Faculty Bibliography

BACKGROUND:Endotracheal intubation in the emergency department (ED) is a critical and time-sensitive procedure requiring both technical skills and cognitive-based reasoning. Evidence on supervised resident-attending dyads with differing years of seniority on decision making during clinical encounters with endotracheal intubations is nascent. OBJECTIVE:To investigate the intersection of postgraduate years in clinical practice between resident and attending supervisor dyads and its associations for clinician choice of laryngoscopy technique and paralytic agent during ED intubations. METHODS:We conducted a retrospective analysis of intubations performed at a multi-site, urban, academic emergency medicine training program, analyzing institutional airway registry data from 2013 to 2023. Using a standardized predictor that accounted for similarity in years of clinical experience within a dyad between a resident and their supervising attending, we performed adjusted mixed-effects logistic regression examining the association of this dyad on two primary outcomes in endotracheal intubation decision making. Our primary outcome measures were the selection of a laryngoscopy technique (either DL or VL), and of a paralytic agent (either short-acting or long-acting) analyzed as categorical variables with a linear mixed effects model, using a binomial response distribution. RESULTS:We examined 2969 intubations for choice of laryngoscopy technique (n = 1117, 37.6 %) and paralytic agent (n = 967, 32.6 %). Higher adjusted odds (aOR) were associated with resident choice of DL over VL when years of experience between residents and supervising attendings were more concordant (aOR 3.05, 95 % CI: 1.1-8.2). Choice of paralytic agent was not associated with differing years of experience. CONCLUSION/CONCLUSIONS:Concordant years of experience between residents and their attendings were associated with technical skill-based laryngoscopy technique choice but not for cognitive-based reasoning in paralytic agent choice among ED intubations, suggesting supervising attending's years in clinical practice may influence decision making during time-sensitive procedures.

Background Emergency Department (ED) handoff to inpatient teams is a potential source of error. Generative Artificial Intelligence (AI) has shown promise in succinctly summarizing large quantities of clinical data and may help improve Emergency Department (ED) handoff. Objectives Our objectives were to: 1) evaluate the accuracy, clinical utility, and safety of AI-generated ED-to-inpatient handoff summaries; 2) identify patient and visit characteristics influencing summary effectiveness; and 3) characterize potential error patterns to inform implementation strategies. Methods This exploratory study evaluated AI-generated handoff summaries at an urban academic ED (February-April 2024). A HIPAA-compliant GPT-4 model generated summaries aligned with the IPASS framework; ED providers assessed summary accuracy, usefulness, and safety through on-shift surveys. Results Among 50 cases, median quality and usefulness scores were 4/5 (SE = 0.13). Safety concerns arose in 6% of cases, with issues including data omissions and mischaracterizations. Consultation status significantly affected usefulness scores (p < 0.05). Omissions of relevant medications, laboratory results, and other essential detailss were noted (n=6), and EM clinicians disagreed with some AI characterizations of patient stability, vitals and workup (n=8). The most common response was positive impressions of the technology incorporated into the handoff process (n=11). Conclusions This exploratory provider-in-the-loop model demonstrated clinical acceptability and highlighted areas for refinement. Future studies should incorporate recipient perspectives and examine clinical outcomes to scale and optimize AI implementation.

INTRODUCTION/UNASSIGNED:With the move toward competency-based medical education (CBME), data from the electronic health record (EHR) for informed self-improvement may be valuable as a part of programmatic assessment. Personalized dashboards are one way to view these clinical data. The purpose of this concept paper is to summarize the current state of clinical dashboards as they can be utilized by emergency medicine (EM) residency programs. METHODS/UNASSIGNED:The author group consisted of EM physicians from multiple institutions with medical education and informatics backgrounds and was identified by querying faculty presenting on resident clinical dashboards at the 2024 Society for Academic Emergency Medicine conference. Additional authors were identified by members of the initial group. Best practice literature was referenced; if none was available, group consensus was used. CATEGORIES OF METRICS/UNASSIGNED:Clinical exposures as well as efficiency, quality, documentation, and diversity metrics may be included in a resident dashboard. Resident dashboard metrics should focus on resident-sensitive measures rather than those primarily affected by attendings or systems-based factors. CONSIDERATIONS FOR IMPLEMENTATION/UNASSIGNED:Implementation of these dashboards requires the technical expertise to turn EHR data into actionable data, a process called EHR phenotyping. The dashboard can be housed directly in the EHR or on a separate platform. Dashboard developers should consider how their implementation plan will affect how often dashboard data will be refreshed and how to best display the data for ease of understanding. IMPLICATIONS FOR EDUCATION & TRAINING/UNASSIGNED:Dashboards can provide objective data to residents, residency leadership and clinical competency committees as they identify areas of strength, growth areas, and set specific and actionable goals. The success of resident dashboards is reliant on resident buy-in and creating a culture of psychological safety through thoughtful implementation, coaching, and regular feedback. . CONCLUSION/UNASSIGNED:Personalized clinical dashboards can play a crucial role in programmatic assessment within CBME, helping EM residents focus their efforts as they advance and refine their skills during training.

BACKGROUND:High-sensitivity cardiac troponin (hs-cTnI) assays can quantify troponin concentrations with low limits of detection, potentially expediting and enhancing myocardial infarction diagnoses. This study investigates the real-world impact of hs-cTnI implementation on operational metrics and downstream cardiac services in patients presenting to the emergency department with chest pain. METHODS AND RESULTS/RESULTS:[lt] 0.001) during the index encounter. CONCLUSION/CONCLUSIONS:Implementation of the hs-cTnI assay was associated with reduced hospital admissions, shorter length of stay, and decreases in most downstream cardiac testing.

Clinical documentation in the United States has grown longer and more difficult to read, a phenomenon described as "note bloat." This issue is especially pronounced in emergency medicine, where high diagnostic uncertainty and brief evaluations demand focused, efficient chart review to inform decision-making. Note bloat arises from multiple factors: efforts to enhance billing, mitigate malpractice risk, and leverage electronic health record tools that improve speed and completeness. We discuss best practices based on available evidence and expert opinion to improve note clarity and concision. Recent E/M coding reforms aim to streamline documentation by prioritizing medical decision-making over details of historical and physical examination, though implementation varies. New technologies such as generative artificial intelligence present opportunities and challenges for documentation practices. Addressing note bloat will require ongoing effort from clinical leadership, electronic health record vendors, and professional organizations.

IMPORTANCE/UNASSIGNED:The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness. OBJECTIVE/UNASSIGNED:To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded. INTERVENTION/UNASSIGNED:A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff. MAIN OUTCOME AND MEASURES/UNASSIGNED:The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months. RESULTS/UNASSIGNED:There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03424109.

OBJECTIVES/OBJECTIVE: This study aimed to highlight the necessity of developing and implementing appropriate reference ranges for transgender and nonbinary (TGNB) patient populations to minimize misinterpretation of laboratory results and ensure equitable health care. CASE REPORT/METHODS: We describe a situation where a TGNB patient's abnormal laboratory values were not flagged due to undefined reference ranges for gender "X" in the Laboratory Information System (LIS). Implementation of additional reference ranges mapped to sex label "X" showed significant improvement in flagging abnormal lab results, utilizing sex-invariant reporting as an interim solution while monitoring developments on TGNB-specific reference ranges. CONCLUSION/CONCLUSIONS: Informatics professionals should assess their institution's policies for registration and lab reporting on TGNB patients as nonimplementation poses significant patient safety risks. Best practices include using TGNB-specific reference ranges emerging in the literature, reporting both male and female reference ranges for clinical interpretation and sex-invariant reporting.