Publications

AIM: Point of Care Ultrasound (POCUS) excels in the assessment of patients with hypotension and shock. Whether using real patients or a manikin simulator to teach POCUS skills is preferable is not completely clear. We designed a randomized-controlled trial to compare these two different teaching methods of POCUS.

METHODS: We enrolled 47 medical students on an internal medicine sub-internship in this randomized-controlled trial. Twenty-four students were randomly assigned to the experimental group to learn from volunteer patients in the emergency department (ED), and 23 were randomly assigned to the control group to learn from a manikin simulator in a simulation center. All students received a didactic workshop focused on hypotension and shock, followed by supervised learning from either volunteer patients in the ED or a manikin simulator in a simulation center. Student knowledge and confidence were assessed through a pre-survey before the workshop, post-survey after the workshop, and a 3-month longitudinal survey after both the workshop and supervised POCUS learning were completed. The primary end point was assessment of student knowledge and confidence at the 3-month longitudinal time period.

RESULTS: At the 3-month longitudinal survey, there was no statistical difference in the primary end point of questions correctly answered by students in the experimental group compared to those in the control group (88% vs 86.5%, p = 0.713, NS), and no statistical difference in reported confidence between students in the experimental group from those in the control group (4.22 vs 4.10, p = 0.846, NS).

CONCLUSION: In this randomized-controlled trial using POCUS to assess hypotension and shock, there were no significant differences in learner knowledge and confidence between students in the ED experimental group learning from volunteer patients versus the control group learning from a manikin simulator indicating that the methods may be equally effective in teaching POCUS.

BACKGROUND: Point of care ultrasound (POCUS) is a critical skill for physicians across multiple medical specialties, yet substantial heterogeneity exists in how competency is assessed. Computer-based approaches can be used to deliver, grade, and analyze learner performance, and may be more objective and reliable than traditional approaches using expert assessments. This study aimed to systematically review and summarize the existing literature surrounding computer-based approaches to assessing POCUS competency.

METHODS: We searched six online databases (MEDLINE, IEEE Xplore Digital Library, Association for Computing Machinery Digital Library, PsycINFO (Ovid), EMBASE, Web of Science Core Collection). We included original peer-reviewed studies that assessed computer-based metrics of POCUS competence among any learner group performing POCUS. We also reviewed reference lists of all included studies. We extracted data elements that included the specialty of participants, POCUS experience, POCUS modality used, and type and results of computer-based competency assessments. At least two authors conducted title and abstract screening, full text review, and data extraction, with discrepancies adjudicated by a third author. We present a qualitative synthesis of study findings.

RESULTS: Of 7375 identified studies, we included 28 in our final analysis. Computer-based metrics were used to assess knowledge (n = 10), skills (n = 25), and cognitive load (n = 1) using hand tracking (n = 14), eye tracking (n = 7), image analysis (n = 6), and simulation scores (n = 1). In general, hand tracking analysis showed that experts had shorter probe path lengths, took less time to identify areas of interest, and had fewer discrete movements compared with novices. Eye tracking assessment showed increased dwell time was associated with successful completion of procedures and increased accuracy in interpreting images.

CONCLUSION: We identified four computer-based metrics for assessing POCUS competence, many of which demonstrated consistent performance in distinguishing skill level. Further work is needed to standardize and validate those approaches.

OBJECTIVES: Our primary objective was to estimate the realistic impact of an artificial intelligence (AI)-based trans-thoracic echocardiogram (TTE)-first strategy on the annual national cost savings among eligible adult emergency department (ED) patients presenting with syncope in the United States. Our secondary outcomes were the estimated reduction in avoidable ED bed hours and comprehensive TTE studies.

METHODS: Using publicly available estimates for inputs such as the size of the adult ED syncope population, typical disposition and risk stratification proportions, and frequency of comprehensive TTE studies, we created a model and ran 1000 trials of a Monte Carlo simulation. Using this simulation, we modeled the national annual cost savings and potential bed hours averted through the impact of avoiding comprehensive TTE studies. We report the descriptive statistics modeling the distribution of all endpoints.

RESULTS: An AI-assisted TTE-first strategy was estimated to save a mean (±SD) of $815 million (±$260 million) by avoiding 468,000 (±141,000) comprehensive TTE studies resulting in 12,500,000 (±4,600,000) bed hours saved.

CONCLUSION: If adopted widely, an AI-based TTE-first strategy applied to eligible ED patients presenting with syncope could yield substantial benefits by averting avoidable comprehensive TTE studies and saving bed hours.

BACKGROUND: Recent studies have validated the efficacy of point-of-care ultrasound (POCUS) as an alternative diagnostic imaging approach to computed tomography (CT) for patients with suspected acute diverticulitis. This study aimed to quantify the national impact of this approach in cost savings, ED length-of-stay (LOS), and radiation risk mitigation using a POCUS-first approach for acute diverticulitis in the emergency department (ED).

METHODS: Using published data, we constructed a Monte Carlo simulation model to compare two POCUS-first strategies (nonselective and selective approaches) for evaluating patients with suspected acute diverticulitis in the ED. Primary outcomes were cost savings, reduction in ED LOS, and radiation risk mitigation.

RESULTS: In our simulation model, both nonselective and selective POCUS-first strategies showed substantial potential reductions in the annual number of CTs. Notably, the selective approach led to significantly fewer estimated POCUS examinations (433,847 ± 45,103 exams vs 720,048 ± 55,815 exams, p < 0.001) resulting in greater cost savings ($94,620,235 ± $10,090,807 vs $70,017,473 ± $11,583,911, p < 0.001) and greater reductions in ED LOS (508,569 ± 640,048 bed-hours vs 332,518 ± 774,485 bed-hours, p < 0.001). Reduction in radiation exposure was comparable between the two approaches (8,779,414 ± 2,389,982 mSv vs 8,846,058 ± 2,420,185 mSv, p = 0.536).

CONCLUSION: Both POCUS-first models can achieve substantial national annual cost savings, ED LOS reduction, and decreases in radiation exposure compared to the traditional CT-first approach. POCUS should be strongly considered as a first-line imaging modality for acute diverticulitis especially among low-risk patients.

IMPORTANCE: Ultrasonography-guided nerve blocks (UGNBs) have become a core component of multimodal analgesia for acute pain management in the emergency department (ED). Despite their growing use, national adoption of UGNBs has been slow due to a lack of procedural safety in the ED.

OBJECTIVE: To assess the complication rates and patient pain scores of UGNBs performed in the ED.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included data from the National Ultrasound-Guided Nerve Block Registry, a retrospective multicenter observational registry encompassing procedures performed in 11 EDs in the US from January 1, 2022, to December 31, 2023, of adult patients who underwent a UGNB.

EXPOSURE: UGNB encounters.

MAIN OUTCOMES AND MEASURES: The primary outcome of this study was complication rates associated with ED-performed UGNBs recorded in the National Ultrasound-Guided Nerve Block Registry from January 1, 2022, to December 31, 2023. The secondary outcome was patient pain scores of ED-based UGNBs. Data for all adult patients who underwent an ED-based UGNB at each site were recorded. The volume of UGNB at each site, as well as procedural outcomes (including complications), were recorded. Data were analyzed using descriptive statistics of all variables.

RESULTS: In total, 2735 UGNB encounters among adult patients (median age, 62 years [IQR, 41-77 years]; 51.6% male) across 11 EDs nationwide were analyzed. Fascia iliaca blocks were the most commonly performed UGNBs (975 of 2742 blocks [35.6%]). Complications occurred at a rate of 0.4% (10 of 2735 blocks). One episode of local anesthetic systemic toxicity requiring an intralipid was reported. Overall, 1320 of 1864 patients (70.8%) experienced 51% to 100% pain relief following UGNBs. Operator training level varied, although 1953 of 2733 procedures (71.5%) were performed by resident physicians.

CONCLUSIONS AND RELEVANCE: The findings of this cohort study of 2735 UGNB encounters support the safety of UGNBs in ED settings and suggest an association with improvement in patient pain scores. Broader implementation of UGNBs in ED settings may have important implications as key elements of multimodal analgesia strategies to reduce opioid use and improve patient care.

BACKGROUND: Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline.

STUDY DESIGN: We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed.

RESULTS: A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively.

CONCLUSIONS: Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.

OBJECTIVES: During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition.

METHODS: Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time.

RESULTS: The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p < 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p = 0.09).

CONCLUSIONS: Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.

IMPORTANCE: Emergency department (ED) visits by older adults with life-limiting illnesses are a critical opportunity to establish patient care end-of-life preferences, but little is known about the optimal screening criteria for resource-constrained EDs.

OBJECTIVES: To externally validate the Geriatric End-of-Life Screening Tool (GEST) in an independent population and compare it with commonly used serious illness diagnostic criteria.

DESIGN, SETTING, AND PARTICIPANTS: This prognostic study assessed a cohort of patients aged 65 years and older who were treated in a tertiary care ED in Boston, Massachusetts, from 2017 to 2021. Patients arriving in cardiac arrest or who died within 1 day of ED arrival were excluded. Data analysis was performed from August 1, 2023, to March 27, 2024.

EXPOSURE: GEST, a logistic regression algorithm that uses commonly available electronic health record (EHR) datapoints and was developed and validated across 9 EDs, was compared with serious illness diagnoses as documented in the EHR. Serious illnesses included stroke/transient ischemic attack, liver disease, cancer, lung disease, and age greater than 80 years, among others.

MAIN OUTCOMES AND MEASURES: The primary outcome was 6-month mortality following an ED encounter. Statistical analyses included area under the receiver operating characteristic curve, calibration analyses, Kaplan-Meier survival curves, and decision curves.

RESULTS: This external validation included 82 371 ED encounters by 40 505 unique individuals (mean [SD] age, 76.8 [8.4] years; 54.3% women, 13.8% 6-month mortality rate). GEST had an external validation area under the receiver operating characteristic curve of 0.79 (95% CI, 0.78-0.79) that was stable across years and demographic subgroups. Of included encounters, 53.4% had a serious illness, with a sensitivity of 77.4% (95% CI, 76.6%-78.2%) and specificity of 50.5% (95% CI, 50.1%-50.8%). Varying GEST cutoffs from 5% to 30% increased specificity (5%: 49.1% [95% CI, 48.7%-49.5%]; 30%: 92.2% [95% CI, 92.0%-92.4%]) at the cost of sensitivity (5%: 89.3% [95% CI, 88.8-89.9]; 30%: 36.2% [95% CI, 35.3-37.1]). In a decision curve analysis, GEST outperformed serious illness criteria across all tested thresholds. When comparing patients referred to intervention by GEST with serious illness criteria, GEST reclassified 45.1% of patients with serious illness as having low risk of mortality with an observed mortality rate 8.1% and 2.6% of patients without serious illness as having high mortality risk with an observed mortality rate of 34.3% for a total reclassification rate of 25.3%.

CONCLUSIONS AND RELEVANCE: The findings of this study suggest that both serious illness criteria and GEST identified older ED patients at risk for 6-month mortality, but GEST offered more useful screening characteristics. Future trials of serious illness interventions for high mortality risk in older adults may consider transitioning from diagnosis code criteria to GEST, an automatable EHR-based algorithm.

OBJECTIVES: This study aimed to compare the different respiratory rate (RR) monitoring methods used in the emergency department (ED): manual documentation, telemetry, and capnography.

METHODS: This is a retrospective study using recorded patient monitoring data. The study population includes patients who presented to a tertiary care ED between January 2020 and December 2022. Inclusion and exclusion criteria were patients with simultaneous recorded RR data from all three methods and less than 10 min of recording, respectively. Linear regression and Bland-Altman analysis were performed between different methods.

RESULTS: A total of 351 patient encounters met study criteria. Linear regression yielded an R-value of 0.06 (95% confidence interval [CI] 0.00-0.12) between manual documentation and telemetry, 0.07 (95% CI 0.01-0.13) between manual documentation and capnography, and 0.82 (95% CI 0.79-0.85) between telemetry and capnography. The Bland-Altman analysis yielded a bias of -0.8 (95% limits of agreement [LOA] -12.2 to 10.6) between manual documentation and telemetry, bias of -0.6 (95% LOA -13.5 to 12.3) between manual documentation and capnography, and bias of 0.2 (95% LOA -6.2 to 6.6) between telemetry and capnography.

CONCLUSION: There is a poor correlation between manual documentation and both automated methods, while there is relatively good agreement between the automated methods. This finding highlights the need to further investigate the methodology used by the ED staff in monitoring and documenting RR and ways to improve its reliability given that many important clinical decisions are made based on these assessments.

BACKGROUND: In the emergency department (ED), certain anatomical and physiological airway characteristics may predispose patients to tracheal intubation complications and poor outcomes. We hypothesized that both anatomically difficult airways (ADAs) and physiologically difficult airways (PDAs) would have lower first-attempt success than airways with neither in a cohort of ED intubations.

METHODS: We performed a retrospective, observational study using the National Emergency Airway Registry (NEAR) to examine the association between anticipated difficult airways (ADA, PDA, and combined ADA and PDA) vs those without difficult airway findings (neither ADA nor PDA) with first-attempt success. We included adult (age ≥14 years) ED intubations performed with sedation and paralysis from January 1, 2016 to December 31, 2018 using either direct or video laryngoscopy. We excluded patients in cardiac arrest. The primary outcome was first-attempt success, while secondary outcomes included first-attempt success without adverse events, peri-intubation cardiac arrest, and the total number of airway attempts. Mixed-effects models were used to obtain adjusted estimates and confidence intervals (CIs) for each outcome. Fixed effects included the presence of a difficult airway type (independent variable) and covariates including laryngoscopy device type, intubator postgraduate year, trauma indication, and patient age as well as the site as a random effect. Multiplicative interaction between ADAs and PDAs was assessed using the likelihood ratio (LR) test.

RESULTS: Of the 19,071 subjects intubated during the study period, 13,938 were included in the study. Compared to those without difficult airway findings (neither ADA nor PDA), the adjusted odds ratios (aORs) for first-attempt success were 0.53 (95% CI, 0.40-0.68) for ADAs alone, 0.96 (0.68-1.36) for PDAs alone, and 0.44 (0.34-0.56) for both. The aORs for first-attempt success without adverse events were 0.72 (95% CI, 0.59-0.89) for ADAs alone, 0.79 (0.62-1.01) for PDAs alone, and 0.44 (0.37-0.54) for both. There was no evidence that the interaction between ADAs and PDAs for first-attempt success with or without adverse events was different from additive (ie, not synergistic/multiplicative or antagonistic).

CONCLUSIONS: Compared to no difficult airway characteristics, ADAs were inversely associated with first-attempt success, while PDAs were not. Both ADAs and PDAs, as well as their interaction, were inversely associated with first-attempt success without adverse events.