Tools used to measure the impact of comorbidities on surgical outcomes in children with complex chronic conditions: A scoping review

AIM

To identify and describe assessment tools used to measure the impact of comorbidities on postoperative outcomes in children with complex chronic conditions (CCC).

METHOD

This was a scoping review using five electronic databases. The search was conducted in March 2022 by a medical librarian. There were no date or language restrictions. Included studies were full-text articles published in peer-reviewed journals that described a tool used to measure the impact of comorbidities in children with CCC to assess postoperative outcomes. A standardized data charting tool was used.

RESULTS

A total of 2157 articles were retrieved. Five studies reporting on six comorbidity measures met inclusion criteria. All were cohort studies and were secondary analyses of data from an administrative database (n = 4) or a patient registry (n = 1). Sample sizes ranged from 645 to 25 747 participants. One paper described the assessment of reliability. Only one form of validity - predictive validity - was assessed in three papers for five measures.

INTERPRETATION

Findings from this scoping review revealed a paucity of comorbidity assessment tools validated for use with children with CCC; significant conceptual and measurement challenges exist in the current scientific literature.

Racial differences in triage assessment at rural vs urban Maine emergency departments

Data continue to accumulate demonstrating that those belonging to racialized groups face implicit bias in the emergency care delivery system across many indices, including triage assessment. The Emergency Severity Index (ESI) was developed and widely implemented across the US to improve the objectivity of triage assessment and prioritization of care delivery; however, research continues to support the presence of subjective bias in triage assessment. We sought to assess the relationship between perceived race and/or need for translator and assigned ESI score and whether this was impacted by hospital geography. We performed retrospective EMR-based review of patients presenting to urban and rural emergency departments of a health system in Maine with one of the top ten most common chief complaints (CC) across a 5-year period, excluding psychiatric CCs. We used multivariable regression to analyze the relationships between perceived race, need for translator, and gender with ESI score, wait time, and hallway bed assignments. We found that patients perceived as non-white were more likely to receive lower acuity ESI scores and have longer wait times as compared to patients perceived as white. Patients perceived as female were more likely to receive lower acuity scores and wait longer to be seen than patients perceived as male. The need for an interpreter was associated with increased wait times but not significantly associated with ESI score. After stratification by hospital geography, evidence of subjective bias was limited to urban emergency departments and was not evident in rural emergency departments. Further investigation of subjective bias in emergency departments in Maine, particularly in urban settings, is warranted.

"I don't want to be the squeaky wheel": Addressing bias as a leader in emergency medicine

BACKGROUND

Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related to implicit bias, emergency medicine (EM) leaders' self-awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace.

METHODS

Investigators facilitated an hour-long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts-based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach.

RESULTS

A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias.

CONCLUSIONS

This qualitative analysis of reflections from an arts-based workshop highlights perceived fears and barriers that may impact EM physicians' motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.

Utilization of the Fordham Risk Screening Tool for violence risk assessment in an emergency department

BACKGROUND

Violence is a critical problem in the emergency department (ED) and patients experiencing mental health crises are at greater violence risk; however, tools appropriate for assessing violence risk in the ED are limited. Our goal was to evaluate the utility of the Fordham Risk Screening Tool (FRST) in reliability assessing violence risk in adult ED patients with acute mental health crises through evaluation of test characteristics compared to a reference standard.

METHODS

We evaluated performance of the FRST when used with a convenience sample of ED patients undergoing acute psychiatric evaluation. Participants underwent assessment with the FRST and an established reference standard, the Historical Clinical Risk Management-20, Version 3 (HCR-20 V3). Diagnostic performance was assessed through evaluation of test characteristics and area under the receiver operating characteristic curve (AUROC). Psychometric assessments examined the measurement properties of the FRST.

RESULTS

A total of 105 participants were enrolled. In comparison to the reference standard, the AUROC for the predictive ability of the FRST was 0.88 (standard error 0.39, 95% confidence interval [CI] 0.81-0.96). Sensitivity was 84% (95% CI 69%-94%) while specificity was 93% (95% CI 83%-98%). The positive predictive value was 87% (95% CI 73%-94%) and negative predictive value was 91% (95% CI 83%-86%). Psychometric analyses provided reliability and validity evidence for the FRST when used in the ED setting.

CONCLUSIONS

These findings support the potential utility of the FRST when used to assess violence risk in adult ED patients experiencing a mental health crisis. Future research with more diverse populations and ED settings is warranted.

The research escape hunt: An escape room-scavenger hunt for resident education

Objectives

Research and evidence-based medicine (EBM) education are important elements of emergency medicine (EM) residency training; however, curricular time is limited and integrating novel strategies to engage learners and improve understanding of complex concepts is challenging. We sought to develop a unique research escape hunt educational experience to teach EM residents basic research and EBM skills using an active-learning, team-based strategy.

Methods

A nine-station escape room-scavenger hunt was designed around educational content including (1) predictive statistics and diagnostic test characteristics, (2) interpretation of data and statistical analysis, (3) study design, (4) informed consent for research, and (5) the ethical principles guiding research. Stations required participants to use a variety of strategies to solve puzzles, with a correct response required to progress through the escape hunt. Teams worked together to solve each station's puzzles, with opportunities to reinforce the content in real time. Subsequent sessions were presented in a virtual format using Zoom breakout rooms over the past 2 years.

Results

Postactivity assessments were grounded in Kirkpatrick's model and focused on participants' reactions, learning, and behavior. Participants reported high levels of satisfaction (100% [21/21] "satisfied" or "extremely satisfied") and engagement (95% [20/21] "engaged" or "very engaged") with the activity, as well as increased comfort with the research and EBM concepts covered (91% [19/21] "agree" or "strongly agree" increased comfort), and demonstrated improvements in knowledge across each content area presented (91% [19/21]).

Reflective Discussion

This practical, team-based curriculum was found to be a successful way to engage residents with research methodology and EBM content. This curriculum is feasible for both in-person and virtual formats and we will continue to use this as a component of our EM residency program moving forward.

Scheduling practices for pregnant emergency medicine residents

Background

Night shift work is associated with adverse pathophysiologic effects on maternal and fetal well-being. Although emergency medicine (EM) residents work frequent night shifts, there is no existing guidance for residency program directors (PDs) regarding scheduling pregnant residents. Our study assessed scheduling practices for pregnant EM residents, differences based on program and PD characteristics, barriers and attitudes toward implementing a formal scheduling policy, and PDs' awareness of literature describing adverse effects of night shifts on maternal-fetal outcomes.

Methods

We conducted an anonymous, web-based survey of U.S. EM residencies (N = 276). Quantitative data were summarized; chi-square analysis and logistic regression were used to assess relationships between program and PD characteristics and schedule accommodations. Qualitative description was used to analyze an open-ended question, organizing findings into major and minor themes.

Results

Of the 167 completed surveys (response rate 61%), 67% of programs reported no formal policy for scheduling pregnant residents but made adjustments on an individual basis including block changes (85%), decreased (46%) or no night shifts (34%), and working shifts earlier in pregnancy to cover later shifts (20%). Barriers to adjustments included staffing constraints (60%), equity concerns (45%), or impact on wellness (41%) among all residents and privacy (28%). PDs endorsed scheduling adjustments as important (mean 8.1, 0-10 scale) and reported guidance from graduate medical education governance would be useful (60%). Larger program size, but not PD gender or proportion of female residents, was associated with an increased likelihood of scheduling modifications. Twenty-five percent of PDs reported little knowledge of literature regarding night shift work and pregnancy. Qualitative themes supported quantitative findings.

Conclusions

Most EM residency programs do not have formal scheduling policies for pregnant residents, but most PDs support making adjustments and do so informally. More education and guidance for PDs are needed to promote the development of formal policies.

Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Improves Pain Control in Patients With Rib Fractures

OBJECTIVES

The serratus anterior plane block (SAPB) is an ultrasound-guided compartment block; limited data suggest that it can decrease pain in patients with rib fractures or chest wall pain. We sought to determine the effect of SAPB on pain and incentive spirometry (IS) maximal vital capacity in adult patients with rib fractures.

METHODS

We enrolled a prospective sample of adult patients with at least two unilateral rib fractures who were being admitted for pain control. SAPB was performed by trained emergency physicians. Patients reported pain on an 11-point Numeric Rating Scale at rest and during IS, before, 15, and 60 minutes after SAPB.

RESULTS

Mean pain scores decreased by 1.8 (SD 2.17, 95% confidence interval [CI]: 0.79-2.81) at 15 minutes and 2.5 (SD 2.69, 95% CI: 1.24-3.76) at 60 minutes. Compared to pre-block pain scores during IS, mean pain scores decreased by 1.95 (SD 1.99, 95% CI: 1.02-2.88) at 15 minutes and 2.4 (SD 2.42, 95% CI: 1.27-3.53) at 60 minutes. Mean maximum vital capacity increased by 232 mL (SD 406, 95% CI: 36-427) at 60 minutes. Zero SAPB-attributable complications were identified in the 24 hours post-enrollment.

CONCLUSIONS

In patients with multiple rib fractures, SAPB reduced pain scores at rest and during IS, and increased maximal vital capacity. The SABP may be a safe and effective modality for pain control in trauma patients with multiple rib fractures.

"Going through the motions": A qualitative exploration of the impact of emergency medicine resident burnout on patient care

Objectives

Burnout occurs frequently in emergency medicine (EM) residents and has been shown to have a negative impact on patient care. The specific effects of burnout on patient care are less well understood. This study qualitatively explores how burnout may change the way EM residents provide patient care.

Methods

Qualitative data were obtained from a sample of 29 EM residents in four semistructured focus groups across four institutions in the United States in early 2019. Transcripts were coded and organized into major patient care themes.

Results

Residents described many ways in which feelings of burnout negatively impacted patient care. These detrimental effects most often fit into one of four main themes: reduced motivation to care for patients, poor communication with patients, difficult interactions with health care colleagues, and impaired decision making.

Conclusions

According to EM residents, burnout negatively impacts several important aspects of patient care. Resident engagement with clinical care, communication with patients and colleagues, and clinical care may suffer as a result of burnout.

Epistemic Beliefs: Relationship to Future Expectancies and Quality of Life in Cancer Patients

CONTEXT

Expectations about the future (future expectancies) are important determinants of psychological well-being among cancer patients, but the strategies patients use to maintain positive and cope with negative expectancies are incompletely understood.

OBJECTIVES

To obtain preliminary evidence on the potential role of one strategy for managing future expectancies: the adoption of "epistemic beliefs" in fundamental limits to medical knowledge.

METHODS

A sample of 1307 primarily advanced-stage cancer patients participating in a genomic tumor testing study in community oncology practices completed measures of epistemic beliefs, positive future expectancies, and mental and physical health-related quality of life (HRQOL). Descriptive and linear regression analyses were conducted to assess the relationships between these factors and test two hypotheses: 1) epistemic beliefs affirming fundamental limits to medical knowledge ("fallibilistic epistemic beliefs") are associated with positive future expectancies and mental HRQOL, and 2) positive future expectancies mediate this association.

RESULTS

Participants reported relatively high beliefs in limits to medical knowledge (M = 2.94, s.d.=.67) and positive future expectancies (M = 3.01, s.d.=.62) (range 0-4), and relatively low mental and physical HRQOL. Consistent with hypotheses, fallibilistic epistemic beliefs were associated with positive future expectancies (b = 0.11, SE=.03, P< 0.001) and greater mental HRQOL (b = 0.99, SE=.34, P = 0.004); positive expectancies also mediated the association between epistemic beliefs and mental HRQOL (Sobel Z=4.27, P<0.001).

CONCLUSIONS

Epistemic beliefs in limits to medical knowledge are associated with positive future expectancies and greater mental HRQOL; positive expectancies mediate the association between epistemic beliefs and HRQOL. More research is needed to confirm these relationships and elucidate their causal mechanisms.

A retrospective multistate analysis: Do regional football games impact emergency department patient volume?

OBJECTIVE

We sought to assess the effect of National Football League (NFL) games played by a regional sports team, the New England Patriots, on emergency department (ED) patient volume.

METHODS

We conducted a multicenter, retrospective chart review at the following 3 tertiary centers in New England from 2012 to 2019: Beth Israel Deaconess Medical Center, Boston, MA; Dartmouth Hitchcock Medical Center, Lebanon, NH; and Maine Medical Center, Portland, ME.

RESULTS

Within the NFL season, we observed a 2.6% overall decrease (-10.4 patients) in average total daily volume across the study sites on Sundays when Patriots games were played compared with Sundays when games were not played (P = 0.07; 95% confidence interval [CI], -22.37 to 1.62). We observed a 4.3% reduction (-19.0 patients) in average total daily volume across the study sites on Mondays during which Patriots games were played compared with Mondays without games (P = 0.15; 95% CI, -43.51 to 5.47). Subanalyses on the 5-hour period corresponding with each Patriots game showed reductions in mean patient volume per hour. Although our primary and subanalyses showed reductions in patient volume during Patriots games, these results were not statistically significant.

CONCLUSIONS

Our data support prior studies that showed a minimal impact of major sporting events on ED patient volume at tertiary centers. These results add to the limited data on this topic and can inform administrators whether staffing adjustments are necessary during similar types of sporting events.

How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD?

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.

OBJECTIVE

To assess how well the SQ predicts mortality and prompts ACP for COPD patients.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.

MAIN MEASURES

Emergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).

KEY RESULTS

The 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64-4.36).

CONCLUSIONS

The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.

Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses

Opioid use disorder is a critical public health problem that continues to broaden in scope, adversely affecting millions of people worldwide. Significant efforts have been made to expand access to medication therapy for opioid use disorder, in particular buprenorphine. As the emergency department is a critical point of access for many patients with opioid use disorder, the initiation of buprenorphine therapy in the emergency department is increasing, and emergency nurses should be familiar with the care of these vulnerable patients. The purpose of this article is to provide a clinical review of opioid use disorder and opioid withdrawal syndrome, medication treatments for opioid use disorder, best clinical practices for ED-initiated buprenorphine therapy, assessment of withdrawal symptoms, discharge considerations, and concerns for special populations. With expanded understanding of opioid use disorder, withdrawal, and available treatments, emergency nurses will be better prepared to deliver and support life-saving treatments for patients and families suffering from this disease. In addition, emergency nurses are well positioned to play an important role in public health advocacy around opioid use disorder, providing critical support for destigmatization and expanded access to safe and efficacious treatments.

"Pulling the Parachute": A Qualitative Study of Burnout's Influence on Emergency Medicine Resident Career Choices

OBJECTIVES

About half of all resident physicians report symptoms of burnout. Burnout negatively influences multiple aspects of their education and training. How burnout may impact residents' career choices remains unclear. The authors explored the role burnout played in residents' career decisions.

METHODS

This was a qualitative study among a sample of 29 emergency medicine residents from four institutions. Qualitative data were generated through four semistructured focus groups. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major themes.

RESULTS

Five major themes connecting burnout with residents' career choices emerged: 1) residents' current burnout and the prevention of future burnout figured prominently in their career considerations, 2) residents aimed to mitigate sources of burnout through their career choices, 3) residents' view of clinical work as a burden and a burnout contributor spurred the pursuit of other interests, 4) faculty advice and role modeling in relation to burnout shaped residents' career perspectives, and 5) residents weighed long-term burnout concerns with short-term financial needs.

CONCLUSION

Burnout played an important role in multiple aspects of residents' career considerations. Educators, program directors, and organization leaders can focus on identified target areas to address burnout's influence on residents' career decisions.

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

BACKGROUND

Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described.

OBJECTIVES

To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty.

DESIGN

Qualitative study using individual in-depth interviews.

PARTICIPANTS

Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital.

MEASUREMENTS

Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies.

RESULTS

Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness.

CONCLUSIONS

Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

"Necessary Compromises": A Qualitative Exploration of the Influence of Burnout on Resident Education

OBJECTIVE

Burnout is prevalent among resident physicians and has a negative impact on their well-being and effectiveness at work. How burnout shapes residents' educational experiences, attitudes, habits, and practices is not well understood. There is also a lack of research regarding self-identified mitigation strategies for residents. The authors qualitatively explored burnout's role in the educational experiences of resident physicians.

METHODS

Qualitative data were generated from a sample of 29 emergency medicine residents through four semistructured focus groups across four institutions in January and February 2019. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major and minor themes.

RESULTS

Residents reported that a misalignment of their individual versus institutional priorities and a lack of agency were significant contributors to their burnout. Residents described how burnout affected multiple aspects of their education, including their motivation and curiosity to learn, engagement in scholarly activity, and teaching of others. Residents identified several ways of building a sense of community that they explained was most useful in mitigating their experiences with burnout.

CONCLUSION

Burnout had a negative influence on many facets of residents' educational experiences during training. Program directors and educators can take resident-identified steps to moderate its detrimental role on trainee education.

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

BACKGROUND

Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described.

OBJECTIVES

To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty.

DESIGN

Qualitative study using individual in-depth interviews.

PARTICIPANTS

Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital.

MEASUREMENTS

Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies.

RESULTS

Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness.

CONCLUSIONS

Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

Predicting emergency department orders with multilabel machine learning techniques and simulating effects on length of stay

OBJECTIVE

Emergency departments (EDs) continue to pursue optimal patient flow without sacrificing quality of care. The speed with which a healthcare provider receives pertinent information, such as results from clinical orders, can impact flow. We seek to determine if clinical ordering behavior can be predicted at triage during an ED visit.

MATERIALS AND METHODS

Using data available during triage, we trained multilabel machine learning classifiers to predict clinical orders placed during an ED visit. We benchmarked 4 classifiers with 2 multilabel learning frameworks that predict orders independently (binary relevance) or simultaneously (random k-labelsets). We evaluated algorithm performance, calculated variable importance, and conducted a simple simulation study to examine the effects of algorithm implementation on length of stay and cost.

RESULTS

Aggregate performance across orders was highest when predicting orders independently with a multilayer perceptron (median F1 score = 0.56), but prediction frameworks that simultaneously predict orders for a visit enhanced predictive performance for correlated orders. Visit acuity was the most important predictor for most orders. Simulation results indicated that direct implementation of the model would increase ordering costs (from $21 to $45 per visit) but reduce length of stay (from 158 minutes to 151 minutes) over all visits.

DISCUSSION

Simulated implementations of the predictive algorithm decreased length of stay but increased ordering costs. Optimal implementation of these predictions to reduce patient length of stay without incurring additional costs requires more exploration.

CONCLUSIONS

It is possible to predict common clinical orders placed during an ED visit with data available at triage.

Serotonin Syndrome Associated With Vilazodone Overdose in a 22-Month-Old Treated With Dexmedetomidine

BACKGROUND

Vilazodone was approved by the U.S. Food and Drug Administration in 2011 as a treatment for major depression disorder. Vilazodone is a selective serotonin reuptake inhibitor and 5-HT1A agonist used in the treatment of depression in adults. Vilazodone increases the availability and activity of serotonin and its neural pathways. Vilazodone blocks the serotonin reuptake pump and desensitizes serotonin receptors (especially 5HT1A autoreceptors), therefore increasing serotonergic neurotransmission. Its partial agonist actions at presynaptic somatodendritic 5HT1A autoreceptors theoretically enhance serotonergic activity, contributing to antidepressant actions. There are limited reports exploring its effects in children after unintentional ingestion. Typical adult dosing is titrated from an initial dose of 10 mg up to a maximum dose of 40 mg daily. Serotonin syndrome classically manifests with restlessness, hyperthermia, tachycardia, mydriasis, and increased tone, and is typically treated with benzodiazepines, cyproheptadine, and supportive care. Dexmedetomidine has also been used in case reports to treat serotonin syndrome.

CASE REPORT

We report the case of a toddler with a laboratory-confirmed vilazodone overdose exhibiting symptoms of serotonin syndrome, including restlessness, hyperthermia, mydriasis, dystonia, agitation, seizure-like activity, roving eye movement, tachycardia, and elevated creatine kinase. The patient was admitted and initially treated with supportive care and lorazepam per recommendations of the poison center, which did not recommend cyproheptadine use. On decompensation with suspected serotonin syndrome, the patient was treated with dexmedetomidine. In addition, urine toxicology screening (Amphetamines II assay; Roche, Indianapolis, IN) was positive for amphetamines; however, confirmatory testing (gas chromatography-mass spectrometry) was negative. The patient improved and was discharged after returning to her baseline status at 74 h post ingestion. Importantly, this patient did not require intubation and mechanical intubation, in spite of the large amount of vilazodone ingested. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing prescription of vilazodone, emergency physicians should have a high level of suspicion so as not to miss this toxidrome. The possibility of false-positive amphetamine screenings when an overdose of vilazodone is suspected should be investigated. Finally, systematic evaluation of the use of dexmedetomidine as treatment for serotonin syndrome or vilazodone ingestion should be done to confirm efficacy.

Academic Emergency Medicine Faculty Experiences with Racial and Sexual Orientation Discrimination

INTRODUCTION

Despite the increasing diversity of individuals entering medicine, physicians from racial and sexual minority groups continue to experience bias and discrimination in the workplace. The objective of this study was to determine the current experiences and perceptions of discrimination on the basis of race and sexual orientation among academic emergency medicine (EM) faculty.

METHODS

We conducted a cross-sectional survey of a convenience sample of EM faculty across six programs. Survey items included the Overt Gender Discrimination at Work (OGDW) Scale adapted for race and sexual orientation, and the frequency and source of experienced and observed discrimination. Group comparisons were made using t-tests or chi-square analyses, and relationships between race or sexual orientation, and we evaluated physicians' experiences using correlation analyses.

RESULTS

A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Non-White physicians reported higher mean racial OGDW scores than their White counterparts (13.4 vs 8.6; 95% confidence interval (CI) for difference, -7.7 - -2.9). Non-White EM faculty were also more likely to report having experienced discriminatory treatment based on race than were White EM faculty (48.0% vs 12.6%; CI for difference, 16.6% - 54.2%), although both groups were equally likely to report having observed race-based discrimination of another physician. EM faculty who identified as sexual minorities reported higher mean sexual minority OGDW scores than their heterosexual counterparts (11.1 vs 7.1; 95% CI for difference, -7.3 - -0.6). There were no significant differences between sexual minority and heterosexual faculty in their reports of experiencing or observing discrimination based on sexual orientation.

CONCLUSION

EM faculty from racial and sexual minority groups perceived more discrimination based on race or sexual orientation in their workplace than their majority counterparts. EM faculty regardless of race or sexual orientation were similar in their observations of discriminatory treatment of another physician based on race or sexual orientation.

#MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment

Introduction

Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians’ experiences with workplace gender discrimination and sexual harassment.

Methods

We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians’ experiences using correlation analyses.

Results

A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6–6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%–65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%–25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%–43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.

Conclusion

Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.

Senior-Year Curriculum in U.S. Medical Schools: A Scoping Review

Phenomenon: Many U.S. medical schools have responded to the adoption of competency-based medical education (CBME) frameworks by renewing their final-year curricula and including internship preparatory courses. The purpose of this scoping review was to map the published literature regarding the final year to discern how medical schools have responded to this paradigm change. Approach: A structured 5-step approach was used to conduct this scoping review. Electronic searches of PubMed, ERIC, Scopus, MedEdPortal, and 8 medical education journals were conducted to identify relevant articles published from 2006 to 2016. Four authors screened articles for inclusion using standardized eligibility criteria; interrater agreement was discussed and calculated. Authors extracted data elements, and a consensus-based approach was used to categorize, sort, and structure information gathered. Findings: Among 6,485 articles retrieved, 817 articles were included in the study. From 2007-2011 to 2012-2016, articles addressing the final year of medical school increased 93%, whereas articles describing internship preparatory courses increased 218%. The majority of articles did not reference a CBME framework (572/817; 70%), the frequency of mentions increased 268% from 2007-2011 to 2012-2016. Nearly three fourths of preparatory course-related papers reference a CBME framework (37/50; 74%). Insights: Our findings may reflect a movement in U.S. medical schools toward using shared assessment metrics to support 4th-year medical students' preparation for their postgraduate medical education. Despite an increased reference to CBME, there is relatively little use of competency-based assessment frameworks to evaluate learning outcomes. This review also found a substantial increase in the frequency of articles referencing senior-year preparatory courses in U.S. medical schools. Articles tended to describe institution-specific research or experiences. Opportunities likely exist for multi-institutional and organizational collaboration in determining the structure of the final year of medical school.

Infant with bilious emesis

Clinical findings and imaging studies revealed an additional cause for concern.

Prognostic value of a modified surprise question designed for use in the emergency department setting

OBJECTIVE

Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, "Would you be surprised if this patient died in the next 30 days" could predict in-hospital mortality and resource utilization for hospitalized emergency department patients.

METHODS

For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated.

RESULTS

6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of 'comfort measures' orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses.

CONCLUSION

The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely.

Item Generation and Content Validity of the Child-Adolescent Bullying Scale

BACKGROUND

Healthcare providers do not uniformly screen young patients for exposure to bullying, and no screening instruments have been developed for widespread use in clinical settings.

OBJECTIVES

The objectives of this study were to (a) generate scale items by identifying and eliciting concepts relevant to youths with potential exposure to bullying as well as to professionals who work with bullied youths and (b) assess the content validity of the new Child-Adolescent Bullying Scale (CABS) instrument.

METHODS

A mixed-methods design was used to develop an initial pool of 52 items. The study was conducted in four phases: (I) comprehensive review of the existing literature; (II) concept elicitation through the conduct of focus groups with school-age youths and professionals who work with bullied youths; (III) concept selection and item construction; and (IV) content validation assessment of relevance, clarity, and dimension of each item by a panel of 30 international bullying and measurement experts through completion of an online survey.

RESULTS

An initial pool of 52 potential items was developed during Phases I-III of the study. During Phase IV, item- and scale-level content validity indices were calculated and were used to refine the item pool. These strategies resulted in a new, 22-item tool, with scale-level content validity indices of .954 for clarity and .920 for representativeness.

DISCUSSION

Evaluation of the CABS tool with a sample of youths drawn from healthcare settings will be necessary to assess the performance of the CABS items, further evaluate its psychometric properties, and further refine the tool.

Why Residents Quit: National Rates of and Reasons for Attrition Among Emergency Medicine Physicians in Training

Introduction

Recruiting and retaining residents who will complete their emergency medicine (EM) training is vital, not only because residency positions are a limited and costly resource, but also to prevent the significant disruptions, increased workload, and low morale that may arise when a resident prematurely leaves a program. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition.

Methods

In this retrospective, observational study we used national data from the American Medical Association National Graduate Medical Education Census for all residents who entered Accreditation Council for Graduate Medical Education-accredited EM programs between academic years 2006–2007 and 2015–2016. Our main outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main reason for attrition as well as resident factors associated with attrition.

Results

Compared to the other 10 largest specialties, EM had the lowest rate of attrition (0.8%, 95% confidence interval [CI] [0.7–0.9]), or approximately 51.6 (95% CI [44.7–58.5]) residents per year. In the attrition population, 44.2% of the residents were women, a significantly higher proportion when compared to the proportion of female EM residents overall (38.8%, p=0.011). A greater proportion of Hispanic/Latino (1.8%) residents also left their programs when compared to their White (0.9%) counterparts (p<0.001). In examining reasons for attrition as reported by the program director, female residents were significantly more likely than male residents to leave due to “health/family reasons” (21.5% vs 9.6%, p=0.019).

Conclusion

While the overall rate of attrition among EM residents is low, women and some under-represented minorities in medicine had a higher than expected rate of attrition. Future studies that qualitatively investigate the factors contributing to greater attrition among female and some ethnic minority residents are necessary to inform efforts promoting inclusion and diversity within the specialty.

Identifying Bullied Youth: Re-engineering the Child-Adolescent Bullying Scale into a Brief Screen

While youth bullying is a critical public health problem, standardized exposure screening is not routinely practiced. The Child-Adolescent Bullying Scale, (CABS), a psychometrically robust 22-item tool, was designed and evaluated for this purpose using classical test theory. The goals of the present study were to examine and optimize the measurement properties of the CABS using a Rasch psychometric analysis to develop a brief screening tool appropriate for clinical use. A methodologic design and the Rasch rating scale model were employed. Three hundred and fifty-two youths from two clinical sites participated. Rasch-based analyses included evaluation of response category functioning, measurement precision, dimensionality, targeting, differential item functioning and guidance in item reduction. After iterative revisions, the resulting screening instrument consists of 9 items. Cut-scores and interpretive guidance are provided to aid clinical identification of bullying-related risk. Findings suggest the CABS-9 holds promise as a useful screening tool for identifying bullying exposure.

Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes

BACKGROUND

Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes.

METHODS

We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme.

RESULTS

Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being.

CONCLUSIONS

Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.

Emergency Medicine Trainee Burnout Is Associated With Lower Patients' Satisfaction With Their Emergency Department Care

INTRODUCTION

Emergency medicine (EM) physicians and trainees report high levels of burnout. Burnout negatively impacts physician well-being and career satisfaction but it remains unclear how burnout may influence patient care. We examined the degree to which EM trainee burnout at one institution was associated with patients' satisfaction with their emergency department (ED) care.

METHODS

In this cross-sectional, pilot study conducted at a single institution, we measured EM trainee burnout using the Maslach Burnout Inventory through a confidential, electronic survey. We subsequently linked individual trainee burnout results with their individual Press Ganey (PG) ED patient satisfaction scores. We compared burnout scores across sex and postgraduate year using chi-square tests and PG results via analysis of variance.

RESULTS

Twenty-seven of 53 (50.9%) eligible EM trainees completed the burnout assessment. Trainees reported an overall burnout rate of 77.8% (95% confidence interval = 59.2%-89.4%). There were no significant differences in burnout based on sex (p = 0.888) or postgraduate year (p = 0.671). Trainee burnout was significantly associated with lower trainee-specific PG scores, including patient ratings of resident physician courtesy (p = 0.011), taking the time to listen (p = 0.004), keeping informed of treatment (p = 0.014), and concern for patient comfort (p = 0.006). There was no significant association between trainee burnout and patients' overall likelihood to recommend the ED to others (p = 0.364).

CONCLUSION

Emergency medicine trainee burnout is associated with lower trainee-specific PG ED patient satisfaction scores across all four physician domains. In addition to its detrimental impact on physician wellness, burnout may play a significant adverse role in patients' perceptions of their ED providers' interpersonal and communication skills.

The Child Adolescent Bullying Scale (CABS): Psychometric evaluation of a new measure

While youth bullying is a significant public health problem, healthcare providers have been limited in their ability to identify bullied youths due to the lack of a reliable, and valid instrument appropriate for use in clinical settings. We conducted a multisite study to evaluate the psychometric properties of a new 22-item instrument for assessing youths' experiences of being bullied, the Child Adolescent Bullying Scale (CABS). The 20 items summed to produce the measure's score were evaluated here. Diagnostic performance was assessed through evaluation of sensitivity, specificity, predictive values, and area under receiver operating characteristic (AUROC) curve. A sample of 352 youths from diverse racial, ethnic, and geographic backgrounds (188 female, 159 male, 5 transgender, sample mean age 13.5 years) were recruited from two clinical sites. Participants completed the CABS and existing youth bullying measures. Analyses grounded in classical test theory, including assessments of reliability and validity, item analyses, and principal components analysis, were conducted. The diagnostic performance and test characteristics of the CABS were also evaluated. The CABS is comprised of one component, accounting for 67% of observed variance. Analyses established evidence of internal consistency reliability (Cronbach's α = 0.97), construct and convergent validity. Sensitivity was 84%, specificity was 65%, and the AUROC curve was 0.74 (95% CI: 0.69-0.80). Findings suggest that the CABS holds promise as a reliable, valid tool for healthcare provider use in screening for bullying exposure in the clinical setting.

Intern as Patient: A Patient Experience Simulation to Cultivate Empathy in Emergency Medicine Residents

Introduction

Prior work links empathy and positive physician-patient relationships to improved healthcare outcomes. The objective of this study was to analyze a patient experience simulation for emergency medicine (EM) interns as a way to teach empathy and conscientious patient care.

Methods

We conducted a qualitative descriptive study on an in situ, patient experience simulation held during EM residency orientation. Half the interns were patients brought into the emergency department (ED) by ambulance and half were family members. Interns then took part in focus groups that discussed the experience. Data collected during these focus groups were coded by two investigators using a grounded theory approach and constant comparative methodology.

Results

We identified 10 major themes and 28 subthemes in the resulting qualitative data. Themes were in three broad categories: the experience as a patient or family member in the ED; application to current clinical practice; and evaluation of the exercise itself. Interns experienced firsthand the physical discomfort, emotional stress and confusion patients and families endure during the ED care process. They reflected on lessons learned, including the importance of good communication skills, frequent updates on care and timing, and being responsive to the needs and concerns of patients and families. All interns felt this was a valuable orientation experience.

Conclusion

Conducting a patient experience simulation may be a practical and effective way to develop empathy in EM resident physicians. Additional research evaluating the effect of participation in the simulation over a longer time period and assessing the effects on residents' actual clinical care is warranted.

Free Open Access Medical Education (FOAM) Resources in a Team-Based Learning Educational Series

Although Free Open Access Medical Education (FOAM) has become popular within emergency medicine, concerns exist regarding its role in resident education. We sought to develop an educational intervention whereby residents could review FOAM resources while maintaining faculty oversight. We created a novel curriculum pairing FOAM from the Academic Life in Emergence Medicine (ALiEM) Approved Instructional Resources (Air) series with a team-based learning (TBL) format. Residents have an opportunity to engage with FOAM in a structured setting with faculty input on possible practice changes. This series has been well-received by residents and appears to have increased engagement with core content material. Qualitative feedback from residents on this series has been positive and we believe this is the first described use of TBL in emergency medicine.

Impact of Non-medical Out-of-pocket Expenses on Families of Children With Cerebral Palsy Following Orthopaedic Surgery

PURPOSE

Limited research has been conducted on the non-medical out-of-pocket expenses (NOOPEs) incurred by families of children with chronic health conditions. The study objectives were to: 1) calculate the estimated NOOPEs incurred by families during hospitalization of their child, 2) identify predictors of high NOOPEs, and 3) assess the impact of the child's chronic health condition on the family's finances.

DESIGN AND METHODS

Prospective observational study. Parents were included if their child was 3-20years old, had severe, non-ambulatory cerebral palsy (CP), and scheduled for hip or spine surgery. Parents reported all NOOPEs incurred during their child's hospitalization using the Family Expense Diary. Families completed the subscales of the Impact on Family Scale and the Assessment of Caregivers Experience with Neuromuscular Disease. Descriptive and univariate and multiple hierarchical regression models were used in the analysis.

RESULTS

Fifty two parents participated. The total NOOPEs ranged from $193.00 to $7192.71 (M=$2001.92) per hospitalization representing an average of 4% of the family's annual earned income. Caregiver age (F=8.393, p<0.001), income (F=7.535, p<0.001), and distance traveled to the hospital (F=4.497, p=0.039) were significant predictors of high NOOPEs. The subscale scores indicated that a child's chronic health condition had a significant impact on family finances.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Hospitalization is associated with numerous NOOPEs that create additional financial demands for families caring for a child with severe CP. NOOPEs should be addressed when preparing families for their children's planned hospital admissions, especially those families of CSHCN who experience significant financial impacts secondary to their children's care.

"I Didn't Even Know You Cared About That Stuff": Youths' Perceptions of Health Care Provider Roles in Addressing Bullying

INTRODUCTION

Youth bullying is a critical public health problem, with those exposed to bullying at risk for development of serious sequelae lasting into adulthood. The purpose of this study was to explore youths' perceptions regarding the role that advanced practice nurses and physicians play in addressing bullying.

METHODS

A qualitative descriptive approach was used; focus groups were used to generate study data. Twenty-four adolescents participated in focus groups centered on exploring health care providers' roles in addressing bullying.

RESULTS

Three themes emerged through qualitative analysis: (a) Not sure that's part of their job, (b) That's way too personal, and (c) They couldn't help anyway. Participants described a very limited role for health care providers in addressing bullying.

DISCUSSION

Youths recognized a narrow role for health care providers in addressing bullying, characterizing bullying as a school- or-community-related issue rather than one influencing health.

Technology-enhanced focus groups as a component of instrument development

Background Bullying is a critical public health problem and a screening tool for use in healthcare is needed. Focus groups are a common tool for generating qualitative data when developing an instrument and evidence suggests that technology-enhanced focus groups can be effective in simultaneously engaging participants from diverse settings. Aim To examine the use of technology-enhanced focus groups in generating an item pool to develop a youth-bullying screening tool. Discussion The authors explore methodological and ethical issues related to conducting technology-enhanced focus groups, drawing on their experience in developing a youth-bullying measure. They conducted qualitative focus groups with professionals from the front lines of bullying response and intervention. They describe the experience of conducting technology-enhanced focus group sessions, focusing on the methodological and ethical issues that researchers engaging in similar work may encounter. Challenges associated with this methodology include establishing rapport among participants, privacy concerns and limited non-verbal communication. Conclusion The use of technology-enhanced focus groups can be valuable in obtaining rich data from a wide variety of disciplines and contexts. Organising these focus groups was inexpensive and preferred by the study's participants. Implications for practice Researchers should consider using technology-enhanced focus groups to generate data to develop health-related measurement tools.

Congratulations, You're Pregnant! Now About Your Shifts . . . : The State of Maternity Leave Attitudes and Culture in EM

INTRODUCTION

Increasing attention has been focused on parental leave, but little is known about early leave and parental experiences for male and female attending physicians. Our goal was to describe and quantify the parental leave experiences of a nationally representative sample of emergency physicians (EP).

METHODS

We conducted a web-based survey, distributed via emergency medicine professional organizations, discussion boards, and listservs, to address study objectives.

RESULTS

We analyzed data from 464 respondents; 56% were women. Most experienced childbirth while employed as an EP. Fifty-three percent of women and 60% of men reported working in a setting with a formal maternity leave policy; however, 36% of women and 18% of men reported dissatisfaction with these policies. Most reported that other group members cover maternity-related shift vacancies; a minority reported that pregnant partners work extra shifts prior to leave. Leave duration and compensation varied widely, ranging from no compensated leave (18%) to 12 or more weeks at 100% salary (7%). Supportive attitudes were reported during pregnancy (53%) and, to a lesser degree (43%), during leave. Policy improvement suggestions included the development of clear, formal policies; improving leave duration and compensation; adding paternity and adoption leave; providing support for physicians working extra to cover colleagues' leave; and addressing breastfeeding issues.

CONCLUSION

In this national sample of EPs, maternity leave policies varied widely. The duration and compensation during leave also had significant variation. Participants suggested formalizing policies, increasing leave duration and compensation, adding paternity leave, and changing the coverage for vacancies to relieve burden on physician colleagues.

The evolution of uncertainty in second opinions about prostate cancer treatment

Background

People who have cancer increasingly seek second opinions. Yet, we know little about what motivates patients to seek them and how beneficial they are. Uncertainty—experienced by patients or communicated by physician and patient—may be crucial throughout the second opinion process.

Objective

This study sought to investigate (1) how uncertainty influences men with prostate cancer to seek second opinions and (2) how second opinions may affect these patients’ sense of uncertainty and subsequent experiences with their care.

Methods

A qualitative study using semi‐structured interviews was performed. Men with localized or advanced prostate cancer (n=23) were interviewed by telephone about their motivations and experiences with seeking second opinions and the uncertainties they experienced. Analysis was performed using the constant comparative method.

Results

Patients sought second opinions because they were uncertain about receiving too little or biased information, experienced insufficient support in coming to a treatment decision, or because physicians expressed different levels of uncertainty than they did (“unshared uncertainty”). Uncertainty was reduced by the second opinion process for most patients, whereas for others, it increased or was sustained. This evolution depended on the way uncertainty was addressed during the second opinion consultation.

Conclusions

Second opinions may be a useful tool for some but not all patients. They should be used judiciously and not be viewed as a solution for current limitations to health‐care organization. An important yet challenging task for physicians is to focus less on information per se and more on how to assist patients manage irreducible uncertainty.

Using the Surprise Question To Identify Those with Unmet Palliative Care Needs in Emergency and Inpatient Settings: What Do Clinicians Think?

BACKGROUND

The surprise question (SQ), "Would you be surprised if this patient died within the next year?" is effective in identifying end-stage renal disease and cancer patients at high risk of death and therefore potentially unmet palliative care needs. Following implementation of the SQ in our acute care setting, we sought to explore hospital-based providers' perceptions of the tool.

OBJECTIVES

To evaluate (1) providers' perceptions regarding the feasibility of SQ use in emergency and inpatient settings, (2) clinician perceptions regarding the utility of the SQ, and (3) barriers to SQ use.

DESIGN

A cross-sectional survey of medical providers following addition of the SQ to the electronic record for all patients admitted to a tertiary care hospital.

RESULTS

A total of 111/203 (55%) providers participated: 48/57 (84%) emergency physicians (EPs) and 63/146 (43%) inpatient providers (IPs). Most reported no difficulty using the SQ. Modest numbers in both groups reported that the SQ influenced care delivery (EPs 37%, IPs 42%) as well as goals of care (EPs 45%, IPs 52%). At least some advance care planning discussions were prompted by the SQ (EPs 45%, IPs 58%). Team discussions were influenced by SQ use for more than half of each group. Most respondents (55%) expressed some concern that their SQ responses could be inaccurate.

CONCLUSIONS

In this setting, clinicians indicated that use of the SQ is feasible, acceptable, and useful in facilitating advance care planning discussions among teams, patients, and families. Many reported that SQ use influenced goals of care, but concern regarding accuracy was a barrier. Additional research examining SQ accuracy and predictive ability is warranted.

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay

OBJECTIVE

The objective was to evaluate the effect of an emergency clinician-initiated "ED admission holding order set" on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients.

METHODS

We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a "non-value-added" activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior.

RESULTS

The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention.

CONCLUSIONS

We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change.

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation

Introduction

Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings’ education, experience, and knowledge regarding mechanical ventilation in the emergency department.

Methods

We developed a survey of academic EM attendings’ educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings’ scores on the assessment instrument and their training, education, and comfort with ventilation.

Results

Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0–1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one’s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education.

Conclusion

EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0–1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.

Psychometric properties of a novel knowledge assessment tool of mechanical ventilation for emergency medicine residents in the northeastern United States

PURPOSE

Prior descriptions of the psychometric properties of validated knowledge assessment tools designed to determine Emergency medicine (EM) residents understanding of physiologic and clinical concepts related to mechanical ventilation are lacking. In this setting, we have performed this study to describe the psychometric and performance properties of a novel knowledge assessment tool that measures EM residents' knowledge of topics in mechanical ventilation.

METHODS

Results from a multicenter, prospective, survey study involving 219 EM residents from 8 academic hospitals in northeastern United States were analyzed to quantify reliability, item difficulty, and item discrimination of each of the 9 questions included in the knowledge assessment tool for 3 weeks, beginning in January 2013.

RESULTS

The response rate for residents completing the knowledge assessment tool was 68.6% (214 out of 312 EM residents). Reliability was assessed by both Cronbach's alpha coefficient (0.6293) and the Spearman-Brown coefficient (0.6437). Item difficulty ranged from 0.39 to 0.96, with a mean item difficulty of 0.75 for all 9 questions. Uncorrected item discrimination values ranged from 0.111 to 0.556. Corrected item-total correlations were determined by removing the question being assessed from analysis, resulting in a range of item discrimination from 0.139 to 0.498.

CONCLUSION

Reliability, item difficulty and item discrimination were within satisfactory ranges in this study, demonstrating acceptable psychometric properties of this knowledge assessment tool. This assessment indicates that this knowledge assessment tool is sufficiently rigorous for use in future research studies or for assessment of EM residents for evaluative purposes.

Temporal changes in tolerance of uncertainty among medical students: insights from an exploratory study

BACKGROUND

Physicians' tolerance of uncertainty (TU) is a trait potentially associated with desirable outcomes, and emerging evidence suggests it may change over time. Past studies of TU, however, have been cross-sectional and have not measured tolerance of the different, specific types of uncertainty that physicians confront. We addressed these limitations in a longitudinal exploratory study of medical students.

METHODS

At the end of medical school (Doctor of Medicine degree) Years 1 and 4, a cohort of 26 students at a US medical school completed measures assessing tolerance of different types of uncertainty: 1) complexity (uncertainty arising from features of information that make it difficult to comprehend); 2) risk (uncertainty arising from the indeterminacy of future outcomes); and 3) ambiguity (uncertainty arising from limitations in the reliability, credibility, or adequacy of information). Change in uncertainty-specific TU was assessed using paired t-tests.

RESULTS

Between Years 1 and 4, there was a significant decrease in tolerance of ambiguity (t=3.22, p=0.004), but no change in students' tolerance of complexity or risk.

CONCLUSIONS

Tolerance of ambiguity--but not other types of uncertainty--decreases during medical school, suggesting that TU is a multidimensional, partially mutable state. Future studies should measure tolerance of different uncertainties and examine how TU might be improved.