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Accelerating Knowledge Translation: Reflections From the Online ALiEM-Annals Global Emergency Medicine Journal Club Experience.
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Accelerating Knowledge Translation: Reflections From the Online ALiEM-Annals Global Emergency Medicine Journal Club Experience.

Ann Emerg Med. 2017 Jan 19;:

Authors: Lin M, Joshi N, Hayes BD, Chan TM

PMID: 28110995 [PubMed - as supplied by publisher]




Modeling Hourly Resident Productivity in the Emergency Department.
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Modeling Hourly Resident Productivity in the Emergency Department.

Ann Emerg Med. 2017 Jan 19;:

Authors: Joseph JW, Henning DJ, Strouse CS, Chiu DT, Nathanson LA, Sanchez LD

Abstract
STUDY OBJECTIVE: Resident productivity, defined as new patients per hour, carries important implications for emergency department operations. In high-volume academic centers, essential staffing decisions can be made on the assumption that residents see patients at a static rate. However, it is unclear whether this model mirrors reality; previous studies have not rigorously examined whether productivity changes over time. We examine residents' productivity across shifts to determine whether it remained consistent.
METHODS: This was a retrospective cohort study conducted in an urban academic hospital with a 3-year emergency medicine training program in which residents acquire patients ad libitum throughout their shift. Time stamps of all patient encounters were automatically logged. A linear mixed model was constructed to predict productivity per shift hour.
RESULTS: A total of 14,364 8- and 9-hour shifts were worked by 75 residents between July 1, 2010, and June 20, 2015. This comprised 6,127 (42.7%) postgraduate year (PGY) 1 shifts, 7,236 (50.4%) PGY-2 shifts, and 998 (6.9%) PGY-3 nonsupervisory shifts (Table 1). Overall, residents treated a mean of 10.1 patients per shift (SD 3.2), with most patients at Emergency Severity Index level 3 or more acute (93.8%). In the initial hour, residents treated a mean of 2.14 patients (SD 1.2), and every subsequent hour was associated with a significant decrease, with the largest in the second, third, and final hours.
CONCLUSION: Emergency medicine resident productivity during a single shift follows a reliable pattern that decreases significantly hourly, a pattern preserved across PGY years and types of shifts. This suggests that resident productivity is a dynamic process, which should be considered in staffing decisions and studied further.

PMID: 28110994 [PubMed - as supplied by publisher]




Observers in the Medical Setting.
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Observers in the Medical Setting.

Ann Emerg Med. 2017 Jan 19;:

Authors: Geiderman JM

Abstract
Requests for observation experiences are common in the emergency department and other medical settings. There is little guidance in the literature or in professional societies' polices about who should be granted this privilege. This article reviews the ethical and legal issues that should be taken into account when one decides whether to allow observers in the medical setting. At the heart of the issue is patient privacy. This article recommends that institutions have policies in place that address these activities and suggests content for such policies.

PMID: 28110993 [PubMed - as supplied by publisher]




Idarucizumab for the Reversal of Dabigatran.
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Idarucizumab for the Reversal of Dabigatran.

Ann Emerg Med. 2017 Jan 19;:

Authors: Gottlieb M, Khishfe B

PMID: 28110992 [PubMed - as supplied by publisher]




Ultrasonography for Infant Lumbar Puncture: Time to Pop the Champagne?
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Ultrasonography for Infant Lumbar Puncture: Time to Pop the Champagne?

Ann Emerg Med. 2017 Jan 19;:

Authors: Marin JR

PMID: 28110991 [PubMed - as supplied by publisher]




Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection.
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Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection.

Ann Emerg Med. 2017 Jan 19;:

Authors: Singer AJ, Ng J, Thode HC, Spiegel R, Weingart S

Abstract
STUDY OBJECTIVE: The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection.
METHODS: We performed a single-site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast-track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality.
RESULTS: We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively.
CONCLUSION: qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.

PMID: 28110990 [PubMed - as supplied by publisher]




Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations.
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Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations.

Ann Emerg Med. 2017 Jan 19;:

Authors: Driver BE, McGill JW

Abstract
STUDY OBJECTIVE: Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution.
METHODS: We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort.
RESULTS: We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated.
CONCLUSION: In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.

PMID: 28110989 [PubMed - as supplied by publisher]




Comparison of Fresh Frozen Plasma With Prothrombin Complex Concentrate for Warfarin Reversal.
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Comparison of Fresh Frozen Plasma With Prothrombin Complex Concentrate for Warfarin Reversal.

Ann Emerg Med. 2017 Jan 19;:

Authors: Harrison NE, Gottlieb M

PMID: 28110988 [PubMed - as supplied by publisher]




Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals.
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Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals.

Ann Emerg Med. 2017 Jan 19;:

Authors: Stiell IG, Clement CM, Rowe BH, Brison RJ, Wyse DG, Birnie D, Dorian P, Lang E, Perry JJ, Borgundvaag B, Eagles D, Redfearn D, Brinkhurst J, Wells GA

Abstract
STUDY OBJECTIVE: Recent-onset atrial fibrillation and flutter are the most common arrhythmias managed in the emergency department (ED). We evaluate the management and 30-day outcomes for recent-onset atrial fibrillation and flutter patients in Canadian EDs, where cardioversion is commonly practiced.
METHODS: We conducted a prospective cohort study in 6 academic hospital EDs and enrolled patients who had atrial fibrillation and flutter onset within 48 hours. Patients were followed for 30 days by health records review and telephone. Adverse events included death, stroke, acute coronary syndrome, heart failure, subsequent admission, or ED electrocardioversion.
RESULTS: We enrolled 1,091 patients with mean age 63.9 years, atrial fibrillation 84.7%, atrial flutter 15.3%, hospital admission 9.0%, and converted to sinus rhythm 80.1%. Although 10.5% of recent-onset atrial fibrillation and flutter patients had adverse events within 30 days, there were no related deaths and 1 stroke (0.1%). Adjusted odds ratios for factors associated with adverse event were hours from onset (1.03/hour; 95% confidence interval [CI] 1.01 to 1.05), history of stroke or transient ischemic attack (2.09; 95% CI 1.01 to 4.36), and pulmonary congestion on chest radiograph (7.37; 95% CI 2.40 to 22.64). Patients who left the ED in sinus rhythm were much less likely to experience an adverse event (P<.001).
CONCLUSION: Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe.

PMID: 28110987 [PubMed - as supplied by publisher]




Nurse-Led Competency Model for Emergency Physicians: A Qualitative Study.
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Nurse-Led Competency Model for Emergency Physicians: A Qualitative Study.

Ann Emerg Med. 2017 Jan 19;:

Authors: Daouk-Öyry L, Mufarrij A, Khalil M, Sahakian T, Saliba M, Jabbour R, Hitti E

Abstract
STUDY OBJECTIVE: To develop a competency model for emergency physicians from the perspective of nurses, juxtapose this model with the widely adopted Accreditation Council for Graduate Medical Education (ACGME) model, and identify competencies that might be unique to the nurses' perspective.
METHODS: The study relied on secondary data originally collected as part of nurses' assessment of emergency physicians' nonclinical skills in the emergency department (ED) of an academic medical center in the Middle East. Participants were 36 registered nurses who had worked in the ED for at least 2 years and had worked for at least 2 shifts per month with the physician being evaluated.
RESULTS: Through content analysis, a nurse-led competency model was identified, including 8 core competencies encompassing 33 subcompetencies. The 8 core competencies were emotional intelligence; problem-solving and decisionmaking skills; operations management; patient focus; patient care, procedural skills, and medical knowledge; professionalism; communication skills; and team leadership and management. When the developed model was compared with the ACGME model, the 2 models diverged more than they converged.
CONCLUSION: The nurses' perspective offered distinctive insight into the competencies needed for physicians in an emergency medicine environment, indicating the value of nurses' perspective and shedding light on the need for more systematic and more methodologically sound studies to examine the issue further. The differences between the models highlighted the competencies that were unique to the nurse perspective, and the similarities were indicative of the influence of different perspectives and organizational context on how competencies manifest.

PMID: 28110986 [PubMed - as supplied by publisher]




A Profile of Indian Health Service Emergency Departments.
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A Profile of Indian Health Service Emergency Departments.

Ann Emerg Med. 2017 Jan 19;:

Authors: Bernard K, Hasegawa K, Sullivan A, Camargo C

Abstract
STUDY OBJECTIVE: The Indian Health Service provides health care to eligible American Indians and Alaskan Natives. No published data exist on emergency services offered by this unique health care system. We seek to determine the characteristics and capabilities of Indian Health Service emergency departments (EDs).
METHODS: All Indian Health Service EDs were surveyed about demographics and operational characteristics for 2014 with the National Emergency Department Inventory survey (available at http://www.emnet-nedi.org/).
RESULTS: Of the forty eligible sites, there were 34 respondents (85% response rate). Respondents reported a total of 637,523 ED encounters, ranging from 521 to 63,200 visits per site. Overall, 85% (95% confidence interval 70% to 94%) had continuous physician coverage. Of all physicians staffing the ED, a median of 13% (interquartile range 0% to 50%) were board certified or board prepared in emergency medicine. Overall, 50% (95% confidence interval 34% to 66%) of respondents reported that their ED was operating over capacity.
CONCLUSION: Indian Health Service EDs varied widely in visit volume, with many operating over capacity. Most were not staffed by board-certified or -prepared emergency physicians. Most lacked access to specialty consultation and telemedicine capabilities.

PMID: 28110985 [PubMed - as supplied by publisher]