Faculty Bibliography

INTRODUCTION/BACKGROUND:Critical acyanotic congenital heart lesions are uncommon but potentially life-threatening causes of neonatal shock and cardiovascular collapse. OBJECTIVE:This review highlights key aspects of acyanotic CHD, including presentation, diagnosis, and management in the emergency department (ED), based on current evidence. DISCUSSION/CONCLUSIONS:Acyanotic CHD encompasses a number of conditions, including critical coarctation of the aorta (CoA), interrupted aortic arch (IAA), critical aortic stenosis (AS), and anomalous left coronary artery from the pulmonary artery (ALCAPA). These conditions should be considered in critically ill neonates presenting with shock and cardiovascular collapse, often without prominent cyanosis. Evaluation involves a thorough assessment of the patient's cardiovascular and respiratory status. Diagnostic tools include pulse oximetry, laboratory testing, electrocardiogram, chest radiograph, and ultrasonography. Management requires prompt recognition and hemodynamic stabilization, which may involve the administration of prostaglandin, vasoactive/inotropic agents, and airway management. Expert consultation and coordination of transfer to a tertiary or quaternary care center are crucial. Surgical repair serves as the definitive treatment. CONCLUSION/CONCLUSIONS:A thorough understanding of acyanotic congenital heart disease is essential for emergency clinicians to effectively diagnose and manage these potentially life-threatening conditions.

BACKGROUND:Patients with frequent emergency department (ED) use often have poor connection to primary care, limiting access to preventive screening. Screening patients at risk for diabetes is essential to ensure early treatment via medication and lifestyle changes. While ED screening programs have shown success in diagnosing diabetes, it is unknown the impact on follow-up with subsequent care, and thus downstream patient outcomes. This study aimed to evaluate the efficacy of an emergency department (ED)-based diabetes screening program, assessing follow-up for subsequent management, if patients changed health behaviors or initiated medications, and barriers reported to follow-up if patients did not establish care. METHODS:Screening results and patient data from four ED sites of a health system were retrospectively collected; we then performed a phone-based survey of all patients diagnosed with diabetes via ED screening over one year. Patients were queried about diagnosis awareness, connection to follow-up or barriers to establishing care, and health behavior changes (diet, exercise, medications). RESULTS:Of 9,897 screened ED patients, 615 (6.2%) had diabetes. We surveyed 307 patients (50% response rate). Among newly diagnosed patients; 79% reported obtaining outpatient care, but only 46% recalled ED diagnosis. Health behavior changes included 65% reporting diet improvement, 35% increasing exercise, and 52% starting diabetes medication. Patients who failed to follow-up reported barriers including awareness of screening result, time/scheduling issues, and financial considerations. CONCLUSION/CONCLUSIONS:This study assesses the reported rate of outpatient care following diabetes diagnosis via an ED screening program and identifies barriers experienced by patients who did not obtain follow-up. Improved connections between screening programs and subsequent care are needed to improve outcomes.

BACKGROUND/UNASSIGNED:Knowledge of pregnancy and parental leave practices in US pediatric emergency medicine (PEM) fellowship programs is limited. Occupational exposures of emergency medicine (EM) such as night shifts and high cumulative work fatigue are linked to adverse pregnancy outcomes. Breastfeeding and other post-birth outcomes are improved by longer maternity leave and paid parental leave for both birthing and non-birthing parents. Professional organizations recommend offloading pregnant individuals from night shifts in the third trimester and providing up to 12 weeks of paid parental leave. OBJECTIVE/UNASSIGNED:This study aims to describe pregnancy and parental leave policies and practices in U.S. pediatric emergency medicine (PEM) fellowship programs. METHODS/UNASSIGNED:We distributed the survey to the PEM Program Director listserv, which includes 94 members representing 85 fellowship programs including both program directors (PDs) and assistant program directors (APDs). Data on policies and experiences of women and birthing parents were collected and analyzed using descriptive statistics. RESULTS/UNASSIGNED:We received 51 responses to the survey, representing 60% of the 85 PEM fellowship programs in existence at the time of the survey. Of those to respond, most programs (75%) modify schedules for pregnant fellows. Most allow pregnant individuals to adjust shifts as desired. Most have no standardized stop date prior to delivery. Programs vary widely in their approach to parental leave, with FMLA and Short-Term Disability commonly used to plan paid leave. Most report between 4 and 8 weeks of parental leave for both birthing and non-birthing parents. Many fellows are required to make up missed shifts, despite the lack of minimum shift requirements in fellowship and the existence of a Training Waiver. CONCLUSION/UNASSIGNED:Variability exists in policies across institutions regarding policies for pregnancy and parental leave for PEM fellows. The variability highlights a need for standardized guidelines to support new parents in PEM training.

BACKGROUND:Optimal emergency contraception (EC) can prevent approximately 95% of rape-related pregnancies. However, time to presentation, weight, and BMI influence efficacy of EC, and disparities in access to care, race and ethnicity, language, and socioeconomic status may modify rape-related pregnancy risk. We aimed to increase effective EC administration and eliminate potential health disparities in all sexual assault (SA) survivors managed in the emergency department (ED). METHODS:We conducted a 5-year retrospective review evaluating race and ethnicity, language, selected socioeconomic indicators, and obesity factors in EC administration. We implemented a quality improvement (QI) initiative over 2 years across three urban EDs, with interventions focused on care standardization (e.g., pharmaceutical changes, electronic health record optimizations, and checklists), multimodal and inter-disciplinary education, and sustainability of change (e.g., quality assurance reviews and bi-directional feedback). Statistical process control charts (SPCs) were used to evaluate temporal changes in EC administration to SA survivors. The Pearson Chi-squared was used to analyze differences across race and ethnicity groups in pre- and post-intervention cohorts. We estimated rape-related pregnancy preventions based on estimated pharmaceutical efficacy and previously reported marginal risks of pregnancy. RESULTS:Through two QI improvement cycles, within a pre-initiative cohort of 291 patients and post-initiative cohort of 156 patients, we increased any EC administration from 73.7% to 100% and effective EC from 44.1% to 100%, both of which were sustained for 14 months. Differences in effective EC administration across race and ethnicity groups pre-initiative (p = 0.005) were eliminated post-initiative (p = 0.840). An estimated 2.7-9.1 rape-related pregnancies were prevented in our post-initiative cohort. CONCLUSIONS:We achieved sustained effective EC administration to SA survivors and eliminated race and ethnicity disparities. Multi-modal interventions focusing on care standardization, education, and sustainability demonstrated success in patient preventative health goals and health equity.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Assessment of acute coronary syndrome (ACS) has pressured rapid diagnostic evaluation through point of care troponins (POCT-Tns). However, POCT-Tns have demonstrated inconsistent accuracy compared to laboratory (LABT)-Tn. A POCT-Tn used inappropriately to "rule-out" ACS can lead to premature diagnostic closure. We aimed to minimize indiscriminate POCT-Tn testing, while balancing test turnaround time (TAT), institutional cost, and impact on patient time to disposition (TTD). METHODS:A quality improvement (QI) initiative from 2018 to 2022 included educational interventions and electronic health record (EHR) adaptations. We evaluated test characteristics, trended test frequency, TATs, cost, and TTD. We used statistical process control charts to evaluate changes in test frequency over time. We used the Mann-Whitney U and Wilcoxon Signed-Rank Sum test to analyze changes in TAT, TTD, and cost. RESULTS:POCT-Tn had high discordance with LAB-Tn (9.7%) and low sensitivity (52.5%). SPCs showed a significant decrease in POCT-Tn tests performed over time. LABT-Tn TATs were longer than POCT-Tn (54 vs 21 min; P < .001). Total Tn testing costs decreased by $668 827.83 annually. Compared to pre-initiative, arrival to disposition was 20 min longer for patients receiving a LABT-Tn (P < .001) and 37 min shorter for patients receiving a POCT with reflex to LABT-Tn (P < .001). CONCLUSION/CONCLUSIONS:POCT-Tn test characteristics may place patients at risk for missed ACS. A combined approach using education and EHR adaptations decreased use of indiscriminate POCT-Tn tests, decreased health care costs, and resulted in clinically appropriate changes in disposition times for this large cohort of ED patients.

BACKGROUND/UNASSIGNED:Accurate and complete patient race and ethnicity data are essential for informing health care quality and patient safety initiatives. However, missing data remain a persistent issue. We aimed to explore the utility of preferred language to impute patient race and ethnicity. METHODS/UNASSIGNED:This was a retrospective analysis from 3 emergency departments in New York City, from June 1, 2023, to May 31, 2024. We leveraged a mapping schema for imputation of missing race and ethnicity data using preferred language for categorization into the Office of Management and Budget's 7 categories. We examined concordance between preferred language and predicted categories. RESULTS/UNASSIGNED:The proportion of patients with missing race and ethnicity data decreased from 9.7% to 8.6%, reducing missingness by 11.1%. The greatest proportion of change with the use of preferred language was for Middle Eastern and North African patients (14.7%). CONCLUSION/UNASSIGNED:Our findings support that language-based imputation has the potential to reduce missing race and ethnicity data and may be a helpful tool in quality improvement and research efforts. For health systems where race and ethnicity fields may not be fully detailed or have a high rate of missing data, the use of language may serve as a valuable adjunct in improving the comprehensive picture of a population.

INTRODUCTION/BACKGROUND:Cyanotic critical congenital heart disease (CCHD) is a serious condition associated with high rate of morbidity and mortality. OBJECTIVE:This review highlights key aspects of CCHD, including presentation, diagnosis, and management in the emergency department (ED), based on current evidence. DISCUSSION/CONCLUSIONS:CCHD encompasses several conditions, including truncus arteriosus, dextro-transposition of the great arteries (d-TGA), tricuspid atresia, tetralogy of Fallot (TOF), total anomalous pulmonary venous return (TAPVR), Ebstein's anomaly, critical pulmonary stenosis, and hypoplastic left heart syndrome (HLHS). These conditions should be considered in critically ill neonates presenting with shock and cyanosis. Evaluation involves a thorough assessment of the patient's cardiovascular and respiratory status. Diagnostic tools include pulse oximetry, laboratory testing, electrocardiogram, chest radiography, and ultrasonography. Management requires prompt recognition and hemodynamic stabilization, which may involve the administration of antibiotics, prostaglandins, vasoactive/inotropic agents, and airway management. Expert consultation and coordination of transfer to a tertiary or quaternary care center are crucial. Surgical repair serves as the definitive treatment. CONCLUSION/CONCLUSIONS:A thorough understanding of cyanotic congenital heart disease is essential for emergency clinicians to effectively diagnose and manage this potentially life-threatening condition.

BACKGROUND:Transitions of care are a leading threat to patient safety. Vulnerabilities are intensified in emergency department (ED)-to-inpatient settings. A structure to identify and visualize high-risk patients, coupled with a process for interdisciplinary huddle prior to transport, can improve patient outcomes. METHODS:We conducted a quality improvement initiative within a tertiary-care, academic, pediatric ED. Children with respiratory disease requiring oxygen were identified to be high risk for decompensation. Digital mapping of patient data was established for clinician visibility of high-risk patients using a track-board icon in the electronic health record (EHR). We implemented interdisciplinary bedside huddles prior to ED departure. Outcome measures included escalations to advanced respiratory support (ie, noninvasive positive pressure ventilation or intubation), pediatric intensive care unit (PICU) upgrades, or rapid response systems (RRS) activations within 24 hours. Our process measure was proportion of patients with huddle completion. Our balancing measure was time from bed assignment to ED departure. Statistical process control charts were used to analyze temporal changes. RESULTS:Huddles were performed on 80% of high-risk respiratory patients. We observed a 53.1% reduction in advanced respiratory interventions, a 57.8% reduction in PICU upgrades, and a 59.8% reduction in RRS activations. There was no change in time from bed assignment to ED departure. CONCLUSIONS:Through risk stratification, EHR visualizations, and interdisciplinary huddles, we achieved improved outcomes for pediatric patients. This initiative mitigates risk beyond ED care, with significant implications on hospital resources and patient safety.

BACKGROUND:Inadequate counseling at patient discharge from the emergency department can lead to adverse patient outcomes. Virtual discharge counseling can address gaps in discharge counseling and improve patients' understanding of instructions. METHODS:A previously established virtual discharge counseling program was scaled across three emergency departments and expanded to 13 diagnoses. Utilizing a standardized protocol and script, counselors performed virtual discharge counseling via a remote, secure teleconference platform in the patients' preferred language. RESULTS: < 0.001). Counseling times were the longest for COVID-19 and diabetes (18 min for each). CONCLUSION/CONCLUSIONS:We demonstrate the scalability of a virtual discharge counseling program. Our findings can assist in targeting virtual discharge counseling resources for limited English-proficiency patients and specific diagnoses that require longer counseling times.