Faculty Bibliography

The Clinical Emergency Data Registry (CEDR) is a qualified clinical data registry that collects data from participating emergency departments (EDs) in the United States for quality measurement, improvement, and reporting purposes. This article aims to provide an overview of the data collection and validation process, describe the existing data structure and elements, and explain the potential opportunities and limitations for ongoing and future research use. CEDR data are primarily collected for quality reporting purposes and are obtained from diverse sources, including electronic health records and billing data that are de-identified and stored in a secure, centralized database. The CEDR data structure is organized around clinical episodes, which contain multiple data elements that are standardized using common data elements and are mapped to established terminologies to enable interoperability and data sharing. The data elements include patient demographics, clinical characteristics, diagnostic and treatment procedures, and outcomes. Key limitations include the limited generalizability due to the selective nature of participating EDs and the limited validation and completeness of data elements not currently used for quality reporting purposes, including demographic data. Nonetheless, CEDR holds great potential for ongoing and future research in emergency medicine due to its large-volume, longitudinal, near real-time, clinical data. In 2021, the American College of Emergency Physicians authorized the transition from CEDR to the Emergency Medicine Data Institute, which will catalyze investments in improved data quality and completeness for research to advance emergency care.

BACKGROUND/UNASSIGNED:Gender disparities in emergency medicine (EM) persist, with women underrepresented in leadership positions and faced with unique challenges, such as gender discrimination and harassment. To address these issues, professional development programs for women have been recommended. OBJECTIVES/UNASSIGNED:The purpose of this scoping review was to examine current women's professional development programs for EM and develop a collection of program characteristics, meeting topics, and tips for success that can be useful to new or existing women's professional development programs. METHODS/UNASSIGNED:The authors systematically searched research databases for literature detailing current women's professional development programs for EM physicians. Studies detailing professional development programs for female physicians in EM were included. RESULTS/UNASSIGNED: = 2, 20%). The most common topics covered in program sessions included mentorship and coaching, compensation and/or negotiation, leadership skills, and career advancement and promotion. Challenges and barriers to the success of these programs included a lack of funding and support, difficulty in recruiting participants, lack of institutional recognition and support, lack of time, and difficulty in sustaining the program over time. CONCLUSIONS/UNASSIGNED:The study's findings can inform the development of programs that promote gender equity and support the advancement of women in EM.

BACKGROUND AND OBJECTIVES/OBJECTIVE:As the COVID-19 pandemic brought surges of hospitalized patients, it was important to focus on reducing overuse of tests and procedures to not only reduce potential harm to patients but also reduce unnecessary exposure to staff. The objective of this study was to create a Choosing Wisely in COVID-19 list to guide clinicians in practicing high-value care at our health system. METHODS:A Choosing Wisely in COVID-19 list was developed in October 2020 by an interdisciplinary High Value Care Council at New York City Health + Hospitals, the largest public health system in the United States. The first phase involved gathering areas of overuse from interdisciplinary staff across the system. The second phase used a modified Delphi scoring process asking participants to rate recommendations on a 5-point Likert scale based on criteria of degree of evidence, potential to prevent patient harm, and potential to prevent staff harm. RESULTS:The top 5 recommendations included avoiding tracheal intubation without trial of noninvasive ventilation (4.4); not placing routine central venous catheters (4.33); avoiding routine daily laboratory tests and batching laboratory draws (4.19); not ordering daily chest radiographs (4.17); and not using bronchodilators in the absence of reactive airway disease (4.13). CONCLUSION/CONCLUSIONS:We successfully developed Choosing Wisely in COVID-19 recommendations that focus on evidence and preventing patient and staff harm in a large safety net system to reduce overuse.

BACKGROUND:Echocardiographic strain measurements require extensive operator experience and have significant intervendor variability. Creating an automated, open-source, vendor-agnostic method to retrospectively measure global longitudinal strain (GLS) from standard echocardiography B-mode images would greatly improve post hoc research applications and may streamline patient analyses. OBJECTIVES/OBJECTIVE:This study was seeking to develop an automated deep learning strain (DLS) analysis pipeline and validate its performance across multiple applications and populations. METHODS:Interobserver/-vendor variation of traditional GLS, and simulated effects of variation in contour on speckle-tracking measurements were assessed. The DLS pipeline was designed to take semantic segmentation results from EchoNet-Dynamic and derive longitudinal strain by calculating change in the length of the left ventricular endocardial contour. DLS was evaluated for agreement with GLS on a large external dataset and applied across a range of conditions that result in cardiac hypertrophy. RESULTS:In patients scanned by 2 sonographers using 2 vendors, GLS had an intraclass correlation of 0.29 (95% CI: -0.01 to 0.53, P = 0.03) between vendor measurements and 0.63 (95% CI: 0.48-0.74, P < 0.001) between sonographers. With minor changes in initial input contour, step-wise pixel shifts resulted in a mean absolute error of 3.48% and proportional strain difference of 13.52% by a 6-pixel shift. In external validation, DLS maintained moderate agreement with 2-dimensional GLS (intraclass correlation coefficient [ICC]: 0.56, P = 0.002) with a bias of -3.31% (limits of agreement: -11.65% to 5.02%). The DLS method showed differences (P < 0.0001) between populations with cardiac hypertrophy and had moderate agreement in a patient population of advanced cardiac amyloidosis: ICC was 0.64 (95% CI: 0.53-0.72), P < 0.001, with a bias of 0.57%, limits of agreement of -4.87% to 6.01% vs 2-dimensional GLS. CONCLUSIONS:The open-source DLS provides lower variation than human measurements and similar quantitative results. The method is rapid, consistent, vendor-agnostic, publicly released, and applicable across a wide range of imaging qualities.

STUDY OBJECTIVE/OBJECTIVE:Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients. METHODS:We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3). RESULTS:For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill. CONCLUSION/CONCLUSIONS:We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

OBJECTIVE:Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school. METHODS:This retrospective cohort study examines U.S. medical students who matriculated in academic years 2014-2015 and 2015-2016. Data was provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined two outcomes: 1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery, and 2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation. RESULTS:Among the 5,074 students who reported interest in surgery at matriculation, 2,108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery (aRR: 0.92 (0.85-0.98)), while Asian (aRR: 0.82, 95%CI: 0.74-0.91), Hispanic (aRR: 0.70, 95%CI: 0.59-0.83), and low-income (aRR: 0.85, 95%CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a non-surgical specialty, 1,869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with URiM female students reporting the lowest rates. CONCLUSION AND RELEVANCE/CONCLUSIONS:This study demonstrates significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for female, URiM, and low-income students is essential to diversify the surgical workforce.

BACKGROUND:Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care. METHODS:With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments. RESULTS:Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality. CONCLUSIONS:PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.

OBJECTIVES/OBJECTIVE:We describe our experiences and challenges as community volunteers in assisting individuals in scheduling initial COVID-19 vaccine appointments and highlight disparities and barriers in vaccine access in New York City (NYC). METHODS:Priority for assistance was given to individuals who were eligible for vaccination in NYC and New York State with the following barriers: technological, language, medical, physical and undocumented immigrants. Volunteers in NYC performed outreach and created program to assist in scheduling appointments. RESULTS:In sum, 2101 requests were received to schedule COVID-19 vaccine appointments from 28 February to 30 April 2021. Vaccinations were successfully scheduled for 1935 (92%) individuals. Challenges in this project included limited community outreach, language barriers, transportation difficulties and safety concerns travelling to vaccination sites. Spanish (40.5%) and Chinese (35.6%) were the primary languages spoken by appointment requesters. Most requests came from residents of Queens (40%) and Brooklyn (27.2%). CONCLUSIONS:The older population, public-facing workers, non-English speakers, undocumented immigrants and the medically complicated population experienced challenges in vaccine appointment access. In-person services and early website access in languages in addition to English may have reduced barriers in appointment navigation. While volunteers faced numerous obstacles when assisting individuals in scheduling vaccine appointments, most found the work fulfilling and rewarding.