Remote patient monitoring for ED discharges in the COVID-19 pandemic.

COVID-19 has had a significant effect on healthcare resources worldwide, with our knowledge of the natural progression of the disease evolving for the individual patient. To allow for early detection of worsening clinical status, protect hospital capacity and provide extended access for vulnerable patients, our emergency department developed a remote patient monitoring programme for discharged patients with COVID-19. The programme uses a daily emailed secure link to a survey in which patients submit biometric and symptoms data for monitoring. Patients' meeting criteria are escalated to a physician for a phone or video visit. Here, we describe the development, implementation and preliminary analysis of utilisation of the programme.

National trends in chest pain visits in US emergency departments (2006-2016).

BACKGROUND: Chest pain is a common complaint in EDs. In this study, we describe demographic, care and cost trends in US ED visits for chest pain over 11 years. METHODS: This is a retrospective descriptive study of trends in utilisation and care of ED chest pain visits from 2006 to 2016) using data from the Healthcare Cost and Utilization Project database, a national sample of US ED visits and hospitalisations. RESULTS: From 2006 to 2016, there were 42.48 million chest pain visits. Visits per 100 000 persons increased from 1140.4 in 2006 to 1611.7 in 2016 (p<0.001). The chest pain inpatient admission rate declined from 19% in 2006 to 3.9% in 2016 (p<0.001); associated inpatient hospitalisation costs declined from $10.4 billion (2006-2008) to $6.2 billion (2012-2014). CONCLUSION: From 2006 to 2016, ED visits in the USA for chest pain increased with a significant decline in admission rates and inpatient hospitalisation costs.

Direct Observation Assessment of Ultrasound Competency Using a Mobile Standardized Direct Observation Tool Application With Comparison to Asynchronous Quality Assurance Evaluation.

OBJECTIVES: Competency assessment is a key component of point-of-care ultrasound (POCUS) training. The purpose of this study was to design a smartphone-based standardized direct observation tool (SDOT) and to compare a faculty-observed competency assessment at the bedside with a blinded reference standard assessment in the quality assurance (QA) review of ultrasound images. METHODS: In this prospective, observational study, an SDOT was created using SurveyMonkey containing specific scoring and evaluation items based on the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound: Consensus Document for the Emergency Ultrasound Milestone Project. Ultrasound faculty used the mobile phone-based data collection tool as an SDOT at the bedside when students, residents, and fellows were performing one of eight core POCUS examinations. Data recorded included demographic data, examination-specific data, and overall quality measures (on a scale of 1-5, with 3 and above being defined as adequate for clinical decision making), as well as interpretation and clinical knowledge. The POCUS examination itself was recorded and uploaded to QPath, a HIPAA-compliant ultrasound archive. Each examination was later reviewed by another faculty blinded to the result of the bedside evaluation. The agreement of examinations scored adequate (3 and above) in the two evaluation methods was the primary outcome. RESULTS: A total of 163 direct observation evaluations were collected from 23 EM residents (93 SDOTs [57%]), 14 students (51 SDOTs [31%]), and four fellows (19 SDOTs [12%]). The trainees were evaluated on completing cardiac (54 [33%]), focused assessment with sonography for trauma (34 [21%]), biliary (25 [15%]), aorta (18 [11%]), renal (12 [7%]), pelvis (eight [5%]), deep vein thrombosis (seven [4%]), and lung scan (5 [3%]). Overall, the number of observed agreements between bedside and QA assessments was 81 (87.1% of the observations) for evaluating the quality of images (scores 1 and 2 vs. scores 3, 4, and 5). The strength of agreement is considered to be "fair" (κ = 0.251 and 95% confidence interval [CI] = 0.02-0.48). Further agreement assessment demonstrated a fair agreement for images taken by residents and students and a "perfect" agreement in images taken by fellows. Overall, a "moderate" inter-rater agreement was found in 79.1% for the accuracy of interpretation of POCUS scan (e.g., true positive, false negative) during QA and bedside evaluation (κ = 0.48, 95% CI = 0.34-0.63). Faculty at the bedside and QA assessment reached a moderate agreement on interpretations noted by residents and students and a "good" agreement on fellows' scans. CONCLUSION: Using a bedside SDOT through a mobile SurveyMonkey platform facilitates assessment of competency in emergency ultrasound learners and correlates well with traditional competency evaluation by asynchronous weekly image review QA.

Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia.

BACKGROUND: We compare educational environments (i.e. physical, emotional and intellectual experiences) of emergency medicine (EM) residents training in the United States of America (USA) and Saudi Arabia (SA). METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure (PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales (autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance. RESULTS: A total of 219 surveys were returned for 260 residents across six programs (3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%-100%. All six residencies were qualitatively rated as "more positive than negative but room for improvement". Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries (P=0.243); however, role autonomy (P<0.001) and teaching (P=0.005) were better in USA programs. There were no significant differences by post-graduate training year. CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.

Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia / 世界急诊医学杂志（英文）

BACKGROUND:We compare educational environments (i.e. physical, emotional and intel ectual experiences) of emergency medicine (EM) residents training in the United States of America (USA) and Saudi Arabia (SA). METHODS:A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure (PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales (autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance. RESULTS:A total of 219 surveys were returned for 260 residents across six programs (3 SA, 3 USA), with a response rate of 84％. Program-specific response rates varied from 79％–100％. All six residencies were qualitatively rated as "more positive than negative but room for improvement". Quantitative PHEEM scores for the USA programs were significantly higher:118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries (P=0.243); however, role autonomy (P<0.001) and teaching (P=0.005) were better in USA programs. There were no significant differences by post-graduate training year. CONCLUSION:EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.

Trauma-Induced Bilateral Ectopia Lentis Diagnosed with Point-of-Care Ultrasound.

BACKGROUND: Ocular trauma and acute loss of vision are high-yield patient presentations that may benefit from the use of bedside ultrasound to aid in the diagnosis of a variety of vision-threatening problems. CASE REPORT: We present a case of bilateral lens dislocation in which the diagnosis of lens dislocation was missed on initial computed tomography of the orbits but detected on bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point-of-care ultrasound can rapidly identify ocular pathology and expedite specialist consultation, and if necessary, transfer to a specialty center for further management.