Interhospital Variability in Utilization of Cardioversion for Atrial Fibrillation in the Emergency Department.

The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.

Evaluating Family Medicine Resident Narrative Comments Using the RIME Scheme.

Background: In 2013, the Accreditation Council on Graduate Medical Education (ACGME) launched the Next Accreditation System, which required explicit documentation of trainee competence in six domains. To document narrative comments, the University of North Carolina Family Medicine Residency Program developed a mobile application to document real time observations. Objective: The objective of this work was to assess if the Reporter, Interpreter, Manager, Expert (RIME) framework could be applied to the narrative comments in order to convey a degree of competency. Methods: From August to December 2020, 7 individuals analyzed narrative comments of four family medicine residents. The narrative comments were collected from July to December 2019. Each individual applied the RIME framework to the comments and the team met to discuss. Comments where 5/7 individuals agreed were not further discussed. All other comments were discussed until consensus was achieved. Results: 102 unique comments were assessed. Of those comments, 25 (25.5%) met threshold for assessor agreement after independent review. Group discussion about discrepancies led to consensus about the appropriate classification for 92 (90.2%). General comments on performance were difficult to fit into the RIME framework. Conclusions: Application of the RIME framework to narrative comments may add insight into trainee progress. Further faculty development is needed to ensure comments have discrete elements needed to apply the RIME framework and contribute to overall evaluation of competence.

InstaHisto: Utilizing Instagram as a Medium for Disseminating Visual Educational Resources.

BACKGROUND: Applying active recall during studying vexes medical students. The integration of social media into medical education is rapidly expanding; however, there is minimal use of Instagram in medical education. Histology is a visually dominant subject and pairs well with Instagram. We sought to create a standardized process for medical educators to establish Instagram as a study tool for histology. METHODS: An Instagram account accessible to MS1s was created. Histology images in the course syllabus along with questions and explanations for each image were organized and posted to Instagram in a question and answer format. Instagram analytics on student engagement were gathered along with student survey responses. RESULTS: Seventy-four percent (141/190) of the class followed the account. Images had an average of 442 total views. Images had an average of 3.5 views per user (VPUs), ranging from 2.6 to 4.3 VPUs, suggesting that students are viewing images multiple times. Ninety-eight percent of survey responders found the account easy to use. Ninety-five percent said studying the account increased their confidence when answering histology questions on exams, and 75% said the account led to decreased stress when studying histology. DISCUSSION: Instagram is a platform that the majority of our medical students are already using daily. There was strong evidence of student engagement via Instagram analytics. Once a database of images with questions and answers is established, content can readily be posted to Instagram for students to study. Once established, this process can be applied to other visual content, such as anatomy, radiology, pathology, and microbiology.