of diagnostic quality. There were 148 patients (120 F: 28 M) that had both a diagnostic MRA-PE exam and 1 complete year of EMR follow-up. There were 167 patients (137 F: 30 M) with 3 months or greater follow-up. We found 83% (139/167) and 81% (120/148) MRA-PE exams negative for PE at 3 months and 1 year, respectively. Positive exams for PE were seen in 14% (23/167). During the 1-year follow-up period, five patients (false negative) were diagnosed with DVT (5/148 = 3.4 %), and one of these patients also experienced a non-life-threatening PE. The negative predictive value (NPV) for MRA-PE was 97% (92-99; 95% CI) at 3 months and 96% (90-98; 95% CI) with 1 year of follow-up. CONCLUSION: The NPV of MRA-PE, when used for the primary diagnosis of pulmonary embolism in symptomatic patients, were found to be similar to the published values for CTA-PE. In addition, the technical success rate and safety of MRA-PE were excellent.

Emergency department discharge prescription interventions by emergency medicine pharmacists.

STUDY OBJECTIVE: We determine the rate and details of interventions associated with emergency medicine pharmacist review of discharge prescriptions for patients discharged from the emergency department (ED). Additionally, we evaluate care providers' satisfaction with such services provided by emergency medicine pharmacists. METHODS: This was a prospective observational study in the ED of an academic medical center that serves both adult and pediatric patients. Details of emergency medicine pharmacist interventions on discharge prescriptions were compiled with a standardized form. Interventions were categorized as error prevention or optimization of therapy. The staff of the ED was surveyed related to the influence and satisfaction of this new emergency medicine pharmacist-provided service. RESULTS: The 674 discharge prescriptions reviewed by emergency medicine pharmacists during the study period included 602 (89.3%) for adult patients and 72 (10.7%) for pediatric patients. Emergency medicine pharmacists intervened on 68 prescriptions, resulting in an intervention rate of 10.1% (95% confidence interval [CI] 8.0% to 12.7%). The intervention rate was 8.5% (95% CI 6.4% to 11.1%) for adult prescriptions and 23.6% for pediatric prescriptions (95% CI 14.7% to 35.3%) (difference 15.1%; 95% CI 5.1% to 25.2%). There were a similar number of interventions categorized as error prevention and optimization of medication therapy, 37 (54%) and 31 (46%), respectively. More than 95% of survey respondents believed that the new pharmacist services improved patient safety, optimized medication regimens, and improved patient satisfaction. CONCLUSION: Emergency medicine pharmacist review of discharge prescriptions for discharged ED patients has the potential to significantly improve patient care associated with suboptimal prescriptions and is highly valued by ED care providers.

Quality and safety implications of emergency department information systems.

The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services "meaningful use" incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals' electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital's or physician group's approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order-wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system's ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or enterprise systems.

Emergency department contrast practices for abdominal/pelvic computed tomography-a national survey and comparison with the american college of radiology appropriateness criteria(®).

BACKGROUND: Controversy exists regarding the need for contrast agents for emergency abdominal computed tomography (CT). OBJECTIVES: We surveyed United States (US) academic Emergency Departments (EDs) to document national practice. We hypothesized variable contrast use for abdominal/pelvic CT, including variance from the American College of Radiology's (ACR) Appropriateness Criteria(®), an evidence-based guideline. METHODS: A survey was sent to physician leaders of US academic EDs, defined as primary site of an Emergency Medicine residency program. Respondents were asked about their institutions' use of oral, intravenous (i.v.), and rectal contrast for various abdominal/pelvic CT indications. Responses were compared with the approach given the highest appropriateness rating by the American College of Radiology. RESULTS: One hundred and six of 152 (70%) surveys were completed. Intravenous contrast was the most frequently cited contrast. At least 90% of respondents reported using i.v. contrast in 12 of 18 indications. Oral contrast use was more variable. In no indication did ≥90% of respondents indicate use of oral contrast, and in only two indications did ≥90% avoid its use. Rectal contrast was rarely used. The most common indications for which no contrast agent was used were suspected renal colic (79%), viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%). CONCLUSIONS: Contrast practices for abdominal/pelvic CT vary nationally, according to a survey of US academic EDs. For multiple indications, the contrast practices of a substantial number of respondents deviated from those recommendations given the highest clinical appropriateness rating by the American College of Radiology.

Assessment of Medicare's imaging efficiency measure for emergency department patients with atraumatic headache.

STUDY OBJECTIVE: Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging efficiency measure (Outpatient Measure 15 [OP-15]) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15. METHODS: This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measure's validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Association's Physician Consortium for Performance Improvement. RESULTS: On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval [CI] 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measure's validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measure's accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication (r=-0.11; P=.63). CONCLUSION: The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.

A 9-year-old boy with exertional syncope.

BACKGROUND: Syncope in the pediatric population is a common and mostly benign event. There is a subset of patients, however, in whom exertional syncope is the manifestation of a life-threatening cardiac abnormality. OBJECTIVE: We present a rare but serious cause of syncope in children that often presents as sudden cardiac death. CASE REPORT: A 9-year-old boy presented to the Emergency Department (ED) after an episode of exertional syncope while in physical education class. This was the patient's second episode of exercise-induced syncope within a 2-year period. There was no family history of sudden death or cardiac disease. The child had not undergone any prior diagnostic work-up for the syncope. He was admitted to the hospital for further evaluation, and was found to have an anomalous left coronary artery on transthoracic echocardiogram. CONCLUSION: As a potential precursor of sudden death, exertional syncope in pediatric patients should prompt a thorough evaluation for a cardiac etiology.

Changing Medical Education When Change Is Hard: Implementing an Interdepartmental Entrustable Professional Activity.

BACKGROUND: Entrustable professional activities (EPAs) are a new tool for assessing learners that represents a significant movement in graduate medical education (GME) toward competency-based assessment and serves as a bridge between milestones and clinical practice. Whenever a major change is implemented to any system, resistance to change is expected. Many change management models have been proposed to overcome this resistance; a newer model is outlined in the book Switch. The objective was to describe the change management principles used to institute an EPA. METHODS: The model introduced in Switch was used as a framework for implementing a trauma resuscitation EPA in a joint effort between the departments of surgery and emergency medicine (EM) at the University of Wisconsin Hospitals and Clinics. The Department of Emergency Medicine used the principles of change management, completing 295 faculty evaluations of trauma resuscitations compared to the Department of Surgery, whose faculty completed 50 evaluations between the study period of July 2018 through October 2019. A survey completed winter 2019 of EM faculty was used to determine the most important principles toward successful implementation. RESULTS: Twenty-seven of 35 (78% response rate) of EM faculty identified key concepts from Switch as being instrumental in the successful implementation. Internal discussion of the implementation approach used by the Department of Surgery identified several limitations that would have been overcome by using these same change management principles. CONCLUSION: We conclude that the principles of change management provide a useful framework for successfully implementing EPAs into GME.

Patient Preferences for Diagnostic Imaging: CTA vs MRA When Diagnosing Pulmonary Embolism.

OBJECTIVE: To identify preferences regarding choice of diagnostic imaging (computed tomographic angiography [CTA] vs magnetic resonance angiography [MRA]) for the evaluation of pulmonary embolism. METHODS: We conducted 4 focus group discussions with residents of 2 Wisconsin cities. Community members ≥18 years old were recruited via telephone using a commercially available telephone database. The discussions were audio recorded and professionally transcribed. Three investigators (a research specialist, emergency physician, and qualitative methodologist) independently analyzed these transcripts using inductive thematic coding to identify the overarching themes and underlying concepts. Intercoder discrepancies were resolved through consensus discussion by the reviewers. RESULTS: Focus groups were held over a 3-month period and included 29 participants (16 female). Ages were well represented: 18-30 (n = 7), 31-40 (n = 8), 41-55 (n = 6), and 56+ (n = 8) years old. Analysis revealed 3 central themes: time, risk, and experience. Participants who preferred CTA commonly cited the need for immediate results in the emergency department. When nonemergent scenarios were discussed, the option to undergo MRA was considered more strongly; participants weighed additional details like radiation and diagnostic accuracy. Regarding risks, discussants expressed concerns from multiple sources, including radiation and intravenous contrast. However, understanding of this risk varied across the groups. Prior experience with medical imaging-both personal and indirect experiences-carried considerable weight. CONCLUSIONS: Preferences regarding imaging choice in the diagnosis of pulmonary embolism were mixed, often reliant on vicarious experiences and an exaggerated notion of the difference in timing of imaging results. Participants frequently used incomplete or even incorrect information as the basis for decision-making.

Natural language processing and entrustable professional activity text feedback in surgery: A machine learning model of resident autonomy.

BACKGROUND: Entrustable Professional Activities (EPAs) contain narrative 'entrustment roadmaps' designed to describe specific behaviors associated with different entrustment levels. However, these roadmaps were created using expert committee consensus, with little data available for guidance. Analysis of actual EPA assessment narrative comments using natural language processing may enhance our understanding of resident entrustment in actual practice. METHODS: All text comments associated with EPA microassessments at a single institution were combined. EPA-entrustment level pairs (e.g. Gallbladder Disease-Level 1) were identified as documents. Latent Dirichlet Allocation (LDA), a common machine learning algorithm, was used to identify latent topics in the documents associated with a single EPA. These topics were then reviewed for interpretability by human raters. RESULTS: Over 18 months, 1015 faculty EPA microassessments were collected from 64 faculty for 80 residents. LDA analysis identified topics that mapped 1:1 to EPA entrustment levels (Gammas >0.99). These LDA topics appeared to trend coherently with entrustment levels (words demonstrating high entrustment were consistently found in high entrustment topics, word demonstrating low entrustment were found in low entrustment topics). CONCLUSIONS: LDA is capable of identifying topics relevant to progressive surgical entrustment and autonomy in EPA comments. These topics provide insight into key behaviors that drive different level of resident autonomy and may allow for data-driven revision of EPA entrustment maps.

Inappropriate Antibiotic Prescribing for Respiratory Conditions Does Not Improve Press Ganey Patient Satisfaction Scores in the Emergency Department.

BACKGROUND: The literature has mixed results regarding the relationship between antibiotic prescribing and patient satisfaction in the emergency department (ED) for antibiotic-inappropriate respiratory diagnoses. The objective of the study was to determine if ED patients who receive nonindicated antibiotic prescriptions for respiratory tract conditions have increased Press Ganey patient satisfaction scores compared with those who do not receive antibiotics. METHODS: This was a retrospective observational study. Using an administrative electronic health record data set from 2 EDs in the Midwest, we identified 619 ED encounters resulting in discharge for antibiotic-inappropriate respiratory diagnoses with a corresponding Press Ganey patient satisfaction survey. We compared sociodemographics, encounter variables, and overall Press Ganey patient satisfaction scores between those who did and did not receive antibiotics. We analyzed Press Ganey scores by categorical score distribution and as a dichotomized scale of top box (5) vs other scores. A logistic regression estimated the odds of a top box Press Ganey patient satisfaction score based on antibiotic prescribing while controlling for other covariates. RESULTS: In the final sample, 158 (26%) encounters involving antibiotic-inappropriate respiratory diagnoses involved an antibiotic prescription. There were no differences in sociodemographic, encounter or categorical, or top box Press Ganey overall patient satisfaction scores between the groups that did and did not receive inappropriate antibiotics. In the fully adjusted regression model, antibiotic prescriptions were not associated with increased odds of top box Press Ganey patient satisfaction score (odds ratio, 0.78; 95% CI, 0.53-1.14). CONCLUSIONS: Our findings suggest that nonindicated antibiotic prescribing for respiratory tract conditions is not a primary driver of overall Press Ganey scores in the ED.

Entrustable Professional Activities in General Surgery: Trends in Resident Self-Assessment.

OBJECTIVE: Effective self-assessment is a cornerstone of lifelong professional development; however, evidence suggests physicians have a limited ability to self-assess. Novel strategies to improve the accuracy of learner self-assessment are needed. Our institution's surgical entrustable professional activity (EPA) implementation strategy incorporates resident self-assessment to address this issue. This study evaluates the accuracy of resident self-assessment versus faculty assessment across 5 EPAs in general surgery. DESIGN, SETTING, PARTICIPANTS: Within a single academic general surgery residency program, assessment data for 5 surgery EPAs was prospectively collected using a mobile application. Matched assessments (resident and faculty assessments for the same clinical encounter) were identified and the remainder excluded. Assessment scores were compared using Welch's t test. Agreement was analyzed using Cohen's kappa with squared weights. RESULTS: One thousand eight hundred and fifty-seven EPA assessments were collected in 17 months following implementation. One thousand one hundred and fifty-five (62.2%) were matched pairs. Residents under-rated their own performance relative to faculty assessments (2.36 vs 2.65, p < 0.01). This pattern held true for all subsets except for Postgraduate Year (PGY)2 residents and Inguinal Hernia EPAs. There was at least moderate agreement between matched resident and faculty EPA assessment scores (κ = 0.57). This was consistent for all EPAs except Trauma evaluations, which were completed by faculty from 2 different departments. Surgery resident self-assessments more strongly agreed with Surgery faculty assessments than Emergency Medicine faculty assessments (κ = 0.58 vs 0.36). CONCLUSIONS: Resident EPA self-assessments are equivalent or slightly lower than faculty assessments across a wide breadth of clinical scenarios. Resident and faculty matched assessments demonstrate moderate agreement.

Implementation of Entrustable Professional Activities into a General Surgery Residency.

OBJECTIVE: Concerns over resident ability to practice effectively after graduation have led to the competency-based medical education movement. Entrustable professional activities (EPAs) may facilitate competency-based medical education in surgery, but implementation is challenging. This manuscript describes 1 strategy used to implement EPAs into an academic general surgery residency. DESIGN, SETTING, PARTICIPANTS: A mobile application was developed incorporating 5 EPAs developed by the American Board of Surgery; residents and faculty from the Departments of Surgery, Emergency Medicine, and Hospital Medicine at a single tertiary care center were trained in its use. Entrustment levels and free text feedback were collected. Self-assessment was paired with supervisor assessment, and faculty assessments were used to inform clinical competency committee entrustment decisions. Feedback was regularly solicited from app users and results distributed on a monthly basis. RESULTS: One thousand seven hundred and twenty microassessments were collected over the first 16 months of implementation; 898 (47.8%) were performed by faculty with 569 (66.0%) matched pairs. Engagement was skewed with small numbers of high performers in both resident and faculty groups. Continued development of resident and faculty was required to sustain engagement with the program. Nonsurgical specialties contributed significantly to resident assessments (496, 28.8%). CONCLUSIONS: EPAs are being successfully integrated into the assessment framework at our institution. EPA implementation in surgery residency is a long-term process that requires investment, but may address limitations in the current assessment framework.

A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds.

STUDY OBJECTIVE: We describe the frequency of undesirable events among patients boarding at a single, urban, tertiary, teaching emergency department (ED) through retrospective chart abstraction. METHODS: This was a chart review of all patients admitted during 3 randomly selected days in 2003 (n=162) to track the frequency of undesirable events such as missed relevant home medications, missed laboratory test results, arrhythmias, or other adverse events. RESULTS: One hundred fifty-one charts were abstracted (93.2%); 27.8% had an undesirable event, 17.9% missed a relevant home medication, and 3.3% had a preventable adverse event. There was a higher frequency of undesirable events among older patients (35.9%, aged >50 years; 7.3%, aged 20 to 49 years; 28.6%, aged 0 to 19 years) and those with more comorbidities (44.4% among Charlson score >or=3; 30.8% score 2; 36.1% score 1; 14.5% score 0). CONCLUSION: A substantial frequency of undesirable events occurs while patients board in the ED. These events are more frequent in older patients or those with more comorbidities. Future studies need to compare the rates of undesirable events among patients boarding in the ED versus inpatient units.