ABSTRACT
Background and Objectives: Patients with PE are traditionally admitted on parenteral agents, despite increasing literature that sPESI negative patients can be safely discharged from the ED. Our quality improvement initiative is focused on outpatient treatment for ED-diagnosed pulmonary emboli (OTPE) and our objective is to assess LOS, readmissions and to describe findings of our follow-up phone calls. Methods: This is an actively enrolling prospective study from 7/2020 at a single site with >500 PE cases per year with a PE Response Team (PERT). All ED PE patients are screened for OTPE. Exclusion criteria include sPESI ≥ 1, ESC high or intermediate, bleeding ≤ 30 days, hemoglobin < 8, platelet < 50,000, pregnancy, prior VTE, concomitant COVID-19, recent major surgery and social factors. Patients identified are discussed with PERT and ED physicians. If agreed upon, patients are discharged on DOAC with follow-up within one week. Patients receive calls on days 3, 7, and 30 from the OTPE team to assess AE relating to the DOAC or PE. LOS metrics are reported as mean with standard deviations, and readmissions are reported as percentages. Results: Ninety-eight low-risk patients were identified, of which 50 were OTPE-eligible with mean age 44.5 ± 16.9 years of age and 58% female. When comparing OTPE to low-risk admissions, there are no differences in age (p=0.35) and sex (p=0.72). For OTPE, the follow-up calls on day 3, 7, and 30 revealed no patient reported recurrent VTE, major bleeding or death. There was a similar ED provider to disposition LOS (p=0.74). Low-risk admissions had a higher rate of readmission than OTPE (p=0.19). Conclusion: Our OTPE process does not increase ED provider to disposition LOS, readmissions, or adverse outcomes. Future work will examine financial implications of OTPE and barriers to adoption of the process. As this is actively enrolling quality improvement initiative, we will continue to track postimplementation to optimize our process.
ABSTRACT
Study Objectives: Covid derailed multiple facets of emergency medicine (EM) residency training, including the need to move from in-person to online weekly didactics. While online education has been used within 90% of medical schools, it has not traditionally been used for residency education. Recent studies evaluating post-graduate residents' perception of online education found a receptive audience eager to incorporate the modality. To date, no study has analyzed how EM programs are approaching online education, including content, efficacy, and attendance etiquette. Methods: As part of a process improvement project, an online Survey Monkey questionnaire was sent out to 180 EM residency program directors and coordinators. The survey was open from November 2020 to March 2021. Results: We received 52 responses from program directors and coordinators from all regions of the United States with a majority from academic or university-affiliated programs. Due to COVID-19, over 90% of programs shifted to an online didactic platform with only 10% maintaining in-person didactics. Zoom has been the preferred modality utilized at 89% of programs we surveyed with minimal security and techinical issues. Program consensus was that residents should be on time or no more than 5-minutes late for credit (42% of programs), have video cameras on (52% of programs), and appear attentive (44% of programs). Virtual etiquette was also examined, including screen presence: upright posture (less than 18% of programs reported accountable), background (less than 10%), and lighting (less than 6%). A majority of programs had not set expectations for screen presence. If not presenting, the dress code is generally at the resident’s discretion and was noted to be casual (52%). Sixty percent of programs reported increased faculty attendance since moving to a virtal conference. Programs also reported maintiaing consistency in content (62% of programs), increased utilization of guest speakers (50% of programs), use of national platforms (21% of programs), and maintaing small group sessions (77% of programs). Many residency programs do not record didactics, and only 15% offer credit if lectures are watched at a later date. When safely able, over 65% of programs plan to return to in-person didactics. Conclusion: The online learning platform provides opportunities and proves challenges. Many programs have shifted to online learning and diversified their curriculum. EM residency training requires a strong foundation in core content, which may not entirely be suited for an online platform. This coupled with the loss of face-to-face learning may reflected in the desire for programs to return to in-person learning. The benefits of online learning, which include accessibility, flexibility, and broader reach of topics should not be neglected. Further exploration of the efficacy of knowledge acquisition within online didactics would aid in decisions regarding next steps for return to a potential hybrid teaching model.
ABSTRACT
Rationale: Severe coronavirus disease 2019 (COVID-19) is associated with important variations within the immune system and the coagulation cascade. We have developed a robust method for computing ventilation (CT-V) and perfusion (CT-P) from dynamic non-contrast CT scan, which can detect ventilation-perfusion (VQ) mismatch at a voxel level. We hypothesize that COVID-19 patients with mild disease will still have a higher VQ mismatch compared to patients with no respiratory symptoms. Methods: We included 12 random patients with mild symptoms from a prospective study characterizing quantitative lung function in patients with COVID-19 (NCT04320511) and compared their VQ scores to 12 patients with no respiratory symptoms in the NORM dataset (NCT00848406) matched to age, gender and BMI. The CT-P and CT-V methods apply image processing and physical modeling to an Inhale/Exhale CT image pair to generate a quantitative CT-P and CT-V images. We calculated VQ mismatch as the percent of lung voxels with residual fit errors 4 standard deviations apart from a least median of squares quadratic regression model describing CT-P as a function of CT-V.Results: All included COVID cases were hospitalized to regular floors and were breathing at room air, except for 3 patients on supplemental oxygen < 3L/min. The mean CT-V scores were significantly lower in COVID-19 cases compared to controls (0.46 vs. 1.39, 95% CI difference 0.51, 1.33, p 0.001). Likewise, the mean CT-P scores were significantly lower in COVID-19 cases vs. controls (0.14 vs. 0.18, 95% CI difference 0.02, 0.08, p 0.004). However, the median VQ mismatch scores were significantly higher in COVID-19 cases [0.300 (IQR 0.287,0.320) vs. 0.270 (IQR 0.233,0.293), p 0.04], see figure. Conclusion: Patients with COVID-19 have significant derangements in pulmonary physiology, VQ mismatch despite having minimal to no-oxygen requirements. Progression of VQ mismatch from an early stage could be studied to identify patients at risk for mechanical ventilation and mortality. Figure: (Left) Box plots of the VQ scores for each COVID cases vs. controls. (Right) Representative CT-V and CT-P in a patient with COVID-19 pneumonia with corresponding CT scan. Higher function areas appear red and low function areas appear bluer. Top row depicts "Dead space ventilation" with normal appearing CT scan but diminished areas of perfusion in the right lung and preserved ventilation. Bottom row demonstrates area of pneumonia in the left upper lung zone with "Shunt physiology". CT-P shows increased activity with reddish hue, whereas corresponding ventilation is diminished in the same area.