Impact of Medical Scribes on Provider Efficiency in the Pediatric Emergency Department.

OBJECTIVES: Today's emergency department (ED) providers spend a significant amount of time on medical record documentation, decreasing clinical productivity. One proposed solution is to utilize medical scribes who assist with documentation. We hypothesized that scribes would increase provider productivity and increase provider satisfaction without affecting patient experience or nursing satisfaction. METHODS: We conducted an observational pre-post study comparing ED prescribe and postscribe clinical productivity metrics for 18 pediatric emergency medicine physicians, two general pediatricians, and two nurse practitioners working in the 12-bed nonurgent area of the pediatric ED. Productivity metrics included patients per hour (pts/hr), work relative value units per hour (wRVUs/hr), and visit duration measured for 1 year pre- and postscribe implementation. Cross-sectional satisfaction surveys were administered to patient families, providers, and nurses during the initial scribe rollout. RESULTS: Overall, 24,518 prescribe and 27,062 postscribe visits were analyzed. Following scribe implementation, overall provider efficiency increased by 0.24 pts/hr (11.98%, p < 0.001) and 0.72 wRVUs/hr (20.14%, p < 0.001). The largest efficiency increase (0.36 pts/hr, 0.96 wRVUs/hr) occurred in January-March, when ED census peaked. Patient visit duration was 53 minutes in both the prescribe and the postscribe periods. During initial scribe implementation, 80% of parents of patients without a scribe rated the visit as very good/great compared to 84% with a scribe (p = 0.218). Of the 34 providers surveyed, 88% preferred working with a scribe. A majority of providers (82%) felt that their skills were used more effectively when working with a scribe, decreasing their likelihood of experiencing burnout. Of the 43 nurses surveyed, 51% preferred scribes and 47% were indifferent. CONCLUSIONS: Medical scribes increased ED efficiency without decreasing patient satisfaction. Providers strongly favored the use of scribes, while nurses were indifferent. The next steps include a cost analysis of the scribe program.

Lower Extremity Weakness in an Adolescent Female - A Rare Presentation of Ewing Sarcoma.

BACKGROUND: Ewing sarcoma, a rare cause of cord compression, is predominantly of osseous origin but can also originate in soft tissues. Soft-tissue manifestations account for <15% of all Ewing sarcoma tumors, and even fewer cases of Ewing sarcoma originating in the epidural space have been documented. CASE REPORT: A 19-year-old female presented to the emergency department for worsening low-back pain during the previous 6 months and numbness and weakness in her legs during the prior 2 weeks. Magnetic resonance imaging revealed an epidural mass at the L4-L5 level. Intravenous steroids were started for a presumed diagnosis of lymphoma. Orthopedic surgery consultants deferred computed tomography-guided biopsy of the mass out of concern for tumor seeding. Compression symptoms worsened to include foot drop and saddle anesthesia, prompting urgent radiation therapy. After the patient showed poor response to appropriate treatment for lymphoma, other malignant and infectious causes were considered. Biopsy was performed on day 3 of the patient's hospital stay, and by day 7, preliminary cytology results revealed Ewing sarcoma. Subsequent laminectomy and tumor resection produced immediate relief of pain, along with a gradual return of strength and sensation. The mass was found to be of soft-tissue origin and was classified as an extraosseous Ewing sarcoma. The patient was referred to a pediatric oncologist to complete the appropriate chemotherapy after diagnosis. CONCLUSION: This case demonstrates how an uncommon manifestation of a rare disease can mimic a classic presentation of cord compression. Our aim is to bring awareness to this disease and to emphasize the importance of timely biopsy of any mass.

Irx4 Marks a Multipotent, Ventricular-Specific Progenitor Cell.

While much progress has been made in the resolution of the cellular hierarchy underlying cardiogenesis, our understanding of chamber-specific myocardium differentiation remains incomplete. To better understand ventricular myocardium differentiation, we targeted the ventricle-specific gene, Irx4, in mouse embryonic stem cells to generate a reporter cell line. Using an antibiotic-selection approach, we purified Irx4+ cells in vitro from differentiating embryoid bodies. The isolated Irx4+ cells proved to be highly proliferative and presented Cxcr4, Pdgfr-alpha, Flk1, and Flt1 on the cell surface. Single Irx4+ ventricular progenitor cells (VPCs) exhibited cardiovascular potency, generating endothelial cells, smooth muscle cells, and ventricular myocytes in vitro. The ventricular specificity of the Irx4+ population was further demonstrated in vivo as VPCs injected into the cardiac crescent subsequently produced Mlc2v+ myocytes that exclusively contributed to the nascent ventricle at E9.5. These findings support the existence of a newly identified ventricular myocardial progenitor. This is the first report of a multipotent cardiac progenitor that contributes progeny specific to the ventricular myocardium. Stem Cells 2016;34:2875-2888.