Mortality and Readmission Rates Among Patients With COVID-19 After Discharge From Acute Care Setting With Supplemental Oxygen.

Importance: To optimize patient outcomes and preserve critical acute care access during the COVID-19 pandemic, the Los Angeles County Department of Health Services developed the SAFE @ HOME O2 Expected Practice (expected practice), enabling ambulatory oxygen management for COVID-19. Objective: To assess outcomes of patients with COVID-19 pneumonia discharged via the expected practice approach to home or quarantine housing with supplemental home oxygen. Design, Setting, and Participants: This retrospective cohort study included 621 adult patients with COVID-19 pneumonia who were discharged from 2 large urban public hospitals caring primarily for patients receiving Medicaid from March 20 to August 19, 2020. Patients were included in the analysis cohort if they received emergency or inpatient care for COVID-19 and were discharged with home oxygen. Interventions: Patients receiving at least 3 L per minute of oxygen, stable without other indication for inpatient care, were discharged from either emergency or inpatient encounters with home oxygen equipment, educational resources, and nursing telephone follow-up within 12 to 18 hours of discharge. Nurses provided continued telephone follow up as indicated, always with physician back-up. Main Outcomes and Measures: All-cause mortality and all-cause 30-day return admission. Results: A total of 621 patients with COVID-19 pneumonia (404 male [65.1%] and 217 female [34.9%]) were discharged with home oxygen. Median age of these patients was 51 years (interquartile range, 45-61 years), with 149 (24.0%) discharged from the emergency department and 472 (76%) discharged from inpatient encounters. The all-cause mortality rate was 1.3% (95% CI, 0.6%-2.5%) and the 30-day return hospital admission rate was 8.5% (95% CI, 6.2%-10.7%) with a median follow-up time of 26 days (interquartile range, 15-55 days). No deaths occurred in the ambulatory setting. Conclusions and Relevance: In this cohort study, patients with COVID-19 pneumonia discharged on home oxygen had low rates of mortality and return admission within 30 days of discharge. Ambulatory management of COVID-19 with home oxygen has an acceptable safety profile, and the expected practice approach may help optimize outcomes, by ensuring right care in the right place at the right time and preserving access to acute care during the COVID-19 pandemic.

How Well Does the Standardized Video Interview Score Correlate with Traditional Interview Performance?

INTRODUCTION: In 2017, all medical students applying for residency in emergency medicine (EM) were required to participate in the Standardized Video Interview (SVI). The SVI is a video-recorded, uni-directional interview consisting of six questions designed to assess interpersonal and communication skills and professionalism. It is unclear whether this simulated interview is an accurate representation of an applicant's competencies that are often evaluated during the in-person interview. OBJECTIVE: The goal of this study was to determine whether the SVI score correlates with a traditional in-person interview score. METHODS: Six geographically and demographically diverse EM residency programs accredited by the Accreditation Council for Graduate Medical Education participated in this prospective observational study. Common demographic data for each applicant were obtained through an Electronic Residency Application Service export function prior to the start of any scheduled traditional interviews (TI). On each TI day, one interviewer blinded to all applicant data, including SVI score, rated the applicant on a five-point scale. A convenience sample of applicants was enrolled based on random assignment to the blinded interviewer. We studied the correlation between SVI score and TI score. RESULTS: We included 321 unique applicants in the final analysis. Linear regression analysis of the SVI score against the TI score demonstrated a small positive linear correlation with an r coefficient of +0.13 (p=0.02). This correlation remained across all SVI score subgroups (p = 0.03). CONCLUSION: Our study suggests that there is a small positive linear correlation between the SVI score and performance during the TI.

The Standardized Video Interview: How Does It Affect the Likelihood to Invite for a Residency Interview?

BACKGROUND: The Association of American Medical Colleges instituted a standardized video interview (SVI) for all applicants to emergency medicine (EM). It is unclear how the SVI affects a faculty reviewer's decision on likelihood to invite an applicant (LTI) for an interview. OBJECTIVES: The objective was to determine whether the SVI affects the LTI. METHODS: Nine Accreditation Council of Graduate Medication Education (ACGME)-accredited EM residency programs participated in this prospective, observational study. LTI was defined on a 5-point Likert scale as follows: 1 = definitely not invite, 2 = likely not invite, 3 = might invite, 4 = probably invite, 5 = definitely invite. LTI was recorded at three instances during each review: 1) after typical screening (blinded to the SVI), 2) after unblinding to the SVI score, and 3) after viewing the SVI video. RESULTS: Seventeen reviewers at nine ACGME-accredited residency programs participated. We reviewed 2,219 applications representing 1,424 unique applicants. After unblinding the SVI score, LTI did not change in 2,065 (93.1%), increased in 85 (3.8%) and decreased in 69 (3.1%; p = 0.22). In subgroup analyses, the effect of the SVI on LTI was unchanged by United States Medical Licensing Examination score. However, when examining subgroups of SVI scores, the percentage of applicants in whom the SVI score changed the LTI was significantly different in those that scored in the lower and upper subgroups (p < 0.0001). The SVI video was viewed in 816 (36.8%) applications. Watching the video did not change the LTI in 631 (77.3%); LTI increased in 106 (13.0%) and decreased in 79 (9.7%) applications (p = 0.04). CONCLUSIONS: The SVI score changed the LTI in 7% of applications. In this group, the score was equally likely to increase or decrease the LTI. Lower SVI scores were more likely to decrease the LTI than higher scores were to increase the LTI. Watching the SVI video was more likely to increase the LTI than to decrease it.

Are You Applying to More Than One Specialty?

Although the majority of U.S. medical students predominantly apply to only one specialty, some apply to more than one. When it comes to emergency medicine (EM), applicants may apply to additional specialties due to several reasons: being international medical graduates as well as their inability to make a decision regarding the choice of specialty, fear from the growing competitiveness of EM, or the desire to stay in a specific geographic area. Accordingly, in this article we aim to guide medical students through the process of applying to more than one specialty, including using the Electronic Residency Application Service application, writing a personal statement, getting letters of recommendation, and an Early Match. Moreover, we elaborate on the effect of applying to more than one specialty on a student's application to a residency in EM.

Standardized Video Interviews Do Not Correlate to United States Medical Licensing Examination Step 1 and Step 2 Scores.

INTRODUCTION: In 2017, the Standardized Video Interview (SVI) was required for applicants to emergency medicine (EM). The SVI contains six questions highlighting professionalism and interpersonal communication skills. The responses were scored (6-30). As it is a new metric, no information is available on correlation between SVI scores and other application data. This study was to determine if a correlation exists between applicants' United States Medical Licensing Examination (USMLE) and SVI scores. We hypothesized that numeric USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores would not correlate with the SVI score, but that performance on the Step 2 Clinical Skills (CS) portion may correlate with the SVI since both test communication skills. METHODS: Nine EM residency sites participated in the study with data exported from an Electronic Residency Application Service (ERAS®) report. All applicants with both SVI and USMLE scores were included. We studied the correlation between SVI scores and USMLE scores. Predetermined subgroup analysis was performed based on applicants' USMLE Step 1 and Step 2 CK scores as follows: (≥ 200, 201-220, 221-240, 241-260, >260). We used linear regression, the Kruskal-Wallis test and Mann-Whitney U test for statistical analyses. RESULTS: 1,325 applicants had both Step 1 and SVI scores available, with no correlation between the overall scores (p=0.58) and no correlation between the scores across all Step 1 score ranges, (p=0.29). Both Step 2 CK and SVI scores were available for 1,275 applicants, with no correlation between the overall scores (p=0.56) and no correlation across all ranges, (p=0.10). The USMLE Step 2 CS and SVI scores were available for 1,000 applicants. Four applicants failed the CS test without any correlation to the SVI score (p=0.08). CONCLUSION: We found no correlation between the scores on any portion of the USMLE and the SVI; therefore, the SVI provides new information to application screeners.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework.

OBJECTIVES: Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM. METHODS: The American College of Emergency Physicians Palliative Medicine Section assembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine. RESULTS: The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators. CONCLUSIONS: Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.

Does the Flipped Classroom Improve Learning in Graduate Medical Education?

BACKGROUND: The flipped classroom model for didactic education has recently gained popularity in medical education; however, there is a paucity of performance data showing its effectiveness for knowledge gain in graduate medical education. OBJECTIVE: We assessed whether a flipped classroom module improves knowledge gain compared with a standard lecture. METHODS: We conducted a randomized crossover study in 3 emergency medicine residency programs. Participants were randomized to receive a 50-minute lecture from an expert educator on one subject and a flipped classroom module on the other. The flipped classroom included a 20-minute at-home video and 30 minutes of in-class case discussion. The 2 subjects addressed were headache and acute low back pain. A pretest, immediate posttest, and 90-day retention test were given for each subject. RESULTS: Of 82 eligible residents, 73 completed both modules. For the low back pain module, mean test scores were not significantly different between the lecture and flipped classroom formats. For the headache module, there were significant differences in performance for a given test date between the flipped classroom and the lecture format. However, differences between groups were less than 1 of 10 examination items, making it difficult to assign educational importance to the differences. CONCLUSIONS: In this crossover study comparing a single flipped classroom module with a standard lecture, we found mixed statistical results for performance measured by multiple-choice questions. As the differences were small, the flipped classroom and lecture were essentially equivalent.

Low Back Pain in the Emergency Medicine Department: A Flipped Classroom Module.

INTRODUCTION: Current residency didactic schedules that are built upon hour-long, lecture-based presentations are incongruous with adult learning theory and the needs of millennial generation residents. An alternative to the traditional lecture, the flipped classroom involves viewing a short video lecture at home, followed by an active discussion during class time. This module was developed for emergency medicine residents and rotating medical students without previous training on the subject. METHODS: The at-home portion of the module was designed to be delivered at home, while the in-class discussion was designed to be carried out over 30-45 minutes during a regularly scheduled didactic time. Small-group size may be determined by faculty availability, though groups of five are optimal. There is no requirement for faculty preparation prior to the in-class session. Associated materials include objectives, the at-home video, a discussion guide for faculty facilitators, a case-based handout for students and residents, and assessment questions. We assessed our module with a pretest, immediate posttest, and the posttest again after 90 days. RESULTS: The mean pretest score was 66%, mean posttest score 76%, and mean retention test score 66%. There was an immediate increase of 10%, which did not remain at 90 days. DISCUSSION: We developed a flipped classroom module that can be implemented in any emergency medicine residency or clerkship. It addresses the theoretical challenges posed to traditional conference didactics by increasing the focus on problem solving and self-directed learning.

A Missed Case of Occult Bilateral Temporomandibular Dislocation Mistaken for Dystonia.

A 24-year-old male with a history of psychiatric disorder and no prior significant temporomandibular joint (TMJ) pathology presented to the emergency department for "lockjaw." Plain film X-rays of the mandible were read as unremarkable by an attending radiologist, leading to the initial diagnosis of medication-induced dystonic reaction. Following unsuccessful medical treatment a maxillofacial computed tomography (CT) was ordered. CT confirmed bilateral dislocation, illustrating the importance of clinical judgment, and limitations of certain radiographic images. The authors believe this case to be the first reported case in the medical literature of bilateral anterior TMJ dislocation with a false negative X-ray.

Nebulized Tranexamic Acid as a Noninvasive Therapy for Cancer-Related Hemoptysis.

BACKGROUND: Many patients with cancer involving the respiratory system suffer from the frequent recurrence of significant, submassive hemoptysis, which may result in invasive procedures, hospital stays, and a reduction in quality of life. Currently, there are no widely accepted noninvasive therapeutic options. Few case studies have looked at the benefit of tranexamic acid (TXA) as a noninvasive therapy in the treatment of hemoptysis. METHODS: A patient with an invasive airway malignancy presented to the emergency department with substantial hemoptysis. A nebulized TXA solution was used as a noninvasive therapy to control the hemorrhage. RESULTS: The patient's hemoptysis resolved fifteen minutes after the nebulized TXA therapy was initiated. There were no known adverse events. CONCLUSION: Nebulized TXA seems to be a safe, effective, and noninvasive method for controlling, or at least temporizing, hemoptysis in select patients. Nebulized TXA may be useful as a palliative therapy for chronic hemoptysis and as a tool in the acute stabilization of hemoptysis.

Death notification in the emergency department: survivors and physicians.

When patients die in the emergency department (ED), emergency physicians (EP) must disclose the bad news to family members. The death is often unexpected and the act of notification can be difficult. Many EPs have not been trained in the skill of communicating death to family members. This article reviews the available literature regarding ED death notification training and proposes future directions for educational interventions to improve physician communication in ED death disclosure.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound.

A 57-year-old man presented to our emergency department with altered mental status. He had a past medical history significant for cirrhosis and previous placement of a transjugular intrahepatic portosystemic shunt (TIPS). On cardiac auscultation, a new heart murmur and an unexpected degree of cardiac ectopy were noted. On the 12-lead electrocardiogram, the patient was noted to have multiple premature atrial contractions, corroborating the irregular heart rhythm on physical exam. A focused bedside emergency ultrasound of the heart was then performed. This exam revealed an apparent foreign body in the right atrium. It appeared as if the patient's TIPS had migrated from the heart into the right atrium. This case, as well as the literature describing this unusual complication of TIPS placement, is reviewed in this case report.

Emergency medicine physicians' perspectives of providing palliative care in an emergency department.

This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

Left ventricular hypertrophy may be transient in the emergency department.

BACKGROUND: While research has established that the bedside electrocardiogram (ECG) is an insensitive test for the presence or absence of left ventricular hypertrophy (LVH), the finding, when present, is thought to be reproducible. OBJECTIVE: To assess the reproducibility of serial ECGs done in the emergency department (ED) with regard to the presence or absence of LVH. METHOD: A prospective study on consecutive patients admitted to an ED-run cardiac observation unit. A single reviewer collected and scored ECGs for the presence of LVH, using three established criteria (Cornell, Sokolow-Lyon and Romhilt-Estes). Demographic and medical history was also collected. RESULTS: Over a three-year time period, 295 patients were enrolled; 132 males and 163 females with a mean age of 54.4 years (range, 19-89 years). The prevalence of LVH ranged from 11-14% and the agreement among all three criteria was fair (kappa = 0.325). Using the Cornell criteria, 33 patients had ECG#1 consistent with LVH. Of the patients meeting LVH criteria on ECG #1, only 15 retained their diagnosis of LVH on ECG#2 (i.e. 55% of the LVH identified in ECG#1 was not seen in ECG#2). Additionally, nine patients developed an ECG diagnosis of LVH between ECG#1 and ECG#2. In total, 27 (nine percent of the total) had ECG measurements that changed between ECG#1 and ECG#2. We made similar findings with the Sokolow-Lyon and Romhilt-Estes criteria. The results were not modified by gender, blood pressure or medication use. CONCLUSION: The finding of LVH on ECG was not very reproducible during serial measurements on the same person during a single 24-hour observation period.

Rocuronium vs. succinylcholine in the emergency department: a critical appraisal.

BACKGROUND: Two methods of paralysis are available for rapid sequence intubation (RSI) in the emergency department (ED): depolarizing agents such as succinylcholine, and non-depolarizing drugs such as rocuronium. Rocuronium is a useful alternative when succinylcholine is contraindicated. Contraindications to succinylcholine include allergy, history of malignant hyperthermia, denervation syndromes, and patients who are 24-48 h post burn or crush injury. Non-depolarizing drugs have the advantage of causing less pain due to post-paralysis myalgias. CLINICAL QUESTION: Can rocuronium replace succinylcholine as the paralytic of choice for RSI in the ED? EVIDENCE REVIEW: Four relevant studies were selected from an evidence search and a structured review performed. RESULTS: For the outcomes of clinically acceptable intubation conditions and time to onset, the two agents were not statistically significantly different. Succinylcholine seems to produce conditions that have higher satisfaction scores. CONCLUSION: Succinylcholine remains the drug of choice for ED RSI unless there is a contraindication to its usage.