Original Research Archives - Page 24 of 40 - The Western Journal of Emergency Medicine

Introducing Medical Students into the Emergency Department: The Impact upon Patient Satisfaction

Volume 16, Issue 6, November 2015.
Christopher Kiefer, MD, et al.

Introduction: Performance on patient satisfaction surveys is becoming increasingly important for
practicing emergency physicians and the introduction of learners into a new clinical environment
may impact such scores. This study aimed to quantify the impact of introducing fourth-year medical
students on patient satisfaction in two university-affiliated community emergency departments (EDs).
Methods: Two community-based EDs in the Indiana University Health (IUH) system began
hosting medical students in March 2011 and October 2013, respectively. We analyzed responses
from patient satisfaction surveys at each site for seven months before and after the introduction
of students. Two components of the survey, “Would you recommend this ED to your friends
and family?” and “How would you rate this facility overall?” were selected for analysis, as they
represent the primary questions reviewed by the Center for Medicare Services (CMS) as part of
value-based purchasing. We evaluated the percentage of positive responses for adult, pediatric,
and all patients combined.
Results: Analysis did not reveal a statistically significant difference in the percentage of positive
response for the “would you recommend” question at both clinical sites with regards to the adult
and pediatric subgroups, as well as the all-patient group. At one of the sites, there was significant
improvement in the percentage of positive response to the “overall rating” question following the
introduction of medical students when all patients were analyzed (60.3% to 68.2%, p=0.038).
However, there was no statistically significant difference in the “overall rating” when the pediatric or
adult subgroups were analyzed at this site and no significant difference was observed in any group
at the second site.
Conclusion: The introduction of medical students in two community-based EDs is not associated
with a statistically significant difference in overall patient satisfaction, but was associated with a
significant positive effect on the overall rating of the ED at one of the two clinical sites studied.
Further study is needed to evaluate the effect of medical student learners upon patient satisfaction in
settings outside of a single health system.

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Teaching Emotional Intelligence: A Control Group Study of a Brief Educational Intervention for Emergency Medicine Residents

Volume 16, Issue 6, November 2015.
Diane L. Gorgas, MD, et al.

Introduction: Emotional Intelligence (EI) is defined as an ability to perceive another’s emotional
state combined with an ability to modify one’s own. Physicians with this ability are at a distinct
advantage, both in fostering teams and in making sound decisions. Studies have shown that
higher physician EI’s are associated with lower incidence of burn-out, longer careers, more positive
patient-physician interactions, increased empathy, and improved communication skills. We explored
the potential for EI to be learned as a skill (as opposed to being an innate ability) through a brief
educational intervention with emergency medicine (EM) residents.
Methods: This study was conducted at a large urban EM residency program. Residents were
randomized to either EI intervention or control groups. The intervention was a two-hour session
focused on improving the skill of social perspective taking (SPT), a skill related to social awareness.
Due to time limitations, we used a 10-item sample of the Hay 360 Emotional Competence Inventory
to measure EI at three time points for the training group: before (pre) and after (post) training, and at
six-months post training (follow up); and at two time points for the control group: pre- and follow up.
The preliminary analysis was a four-way analysis of variance with one repeated measure: Group x
Gender x Program Year over Time. We also completed post-hoc tests.
Results: Thirty-three EM residents participated in the study (33 of 36, 92%), 19 in the EI intervention
group and 14 in the control group. We found a significant interaction effect between Group and
Time (p<0.05). Post-hoc tests revealed a significant increase in EI scores from Time 1 to 3 for the EI
intervention group (62.6% to 74.2%), but no statistical change was observed for the controls (66.8%
to 66.1%, p=0.77). We observed no main effects involving gender or level of training.
Conclusion: Our brief EI training showed a delayed but statistically significant positive impact on
EM residents six months after the intervention involving SPT. One possible explanation for this
finding is that residents required time to process and apply the EI skills training in order for us to
detect measurable change. More rigorous measurement will be needed in future studies to aid in the
interpretation of our findings.

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Correlation of Simulation Examination to Written Test Scores for Advanced Cardiac Life Support Testing: Prospective Cohort Study

Volume 16, Issue 6, November 2015.
Suzanne L. Strom, MD, et al.

Introduction: Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written
multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been
used in many specialties as a training resource as well as an evaluative tool. There are no data to our
knowledge that compare simulation examination scores with written test scores for ACLS courses.
Objective: To compare and correlate a novel high-fidelity simulation-based evaluation with
traditional written testing for senior medical students in an ACLS course.
Methods: We performed a prospective cohort study to determine the correlation between simulation based
evaluation and traditional written testing in a medical school simulation center. Students
were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario.
Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical
students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome
was comparison of simulation-based vs. written outcome scores.
Results: The composite average score on the written evaluation was substantially higher (93.6%)
than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6-14.0%],
p<0.00005). We found a statistically significant moderate correlation between simulation scenario
test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new
evaluation method.
Conclusion: Simulation-based ACLS evaluation methods correlate with traditional written testing
and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and
challenging testing method, as students scored higher on written evaluation methods compared to
simulation.

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How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

Volume 16, Issue 6, November 2015.
Grant Wei, MD, et al.

Introduction: The effect of emergency department (ED) crowding has been recognized as a
concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction
has been studied extensively. Little research has reviewed the effect of ED crowding on medical
education. Prior studies that have considered this effect have shown no correlation between ED
crowding and resident perception of quality of medical education.
Objective: To determine whether ED crowding, as measured by the National ED Overcrowding
Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective
experiences during emergency medicine (EM) clerkship rotations.
Methods: We collected end-of-rotation examinations and medical student evaluations for 21 EM
rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were
calculated for each corresponding period. Weighted regression analyses examined the correlation
between components of the medical student evaluation, student test scores, and the NEDOCS score
for each period.
Results: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative
correlation with medical student tests scores (regression coefficient= -0.16, p=0.04) and three
elements of the rotation evaluation (attending teaching, communication, and systems-based
practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar
results. When the data were controlled for effect of month of the year, only student test score
remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student
rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases).
Conclusion: ED overcrowding does demonstrate a small but negative association with medical
student performance on end-of-rotation examinations. Additional studies are recommended to further
evaluate this effect.

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Medical Student Performance on the National Board of Medical Examiners Emergency Medicine Advanced Clinical Examination and the National Emergency Medicine M4 Exams

Volume 16 , Issue 6, November 2015.
Katherine Hiller, MD, MPH, et al.

Introduction: In April 2013, the National Board of Medical Examiners (NBME) released an Advanced
Clinical Examination (ACE) in emergency medicine (EM). In addition to this new resource, CDEM
(Clerkship Directors in EM) provides two online, high-quality, internally validated examinations.
National usage statistics are available for all three examinations, however, it is currently unknown how
students entering an EM residency perform as compared to the entire national cohort. This information
may help educators interpret examination scores of both EM-bound and non-EM-bound students.
Objectives: The objective of this study was to compare EM clerkship examination performance
between students who matched into an EM residency in 2014 to students who did not. We made
comparisons were made using the EM-ACE and both versions of the National fourth year medical
student (M4) EM examinations.
Method: In this retrospective multi-institutional cohort study, the EM-ACE and either Version 1 (V1)
or 2 (V2) of the National EM M4 examination was given to students taking a fourth-year EM rotation
at five institutions between April 2013 to February 2014. We collected examination performance,
including the scaled EM-ACE score, and percent correct on the EM M4 exams, and 2014 NRMP
Match status. Student t-tests were performed on the examination averages of students who matched
in EM as compared with those who did not.
Results: A total of 606 students from five different institutions took both the EM-ACE and one of the
EM M4 exams; 94 (15.5%) students matched in EM in the 2014 Match. The mean score for EM-bound
students on the EM-ACE, V1 and V2 of the EM M4 exams were 70.9 (n=47, SD=9.0), 84.4 (n=36,
SD=5.2), and 83.3 (n=11, SD=6.9), respectively. Mean scores for non-EM-bound students were 68.0
(n=256, SD=9.7), 82.9 (n=243, SD=6.5), and 74.5 (n=13, SD=5.9). There was a significant difference
in mean scores in EM-bound and non-EM-bound student for the EM-ACE (p=0.05) and V2 (p<0.01)
but not V1 (p=0.18) of the National EM M4 examination.
Conclusion: Students who successfully matched in EM performed better on all three exams at the
end of their EM clerkship.

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Correlation of the National Board of Medical Examiners Emergency Medicine Advanced Clinical Examination Given in July to Intern American Board of Emergency Medicine in-training Examination Scores: A Predictor of Performance?

Volume 16, Issue 6, November 2015.
Katherine Hiller, MD, MPH

Introduction: There is great variation in the knowledge base of Emergency Medicine (EM) interns
in July. The first objective knowledge assessment during residency does not occur until eight months
later, in February, when the American Board of EM (ABEM) administers the in-training examination
(ITE). In 2013, the National Board of Medical Examiners (NBME) released the EM Advanced Clinical
Examination (EM-ACE), an assessment intended for fourth-year medical students. Administration of
the EM-ACE to interns at the start of residency may provide an earlier opportunity to assess the new
EM residents’ knowledge base. The primary objective of this study was to determine the correlation
of the NBME EM-ACE, given early in residency, with the EM ITE. Secondary objectives included
determination of the correlation of the United States Medical Licensing Examination (USMLE) Step 1
or 2 scores with early intern EM-ACE and ITE scores and the effect, if any, of clinical EM experience
on examination correlation.
Methods: This was a multi-institutional, observational study. Entering EM interns at six residencies
took the EM-ACE in July 2013 and the ABEM ITE in February 2014. We collected scores for the EMACE
and ITE, age, gender, weeks of clinical EM experience in residency prior to the ITE, and USMLE
Step 1 and 2 scores. Pearson’s correlation and linear regression were performed.
Results: Sixty-two interns took the EM-ACE and the ITE. The Pearson’s correlation coefficient
between the ITE and the EM-ACE was 0.62. R-squared was 0.5 (adjusted 0.4). The coefficient of
determination was 0.41 (95% CI [0.3-0.8]). For every increase of one in the scaled EM-ACE score,
we observed a 0.4% increase in the EM in-training score. In a linear regression model using all
available variables (EM-ACE, gender, age, clinical exposure to EM, and USMLE Step 1 and Step 2
scores), only the EM-ACE score was significantly associated with the ITE (p<0.05). We observed
significant colinearity among the EM-ACE, ITE and USMLE scores. Gender, age and number of
weeks of EM prior to the ITE had no effect on the relationship between EM-ACE and the ITE.
Conclusion Given early during intern year, the EM-ACE score showed positive correlation with ITE.
Clinical EM experience prior to the in-training exam did not affect the correlation.

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Emergency Department Operations

Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice

Volume 16, Issue 5, September 2015.
Jeremy J. Hess, MD, MPH

Introduction: Physicians dedicate substantial time to documentation. Scribes are sometimes used
to improve efficiency by performing documentation tasks, although their impacts have not been
prospectively evaluated. Our objective was to assess a scribe program’s impact on emergency
department (ED) throughput, physician time utilization, and job satisfaction in a large academic
emergency medicine practice.
Methods: We evaluated the intervention using pre- and post-intervention surveys and administrative
data. All site physicians were included. Pre- and post-intervention data were collected in fourmonth
periods one year apart. Primary outcomes included changes in monthly average ED length
of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized
to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent
documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate
tests for paired pre-post differences in continuous, categorical, and ranked variables.
Results: Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded
positively to the intervention, although 9.5% reported negative impressions. There was a 36%
reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in
time spent in direct patient contact. No statistically significant changes were seen in job satisfaction
or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04)
pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped,
and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and
per patient 5.3%; both were statistically significant. No statistically significant changes were seen
in patients seen per hour. There was moderate correlation between changes in ED volume and
changes in productivity metrics.
Conclusion: Scribes were well received in our practice. Documentation time was substantially
reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained,
with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour
and per patient both increased.

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Emergency Department Operations

Identifying Patient Door-to-Room Goals to Minimize Left-Without-Being-Seen Rates

Volume 16, Issue 5, September 2015.
Shea Pielsticker, BS, et al.

Introduction: Emergency department (ED) patients in the leave-without-being-seen (LWBS) group
risk problems of inefficiency, medical risk, and financial loss. The goal at our hospital is to limit LWBS
to <1%. This study’s goal was to assess the influence on LWBS associated with prolonging intervals
between patient presentation and placement in an exam room (DoorRoom time). This study’s major
aim was to identify DoorRoom cutoffs that maximize likelihood of meeting the LWBS goal (i.e. <1%).
Methods: We conducted the study over one year (8/13-8/14) using operations data for an ED with
annual census ~50,000. For each study day, the LWBS endpoint (i.e. was LWBS <1%: “yes or
no”) and the mean DoorRoom time were recorded. We categorized DoorRoom means by intervals
starting with ≤10min and ending at >60min. Multivariate logistic regression was used to assess
for DoorRoom cutoffs predicting high LWBS, while adjusting for patient acuity (triage scores and
admission %) and operations parameters. We used predictive marginal probability to assess utility of
the regression-generated cutoffs. We defined statistical significance at p<0.05 and report odds ratio
(OR) and 95% confidence intervals (CI).
Results: Univariate results suggested a primary DoorRoom cutoff of 20’, to maintain a high
likelihood (>85%) of meeting the LWBS goal. A secondary DoorRoom cutoff was indicated at 35’, to
prevent a precipitous drop-off in likelihood of meeting the LWBS goal, from 61.1% at 35’ to 34.4%
at 40’. Predictive marginal analysis using multivariate techniques to control for operational and
patient-acuity factors confirmed the 20’ and 35’ cutoffs as significant (p<0.001). Days with DoorRoom
between 21-35’ were 74% less likely to meet the LWBS goal than days with DoorRoom ≤20’ (OR
0.26, 95% CI [0.13-0.53]). Days with DoorRoom >35’ were a further 75% less likely to meet the
LWBS goal than days with DoorRoom of 21-35’ (OR 0.25, 95% CI [0.15-0.41]).
Conclusion: Operationally useful DoorRoom cutoffs can be identified, which allow for rational
establishment of performance goals for the ED attempting to minimize LWBS.

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Not Just an Urban Phenomenon: Uninsured Rural Trauma Patients at Increased Risk for Mortality

Volume 16, Issue 5, September 2015.
Azeemuddin Ahmed, MD, MBA, et al.

Introduction: National studies of largely urban populations showed increased risk of traumatic death
among uninsured patients, as compared to those insured. No similar studies have been done for
major trauma centers serving rural states.
Methods: We performed retrospective analyses using trauma registry records from adult, non-burn
patients admitted to a single American College of Surgeons-certified Level 1 trauma center in a rural
state (2003-2010, n=13,680) and National Trauma Data Bank (NTDB) registry records (2002-2008,
n=380,182). Risk of traumatic death was estimated using multivariable logistic regression analysis.
Results: We found that 9% of trauma center patients and 27% of NTDB patients were uninsured.
Overall mortality was similar for both (~4.5%). After controlling for covariates, uninsured trauma
center patients were almost five times more likely to die and uninsured NTDB patients were 75%
more likely to die than commercially insured patients. The risk of death among Medicaid patients
was not significantly different from the commercially insured for either dataset.
Conclusion: Our results suggest that even with an inclusive statewide trauma system and an
emergency department that does not triage by payer status, uninsured patients presenting to
the trauma center were at increased risk of traumatic death relative to patients with commercial
insurance.

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Treatment Failure Outcomes for Emergency Department Patients with Skin and Soft Tissue Infections

Volume 16, Issue 5, September 2015.
Larissa S. May, MD, et al.

Introduction: Skin and soft tissue infections (SSTIs) are commonly evaluated in the emergency
department (ED). Our objectives were to identify predictors of SSTI treatment failure within one week
post-discharge in patients with cutaneous abscesses, as well as to identify predictors of recurrence
within three months in that proportion of participants.
Methods: This was a sub-analysis of a parent study, conducted at two EDs, evaluating a new,
nucleic acid amplification test (NAAT) for Staphylococcus aureus in ED patients. Patients ≥18 years
receiving incision and drainage (I&D) were eligible. Patient-reported outcome data on improvement
of fever, swelling, erythema, drainage, and pain were collected using a structured abstraction form at
one week, one month, and three months post ED visit.
Results: We enrolled 272 participants (20 from a feasibility study and 252 in this trial), of which 198
(72.8%) completed one-week follow up. Twenty-seven additional one-week outcomes were obtained
through medical record review rather than by the one-week follow-up phone call. One hundred
ninety-three (73%) patients completed either the one- or three-month follow up. Most patients
recovered from their initial infection within one week, with 10.2% of patients reporting one-week
treatment failure. The odds of treatment failure were 66% lower for patients who received antibiotics
following I&D at their initial visit. Overall SSTI recurrence rate was 28.0% (95% CI [21.6%-34.4%])
and associated with contact with someone infected with methicillin resistant S. aureus (MRSA),
previous SSTI history, or clinician use of wound packing.
Conclusion: Treatment failure was reduced by antibiotic use, whereas SSTI recurrence was
associated with prior contact, SSTI, or use of packing.

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Accuracy of ‘My Gut Feeling:’ Comparing System 1 to System 2 Decision-Making for Acuity Prediction, Disposition and Diagnosis in an Academic Emergency Department

Volume 16, Issue 5, September 2015.
Daniel Cabrera, MD, et al.

Introduction: Current cognitive sciences describe decision-making using the dual-process theory,
where a System 1 is intuitive and a System 2 decision is hypothetico-deductive. We aim to compare
the performance of these systems in determining patient acuity, disposition and diagnosis.
Methods: Prospective observational study of emergency physicians assessing patients in the
emergency department of an academic center. Physicians were provided the patient’s chief
complaint and vital signs and allowed to observe the patient briefly. They were then asked to predict
acuity, final disposition (home, intensive care unit (ICU), non-ICU bed) and diagnosis. A patient was
classified as sick by the investigators using previously published objective criteria.
Results: We obtained 662 observations from 289 patients. For acuity, the observers had a sensitivity
of 73.9% (95% CI [67.7-79.5%]), specificity 83.3% (95% CI [79.5-86.7%]), positive predictive value
70.3% (95% CI [64.1-75.9%]) and negative predictive value 85.7% (95% CI [82.0-88.9%]). For final
disposition, the observers made a correct prediction in 80.8% (95% CI [76.1-85.0%]) of the cases.
For ICU admission, emergency physicians had a sensitivity of 33.9% (95% CI [22.1-47.4%]) and a
specificity of 96.9% (95% CI [94.0-98.7%]). The correct diagnosis was made 54% of the time with
the limited data available.
Conclusion: System 1 decision-making based on limited information had a sensitivity close to 80%
for acuity and disposition prediction, but the performance was lower for predicting ICU admission
and diagnosis. System 1 decision-making appears insufficient for final decisions in these domains
but likely provides a cognitive framework for System 2 decision-making.

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Pediatric Tape: Accuracy and Medication Delivery in the National Park Service

Volume 16, Issue 5, September 2015.
Danielle D. Campagne, MD, et al.

Introduction: The objective is to evaluate the accuracy of medication dosing and the time to
medication administration in the prehospital setting using a novel length-based pediatric emergency
resuscitation tape.
Methods: This study was a two-period, two-treatment crossover trial using simulated pediatric
patients in the prehospital setting. Each participant was presented with two emergent scenarios;
participants were randomized to which case they encountered first, and to which case used the
National Park Service (NPS) emergency medical services (EMS) length-based pediatric emergency
resuscitation tape. In the control (without tape) case, providers used standard methods to determine
medication dosing (e.g. asking parents to estimate the patient’s weight); in the intervention (with
tape) case, they used the NPS EMS length-based pediatric emergency resuscitation tape. Each
scenario required dosing two medications (Case 1 [febrile seizure] required midazolam and
acetaminophen; Case 2 [anaphylactic reaction] required epinephrine and diphenhydramine). Twenty
NPS EMS providers, trained at the Parkmedic/Advanced Emergency Medical Technician level,
served as study participants.
Results: The only medication errors that occurred were in the control (no tape) group (without tape:
5 vs. with tape: 0, p=0.024). Time to determination of medication dose was significantly shorter
in the intervention (with tape) group than the control (without tape) group, for three of the four
medications used. In case 1, time to both midazolam and acetaminophen was significantly faster in
the intervention (with tape) group (midazolam: 8.3 vs. 28.9 seconds, p=0.005; acetaminophen: 28.6
seconds vs. 50.6 seconds, p=0.036). In case 2, time to epinephrine did not differ (23.3 seconds vs.
22.9 seconds, p=0.96), while time to diphenhydramine was significantly shorter in the intervention
(with tape) group (13 seconds vs. 37.5 seconds, p<0.05).
Conclusion: Use of a length-based pediatric emergency resuscitation tape in the prehospital setting
was associated with significantly fewer dosing errors and faster time-to-medication administration in
simulated pediatric emergencies. Further research in a clinical field setting to prospectively confirm
these findings is needed.

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Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage

Volume 16, Issue 5, September 2015.
Dustin G. Mark, MD, et al.

Introduction: Application of a clinical decision rule for subarachnoid hemorrhage, in combination with
cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able
to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study’s
objective was to examine the sensitivity of both early cranial CT and a previously validated clinical
decision rule among emergency department (ED) patients with aSAH and a normal mental status.
Methods: Patients were evaluated in the 21 EDs of an integrated health delivery system between
January 2007 and June 2013. We identified by chart review a retrospective cohort of patients
diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT.
Variables comprising the SAH clinical decision rule (age >40, presence of neck pain or stiffness,
headache onset with exertion, loss of consciousness at headache onset) were abstracted from the
chart and assessed for inter-rater reliability.
Results: One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of
early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity of the SAH clinical decision rule
was also 95.5% (95% CI [90.9-98.2]). Since all false negative cases for each diagnostic modality
were mutually independent, the combined use of both early cranial CT and the clinical decision rule
improved sensitivity to 100% (95% CI [97.6-100.0]).
Conclusion: Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal
sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might
optimize sensitivity for this life-threatening disease.

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Treatment Protocol Assessment

Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department

Volume 16, Issue 5, September 2015.
Kelly N. Sawyer, MD, MS, et al.

Introduction: Undifferentiated chest pain in the emergency department (ED) is a diagnostic
challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary
embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a
coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study
was to describe the ED patient course and short-term safety for these evaluation methods.
Methods: This was a retrospective observational study of adult patients presenting to a large,
community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal
biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation
exposures. We evaluated 30-day return visits for major adverse cardiac events.
Results: A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing
TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs.
30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to
incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs.
16.6mSv). No patient in either group had a related 30-day revisit.
Conclusion: Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO
safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to
further assess this approach to ED chest pain evaluation.

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Treatment Protocol Assessment

Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes

Volume 16, Issue 5, September 2015.
Ann-Jean CC. Beck, MD

Introduction: Guidelines are designed to encompass the needs of the majority of patients with a
particular condition. The American Heart Association (AHA) in conjunction with the American College
of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk
stratification guidelines to aid physicians with accurate and efficient diagnosis and management
of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the
unique environment of an emergency department (ED), the feasibility of incorporating guidelines
into clinical workflow remains in question. We aim to compare emergency physicians’ (EP) clinical
risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in
predicting ACS.
Methods: We conducted a prospective observational cohort study in an urban teaching hospital
ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk
stratification scores assigned: one by the treating physician based on clinical evaluation and
the other by the AHA/ACC/ACEP guideline aforementioned. The patient’s ACS risk stratification
classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30
days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits,
and objective cardiac testing performed.
Results: We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a
difference between the physician’s clinical assessment used in the ED, and the AHA/ACC/ACEP
task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/
ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of
the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS.
AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients
diagnosed with no ACS.
Conclusion: In the ED, physicians are more efficient at correctly placing patients with underlying
ACS into a high-risk category. A small percentage of patients were considered low risk when
applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to
make an efficient assessment of cardiac risk and established criteria may be overly conservative
when applied to an acute care population.

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Healthcare Utilization

Invasive Mechanical Ventilation in California Over 2000–2009: Implications for Emergency Medicine

Volume 16, Issue 5, September 2015.
Seshadri C. Mudumbai, MD, MS, et al.

Introduction: Patients who require invasive mechanical ventilation (IMV) often represent a sequence
of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most
populous state, little information exists to define patterns of IMV use within the state of California.
Methods: We examined data from the masked Patient Discharge Database of California’s Office
of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV
during their stay were identified using the International Classification of Diseases 9th Revision
and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age
strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV
discharges during the study period, we quantified the number of ED vs. non-ED based admissions;
changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV;
determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and
projected the number of IMV discharges and ED-based admissions by year 2020.
Results: There were 696,634 IMV discharges available for analysis. From 2000–2009, IMV
discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868
(328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based
admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35–64
year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients
requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by
29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of
patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for
younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest
predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites;
and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to
n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.
Conclusion: Based on sustained growth over the past decade, by the year 2020, we project a further
increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed
capacities, ongoing increases in the number and type of IMV patients have the potential to adversely
affect California EDs that often admit patients to ICUs.

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Patient Communication

Patient Admission Preferences and Perceptions

Volume 16, Issue 5, September 2015.
Clayton Wu, MD, et al.

Introduction: Understanding patient perceptions and preferences of hospital care is important to
improve patients’ hospitalization experiences and satisfaction. The objective of this study was to
investigate patient preferences and perceptions of hospital care, specifically differences between
intensive care unit (ICU) and hospital floor admissions.
Methods: This was a cross-sectional survey of emergency department (ED) patients who were
presented with a hypothetical scenario of a patient with mild traumatic brain injury (TBI). We
surveyed their preferences and perceptions of hospital care related to this scenario. A closed-ended
questionnaire provided quantitative data on patient preferences and perceptions of hospital care and
an open-ended questionnaire evaluated factors that may not have been captured with the closedended
questionnaire.
Results: Out of 302 study patients, the ability for family and friends to visit (83%), nurse availability
(80%), and physician availability (79%) were the factors most commonly rated “very important,” while
the cost of hospitalization (62%) and length of hospitalization (59%) were the factors least commonly
rated “very important.” When asked to choose between the ICU and the floor if they were the patient
in the scenario, 33 patients (10.9%) choose the ICU, 133 chose the floor (44.0%), and 136 (45.0%)
had no preference.
Conclusion: Based on a hypothetical scenario of mild TBI, the majority of patients preferred
admission to the floor or had no preference compared to admission to the ICU. Humanistic factors
such as the availability of doctors and nurses and the ability to interact with family appear to have a
greater priority than systematic factors of hospitalization, such as length and cost of hospitalization
or length of time in the ED waiting for an in-patient bed.

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Evaluation of Social Media Use by Emergency Medicine Residents and Faculty

Volume 16, Issue 5, September 2015.
David Pearson, MD, MS, et al.

Introduction: Clinicians and residency programs are increasing their use of social media (SM) websites
for educational and promotional uses, yet little is known about the use of these sites by residents and
faculty. The objective of the study is to assess patterns of SM use for personal and professional purposes
among emergency medicine (EM) residents and faculty.
Methods: In this multi-site study, an 18-question survey was sent by e-mail to the residents and faculty in 14
EM programs and to the Council of Emergency Medicine Residency Directors (CORD) listserv via the online
tool SurveyMonkey™. We compiled descriptive statistics, including assessment with the chi-square test or
Fisher’s exact test. StatsDirect software (v 2.8.0, StatsDirect, Cheshire, UK) was used for all analyses.
Results: We received 1,314 responses: 63% of respondents were male, 40% were <30 years of age,
39% were between the ages 31 and 40, and 21% were older than 40. The study group consisted of
772 residents and 542 faculty members (15% were program directors, 21% were assistant or associate
PDs, 45% were core faculty, and 19% held other faculty positions. Forty-four percent of respondents
completed residency more than 10 years ago. Residents used SM markedly more than faculty for social
interactions with family and friends (83% vs 65% [p<0.0001]), entertainment (61% vs 47% [p<0.0001]),
and videos (42% vs 23% [p=0.0006]). Residents used Facebook™ and YouTube™ more often than
faculty (86% vs 67% [p<0.001]; 53% vs 46% [p=0.01]), whereas residents used Twitter™ (19% vs
26% [p=0.005]) and LinkedIn™ (15% vs 32% [p<0.0001]) less than faculty. Overall, residents used SM
sites more than faculty, notably in daily use (30% vs 24% [p<0.001]). For professional use, residents
were most interested in its use for open positions/hiring (30% vs 18% [p<0.0001]) and videos (33%
vs 26% [p=0.005]) and less interested than faculty with award postings (22% vs 33% [p<0.0001]) or
publications (30% vs 38% [p=0.0007]).
Conclusion: EM residents and faculty have different patterns and interests in the personal and professional
uses of social media. Awareness of these utilization patterns could benefit future educational endeavors.

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Effectiveness of a 40-minute Ophthalmologic Examination Teaching Session on Medical Student Learning

Volume 16, Issue 5, September 2015.
Wirachin Hoonpongsimanont, MD, MS, et al.

Introduction: Emergency physicians are among the few specialists besides ophthalmologists
who commonly perform ophthalmologic examinations using the slit lamp and other instruments.
However, most medical schools in the United States do not require an ophthalmology rotation
upon completion. Teaching procedural skills to medical students can be challenging due to limited
resources and instructor availability. Our study assesses the effectiveness of a 40-minute hands-on
teaching session on ophthalmologic examination for medical students using only two instructors and
low-cost equipment.
Methods: We performed an interventional study using a convenience sample of subjects. Pre- and
post-workshop questionnaires on students’ confidence in performing ophthalmologic examination
were administered. We used a paired t-test and Wilcoxon rank test to analyze the data.
Results: Of the 30 participants in the study, the mean age was 25 and the majority were first-year
medical students. The students’ confidence in performing every portion of the ophthalmologic exam
increased significantly after the teaching session. We found that the average confidence level before
the teaching session were below 2 on a 1-5 Likert scale (1 being the least confident). Confidence
levels in using the slit lamp had the highest improvement among the skills taught (2.17 95% CI
[1.84-2.49]). Students reported the least improvement in their confidence in assessing extraocular
movements (0.73, 95% CI [0.30-1.71]) and examining pupillary function (0.73, 95% CI [0.42-1.04]).
We observed the biggest difference in median confidence level in the use of the tonometer (4 with a
p-value of <0.05).
Conclusion: A 40-minute structured hands-on training session can significantly improve students’
confidence levels in ophthalmologic skills.

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Prehospital Care

Hand Washing Practices Among Emergency Medical Services Providers

Volume 16, Issue 5, September 2015.
Bucher, MD, et al.

Introduction: Hand hygiene is an important component of infection control efforts. Our primary and
secondary goals were to determine the reported rates of hand washing and stethoscope cleaning in
emergency medical services (EMS) workers, respectively.
Methods: We designed a survey about hand hygiene practices. The survey was distributed to
various national EMS organizations through e-mail. Descriptive statistics were calculated for
survey items (responses on a Likert scale) and subpopulations of survey respondents to identify
relationships between variables. We used analysis of variance to test differences in means between
the subgroups.
Results: There were 1,494 responses. Overall, reported hand hygiene practices were poor among
pre-hospital providers in all clinical situations. Women reported that they washed their hands more
frequently than men overall, although the differences were unlikely to be clinically significant.
Hygiene after invasive procedures was reported to be poor. The presence of available hand sanitizer
in the ambulance did not improve reported hygiene rates but improved reported rates of cleaning
the stethoscope (absolute difference 0.4, p=0.0003). Providers who brought their own sanitizer were
more likely to clean their hands.
Conclusion: Reported hand hygiene is poor amongst pre-hospital providers. There is a need for
future intervention to improve reported performance in pre-hospital provider hand washing.

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Prehospital Care

Telephone CPR Instructions in Emergency Dispatch Systems: Qualitative Survey of 911 Call Centers

Volume 16, Issue 5, September 2015.
John Sutter, BS, et al.

Introduction: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death. The 2010
American Heart Association Emergency Cardiovascular Care (ECC) Guidelines recognize
emergency dispatch as an integral component of emergency medical service response to OHCA
and call for all dispatchers to be trained to provide telephone cardiopulmonary resuscitation
(T-CPR) pre-arrival instructions. To begin to measure and improve this critical intervention, this
study describes a nationwide survey of public safety answering points (PSAPs) focusing on the
current practices and resources available to provide T-CPR to callers with the overall goal of
improving survival from OHCA.
Methods: We conducted this survey in 2010, identifying 5,686 PSAPs; 3,555 had valid e-mail
addresses and were contacted. Each received a preliminary e-mail announcing the survey, an e-mail
with a link to the survey, and up to three follow-up e-mails for non-responders. The survey contained
23 primary questions with sub-questions depending on the response selected.
Results: Of the 5,686 identified PSAPs in the United States, 3,555 (63%) received the survey, with
1,924/3,555 (54%) responding. Nearly all were public agencies (n=1,888, 98%). Eight hundred
seventy-eight (46%) responding agencies reported that they provide no instructions for medical
emergencies, and 273 (14%) reported that they are unable to transfer callers to another facility
to provide T-CPR. Of the 1,924 respondents, 975 (51%) reported that they provide pre-arrival
instructions for OHCA: 67 (3%) provide compression-only CPR instructions, 699 (36%) reported
traditional CPR instructions (chest compressions with rescue breathing), 166 (9%) reported some
other instructions incorporating ventilations and compressions, and 92 (5%) did not specify the type
of instructions provided. A validation follow up showed no substantial difference in the provision of
instructions for OHCA by non-responders to the survey.
Conclusion: This is the first large-scale, nationwide assessment of the practices of PSAPs in
the United States regarding T-CPR for OHCA. These data showing that nearly half of the nation’s
PSAPs do not provide T-CPR for OHCA, and very few PSAPs provide compression-only instructions,
suggest that there is significant potential to improve the implementation of this critical link in the
chain of survival for OHCA.

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Access to and Use of Point-of-Care Ultrasound in the Emergency Department

Volume 16, Issue 5, September 2015.
Jason L. Sanders, MD, PhD, et al.

Introduction: Growing evidence supports emergency physician (EP)-performed point-of-care
ultrasound (PoC US). However, there is a utilization gap between academic emergency departments
(ED) and other emergency settings. We elucidated barriers to PoC US use in a multistate sample
of predominantly non-academic EDs to inform future strategies to increase PoC US utilization,
particularly in non-academic centers.
Methods: In 2010, we surveyed ED directors in five states (Arkansas, Hawaii, Minnesota,
Vermont, and Wyoming; n=242 EDs) about general ED characteristics. In four states we
determined barriers to PoC US use, proportion of EPs using PoC US, use privileges, and
whether EPs can bill for PoC US.
Results: Response rates were >80% in each state. Overall, 47% of EDs reported PoC US
availability. Availability varied by state, from 34% of EDs in Arkansas to 85% in Vermont. Availability
was associated with higher ED visit volume, and percent of EPs who were board certified/board
eligible in emergency medicine. The greatest barriers to use were limited training (70%), expense
(39%), and limited need (perceived or real) (32%). When PoC US was used by EPs, 50% used it
daily, 44% had privileges not requiring radiology confirmation, and 34% could bill separately for PoC
US. Only 12% of EPs used it ≥80% of the time when placing central venous lines.
Conclusion: Only 47% of EDs in our five-state sample of predominantly non-academic EDs had
PoC US immediately available. When available, the greatest barriers to use were limited training,
expense, and limited need. Recent educational and technical advancements may help overcome
these barriers.

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Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms

Volume 16, Issue 5, September 2015.
Mamata V. Kene, MD, MPH, et al.

Introduction: We evaluated emergency physicians’ (EP) current perceptions, practice, and attitudes
towards evaluating stroke as a cause of dizziness among emergency department patients.
Methods: We administered a survey to all EPs in a large integrated healthcare delivery system.
The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes
about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We
calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.
Results: The response rate was 68% (366/535). Respondents’ median practice tenure was
eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical
vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents
reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and
felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used
the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew
deviation) testing (30%); however, few EPs reported confidence in these tests’ bedside application
(35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical
prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to
reduce stroke risk to <0.5% to be clinically useful.
Conclusion: EPs report relying on symptom quality, vascular risk factors, simple physical exam
elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated
clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5%
post-test stroke probability for acceptability.

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Emergency Department Access

Rural Ambulatory Access for Semi-Urgent Care and the Relationship of Distance to an Emergency Department

Volume 16, Issue 4, July 2015.
Ashley Parks, MD, et al.

Availability of timely access to ambulatory care for semi-urgent medical concerns in
rural and suburban locales is unknown. Further distance to an emergency department (ED) may
require rural clinics to serve as surrogate EDs in their region, and make it more likely for these clinics
to offer timely appointments. We determined the availability of urgent (within 48 hours) access to
ambulatory care for non-established visiting patients, and assessed the effect of insurance and
ability to pay cash on a patient’s success in scheduling an appointment in rural and suburban
Eastern United States.

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Treatment Protocol Assessment

Comparison of Preloaded Bougie versus Standard Bougie Technique for Endotracheal Intubation in a Cadaveric Model

Volume 16, Issue 4, July 2015
Jay B. Baker, MD, et al.

We compared intubating with a preloaded bougie (PB) against standard bougie
technique in terms of success rates, time to successful intubation and provider preference on a
cadaveric airway model.

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Importance of Decision Support Implementation in Emergency Department Vancomycin Dosing

Volume 16, Issue 4, July 2015
Brett Faine, PharmD, et al.

The emergency department (ED) plays a critical role in the management of lifethreatening infection. Prior data suggest that ED vancomycin dosing is frequently inappropriate. The objective is to assess the impact of an electronic medical record (EMR) intervention designed to improve vancomycin dosing accuracy, on vancomycin dosing and clinical outcomes in critically ill ED patients.

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