Mpox Surveillance Based on Rash Characteristics - 13 Emergency Departments, United States, June-December 2023.

In 2022, a global mpox outbreak occurred, primarily affecting gay and bisexual men who have sex with men (GBMSM). To screen for mpox's reemergence and investigate potentially unsuspected cases among non-GBMSM, prospective surveillance of patients aged ≥3 months with an mpox-compatible rash (vesicular, pustular, ulcerated, or crusted) was conducted at 13 U.S. emergency departments (EDs) during June-December 2023. Demographic, historical, and illness characteristics were collected using questionnaires and electronic health records. Lesions were tested for monkeypox virus using polymerase chain reaction. Among 196 enrolled persons, the median age was 37.5 years (IQR = 21.0-53.5 years); 39 (19.9%) were aged <16 years, and 108 (55.1%) were male. Among all enrollees, 13 (6.6%) were GBMSM. Overall, approximately one half (46.4%) and one quarter (23.5%) of enrolled persons were non-Hispanic White and non-Hispanic Black or African American, respectively, and 38.8% reported Hispanic or Latino (Hispanic) ethnicity. Unstable housing was reported by 21 (10.7%) enrollees, and 24 (12.2%) lacked health insurance. The prevalence of mpox among ED patients evaluated for an mpox-compatible rash was 1.5% (95% CI = 0.3%-4.4%); all persons with a confirmed mpox diagnosis identified as GBMSM and reported being HIV-negative, not being vaccinated against mpox, and having engaged in sex with one or more partners met through smartphone dating applications. No cases were identified among women, children, or unhoused persons. Clinicians should remain vigilant for mpox and educate persons at risk for mpox about modifying behaviors that increase risk and the importance of receiving 2 appropriately spaced doses of JYNNEOS vaccine to prevent mpox.

Health activism, vaccine, and mpox discourse: BERTopic based mixed-method analyses of tweets from sexual minority men and gender diverse (SMMGD) individuals in the U.S.

Objectives: To synthesize discussions among sexual minority men and gender diverse (SMMGD) individuals on mpox, given limited representation of SMMGD voices in existing mpox literature. Methods: BERTopic (a topic modeling technique) was employed with human validations to analyze mpox-related tweets (n = 8,688; October 2020-September 2022) from 2,326 self-identified SMMGD individuals in the U.S.; followed by content analysis and geographic analysis. Results: BERTopic identified 11 topics: health activism (29.81%); mpox vaccination (25.81%) and adverse events (0.98%); sarcasm, jokes, emotional expressions (14.04%); COVID-19 and mpox (7.32%); government/public health response (6.12%); mpox symptoms (2.74%); case reports (2.21%); puns on the virus' naming (i.e., monkeypox; 0.86%); media publicity (0.68%); mpox in children (0.67%). Mpox health activism negatively correlated with LGB social climate index at U.S. state level, ρ = -0.322, p = 0.031. Conclusions: SMMGD discussions on mpox encompassed utilitarian (e.g., vaccine access, case reports, mpox symptoms) and emotionally-charged themes-advocating against homophobia, misinformation, and stigma. Mpox health activism was more prevalent in states with lower LGB social acceptance. Public Health Implications: Findings illuminate SMMGD engagement with mpox discourse, underscoring the need for more inclusive health communication strategies in infectious disease outbreaks to control associated stigma.

Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients.

STUDY OBJECTIVE: Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients. METHODS: We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3). RESULTS: For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill. CONCLUSION: We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.

BACKGROUND: Incident reports submitted during times of organizational stress may reveal unique insights. PURPOSE: To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. METHODS: We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. RESULTS: Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19. CONCLUSIONS: Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

Comprehensive Pharmacist-led Transitions-of-care Medication Management around Hospital Discharge Adds Modest Cost Relative to Usual Care: Time-and-Motion Cost Analysis.

Optimal medication management is important during hospitalization and at discharge because post-discharge adverse drug events (ADEs) are common, often preventable, and contribute to patient harms, healthcare utilization, and costs. Conduct a cost analysis of a comprehensive pharmacist-led transitions-of-care medication management intervention for older adults during and after hospital discharge. Twelve intervention components addressed medication reconciliation, medication review, and medication adherence. Trained, experienced pharmacists delivered the intervention to older adults with chronic comorbidities at 2 large U.S. academic centers. To quantify and categorize time spent on the intervention, we conducted a time-and-motion analysis of study pharmacists over 36 sequential workdays (14 519 min) involving 117 patients. For 40 patients' hospitalizations, we observed all intervention activities. We used the median minutes spent and pharmacist wages nationally to calculate cost per hospitalization (2020 U.S. dollars) from the hospital perspective, relative to usual care. Pharmacists spent a median of 66.9 min per hospitalization (interquartile range 46.1-90.1), equating to $101 ($86 to $116 in sensitivity analyses). In unadjusted analyses, study site was associated with time spent (medians 111 and 51.8 min) while patient primary language, discharge disposition, number of outpatient medications, and patient age were not. In this cost analysis, comprehensive medication management around discharge cost about $101 per hospitalization, with variation across sites. This cost is at least an order of magnitude less than published costs associated with ADEs, hospital readmissions, or other interventions designed to reduce readmissions. Work is ongoing to assess the current intervention's effectiveness.

Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.

Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively. Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation. Conclusion: If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.

The impact of positive reinforcement on teamwork climate, resiliency, and burnout during the COVID-19 pandemic: The TEAM-ICU (Transforming Employee Attitudes via Messaging strengthens Interconnection, Communication, and Unity) pilot study.

Burnout is an internationally recognized occupational phenomenon that negatively impacts the healthcare workforce and its recipients. The aim of this pilot study was to test whether positive reinforcement and integrating a language of support among co-workers can enhance resiliency, facilitate psychological wellness, and encourage hope. This embedded mixed methods prospective, behavioral, interventional study evaluated the effects of positive feedback on wellness among intensive care unit clinicians during the COVID-19 pandemic in a single center, quaternary care medical center. The deliberate positive feedback paradigm has the potential to augment resiliency and improve attitudes toward a teamwork climate. The routine use of deliberate positivity may represent a scalable, low-cost initiative to enhance wellness in a healthcare organization.

Patient and Visit Characteristics Associated With Physical Restraint Use in the Emergency Department.

Objective Physical restraints are used in emergency departments (EDs) to address behavioral emergencies in situations in which less restrictive methods have failed. The objective of this study was to evaluate for associations between patient/visit characteristics and physical restraint use. Study Design This study was designed as a cross-sectional, retrospective study of all encounters at Kaiser Permanente Northern California EDs from January 1, 2016, to December 31, 2019, to evaluate differences in patient and visit characteristics between visits involving physical restraint use and those without. Methods Using electronic health record data, this study identified physical restraint use among ED encounters and extracted demographic, clinical, and facility characteristics. The authors calculated odds ratios for physical restraint placement, adjusting for patient and visit characteristics and accounting for within-patient clustering. Results Among 4,410,816 encounters (representing 1,791,673 patients), 6369 encounters (0.1%) involved physical restraint use among 5,554 patients (0.3%). Variables associated with the lowest odds of physical restraint included female sex, presentation to the ED in more recent years, and presence of intentional self-harm/suicidal ideation. Variables associated with the highest odds of physical restraint included higher visit acuity and weekend presentations to the ED. Discussion This study, which leveraged a large, diverse patient sample generalizable to the Northern California population, found several patient and visit characteristics associated with physical restraint use in the ED. Conclusion Results of this study may help identify patient groups and situational factors that are most likely to lead to physical restraint use and structural factors contributing to disparities in care, thereby informing interventions to reduce physical restraint use when possible.

Experiences and Perspectives on Stressors and Organizational Strategies to Bolster Resiliency During the COVID-19 Pandemic: A Qualitative Study of Health Care Workers at a Tertiary Medical Center.

OBJECTIVE: This qualitative study included a sample of health care workers (HCWs) at a tertiary care center providing direct care to patients with COVID-19 to explore experiences and perceptions regarding care delivery during the COVID-19 pandemic as well as factors that helped HCWs cope with the challenges of the pandemic. Methods: Grounded theory methodology was used to conduct virtual focus groups with a semistructured interview guide May to June 2020. Results: We identified major themes related to (1) HCWs' emotions during the pandemic, (2) the perceived triggers of these feelings, (3) organizational factors that made HCWs feel more supported and appreciated, and (4) personal factors that helped HCWs cope with the pandemic. Conclusion: Results highlighted the stress and challenges associated with exposure to SARS-CoV-2. The findings can help inform interventions to support HCWs during pandemics and other crises.

Digital Tools Designed to Obtain the History of Present Illness From Patients: Scoping Review.

BACKGROUND: Many medical conditions, perhaps 80% of them, can be diagnosed by taking a thorough history of present illness (HPI). However, in the clinical setting, situational factors such as interruptions and time pressure may cause interactions with patients to be brief and fragmented. One solution for improving clinicians' ability to collect a thorough HPI and maximize efficiency and quality of care could be to use a digital tool to obtain the HPI before face-to-face evaluation by a clinician. OBJECTIVE: Our objective was to identify and characterize digital tools that have been designed to obtain the HPI directly from patients or caregivers and present this information to clinicians before a face-to-face encounter. We also sought to describe outcomes reported in testing of these tools, especially those related to usability, efficiency, and quality of care. METHODS: We conducted a scoping review using predefined search terms in the following databases: MEDLINE, CINAHL, PsycINFO, Web of Science, Embase, IEEE Xplore Digital Library, ACM Digital Library, and ProQuest Dissertations & Theses Global. Two reviewers screened titles and abstracts for relevance, performed full-text reviews of articles meeting the inclusion criteria, and used a pile-sorting procedure to identify distinguishing characteristics of the tools. Information describing the tools was primarily obtained from identified peer-reviewed sources; in addition, supplementary information was obtained from tool websites and through direct communications with tool creators. RESULTS: We identified 18 tools meeting the inclusion criteria. Of these 18 tools, 14 (78%) used primarily closed-ended and multiple-choice questions, 1 (6%) used free-text input, and 3 (17%) used conversational (chatbot) style. More than half (10/18, 56%) of the tools were tailored to specific patient subpopulations; the remaining (8/18, 44%) tools did not specify a target subpopulation. Of the 18 tools, 7 (39%) included multilingual support, and 12 (67%) had the capability to transfer data directly into the electronic health record. Studies of the tools reported on various outcome measures related to usability, efficiency, and quality of care. CONCLUSIONS: The HPI tools we identified (N=18) varied greatly in their purpose and functionality. There was no consensus on how patient-generated information should be collected or presented to clinicians. Existing tools have undergone inconsistent levels of testing, with a wide variety of different outcome measures used in evaluation, including some related to usability, efficiency, and quality of care. There is substantial interest in using digital tools to obtain the HPI from patients, but the outcomes measured have been inconsistent. Future research should focus on whether using HPI tools can lead to improved patient experience and health outcomes, although surrogate end points could instead be used so long as patient safety is monitored.

The impact of mandatory conflict of interest disclosures on editors' manuscript acceptance decisions: A cross-sectional observational study.

Objective: Although current ethical standards mandate conflict of interest (COI) disclosure by authors of peer-reviewed publications, it is unknown whether disclosure affects a manuscript's fate. Our objective was to identify associations between author COI disclosure and editorial decision to publish. Methods: We performed a cross-sectional observational study of editorial decisions for original research and brief research report manuscripts submitted to Annals of Emergency Medicine between June 2014 and January 2018 using data from the journal's editorial decision software and data from a prior study that characterized author COI for the same manuscripts. Outcomes of interest included final editor decision to publish (primary), initial editor decision, and number of revisions. We compared outcomes for manuscripts with COI versus those without and by type of COI (commercial/government/other). Results: Out of 1312 manuscripts in the sample, 65.1% had no COI declarations, and 34.9% had one or more. Overall likelihood of editorial decision to publish was 13.5% (115/854) for articles without COI and 26.9% (123/458) for those with COI. Overall likelihood of editorial decision to publish was 19.8% (19/96) for articles with commercial COI only versus 33.3% (35/105) for those with government COI only. Conclusions: Articles with author-reported COI were more likely to be published than those without such a declaration. Additionally, results suggest that reports of government COI are associated with improved chance of publication. Authorities should consider relaxing COI requirements temporarily to allow investigators to perform larger scale, randomized controlled studies of the impact of mandated COI disclosure.

Artificial intelligence applications used in the clinical response to COVID-19: A scoping review.

Research into using artificial intelligence (AI) in health care is growing and several observers predicted that AI would play a key role in the clinical response to the COVID-19. Many AI models have been proposed though previous reviews have identified only a few applications used in clinical practice. In this study, we aim to (1) identify and characterize AI applications used in the clinical response to COVID-19; (2) examine the timing, location, and extent of their use; (3) examine how they relate to pre-pandemic applications and the U.S. regulatory approval process; and (4) characterize the evidence that is available to support their use. We searched academic and grey literature sources to identify 66 AI applications that performed a wide range of diagnostic, prognostic, and triage functions in the clinical response to COVID-19. Many were deployed early in the pandemic and most were used in the U.S., other high-income countries, or China. While some applications were used to care for hundreds of thousands of patients, others were used to an unknown or limited extent. We found studies supporting the use of 39 applications, though few of these were independent evaluations and we found no clinical trials evaluating any application's impact on patient health. Due to limited evidence, it is impossible to determine the extent to which the clinical use of AI in the pandemic response has benefited patients overall. Further research is needed, particularly independent evaluations on AI application performance and health impacts in real-world care settings.

Emergency clinician participation and performance in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System.

BACKGROUND: The Merit-based Incentive Payment System (MIPS) is the largest national pay-for-performance program and the first to afford emergency clinicians unique financial incentives for quality measurement and improvement. With little known regarding its impact on emergency clinicians, we sought to describe participation in the MIPS and examine differences in performance scores and payment adjustments based on reporting affiliation and reporting strategy. METHODS: We performed a cross-sectional analysis using the Centers for Medicare & Medicaid Services 2018 Quality Payment Program (QPP) Experience Report data set. We categorized emergency clinicians by their reporting affiliation (individual, group, MIPS alternative payment model [APM]), MIPS performance scores, and Medicare Part B payment adjustments. We calculated performance scores for common quality measures contributing to the quality category score if reported through qualified clinical data registries (QCDRs) or claims-based reporting strategies. RESULTS: In 2018, a total of 59,828 emergency clinicians participated in the MIPS-1,246 (2.1%) reported as individuals, 43,404 (72.5%) reported as groups, and 15,178 (25.4%) reported within MIPS APMs. Clinicians reporting as individuals earned lower overall MIPS scores (median [interquartile range {IQR}] = 30.8 [15.0-48.2] points) than those reporting within groups (median [IQR] = 88.4 [49.3-100.0]) and MIPS APMs (median [IQR] = 100.0 [100.0-100.0]; p < 0.001) and more frequently incurred penalties with a negative payment adjustment. Emergency clinicians had higher measure scores if reporting QCDR or QPP non-emergency medicine specialty set measures. CONCLUSIONS: Emergency clinician participation in national value-based programs is common, with one in four participating through MIPS APMs. Those employing specific strategies such as QCDR and group reporting received the highest MIPS scores and payment adjustments, emphasizing the role that reporting strategy and affiliation play in the quality of care.

Primary Care Physicians' Conceptualization of Quality in Medicare's Merit-Based Incentive Payment System.

BACKGROUND: While administrators of pay-for-performance may have good intentions, physicians may be reluctant to participate for various reasons, including poor program alignment with realities of clinical practice. In this study, we sought to characterize how primary care physicians (PCPs) participating in Medicare's Merit-Based Incentive Payment System (MIPS) conceptualize the quality of health care to help inform future measurement strategies that physicians would understand and appreciate. METHODS: We performed semi-structured qualitative interviews with a nationwide sample of 20 PCPs in MIPS. We asked PCPs how they would characterize quality and what distinguished exceptional, good, and poor quality. Interviews were transcribed and 2 coders independently read transcripts, allowing data to emerge from the interviews and developing theories about the data. The coders met intermittently to discuss findings, harmonize the coding scheme, develop a final list of themes and subthemes, and aggregate a list of representative quotations. RESULTS: Participants described quality as consisting of 2 components: (1) evidence-based care that is safe, which included health maintenance and chronic disease control, accurate diagnoses, and guideline adherence, and (2) patient-centered care, which included spending enough time with patients, responding to patient concerns, and establishing long-term relationships founded on trust. CONCLUSIONS: PCPs consider patient-centered care necessary for the provision of exceptional quality. Program administrators for quality measurement and pay-for-performance programs should explore new ways to reward PCPs for providing outstanding patient-centered care. Future research should be undertaken to determine whether patient-centered activities such as forging long-term, favorable patient-physician relationships, are associated with improved health outcomes.

Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients.

OBJECTIVES: Obtaining body temperature is a quick and easy method to screen for acute infection such as COVID-19. Currently, the predictive value of body temperature for acute infection is inhibited by failure to account for other readily available variables that affect temperature values. In this proof-of-concept study, we sought to improve COVID-19 pretest probability estimation by incorporating covariates known to be associated with body temperature, including patient age, sex, comorbidities, month, and time of day. METHODS: For patients discharged from an academic hospital emergency department after testing for COVID-19 in March and April of 2020, we abstracted clinical data. We reviewed physician documentation to retrospectively generate estimates of pretest probability for COVID-19. Using patients' COVID-19 PCR test results as a gold standard, we compared AUCs of logistic regression models predicting COVID-19 positivity that used: (1) body temperature alone; (2) body temperature and pretest probability; (3) body temperature, pretest probability, and body temperature-relevant covariates. Calibration plots and bootstrap validation were used to assess predictive performance for model #3. RESULTS: Data from 117 patients were included. The models' AUCs were: (1) 0.69 (2) 0.72, and (3) 0.76, respectively. The absolute difference in AUC was 0.029 (95% CI -0.057 to 0.114, p=0.25) between model 2 and 1 and 0.038 (95% CI -0.021 to 0.097, p=0.10) between model 3 and 2. CONCLUSIONS: By incorporating covariates known to affect body temperature, we demonstrated improved pretest probability estimates of acute COVID-19 infection. Future work should be undertaken to further develop and validate our model in a larger, multi-institutional sample.

Quantifying Emergency Physician Interruptions due to Electrocardiogram Review.

BACKGROUND: Interruptions are recognized as potentially harmful to safety and efficiency, and are especially prevalent in the emergency department (ED) setting. Policies urging immediate review of all electrocardiograms (ECGs) may lead to numerous and frequent interruptions. OBJECTIVE: We assessed the role of ECG review as a source of ED interruptions to characterize a potential target for interventions. METHODS: We analyzed emergency physician time use during the course of a clinical shift using a time-and-motion design. A research assistant observed a convenience sample of shifts, observing and logging transitions between different tasks using an electronic device. Instances of ECG review were tallied, with start and ending times of ECG review recorded to the nearest second. An ECG review was considered an interruption if the immediate prior and subsequent tasks were the same. RESULTS: Twenty shifts were observed for a total of 149 h. There were 211 ECG reviews, (mean rate 1.4 per hour), with more frequent review among physicians staffing a zone with higher-acuity patients (2.8 per hour), where clustering of multiple ECG reviews in succession was more common. Seventy-five percent of ECG reviews required < 30 s. Of all 211 ECG reviews, 102 (48%) were an interruption. The tasks most frequently interrupted were electronic medical record system use (68 of 102, 67%) and communicating with ED staff in person (18 of 102, 18%). CONCLUSIONS: Review of ECGs was a substantial driver of interruptions for emergency physicians. Interventions to integrate ECG review more naturally into physician workflow may improve patient safety by reducing these interruptions.

Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL).

PURPOSE: To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. METHODS: This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017-2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. RESULTS: 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%-42.6%) for XR, 19.1% (IQR 11.4%-24.9%) for CT, and 0.09% (IQR 0%-0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%-61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%-81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: -12.7%, -4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: -7.3%, -1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: -5.9%, -0;5%), CT (20.1% vs 17.7%; 95% CI: -5.1%, -0.4%) or MRI (0.8% vs 0.7%, 95% CI: -0.4%, -0.3%). CONCLUSIONS: Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.

Practice structure and quality improvement activities among emergency departments in the Emergency Quality (E-QUAL) Network.

OBJECTIVES: Little academic investigation has been done to describe emergency department (ED) practice structure and quality improvement activities. Our objective was to describe staffing, payment mechanisms, and quality improvement activities among EDs in a nationwide quality improvement network and also stratify results to descriptively compare (1) single- versus multi-site EDs and (2) small-group versus large-group EDs. METHODS: Observational study examining EDs that completed activities for the 2018 wave of the Emergency Quality Network (E-QUAL), a voluntary network of EDs nationwide that self-report quality improvement activities. EDs were defined as single-site or multi-site based on self-reported billing practices; additionally, EDs were defined as large-group if they and a majority of other sites with the same group name also identified as multi-site. All other sites were deemed small-group. RESULTS: Data from 377 EDs were included. For staffing, the median number of clinicians was 17 overall (16 single-site; 19 multi-site). For payment, 376 of 377 EDs (99.7%) participated in the Merit-Based Incentive Payment System. Thirty-five EDs (9.2%) participated in a federal alternative payment model, and 19 (5.0%) participated in a commercial alternative payment model. For quality improvement, single- and multi-site EDs reported similar progress on quality improvement strategies; however, small-group EDs reported more advanced quality improvement strategies compared to large-group EDs for 8/10 quality improvement strategies included in a survey (eg, "achieved a formal plan to eliminate waste"). CONCLUSION: Among EDs in E-QUAL, staffing, payment, and quality improvement activities are similar between single- and multi-site EDs. Group-level analysis suggests that practice structure may influence adoption of quality improvement strategies. Future work is needed to further evaluate practice structure and its influence on quality improvement activities and quality.

The safety of home discharge for low-risk emergency department patients presenting with coronavirus-like symptoms during the COVID-19 pandemic: A retrospective cohort study.

Objective: There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID-19) infection who are not hospitalized. The study objective was to assess 30-day outcomes (ED revisit, admission, ICU admission, and death) for low-risk patients discharged after ED evaluation for COVID-19. Methods: This was a retrospective cohort study of patients triaged to a COVID-19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well-appearing with few comorbidities. Data were collected from review of medical records and phone follow-up, and the analysis was descriptive. Results: Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow-up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3-7, range 1-17). There were no known deaths. Conclusions: A minority of low-risk patients with suspected COVID-19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well-appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.

Study design and ethical considerations related to using direct observation to evaluate physician behavior: reflections after a recent study.

In a recent study using direct observation of physicians, we demonstrated that physician-generated clinical documentation is vulnerable to error. In fact, we found that physicians consistently overrepresented their actions in certain areas of the medical record, such as the physical examination. Because of our experiences carrying out this study, we believe that certain investigations, particularly those evaluating physician behavior, should not rely on documentation alone. Investigators seeking to evaluate physician behavior should instead consider using observation to obtain objective information about occurrences in the patient-physician encounter. In this article, we describe our experiences using observation, and we offer investigators our perspectives related to study design and ethical questions to consider when performing similar work.