Publications

When given a sample of 100 emergency department discharge instructions, Claude Sonnet, a large language model, produced accurate Spanish translations as evaluated by Spanish-speaking physicians and medical interpreters.

BACKGROUND: Effective crisis management in operating rooms (ORs) is crucial for patient safety. Despite their benefits, adherence to OR crisis checklists is often limited, highlighting the need for innovative solutions.

OBJECTIVE: The objective of this study was to evaluate the efficacy of augmented reality (AR)-enhanced checklists in improving protocol adherence, compared to traditional paper checklists and no checklist scenarios during simulated OR crises.

METHODS: This study was a randomized comparative efficacy study comparing the utility of AR checklists, paper checklists, and no checklist scenarios using 4 validated and simulated OR crises scenarios: asystolic cardiac arrest, air embolism, unexplained hypotension/hypoxia, and malignant hyperthermia. The study took place in a simulated OR setting and had applicability to the standard procedures in ORs, critical care units, and urgent care scenarios in the emergency department. To form the 24 OR teams, 50 professionals including 24 anesthesiologists, 24 nurses, 1 surgeon, and 1 scrub nurse from two academic hospitals were included. The primary outcome measured was the failure to adhere (FTA) rate for critical actions during simulated OR crises. Adherence was determined using retrospective video analysis involving 595 key processes evaluated across 24 surgical teams. Interrater reliability was assessed using a Cohen κ. Secondary outcomes included checklist usability and cognitive load, as measured by the low-frequency to high-frequency (LF/HF) ratio of the heart rate variability.

RESULTS: The AR checklist group showed a significantly lower FTA rate (mean 15.1%, SD 5.77%) compared to the paper checklist (mean 8.32%, SD 5.65%; t 23=-2.08; P=.048) and the no checklist groups (mean 29.81%, SD 5.59%; t 23=-6.47; P<.001). The AR checklist also resulted in a higher LF/HF ratio for anesthesiologists (F 2,46=4.88; P=.02), showing a potential increase in the level of cognitive load. Survey data indicated positive receptions for both AR and paper checklists.

CONCLUSIONS: These results suggest that AR checklists could offer a viable method for enhancing adherence to critical care protocols. Although, further research is needed to fully assess their impact on clinical outcomes and to address any associated increase in cognitive load.

BACKGROUND: Monitoring hemoglobin A1c (HbA1c) is a population health quality metric associated with improved outcomes in diabetic patients. However, the utility of emergency department (ED)-based interventions for monitoring HbA1c for institutional quality metrics is unknown.

OBJECTIVES: The purpose of this study is to evaluate a program to improve measurement of HbA1c for at-risk ED patients.

METHODS: This was a retrospective observational pre-/poststudy at an academic medical center. In November 2017, an alert was programmed into the ED Information System (EDIS) to identify diabetic patients within the health system who were overdue for HbA1c testing and prompt physicians to order HbA1c levels. Data were extracted from the EDIS from January 1, 2017, to September 30, 2023. The primary outcome was placement of an ED order for HbA1c testing. The secondary outcome was change in HbA1c on follow-up testing.

RESULTS: Of 348,490 ED patient encounters during the study period, 13,609 (3.91%) were diabetic patients within the health system who were identified as noncompliant with institutional HbA1c metrics. Following the intervention, HbA1c ordering for target patients increased from 1.5% to 12.1% (p < 0.001), but rates of testing decreased over time. Postintervention, 313 of 1416 patients (23%) who had an HbA1c ordered in the ED had follow-up HbA1c testing available, with a small average decrease in HbA1c of -0.42% (standard deviation 1.7). However, this was not statistically different compared to the preintervention group (-0.60%, p = 0.40).

CONCLUSION: A targeted ED intervention was associated with increased testing for HbA1c; however, this effect decreased over time. The program demonstrated operational feasibility, but did not appear to significantly improve HbA1c levels relative to the overall ED population. Further study is needed to assess optimal approaches to targeted population health interventions in the ED for chronic illnesses like diabetes.

Non-evidence based factors influence post-surgical opioid prescribing practices. Delivering automated near real-time opioid prescribing feedback may encourage providers to prescribe opioid quantities which are more aligned with patient consumption and institutional guidelines. COVID-19 presented unprecedented challenges to healthcare delivery. We observed a substantial deviation in guideline-concordant opioids prescribing during the initial outbreak. However, our institution's pre-existing opioid prescribing feedback system and decision aid may have helped limit the duration and magnitude of the observed deviations by informing prescribers of atypically large opioid prescriptions and encouraging use of institutional data. Combined with provider education, a non-directive decision aid, in the form of near, real-time email feedback, may be an effective mechanism to advance evidence-based opioid prescribing, as it retains flexibility and provider autonomy while encouraging data-driven decision making.

BACKGROUND: Emergency physician-performed ultrasound-guided nerve blocks are becoming more commonplace as an integral component of multimodal analgesia. Ultrasound-guided nerve blocks (UGNBs) can be used to safely and effectively treat pain from commonly encountered pathologies or to facilitate procedures.

OBJECTIVES: There is, currently, variability in the use of nerve blocks in emergency departments (ED) based on training, comfort, and resources; however, it is likely that this method of analgesia will continue to expand into ED practice. In this piece, we review the evidence for several high-utility nerve blocks that have been successfully used in the ED.

DISCUSSION: In this article, we specifically review the superficial cervical plexus block, interscalene brachial plexus nerve block, serratus anterior plane block, erector spinae plane block, pericapsular nerve block, and transgluteal sciatic nerve block.

CONCLUSION: UGNBs are increasingly being incorporated into ED patient care and becoming a critical tool as a part of an opioid reduction strategy. The group of UGNBs listed in this article represent a list of commonly performed blocks and should be considered when offering optimal multimodal analgesia to the acutely injured patient.

BACKGROUND: Ultrasound-guided nerve blocks (UGNBs) are a core component of multimodal analgesia for acute pain management in emergency departments (EDs). In addition to using standard local anesthetics, adjuncts have been demonstrated to extend the duration of UGNBs. We evaluated the efficacy and safety of dexamethasone and epinephrine as anesthetic adjuncts in UGNBs in the ED.

METHODS: Data were analyzed from the National Ultrasound-guided neRVE (NURVE) Block Registry, a retrospective, multicenter, observational registry evaluating UGNBs performed in 11 EDs from January 1, 2022, to December 31, 2023. A generalized linear mixed effects model (GLMER) with a binomial family examined factors associated with pain reduction when comparing adjunct vs. non-adjunct UGNBs. The dependent variable and primary outcome were pain reduction. Secondary outcomes included safety, dosing of adjuncts, and complications.

RESULTS: A total of 29.6% (812/2742) of UGNBs received adjuncts, most commonly dexamethasone (72.5%, 589/812) and epinephrine (23.5%, 191/812). Dexamethasone had a 1.99 odds ratio of > 50% pain reduction versus isolated local anesthetic blocks, while epinephrine had an odds ratio of 0.99 for > 50% pain reduction. There was no association between adjunct use and complications.

CONCLUSION: Compared to isolated local anesthetic nerve blocks, dexamethasone had an association with improved pain control within 60 min; without additional safety concerns in a large retrospective dataset. Prospective studies are needed to further investigate these findings in the ED setting.