Western Journal of Emergency Medicine最新文献

Introduction: As emergency medicine (EM) residents prepare for the transition into unsupervised practice, their focus shifts from demonstrating competencies within familiar training environments to anticipating their new roles and responsibilities as attending physicians, often in unfamiliar settings. Using the self-regulated learning framework, we explored how senior EM residents proactively identify goals and enact learning strategies leading up to the transition from residency into unsupervised practice.

Methods: In this study we used a constructivist grounded theory approach, interviewing EM residents in their final year of training at two residency programs. Using the self-regulated learning framework as a sensitizing concept for analysis, we conducted inductive, line-by-line coding of interview transcripts and grouped codes into categories. Theoretical sufficiency was reached after 12 interviews, with four subsequent interviews producing no divergent or disconfirming examples.

Results: We interviewed16 senior residents about their self-regulated learning approaches to preparing for unsupervised practice. Participants identified two types of gaps that they sought to address prior to entering practice: knowledge/skill gaps, and autonomy gaps. We employed specific workplace learning strategies to address each type of gap, which we have termed cherry-picking, case-based hypotheticals, parachuting, and making the call, and reflection on both internal and external sources of feedback to assess the effectiveness of these learning strategies. This study presents participants' identification of gaps in their residency training, their learning strategies, and reflections as cyclical processes of self-regulated learning.

Conclusion: In their final months of training EM residents strategically leverage learning strategies to bridge gaps between their self-assessed capabilities and those they anticipate needing to succeed in unsupervised practice. These findings show that trainees have agency in how they use goal setting, strategic actions, and ongoing reflection to prepare themselves for unsupervised practice. Our findings also suggest tailored approaches whereby programs can support learning experiences that foster senior residents' agency when preparing for the challenges of future practice.

Introduction: Many states have legalized the use of cannabis for medical or recreational purposes. Cannabis is commonly used both recreationally and medicinally, with therapeutic applications for conditions including chronic pain, seizure disorders, multiple sclerosis, anxiety, and depression. The purpose of this study was to compare emergency department (ED) patient knowledge of the short- and long-term effects of cannabis between users and non-users, and to understand perspectives and knowledge of cannabis use, to assist in development of public health interventions.

Methods: We conducted this prospective survey study at Penn State Health - Milton S. Hershey Medical Center. Inclusion criteria included adult ED patients, ≥ 18 years of age, who had used cannabis in the most recent 30 days, between May to August 2024. The control group consisted of adult ED patients, ≥ 18 years of age, who had not used cannabis in the most recent 30 days. We conducted thematic analysis to identify subjects' knowledge of positive and negative effects of cannabis use.

Results: Of 258 eligible subjects, 169 consented to participate (65.5%). Most identified as female (54.4%) and White (68.1%), with a mean age of 40 years. Most participants reported cannabis use in their lifetime (75.7%). Participants reported a myriad of reasons for using cannabis, including to treat anxiety (N = 67; 40%); pain (N = 65; 38%); recreational use (N = 62; 37%); sleep (N = 48; 28%); and depression (N = 34; 20%). Commonly perceived positive effects of cannabis use included relaxation (18%), pain relief (16%), and improved mental health symptoms (13%). Commonly perceived negative effects of cannabis use included cognitive impairment (11%), addictive potential (7%), pulmonary effects (8%), and worsened mental health symptoms (6%). Cannabis users were less likely to correctly identify negative short-term and long-term consequences of cannabis use, compared to non-users. Cannabis users scored mean 2.51/5 (95% CI 2.11-2.92) for correctness of negative short-term effects, compared to 3.28/5 (95% CI 2.96-3.6) for non-users (P = .004). Cannabis users scored mean 1.78/5 (95% CI 1.44-2.12) for correctness of negative long-term effects, compared to 2.38/5 (95% CI 2-2.76) for non-users (P = .002).

Conclusion: Among ED patients who reported using cannabis, reasons cited for its use included recreation, anxiety, pain, depression, and sleep. Emergency department patients had significant knowledge gaps regarding the effects of cannabis use, and these knowledge gaps were higher among cannabis users. Cannabis users were less likely to correctly identify negative short-term and long-term consequences of cannabis use, compared to non-users.

Introduction: Residents and medical students spend thousands of hours of medical education learning the physician's perspective but rarely find themselves on the other side of the stethoscope. In this study we evaluated whether a brief, novel curriculum of simulating the patient experience could improve medical learners' reported empathy for patients and ability to explain medical interventions.

Curricular design: Fifty-eight medical learners (medical students and resident physicians) participated in a 50-minute didactic session where learners simulated patient experiences such as wearing a patient gown and cervical collar, walking with crutches, and tasting potassium chloride and thickened water. Learners evaluated their perceptions of the curriculum with a survey.

Impact/effectiveness: Participants reported limited experience as patients, with 66.7% never having been hospitalized and 50% not taking any daily medications. Learners rated the curriculum highly on a seven-point Likert scale with 98% expressing it helped them to empathize with patients (90% either agreed or strongly agreed) and 95% expressing that it would help them explain interventions (81% either agreed or strongly agreed). There was no difference between medical students and residents regarding reported effect on empathy (M 6.24 vs 6.44; P = .30) or effect on ability to explain the intervention (M 6.06 vs 6.24; P = .43). This brief curriculum simulating the patient experience was well-received by medical student and resident learners, who overwhelmingly felt it improved their empathy for patients and explanations of common interventions. This approach to fostering empathy could help both medical student and resident learners, many of whom may have limited experience as a patient.

Introduction: Delirium is a critical neuropsychiatric condition that surged among older adults during the coronavirus disease 2019 (COVID-19) pandemic, likely due to social isolation resulting from distancing measures. In this study we examined trends in delirium-related emergency department (ED) visits before and during the pandemic using nationwide data from South Korea, with a focus on different phases of social distancing, to inform healthcare strategies for older adults during public health crises.

Methods: We obtained data from the National Emergency Department Information System (2017-2022). Changes in ED visits were assessed across pre-pandemic (January 2017-January 2020), early pandemic (February 2020-March 2022), and late pandemic (April 2022-December 2022) phases using interrupted time series analysis.

Results: A total of 80,442 delirium-related ED visits among adults ≥ 65 years of age were recorded. The interrupted time series analysis showed a significant step increase in ED visits during the early pandemic phase (relative risk [RR] 1.290, 95% CI 1.201-1.386; 29.0% increase), followed by a decrease in the late pandemic phase (RR 0.922, 95% CI 0.868-0.981; 7.8% decrease). The most substantial increase was for individuals 65-74 year of age during the early pandemic period (RR 1.406, 95% CI 1.264-1.564) reflecting a 40.6% increase in visits to the ED. Indirect ED visits, such as institutional referrals, also notably increased (RR 1.275, 95% CI 1.184-1.373) reflecting a 27.5% increase.

Conclusion: Delirium-related ED visits among older adults showed a notable 7.8% decrease during the late pandemic period, with key risk groups identified, particularly adults 65-74 of age (40.6% increase) and those referred from institutions (27.5% increase) during the early pandemic period. These findings may help inform targeted interventions and public health responses in similar healthcare settings. Despite limitations including reliance on diagnostic codes, lack of subgroup analysis by COVID-19 status, potential duplicate visit counts, and limited regional granularity this study offers important insight into delirium care needs during crisis periods. Further research should further explore causal mechanisms and the specific impact of COVID-19 infection on delirium incidence.

Introduction: Biliary tract disease is a frequent cause of abdominal pain among emergency department (ED) patients and accounts for a significant portion of hospital admissions and return visits. Our objective was to compare ED outcomes for patients ultimately diagnosed with biliary tract disease based on the use of point-of-care ultrasound (POCUS) during their initial visit. We specifically analyzed patients admitted after an unscheduled return visit within 72 hours vs those admitted directly from the ED.

Methods: In this retrospective cohort study we used propensity score weighting and included 1,228 adults admitted for biliary tract disease, either during their initial ED visit (n = 1,120, 91.2%) or following an unscheduled return visit within 72 hours (n = 108, 8.8%) at a tertiary center in Taiwan between 2021-2023. Outcomes included ED length of stay (LOS), costs, hospital LOS, intensive care unit (ICU) admission, and in-hospital mortality. We used multivariable regression models with inverse probability of treatment weighting adjustment to account for baseline differences.

Results: Initial discharge followed by admission after an unscheduled return visit was not associated with worse clinical outcomes compared to direct admission. There were no significant differences in in-hospital mortality (0.93% vs 1.16%; odds ratio [OR] 0.59, P = .56) or ICU admission (0.93% vs 0.71%; OR 1.78, P = .61). While the initial ED LOS was shorter (mean: 4 hours vs 15.6 hours; regression-adjusted difference -6.66 hours, P < .001) and the initial ED costs were lower (mean: NT5477 vs NT$16,269, a 66% savings; regression-adjusted difference: -NT$6,548, P < .001), this reflects an expected early discharge. Among patients ultimately requiring admission after an unscheduled return visit, those who received POCUS at their index visit had a significantly shorter initial ED LOS (mean: 2.97 hours vs 4.78 hours; regression-adjusted difference -1.42 hours, P = .006) and lower initial ED costs (mean: NT$3,248 vs NT$7,149; a 55% saving; regression-adjusted difference -NT$3,271, P < .001) compared to those who did not. This initial POCUS use did not increase adverse events; only one of the 108 patients in the unscheduled return visit group required ICU admission (0.9%, 95% CI, 0.02-5.1%), and no deaths occurred (0%, 95% CI, 0-2.78%).

Conclusion: Initial discharge following ED assessment appears safe for many low-risk patients ultimately diagnosed with biliary tract disease on repeat visit within 72 hours. Incorporating POCUS during the initial evaluation may shorten ED LOS and reduce costs for patients who later require admission, without apparent measurable negative effects on mortality, hospital, or ICU length of stay.

Introduction: We evaluated the relationship between inpatient boarding, measured as functional bed capacity, and left-without-being-seen (LWBS) rates. Functional bed capacity is defined as the mean percentage of ED beds available for new and existing patients over a 24-hour period.

Methods: We performed quantile regression models examining the association between LWBS and terciles (low, medium, and high) of functional bed capacity, as well as median admit-to-departure times, controlling for other daily operational metrics. We additionally performed an encounter-level analysis to assess the relationship between functional bed capacity at the time of a patient's arrival and their likelihood of LWBS. Study sites included one academic, one community, and one pediatric ED in a single, urban medical system.

Results: Our study included 373,388 visits. In the adjusted regression at the daily level, low functional bed capacity was associated with an increase of 1.59% in LWBS compared to high functional bed capacity, which represented a 26.5% relative increase (about three patients) compared to median LWBS of 6.0% (P < .001). Larger daily census (+ 0.07% for each additional patient, P <.001), resulted in two additional patients LWBS for every 15-patient increase in daily census from the median. Additionally, longer length of stay of discharged patients (+ 0.05% for each minute increase, P < .001), resulted in two additional patients LWBS for every 20-minute increase in length of stay from the median. Weekdays relative to weekend days were associated with a 1.28% decrease in LWBS (P < .001) (approximately three fewer patients who left without being seen relative to the median LWBS of 6.0%). At the encounter level, functional bed capacity in the low and middle tercile was significantly associated with an increased probability of a patient LWBS (91% and 40% increases, respectively, P < .001). Of the patients who LWBS, 9.3% were high acuity, 59.5% medium acuity, and 31.2% low acuity.

Conclusion: Functional bed capacity is a new and pragmatic operational metric strongly associated with left-without-being-seen rates and provides an improved way to measure, study, and communicate the impact of inpatient boarding. We propose using functional bed capacity as a metric in future studies of ED operations. Additional studies that incorporate staffing levels to more accurately approximate functional bed capacity and better characterize its true impact on LWBS rates are needed.

Thirty years ago, education leaders in emergency medicine (EM) developed a standardized letter of recommendation to address limitations of narrative letters of recommendation in the residency selection process. Since then, multiple iterations and improvements with specialty-wide adoption have led to this letter being cited as one of the most essential pieces of a residency application. Based on the experience and success in EM, many other specialties have also now adopted standardized letters of their own. In this paper, we detail the 30-year history of the EM standardized letter including form changes and technological innovations, research and validity evidence, and discussion of research and administrative priorities for the future.