Compassion Fatigue in Emergency Medicine: Current Perspectives.

Compassion fatigue (CF), or loss of ability to empathize or feel compassion for others for whom one cares, is a growing concern for emergency physicians (EP). EPs, by the nature of their jobs, work under unpredictable conditions at odd hours with high levels of exposure to traumatic events. They are placed under substantial psychological, physical, and cognitive pressure, with little opportunity to recover or reflect. CF occurs when this workplace stress leads to feelings of being overwhelmed, helpless, unsupported, and unable to cope. Additionally, primary traumatic stress from threats of workplace violence and secondary traumatic stress (STS) from witnessing the suffering of others increase the likelihood of developing CF. Unchecked, this progression to CF causes reduction in quality of care to patients, reduction in patient satisfaction, increased levels of EP depression and anxiety, increased levels of EP substance use, and increased attrition from the specialty. To truly improve CF, individuals and organizations should be aware of the contributors to CF: namely, emotional exhaustion, depersonalization, primary and STS, and personal achievement. EPs should maximize their resilience to CF by using cognitive behavioral techniques and mindfulness, taking care of their physical health, seeking meaning and development within their work, developing hobbies outside of work, and creating boundaries between work and home. Organizations should actively address the known drivers of physician burnout: workload and job demands, efficiency and resources, meaning in work, culture and values, control and flexibility, work community, and work-life integration. Organizations should also provide adequate safety within facilities to reduce the threat of primary trauma and should supply adequate support and destigmatization for post-traumatic symptoms for EPs suffering from STS.

Failure Rates During Reuse of Disposable N95 Masks in Clinical Practice in the Emergency Department.

INTRODUCTION: The coronavirus 2019 pandemic caused a shortage of disposable N95 respirators, prompting healthcare entities to extend the use of these masks beyond their intended single-use manufacturer recommendation with a paucity of supporting research. METHODS: We performed a prospective cohort study of ED healthcare workers (HCW) ("subjects") required to use respirators at an academic, Level I trauma center. Subjects had been previously fit tested and assigned an appropriately sized N95 mask per hospital protocol. Per study protocol, subjects were fit tested periodically throughout their shifts and on multiple shifts over the eight-week study period. Data points collected included the age of the mask, subjective assessment of mask seal quality, and fit test results. We analyzed the data using Fisher's exact test, and calculated odds ratios (OR) to determine the failure rate of disposable N95 masks following reuse. RESULTS: A total of 130 HCWs underwent fit testing and 127 were included for analysis. Mask failure rate climbed after day 2 of use, with 33.3% of masks failing at day 3, 42.9% at day 4, and 50% at ≥ day 5. Categorizing the masks into those being used for two or fewer days vs those in use for three or more, failure was more common on day 3 of use or older compared to those in the first two days of use (41.8% vs 8.3%, P < 0.0001) with an OR of failure with an older mask of 7.9 (confidence interval [CI], 2.8-22.3). The healthcare workers' assessment of poor seal was 33.3% sensitive (CI, 18.6-51.9) and 95.7% specific (CI, 88.8-98.6) for fit test failure. CONCLUSION: Disposable N95 masks have significant failure rates following reuse in clinical practice. Healthcare personnel also performed poorly in assessing the integrity of the seal of their disposable respirators.

The pragmatic use of industrial elastomeric facemasks in health care practice during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has forced health care workers to explore alternative personal protective equipment (PPE) strategies due to traditional product shortages in the setting of increased global demand. Some physicians have chosen to use elastomeric face masks (EFMs), traditionally used in non-healthcare industries. METHODS: We performed a prospective cohort study of Emergency Medicine (EM) physicians working at a Level 1 Trauma Center who chose to use self-supplied EFMs for PPE. All subjects used commercial EFMs with disposable filters (N95, P95, or P100). All subjects chose their mask size independently with no input from employee health regarding appropriate fit. Per study protocol, subjects were fit tested periodically during clinical shifts over the course of the 6-week study period. All investigators performing fit testing underwent OSHA qualitative fit testing training. Data collected included mask/filters age, subjective assessment of mask seal quality, and fit test results. The data were analyzed using descriptive statistics. RESULTS: 105 fit tests were performed on physicians wearing EFMs over the course of 49 shifts. Physicians felt their fit was adequate for all tests performed. There were no fit test failures in any subjects. CONCLUSIONS: EFMs have an extremely low failure rate. Physicians are able to assess the adequacy of fit and accurately choose EFM size.

The efficacy of continuous use disposable N95 masks in clinical practice in the emergency department.

During the SARS-CoV-2 pandemic, many emergency departments (EDs) initiated continuous use of N95 disposable respirators (N95s) rather than discarding them after each use to conserve respirators. This study investigates the efficacy of wearing disposable N95s continuously during clinical work. METHODS: This is a prospective cohort study of ED staff required to wear N95s continuously throughout their shifts. Subjects were doctors, nurses, and technicians who were previously fitted for their assigned N95 by employee health. Subjects were fit tested periodically throughout their shifts. Investigators filled out a questionnaire for each subject noting the hours of continuous N95 wear. Data were analyzed using descriptive statistics. RESULTS: One hundred thirteen N95s were evaluated, with 23 failures at first testing. These were not retested. Twenty-seven N95s passed at the start of a shift and did not have repeat testing during the course of the shift. These were excluded from further analysis. Seventeen N95s passed testing after several hours of continuous wear, but only had a single fit test done partway or at the end of a shift. These were assumed to have passed if tested at shift start, and were assigned as "passes" for continuous use. Forty-six N95s had an initial pass and were evaluated for continuous use, of which 6 subsequently failed later in the shift, giving a fail rate with continuous use of 9.5%. CONCLUSION: Continuous use of disposable N95s throughout an ED shift is reasonable during a PPE shortage if wearers are assured of fit at the start of their shift.

Prehospital end-tidal CO2 as an early marker for transfusion requirement in trauma patients.

OBJECTIVE: Below normal end-tidal carbon dioxide measurement (ETCO2) is associated with worse outcomes in sepsis and trauma patients as compared to patients with normal ETCO2. We sought to determine if ETCO2 can be used in the prehospital setting to predict transfusion requirement, operative hemorrhage control, or mortality in the first 24 h after admission for trauma. METHODS: This is a retrospective cohort study at a suburban, academic Level 1 Trauma Center. Patients were sequentially identified as prehospital trauma alerts from a single EMS system which requires, per policy, ETCO2 for all traumas. One year of prehospital data was collected and paired with hospital trauma registry data. Comparisons were made between ETCO2 values for patients who required transfusion, operative blood loss control, or who died, and those who did not. RESULTS: Two hundred thirty-five trauma patients were transported via the study EMS system, of which 105 (44.7%) had documented ETCO2 values. Patient mean age was 60 (SD24) years with 59 (56.2%) male. Three patients were intubated prehospital and seven were intubated in the trauma bay. Mean prehospital ETCO2 for those who needed transfusion, surgery, or died (n = 11) was 25.7 (9.1) compared to 30.6 (7.8) for those who did not (p = 0.049). Optimal cutoff for our population was EtCO2 ≤ 27 with a sensitivity of 72.7% (95% CI 32-93) and specificity of 72.2% (62-81). CONCLUSION: Below normal ETCO2 values were associated with increase need for transfusion, operative intervention, and death. Further study is warranted to determine if ETCO2 outperforms other predictors of severe trauma.

The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper.

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus, was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a "new normal" are discussed in this article.

History and physical exam predictors of intracranial injury in the elderly fall patient: A prospective multicenter study.

OBJECTIVES: A prior single-center study demonstrated historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population. METHODS: This is a prospective observational study of patients ≥65 years presenting after a fall to three EDs. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anticoagulants/antiplatelet use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients. RESULTS: 723 patients (median age 83, interquartile range 74-88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulation/antiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6-94) with a specificity of 38.8% (CI 35.1-42.7). The positive predictive value in this population was 10% (CI 7.5-13.3) with a negative predictive value of 97.3% (CI 94.4-98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed. CONCLUSION: In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC.

An observational study of patients' attitudes to tattoos and piercings on their physicians: the ART study.

INTRODUCTION: Perceptions regarding body art change over time as societal norms change. Previous research regarding patients' perceptions of physicians with exposed body art have been hampered by flaws in design methodology that incorporate biases into patient responses. This study was performed to determine whether emergency department (ED) patients perceived a difference in physician competence, professionalism, caring, approachability, trustworthiness and reliability in the setting of exposed body art. METHODS: Standardised surveys about physician competence, professionalism, caring, approachability, trustworthiness and reliability rating providers on a five point Likert scale were administered to patients in an ED after an encounter with a physician provider who demonstrated no body art modification, non-traditional piercings, tattoos, or both piercings and tattoos. Each provider served as their own control. Patients were blinded to the purpose of the survey. RESULTS: Patients did not perceive a difference in physician competence, professionalism, caring, approachability, trustworthiness or reliability in the setting of exposed body art. Patients assigned top box performance in all domains >75% of the time, regardless of physician appearance. CONCLUSION: In the clinical setting, having exposed body art does not significantly change patients' perception of the physician.

Prospective Validation and Refinement of a Decision Rule to Obtain Chest X-ray in Patients With Nontraumatic Chest Pain in the Emergency Department.

OBJECTIVES: The objective was to prospectively validate and refine previously published criteria to determine the potential utility of chest x-ray (CXR) in the evaluation and management of patients presenting to the emergency department (ED) with nontraumatic chest pain (CP). METHODS: A prospective observational study was performed of patients presenting to three EDs in the United States with a chief complaint of nontraumatic CP. Previously defined high-risk history and examination elements were combined into a refined decision rule and these elements were recorded for each patient by the ED physician. CXR results were reviewed and analyzed to determine the presence of clinically significant findings including pneumonia, pleural effusion, pneumothorax, congestive heart failure, or the presence of a new mass. Odds ratios for each history and examination element were analyzed as well as sensitivity, specificity, and negative predictive value (NPV) of the rule overall. RESULTS: A total of 1,111 patients were enrolled and 1,089 CXRs were analyzed. There were 70 (6.4%) patients with clinically relevant findings on CXR. The refined decision rule had a sensitivity of 92.9% (confidence interval [CI] = 83.4%-97.3%) and specificity of 30.4% (CI = 27.6%-33.4%) to predict clinically relevant findings on CXR, with a NPV of 98.4% (CI = 96.1%-99.4%). Five CXRs with clinically significant findings would have been missed by application of the refined rule (three pneumonias and two pleural effusions). Applying these criteria as a CXR decision rule to this population would have reduced CXR utilization by 28.9%. CONCLUSIONS: This study validates previous research suggesting a low clinical yield for CXR in the setting of nontraumatic CP in the ED. This refined clinical decision rule has a favorable sensitivity and NPV in a patient population with low incidence of disease. Further validation is needed prior to use in practice.

The American College of Academic International Medicine 2017 Consensus Statement on International Medical Programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms.

The growth of academic international medicine (AIM) as a distinct field of expertise resulted in increasing participation by individual and institutional actors from both high-income and low-and-middle-income countries. This trend resulted in the gradual evolution of international medical programs (IMPs). With the growing number of students, residents, and educators who gravitate toward nontraditional forms of academic contribution, the need arose for a system of formalized metrics and quantitative assessment of AIM- and IMP-related efforts. Within this emerging paradigm, an institution's "return on investment" from faculty involvement in AIM and participation in IMPs can be measured by establishing equivalency between international work and various established academic activities that lead to greater institutional visibility and reputational impact. The goal of this consensus statement is to provide a basic framework for quantitative assessment and standardized metrics of professional effort attributable to active faculty engagement in AIM and participation in IMPs. Implicit to the current work is the understanding that the proposed system should be flexible and adaptable to the dynamically evolving landscape of AIM - an increasingly important subset of general academic medical activities.

Lyme Disease Presenting with Multiple Cranial Nerve Deficits: Report of a Case.

Lyme disease is a tick-transmitted multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi. With more than 25,000 CDC reported cases annually, it has become the most common vector-borne disease in the United States. We report a case of 38-year-old man with Lyme disease presenting with simultaneous palsy of 3rd, 5th, 7th, 9th, and 10th cranial nerves.

Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients.

INTRODUCTION: The National Emergency X-radiography Utilization Study (NEXUS) criteria are used extensively in emergency departments to rule out C-spine injuries (CSI) in the general population. Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population with two changes: a modified definition for distracting injury and the definition of normal mentation. METHODS: This is a prospective, observational cohort study of geriatric fall patients who presented to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled non-intoxicated patients at baseline mental status with no lateralizing neurologic deficits. They recorded midline neck tenderness, signs of trauma, and presence of other distracting injury. RESULTS: We enrolled 800 patients. One patient fall event was excluded due to duplicate enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range 65-101). The numbers in parenthesis after the negative predictive value represent confidence interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and 10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive (CI [67.9-100]) with a negative predictive value of 100 (98.7-100). CONCLUSION: Our study suggests that a modified NEXUS criteria can be safely applied to low-risk elderly falls.

Elderly fall patients triaged to the trauma bay: age, injury patterns, and mortality risk.

BACKGROUND: Falls in the elderly are a significant cause of morbidity and mortality. We sought to better categorize this patient population and describe factors contributing to their falls. METHODS: This is a retrospective review of geriatric patients presenting to a level 1 community trauma center. We queried our trauma database for all patients 65 years and older presenting with fall and triaged to the trauma bay from 2008 to 2013. Researchers reviewed the patients' trauma intake paperwork to assess mechanism, injury, and location of fall, whereas discharge summaries were reviewed to determine disposition, morbidity, and mortality. RESULTS: A total of 650 encounters were analyzed. Five hundred thirty-nine resided at home (82.9%), 110 presented from nursing homes or assisted living (16.9%), and 1 came from hospice (0.15%). Ninety-five patients died or were placed on hospice as a result of their falls (14.7%), of which 88 came from home. Controlling for Injury Severity Score, living at home was an independent risk factor for fall-related mortality (odds ratio, 3.0). Comparing the elderly (age 65-79 years; n = 274) and the very elderly (age ≥80 years; n = 376), there were no differences in Injury Severity Score (P = .33), likelihood of death (P = .49), likelihood of C-spine injury (P = 1.0), or likelihood of other axial or long bone skeletal injury (P = .23-1.0). There was a trend for increased likelihood of head injury in very elderly patients (P = 0.06). CONCLUSION: Prevention measures to limit morbidity and mortality in elderly fall patients should be aimed at the home setting, where most severe injuries occur. Very elderly patients may be at increased risk for intracranial fall-related injuries.

Application of National Emergency X-Ray Utilizations Study low-risk c-spine criteria in high-risk geriatric falls.

STUDY OBJECTIVES: We sought to validate National Emergency X-Radiography Utilizations Study low-risk cervical spine (C spine) criteria in a geriatric trauma population. We sought to determine whether patients' own baseline mental status (MS) could substitute for Glasgow Coma Scale (GCS) to meet the criteria "normal alertness." We further sought to refine the definition of "distracting injury." METHODS: This is a retrospective review of geriatric fall patients presenting to a level 1 trauma center and triaged to the trauma bay. We queried our database from 2008 to 2013. Abstractors recorded GCS, deviation from baseline MS, midline neck tenderness, intoxication, focal deficit, signs of trauma, and presence of other injury. Patients were considered at baseline MS if specific documentation was present on the chart, or if their GCS was 15. RESULTS: Six hundred sixty elderly fall patients were trauma alerts during the study period. Seventeen were excluded for incomplete records/death before imaging, leaving 647. The median age was 81 (interquartile range, 74-87). Fifty patients (8.0%) had C spine or cord injury. Two hundred ninety-four (44.5%) had baseline MS (including GCS 13-15), no spine tenderness, no intoxication, and no focal neurologic deficit. Of these, 18 had C-spine injury. Using physical findings of head trauma as the only "distracting injury," no injury would have been missed (sensitivity, 100% [confidence interval, 91.1-100]; specificity, 14.2%). CONCLUSIONS: Our study suggests that National Emergency X-Radiography Utilizations Study can be safely applied in elderly fall patients who are at their personal baseline MS. Furthermore, our data support a more narrow definition of distracting injury to include only patients with signs of trauma to the head.

Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury.

BACKGROUND: Falls are a major cause of morbidity in the elderly. OBJECTIVES: We describe the low-acuity elderly fall population and study which historical and clinical features predict traumatic intracranial injuries (ICIs). METHODS: This is a prospective observational study of patients at least 65 years old presenting with fall to a tertiary care facility. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. At presentation, a data form was completed by treating physicians regarding mechanism and position of fall, history of head strike, headache, loss of consciousness (LOC), and signs of head trauma. Radiographic imaging was obtained at the discretion of treating physicians. Medical records were subsequently reviewed to determine imaging results. All patients were called in follow-up at 30 days to determine outcome in those not imaged. The study was institutional review board approved. RESULTS: A total of 799 patients were enrolled; 79.5% of patients underwent imaging. Twenty-seven had ICIs (3.4%). Fourteen had subdural hematoma, 7 had subarachnoid hemorrhage, 3 had cerebral contusion, and 3 had a combination of injuries. Logistic regression demonstrated 2 study variables that were associated with ICIs: LOC (odds ratio, 2.8; confidence interval, 1.2-6.3) and signs of head trauma (odds ratio, 13.2; confidence interval, 2.7-64.1). History of head strike, mechanism and position, headache, and anticoagulant and antiplatelet use were not associated with ICIs. CONCLUSION: Elderly fall patients who are at their baseline mental status have a low incidence of ICIs. The best predictors of ICIs are physical findings of trauma to the head and history of LOC.

Randomized trial of tourniquet vs blood pressure cuff for target vein dilation in ultrasound-guided peripheral intravenous access.

BACKGROUND: Ten percent of the time, peripheral intravenous access (PIV) is not obtained in 2 attempts in the emergency department. Typically, a tourniquet is used to dilate the target vein; but recent research showed that a blood pressure (BP) cuff improves dilation, which may translate to increased PIV success. OBJECTIVES: We sought to determine if there is improved success in obtaining ultrasound-guided PIV using a BP cuff vs a tourniquet in "difficult stick" patients. METHODS: This is a prospective, randomized, single-blinded trial. Adult patients requiring PIV with at least 2 prior failed attempts were enrolled. Patients were assigned to tourniquet or BP cuff for target vein dilation randomly. Nurses prepared the patient for PIV attempt by either placing a BP cuff inflated to 150 mm Hg or placing a tourniquet on the chosen extremity. The extremity was draped to blind the physician to assignment. Physicians then attempted ultrasound-guided PIV. Failures were defined as IVs requiring greater than 3 ultrasound-guided attempts or 30 minutes, or patient intolerance. If failure occurred, the physician was unblinded; and the patient could be crossed over and reattempted. RESULTS: Thirty-eight patients were enrolled. The success rate for the tourniquet group (n = 17) and BP cuff group (n = 21) was 82.4% and 47.6%, respectively (P = .04). There were no differences between groups for vessel depth, diameter, or procedure time. Six in the BP cuff group were crossed over and had successful PIV obtained with tourniquet. CONCLUSIONS: Tourniquet is superior to BP cuff for target vein dilation in ultrasound-guided PIV.

Comparison of resident and mid-level provider productivity in a high-acuity emergency department setting.

INTRODUCTION: Mid-level providers (MLPs) are used in many emergency departments (EDs) to provide care in a low-acuity, high-volume setting, and are able to see more patients and generate more relative value units (RVUs) than residents in this setting. It is unknown if MLPs are as productive as emergency medicine residents in a high-acuity setting. OBJECTIVE: To determine if there are productivity differences between residents and MLPs, as defined by patients seen (pt/h) and RVUs generated per hour (RVU/h), in a high-acuity area of the ED. METHODS: This is a retrospective review of emergency medicine residents and MLPs assigned to a high-acuity area of a single 45,000 volume community ED. Number of patients seen and RVUs generated were recorded, and pt/h, RVU/h and RVU/pt were calculated. Two-tailed t test was used to compare resident and MLP performance. RESULTS: 55 MLP and 98 emergency medicine residency shifts were included for comparison. During the study period, MLPs saw 1.56 pt/h (CI ± 0.14), while residents saw 1.23 pt/h (CI ± 0.06, p<0.0001). MLPs generated 3.19 RVU/h (CI ± 0.29), while residents generated 3.33 RVU/h (CI ± 0.17, p=0.43). Residents generated 2.73 RVU/pt (CI ± 0.09), while MLPs generated 2.05 RVU/pt (CI ± 0.09, p<0.0001). In comparing the subgroup of postgraduate year 3 residents (PGY3s) with MLPs, MLPs still saw significantly more patients (1.30 vs 1.56, p=0.003), but PGY3s generated 3.58 RVU/h compared with 3.19 RVU/h for MLPs (p=0.06). PGY3s generated 2.79 RVU/pt compared with 2.05 for MLPs (p<0.0001). CONCLUSIONS: In a high-acuity area of the ED, MLPs see more patients per hour than residents, but generate fewer RVUs per patient. This suggests that residents may document more thoroughly than MLPs. Alternatively, MLPs may elect to see less sick patients even when working in a high-acuity area.