Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients.

Background: Hypertension (HTN) is common in discharged emergency department (ED) patients, yet the short-term outcomes of treating HTN at ED discharge are unclear. This study aimed to investigate whether emergency physician (EP) prescription of oral antihypertensive therapy at ED discharge for hypertensive patients is associated with a decreased 30-day risk of the severe adverse events (AEs), death, and revisits to the ED. Methods: We conducted an observational cohort study assessing the 30-day outcomes of discharged ED patients with HTN, comparing outcomes based on whether antihypertensive therapy was prescribed. All discharged adult ED patients from an eight-hospital system with a diagnosis of HTN from January 2016 to February 2020 were screened, and consisted of a mix of suburban and urban patients with broad ethnic and socioeconomic backgrounds. Patients were categorized into the treatment group if they received a prescription for antihypertensive medication at ED discharge. The primary outcome was severe composite AEs from HTN (aortic catastrophe, heart failure, myocardial infarction, hemorrhagic and ischemic stroke, or hypertensive encephalopathy) within 30 days of ED discharge. The secondary outcomes were death or ED revisit over the same period. Results: The study sample consisted of 93,512 ED visits; 57.5% were female, and mean age was 59.3 years. 4.7% of patients were prescribed antihypertensive treatment at ED discharge. Within 30 days, 0.7% of patients experienced an AE, 0.1% died, and 15.2% had an ED revisit. The treatment group had significantly lower odds of AE (adjusted odds ratio [aOR]: 0.224, 95%CI 0.106-0.416, p < 0.001), and ED revisits (aOR: 0.610, 95%CI 0.547-0.678, p < 0.001), adjusting for age, race, degree of HTN, ED treatment for elevated HTN, Elixhauser comorbidity index, and heart failure history. There was no difference in odds of death 30 days after discharge. Conclusion and relevance: Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.

Early Emergency Medicine Milestone Assessment for Predicting First-Year Resident Performance.

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) requires emergency medicine (EM) residency training programs to monitor residents' progress using standardized milestones. The first assessment of PGY 1 resident milestones occurs midway through the first year and could miss initial deficiencies. Early assessment of PGY 1 EM resident milestones has potential to identify at-risk residents prior to standard midyear evaluations. We developed an orientation syllabus for PGY 1 residents followed by a milestone assessment. Assessment scores helped predict future milestone scores and American Board of Emergency Medicine (ABEM) In-Training Examination (ITE) scores for PGY 1 residents. Methods: From 2013 to 2020, we developed and implemented Milestone Evaluation Day (MED), a simulation-based day and written exam assessing PGY 1 EM residents during their first month on the 23 ACGME 1.0 milestones. MED stations included a history and physical with verbal presentation, patient simulation, vascular access, wound management, and airway management. MED, Clinical Competency Committee-generated (CCC-generated) milestone, and ABEM ITE scores were averaged and compared utilizing Pearson's correlation coefficient. Results: Of 112 PGY 1 EM residents, 110 (98%) were analyzed over an 8-year period. We observed a moderate positive correlation of MED and CCC-generated milestone scores (r = .34, p < .001). There was a nonstatistically significant weak positive correlation of MED and ABEM ITE scores (r = .13, p = .17). Discussion: An early assessment of EM milestones in the PGY 1 year can assist in the prediction of CCC-generated milestone scores for PGY 1 residents.

A Novel Use of an Electronic Differential Diagnosis Generator in the Emergency Department Setting.

Introduction The ability of electronic differential diagnosis (DDx) tools to generate accurate diagnoses has been well established in simulation and primary care clinical environments. However, the use of such tools has not been well studied in the emergency department (ED). We aimed to characterize the use and perceptions of a DDx tool among emergency medicine (EM) clinicians who were newly provided with access to such a tool. Methods We performed a pilot study investigating the utilization of a DDx tool by clinicians in an ED setting shortly after the tool was introduced. After six months of use, retrospective data were analyzed to characterize the use of the tool among ED clinicians. The clinicians were also surveyed on their perceptions of the use of the tool in the ED setting. Results There were 224 total queries, which were regarding 107 unique patients. The most searched symptoms were related to constitutional, dermatologic, and gastrointestinal complaints whereas symptoms related to toxicology and trauma were less commonly searched. Survey respondents rated the tool favorably, and when not used, reported reasons including forgetting that the tool was available for use, not feeling the need to use the tool, and disruption to workflow. Conclusions Electronic DDx tools may have some utility in assisting ED clinicians in generating a DDx, however, clinician adoption and workflow integration are barriers to their utility.

The impact of medical scribes on emergency physician diagnostic testing and diagnosis charting.

OBJECTIVES: Since the widespread adoption of electronic medical records (EMRs), medical scribes have been increasingly utilized in emergency department (ED) settings to offload the documentation burden of emergency physicians (EPs). Scribes have been shown to increase EP productivity and satisfaction; however, little is known about their effects on the EP's diagnostic process. We aimed to assess what effect, if any, scribes have on EP diagnostic test ordering and their documentation of differential diagnoses. METHODS: We conducted a retrospective cohort study utilizing a chart review to compare diagnostic practices of EPs working both with and without scribes. We analyzed the number of laboratory and radiologic diagnostic studies ordered per encounter as well as characteristics of differential diagnosis documentation. RESULTS: Scribes did not affect laboratory studies ordered per encounter (mean 6.31 by scribes vs. 7.35 by EPs, difference -1.04; 95% confidence interval [CI] -2.34 to 0.26) or radiologic studies ordered per encounter (mean 1.49 by scribes vs. 1.39 by EPs, difference 0.10; 95% CI -0.15 to 0.35). Scribes did not affect the frequency of documenting a differential diagnosis or the number of diagnoses considered in each differential, but they were associated with higher word counts in EP differentials (mean 72.29 by scribes vs. 50.00 by EPs, mean difference 22.79; 95% CI 6.77 to 38.81). CONCLUSIONS: Scribe use does not appear to affect EP diagnostic test ordering but may have a small effect on their documentation of differential diagnoses.

SPRINT Through Tasks: A Novel Curriculum for Improving Resident Task Management in the Emergency Department.

Introduction: The emergency department (ED) presents a challenging task-management environment to emergency medicine (EM) trainees. However, equipping residents with a tool to improve task switching (generically known as multitasking) could have positive impacts on patient care and physician emotional state. We designed a task-management tool and educational curriculum with the goal of improving emergency medicine resident task-switching ability. Methods: The task-management tool uses the acronym SPRINT: (1) stabilize critical patients, (2) perform procedures, (3) rack (see new patients in the chart rack), (4) in or out (reassess and disposition), (5) type it up (chart completion). These tasks and their order were decided on by two seasoned clinicians based on their years of experience in the ED. The SPRINT tool was taught to EM residents through a 1-hour curriculum consisting of an introductory video, a classroom-based workshop with multimedia didactics, and team learning with a card game simulating the use of the SPRINT tool on a shift. Residents were surveyed to evaluate their task-management confidence and perceived effectiveness of the curriculum. Results: A total of 34 EM residents participated in this training on the SPRINT tool. There was an improvement in resident confidence in task management, and residents reporting having a strategy for task prioritization 8 weeks after the workshop. Discussion: The SPRINT curriculum provides EM residents with a tool to manage the complex task-management environment of the ED. Further research in task-management education should focus on patient-oriented outcomes among physicians who have received this training.

The Case of Flecainide Toxicity: What to Look for and How to Treat.

BACKGROUND: Flecainide is a class Ic antidysrhythmic agent used to prevent and treat both ventricular and supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, and Wolff-Parkinson-White syndrome. Flecainide can cause serious side effects, including cardiac arrest, dysrhythmias, and heart failure. Despite its growing use, the presenting signs and symptoms of flecainide toxicity are not familiar to most clinicians. In particular, our patient's particular presentation of acute kidney injury (AKI) resulting in flecainide accumulation is high risk for missed diagnosis in the emergency department. CASE REPORT: A 58-year-old woman presented with altered mental status and hypoxia that was later found to be secondary to sepsis. Medical history was notable for atrial fibrillation, for which she was on flecainide. Laboratory results were notable for hypokalemia and an AKI. Her wide complex tachycardia on admission was ultimately attributed to flecainide toxicity in the setting of AKI. Six days after presentation, it was found that her flecainide level was in the toxic range at 2.02 µg/mL (normal range 0.20-1.00 µg/mL, toxic >1.50 µg/mL). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Flecainide intoxication is rare but serious due to the potential for cardiogenic shock. Its diagnosis can be difficult, as the flecainide serum level may take days to result. This case demonstrates the necessity of keeping flecainide toxicity on the physician's differential for patients who are taking the drug, as well as what electrocardiogram findings suggest it as the etiology. Treatment can be lifesaving if initiated promptly.

Monthly Progression of Emergency Medicine Resident Efficiency: What Can We Expect of Our Residents Throughout Training?

BACKGROUND: Developing the capacity for efficient patient care is essential during emergency medicine (EM) residency training. Previous studies have demonstrated that resident efficiency improves during each year of training. OBJECTIVES: This study assessed the progression of EM resident efficiency monthly and sought to develop a model that describes this progression in terms of patients per hour (pts/h) weighted by month of training. METHODS: We performed a retrospective review of EM resident efficiency as determined by pts/h using EM resident monthly patient logs from a postgraduate year (PGY) 1-3 EM training program. Mean pts/h and standard deviation (SDs) were calculated based on month of training. One-way analysis of variance compared year-to-year training. We formulated several linear regression models to describe this progression. RESULTS: We analyzed 51 consecutive months of patient logs from 110 residents. The mean pts/h for PGY1 was 1.201 (n = 85, SD = 0.241), for PGY2 was 1.497 (n = 82, SD = 0.218), and for PGY3 was 1.676 (n = 80, SD = 0.224). Linear regression was used to describe patients seen per hour by the month of training. A significant regression was found with an R2 of 0.437 and p < 0.000. Over 36 months of training, a resident's predicted pts/h is equal to 1.113 + (0.018 × month of training). CONCLUSIONS: EM resident efficiency increases monthly, with most improvement occurring in the PGY1 year. Understanding this improvement may aid in resident performance evaluation and the understanding of predicted resident workflow.