Faculty Bibliography

BACKGROUND:In situ simulation (ISS) has seen broad use in academic emergency medicine (EM). Studies with limited clinical data suggest a dual paradigm model to assess the efficacy of these educational activities based on their impact on both ongoing and future quality of care. We conducted a retrospective cohort study to assess the impact of government-mandated mass casualty incident (MCI) ISS drills on ongoing department operations and quality clinical care. METHODS:We conducted a retrospective study of patients presenting to an adult tertiary academic emergency department during scheduled and unscheduled ISS MCI drills. We assessed the impact of ISS on operational and triage metrics by comparing scheduled and unscheduled drills. RESULTS:Being treated during an ongoing MCI ISS, in both the scheduled and unscheduled simulation formats, was associated with a higher average door to triage times (20.6 min in the MCI ISS cohort vs 15.8 min in the control cohort; p<0.005) and lower Canadian Triage and Acuity Scale (CTAS) scores (CTAS 1 and 2: 0.8% and 14.5% in the MCI ISS cohort vs 1.6% and 17.1% in the control cohort, p<0.025). Secondary analysis, evaluating differences between case and control cohorts in distinct scheduled and unscheduled ISS subgroups, showed that unscheduled but not scheduled ISS were associated with higher average door to triage times (29.0 min in the unscheduled MCI ISS case cohort vs 21.2 min in the unscheduled MCI ISS control cohort; p<0.001) and lower CTAS acuity scores (CTAS 1 and 2: 0.0% and 17.9% in the unscheduled MCI ISS cohort vs 2.8% and 27.9% in the unscheduled MCI ISS control cohort; p<0.001). CONCLUSION/CONCLUSIONS:In this study, there was a significant association between increased door to triage time and lower acuity triage score designation for patients treated during an ongoing MCI ISS education drill. Secondary analysis demonstrated that these findings were only observed during unscheduled simulations, suggesting that the effects may be modifiable.

STUDY OBJECTIVES/OBJECTIVE:Clinical demands in the emergency department (ED) may contribute to decision and attention fatigue as clinician time-on-shift increases, impacting patient care. Emergency department pharmacists review orders and intervene to correct problems related to safety and appropriateness. This study's objective was to evaluate and characterize the rate of pharmacist interventions on ED medication orders. We hypothesized that pharmacist interventions would increase with clinician time-on-shift. METHODS:We performed a retrospective study of 2 EDs within a single health system between January 2022 and November 2023. Medication and pharmacy intervention details were extracted and linked to clinician schedules, pharmacist schedules, and ED crowding scores. Mixed-effects logistic regression modeling identified factors associated with pharmacist interventions. RESULTS:Pharmacists intervened on 9,054 (1.5%) of 622,171 medication orders placed by 308 clinicians. Pharmacy intervention rate increased with clinician time-on-shift (odds ratio 1.04 for each hour; 95% confidence interval 1.03 to 1.05), with meaningful variation in this effect between individual clinicians. Stratified by clinician type (attendings, residents, or physician assistants) and shift timing (overnight versus daytime shifts), the association between time-on-shift and pharmacy intervention rate remained positive. Stratified by site (A versus B), the association was positive at site A but not at site B. CONCLUSION/CONCLUSIONS:The likelihood of orders requiring pharmacist interventions increased as ED clinicians' time-on-shift increased. This association was consistently observed across differing clinician types and shift timing, but variable across the 2 sites of the study. Clinical staffing models and quality of care could be improved by addressing stressors and fatigue accumulation informed by this analytical model.

PROBLEM/OBJECTIVE:Graduate medical education requires learners to acquire broad clinical exposures to meet core competencies for unsupervised practice, but variability in clinical learning environments and reliance on resource-intensive assessments hinder precise assessment of trainees' clinical experiences. Electronic health records hold promise for precision medical education, yet manual mapping of International Classification of Diseases, Tenth Revision (ICD-10) codes to specialty-specific clinical practice domains limits scalability. APPROACH/METHODS:The authors leveraged electronic health record data and artificial intelligence (AI) to map residents' encounter diagnoses to the American Board of Emergency Medicine's Model of the Clinical Practice of Emergency Medicine (MCPEM). Resident encounters across 3 sites at a single academic system (January 1 to October 31, 2023) were analyzed with an AI model, mapped to MCPEM categories with ICD-10 descriptors, and quantified with vectors to match to the closest MCPEM category. Faculty raters validated the most common mappings iteratively, which were subsequently integrated into interactive learner dashboards. OUTCOMES/RESULTS:Among 119,320 encounters, 5,960 unique ICD-10 descriptors (1,126 stem codes) were identified. For the 650 most common diagnoses, 507 (78.0%) of emergency department diagnosis text descriptors were determined as valid mappings to an MCPEM subcategory. In mappings where faculty were discordant with the lowest distance mapping, 171 of 305 alternative subcategory mappings (56.0%) achieved agreement, increasing the concordance between reviewers to 515 of 650 (79.2%) overall. Interactive dashboards displayed resident-level case mix mapped to MCPEM categories, with anonymized peer comparisons and program-level aggregates, enabling identification of patterns and gaps by domain. NEXT STEPS/CONCLUSIONS:Planned work includes iterating AI-automated mappings by expanding inputs beyond diagnoses, engaging wider stakeholder review of mapping validations, and assessing generalizability to other specialties' content outlines to produce a scalable and reproducible model to increase the precision of feedback loops to inform graduate medical education, the clinical learning environment, and training design.

INTRODUCTION/UNASSIGNED:Mass Casualty Incidents (MCIs) represent a unique challenge to both healthcare systems and staff, however, limited quantitative research exists to describe the variable impact of natural and manmade MCIs on healthcare professional wellness (HCPW) measures. STUDY OBJECTIVE/UNASSIGNED:To compare resilience, burnout and secondary traumatic stress (STS) outcomes between health care professional (HCP) respondents during the Covid-19 (C-19) pandemic and post October 7th War (MM23). We considered factors such as direct patient contact (DPC) and the role of non-clinical activities and previous experiences on HCPW measures. METHODS/UNASSIGNED:A retrospective cross-sectional survey-based study. Continuous variables were summarized as means and standard deviations with analysis including Mann-Whitney U and Kruskal-Wallis tests. Categorical variables were assessed via Chi-square or Fisher's exact test. RESULTS/UNASSIGNED: < 0.021). CONCLUSION/UNASSIGNED:In our retrospective study we found no difference in rates of HCP resilience but did find variable differences in rates of burnout and STS based on the type of MCI. An analysis, considering the association between DPC and HCPW metrics, demonstrated significant differences in the rates of resilience, burnout and STS between the two cohorts. Furthermore, subgroup analysis demonstrated that factors such as non-clinical military service, volunteerism, previous MCI experience and a history of prior military service were all associated with higher levels of respondent resilience during a manmade MCI. These findings demonstrate that differences in HCPW experiences may exist between varying types of MCIs, and that some individual-based, and interpersonal, variables may be associated with differing rates of impact.

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:Mass Casualty Events (MCI) which have a direct and persisting impact on the safety and well-being of an emergency department (ED) and its staff, secondary to specific targeting of the healthcare setting, represent a distinct and complex operational challenge. ED physicians may be faced with the prospect of providing ongoing patient care while simultaneously experiencing direct threats to their own health or physical safety. In our study we considered the unique operational challenges encountered, and management strategies adopted, by the ED staff and its leadership to an all-hazard MCI impacting an academic urban emergency department. METHODS:We conducted a retrospective, observational study of data from a tertiary academic medical center of patients arriving to the ED during a protracted MCI lasting from May 11th to May 21st, 2021. No arriving patients were excluded from analysis. Patient demographics, ED resource utilization, throughput, disposition and other pertinent data were considered. Analysis was done of three distinct patient populations including the event-group (EG), a non-event-group (NEG) and a control group (CG). Descriptive statistics were used to evaluating observational findings. RESULTS:We reviewed the records of 8527 total patients presenting to the Shamir Medical Center ED during the event and control periods. Of those, 283 patients were identified as an EG consisting of casualties from the MCI. 3563 patients were identified as the NEG presenting with complaints not related to the event. Our CG consisted of the 4681 patients who presented in the two weeks prior to the MCI. EG patients were noted to have important characteristics including higher relative numbers of men n = 173 (61.6 %), higher CTAS triage acuities [n = 10 (3.8 %), classified as CTAS 1], and an increase utilization of specialty consultation and admission consistent with observed injury patterns, most notably for the orthopedic services [orthopedic consultations: n = 126 (44.5 %) / orthopedic admissions: n = 13 (4.6 %)]. CONCLUSION/CONCLUSIONS:Findings from our observational study suggested that in the absence of larger public health interventions a manmade MCI, with direct threats to an ED and its staff, could force EDs to concurrently address the unique clinical needs of two distinct patient populations while simultaneously needing to take measures to protect hospital staff. Additionally, a higher burden of patient volumes and clinical acuity are likely to be encountered by select specialty consultation services. Further studies could focus on quantitative analysis to better understand the operational impact of these types of events on both patients and staff.

Demands for whole blood (WB) and COVID-19 convalescent plasma (CCP) donations during the SARS-CoV-2 (COVID-19) pandemic presented unprecedented challenges for blood services throughout the world. This study aims to understand the motivating factors that drive WB and CCP donations in the context of the pandemic. This cross-sectional study is based on data extracted from surveys of the two volunteer donor cohorts. The findings reveal that when compared to CCP donors, WB donors were more likely to view donation as a form of social engagement (97.7% vs. 87.1%, p < 0.01), advantageous in the workplace (46.4% vs. 28.6%, p < 0.01), advantageous in their social network (58.6% vs. 47.0%, p = 0.01), and view their donation in the context of positive self-satisfaction (99% vs. 95.1%, p = 0.01). The average age of CCP donors was 7.1 years younger than those who donated WB (p < 0.01). Motivational factors were also analyzed by sex and religiosity. In conclusion, whereas both donor groups showed a high motivation to partake in these life-saving commitments, WB donors were more likely to be motivated by factors that, when better-understood and implemented in policies concerning plasma donations, may help to increase these donations.

STUDY OBJECTIVE/OBJECTIVE:Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success. METHODS:We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success. RESULTS:After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1. CONCLUSION/CONCLUSIONS:Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.