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Workforce Attrition Among Emergency Medicine Non-Physician Practitioners. 急诊医学非医师从业人员的劳动力流失。
IF 6.2 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-17 DOI: 10.1016/j.annemergmed.2024.12.013
Cameron J Gettel,Rohini Ghosh,Craig Rothenberg,Thomas Balga,Sharon Chekijian,Stephanie Colella,Pooja Agrawal,Michael Holmes,Arjun K Venkatesh
STUDY OBJECTIVENon-physician practitioners, including nurse practitioners and physician assistants, increasingly practice in emergency departments, especially in rural areas, where they help mitigate physician shortages. However, little is known about non-physician practitioner durability and demographic trends in emergency departments. Our objective was to examine attrition rates and ages among non-physician practitioners in emergency medicine.METHODSWe conducted a repeated cross-sectional analysis using the Medicare Data on Provider Practice and Specialty and Medicare Provider Utilization and Payment Data. The study included non-physician practitioners providing at least 25 independent evaluation and management services annually for Medicare beneficiaries between 2014 and 2021. Attrition rates, defined as the absence of emergency medicine clinical services in subsequent years, were stratified by gender, clinician type, and practice urbanicity.RESULTSThe emergency medicine non-physician practitioner workforce grew from 14,559 to 17,679 between 2014 and 2021. Women non-physician practitioners comprised 64.6% of the workforce, and rural non-physician practitioners accounted for 15.7%. Across study years, the weighted annual attrition rate was 13.8%, rising from 12.1% in 2014 to 17.6% in 2019. Attrition rates were higher among physician assistants as well as women and rural non-physician practitioners, with median ages at attrition of 40.2 years for women and 45.9 years for men, and 38.6 years for urban non-physician practitioners versus 43.6 years for rural non-physician practitioners.CONCLUSIONThe rate of non-physician practitioner attrition from the emergency medicine workforce is considerably higher and occurs at younger ages than prior work evaluating emergency physician attrition, with similar identified gender and geographic disparities. Targeted retention strategies are needed to support a more durable emergency medicine workforce and reduce disparities.
研究目的:非医师从业人员,包括执业护士和医师助理,越来越多地在急诊科执业,特别是在农村地区,他们有助于缓解医生短缺。然而,对于非内科医生的持久性和急诊科的人口趋势知之甚少。我们的目的是检查急诊医学非医师从业人员的流失率和年龄。方法我们使用医疗保险提供者实践和专业数据以及医疗保险提供者使用和支付数据进行了重复的横断面分析。该研究包括2014年至2021年间每年为医疗保险受益人提供至少25项独立评估和管理服务的非医师从业人员。流失率,定义为在随后的几年中缺乏急诊医学临床服务,按性别、临床医生类型和执业城市划分。结果急诊医学非医师从业人员从2014年的14,559人增加到2021年的17,679人。女性非医师从业人员占总从业人员的64.6%,农村非医师从业人员占总从业人员的15.7%。在整个学习期间,加权年损失率为13.8%,从2014年的12.1%上升到2019年的17.6%。医师助理、女性和农村非医师从业人员的流失率更高,女性的流失率中位数为40.2岁,男性为45.9岁,城市非医师从业人员为38.6岁,农村非医师从业人员为43.6岁。结论:与之前评估急诊医师流失率的工作相比,急诊医学劳动力中非医师从业人员的流失率要高得多,而且发生在更年轻的年龄,并且存在类似的性别和地域差异。需要有针对性的留住战略,以支持一支更持久的急诊医务人员队伍,并缩小差距。
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引用次数: 0
ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review. 闭塞性心肌梗死的心电图模式:一个叙述性的回顾。
IF 6.2 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-17 DOI: 10.1016/j.annemergmed.2024.11.019
Fabrizio Ricci,Chiara Martini,Davide Maria Scordo,Davide Rossi,Sabina Gallina,Artur Fedorowski,Luigi Sciarra,C Anwar A Chahal,H Pendell Meyers,Robert Herman,Stephen W Smith
The traditional management of acute coronary syndrome has relied on the identification of ST-segment elevation myocardial infarction (STEMI) as a proxy of acute coronary occlusion. This conflation of STEMI with acute coronary occlusion has historically overshadowed non-ST-segment elevation myocardial infarction (NSTEMI), despite evidence suggesting 25% to 34% of NSTEMI cases may also include acute coronary occlusion. Current limitations in the STEMI/NSTEMI binary framework underscore the need for a revised approach to chest pain and acute coronary syndrome management. The emerging paradigm distinguishing occlusion myocardial infarction from nonocclusion myocardial infarction (NOMI) seeks to enhance diagnostic accuracy and prognostic effect in acute coronary syndrome care. This approach not only emphasizes the urgency of reperfusion therapy for high-risk ECG patterns not covered by current STEMI criteria, but also emphasizes the broader transition from viewing acute coronary syndrome as a disease defined by the ECG to a disease defined by its underlying pathology, for which the ECG is an important but insufficient surrogate test. This report outlines the emerging occlusion myocardial infarction paradigm, detailing specific ECG patterns linked to acute coronary occlusion, and proposes a new framework that could enhance triage accuracy and treatment strategies for acute coronary syndrome. Although further validation is required, the occlusion myocardial infarction pathway holds promise for earlier acute coronary occlusion detection, timely cath lab activation, and improved myocardial salvage-offering potentially significant implications for both clinical practice and future research in acute coronary syndrome management.
传统的急性冠状动脉综合征治疗依赖于st段抬高型心肌梗死(STEMI)作为急性冠状动脉闭塞的替代诊断。STEMI与急性冠状动脉闭塞的合并在历史上掩盖了非st段抬高型心肌梗死(NSTEMI),尽管有证据表明25%至34%的NSTEMI病例也可能包括急性冠状动脉闭塞。目前STEMI/NSTEMI二元框架的局限性强调了修订胸痛和急性冠状动脉综合征治疗方法的必要性。区分闭塞性心肌梗死和非闭塞性心肌梗死(NOMI)的新模式旨在提高急性冠状动脉综合征护理的诊断准确性和预后效果。这种方法不仅强调了对目前STEMI标准未涵盖的高危心电图模式进行再灌注治疗的紧迫性,而且强调了从将急性冠状动脉综合征视为由ECG定义的疾病到由其潜在病理定义的疾病的更广泛的转变,其中ECG是一个重要但不充分的替代测试。本报告概述了新出现的闭塞性心肌梗死范式,详细介绍了与急性冠状动脉闭塞相关的特定ECG模式,并提出了一个新的框架,可以提高急性冠状动脉综合征的分诊准确性和治疗策略。虽然需要进一步的验证,但闭塞心肌梗死途径有望早期检测急性冠状动脉闭塞,及时激活导管实验室,并改善心肌抢救-为临床实践和未来急性冠状动脉综合征管理的研究提供潜在的重要意义。
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引用次数: 0
Extracorporeal Cardiopulmonary Resuscitation: Outcomes Improve With Center Experience. 体外心肺复苏:中心经验改善结果。
IF 6.2 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-17 DOI: 10.1016/j.annemergmed.2024.12.004
Ingrid Magnet,Wilhelm Behringer,Felix Eibensteiner,Florian Ettl,Jürgen Grafeneder,Gottfried Heinz,Michael Holzer,Mario Krammel,Elisabeth Lobmeyr,Heidrun Losert,Matthias Müller,Alexander Nürnberger,Julia Riebandt,Christoph Schriefl,Thomas Staudinger,Alexandra-Maria Stommel,Christoph Testori,Christian Zauner,Andrea Zeiner-Schatzl,Michael Poppe
STUDY OBJECTIVEExtracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for selected patients when conventional cardiopulmonary resuscitation (CPR) fails. Current evidence suggests that the success of eCPR depends on well-structured in- and out-of-hospital protocols. This article describes the Vienna eCPR program, and the interventions implemented to improve clinical processes and patient outcomes.METHODSIn this retrospective study, we report on all patients with inhospital and out-of-hospital cardiac arrest treated with eCPR at our department between 2020 and 2023. During this period, the program was restructured, including the introduction of out-of-hospital and inhospital algorithms and interprofessional training. The primary endpoint was survival with favorable neurologic outcomes at 6 months, defined as a cerebral performance category score of 1 or 2.RESULTSOverall, 192 patients were treated with eCPR. The proportion of patients with favorable neurologic outcomes was 25% (n=48), increasing each year: 15% (5/34) in 2020, 19% (8/42) in 2021, 23% (12/53) in 2022, and 37% (23/63) in 2023. This was particularly true for out-of-hospital cardiac arrest patients: 7% (2/29), 14% (4/29), 17% (7/41), and 32% (16/50), respectively. Simultaneously, rates of witnessed arrest, bystander CPR, and initial shockable rhythm increased, whereas low-flow durations decreased.CONCLUSIONAfter restructuring the Vienna eCPR program, we were able to improve survival rates with favorable neurologic outcomes after eCPR. This improvement was accompanied with increased case volumes, rates of witnessed arrest, bystander CPR, and initial shockable rhythm, and decreased low-flow durations. The learning curve we observed illustrates that outcomes can improve with experience, a summation effect of training, patient selection, and process standardization.
研究目的体外心肺复苏(eCPR)是常规心肺复苏(CPR)失败时的一种抢救治疗方法。目前的证据表明,eCPR的成功取决于结构良好的院内和院外协议。本文描述了维也纳eCPR计划,以及为改善临床过程和患者预后而实施的干预措施。方法:在这项回顾性研究中,我们报告了2020年至2023年在我科接受eCPR治疗的所有院内和院外心脏骤停患者。在此期间,该方案进行了重组,包括引入院外和院内算法以及跨专业培训。主要终点是6个月时神经系统预后良好的生存期,定义为大脑表现类别得分为1或2。结果共192例患者接受eCPR治疗。神经系统预后良好的患者比例为25% (n=48),逐年增加:2020年为15%(5/34),2021年为19%(8/42),2022年为23%(12/53),2023年为37%(23/63)。院外心脏骤停患者尤其如此:分别为7%(2/29)、14%(4/29)、17%(7/41)和32%(16/50)。同时,目睹骤停、旁观者心肺复苏术和初始休克节律的比率增加,而低流量持续时间减少。结论:在重组维也纳eCPR计划后,我们能够提高eCPR后的生存率和良好的神经预后。这种改善伴随着病例量的增加、目击骤停率的增加、旁观者CPR的增加和初始休克节律的增加,以及低流量持续时间的减少。我们观察到的学习曲线表明,结果可以随着经验、培训、患者选择和流程标准化的综合效应而改善。
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引用次数: 0
Estimating the Proportion of Telehealth-Able United States Emergency Department Visits. 估计美国急诊部门可远程医疗的比例。
IF 6.2 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-14 DOI: 10.1016/j.annemergmed.2024.12.003
K Noelle Tune,Kori S Zachrison,Jesse M Pines,Hui Zheng,Emily M Hayden
STUDY OBJECTIVEWe use national emergency department (ED) data to identify the proportion of "telehealth-able" ED visits, defined as potentially conductible by Video Only or Video Plus (with limited outpatient testing).METHODSWe used ED visits by patients 4 years of age and older from the 2019 National Hospital Ambulatory Medical Care Survey and applied survey weighting for national representativeness. Two raters categorized patient-described Reasons for Visit (RFV) as telehealth-able (yes, no, uncertain) for both Video Only and Video Plus visits. This categorization was stratified by age (4 to 17 years old, 18 to 35, 36 to 64, and 65 and older). Visit characteristics that were used to remove further nontelehealth-able visits included admission, procedures, diagnostic testing, acuity level, and pain score.RESULTSOur sample included 133.6 million United States ED visits in 2019 for patients aged 4 years or older. Of those, between 3.4% and 8.8% of visits were telehealth-able by Video Only and between 5.0% and 9.7% by Video Plus, considering only the first RFV. Visits by younger patients were more often telehealth-able, with the proportion of telehealth-able visits decreasing with advancing age. Considering all RFVs, between 0% to 6.6% of ED visits were telehealth-able with Video Only and 0.02% to 7.6% with Video Plus.CONCLUSIONBetween 3% and 10% of United States ED visits may be potentially telehealth-able for patients aged 4 years and older, considering the first listed RFV and ED visit characteristics. Fewer visits may be telehealth-able when all reasons for visits are considered.
研究目的:我们使用国家急诊科(ED)数据来确定“远程医疗”急诊科就诊的比例,定义为可能通过视频或视频附加(有限的门诊测试)进行。方法:我们使用2019年全国医院门诊医疗调查中4岁及以上患者的急诊就诊数据,并应用调查加权法进行全国代表性。两名评分者将患者描述的就诊原因(RFV)归类为可远程医疗(是,否,不确定),包括仅视频就诊和视频附加就诊。这种分类按年龄分层(4至17岁,18至35岁,36至64岁,65岁及以上)。用于排除进一步非远程医疗访问的访问特征包括入院、程序、诊断测试、视力水平和疼痛评分。我们的样本包括2019年美国4岁及以上患者的1.336亿次急诊就诊。其中,仅通过视频进行远程医疗的占3.4%至8.8%,通过视频+进行远程医疗的占5.0%至9.7%,仅考虑第一个RFV。年轻患者的远程医疗访问次数更多,随着年龄的增长,远程医疗访问的比例下降。考虑到所有rfv,只有视频的急诊科就诊人数为0%至6.6%,有视频辅助的为0.02%至7.6%。考虑到第一个列出的RFV和ED就诊特征,美国4岁及以上患者的ED就诊中有3%至10%可能是远程医疗的。考虑到所有的就诊原因,远程医疗可能会减少。
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引用次数: 0
Intubation Practices in Community Emergency Departments. 社区急诊科的插管实践
IF 5 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-10 DOI: 10.1016/j.annemergmed.2024.11.021
Jonathan Kei, Travis Eurick, Tom A Hauck

Study objective: This study analyzes emergency medicine airway management trends and outcomes among community emergency departments.

Methods: A multicenter, retrospective chart review was conducted on 11,475 intubations from 15 different community emergency departments between January 1, 2015, and December 31, 2022. Data collected included patient's age, sex, rapid sequence intubation medications, use of cricoid pressure, method of intubation, number of attempts, admission diagnosis, and all-cause mortality rates.

Results: Active cardiopulmonary resuscitation occurred in 11.4% of intubations. When rapid sequence intubation was employed, the most frequently used induction agents were etomidate (91.6%), propofol (4.3%), and ketamine (4.1%). From 2015 to 2022, the use of rocuronium (versus succinylcholine) increased from 33.9% to 61.9%, a difference of 28% (95% confidence interval [CI] 21.1% to 34.9%). During the same period, video laryngoscopy (versus direct laryngoscopy) increased from 27.4% to 77.7%, a difference of 50.3% (95% CI 44.2% to 56.4%). Only 46% of intubations used cricoid pressure. Physicians had a first-pass success rate of 80.5% and a failure rate of 0.2%. The most common documented admission diagnoses among intubated patients were respiratory etiologies (27.8%), neurologic causes (21.4%), and sepsis (16.0%). All-cause mortality rates were high for intubated patients at 24 hours (19.7%), 7 days (29.4%), 30 days (38.4%), and 1 year (45.4%).

Conclusion: Physicians intubating in community emergency departments have similar rates of first-pass success and failure seen in academic Level-1 trauma centers despite treating medically sick patients with high all-cause mortality rates. Dramatic shifts in choice of paralytic and method for intubation were seen.

研究目的:分析社区急诊科急诊医学气道管理趋势及结果。方法:对2015年1月1日至2022年12月31日期间来自15个不同社区急诊科的11475例插管进行多中心回顾性图表分析。收集的数据包括患者的年龄、性别、快速序贯插管药物、环状压迫的使用、插管方法、尝试次数、入院诊断和全因死亡率。结果:主动心肺复苏率为11.4%。采用快速序贯插管时,最常用的诱导药物是依托咪酯(91.6%)、异丙酚(4.3%)和氯胺酮(4.1%)。从2015年到2022年,罗库溴铵(相对于琥珀胆碱)的使用率从33.9%增加到61.9%,差异为28%(95%置信区间[CI] 21.1%至34.9%)。在同一时期,视频喉镜检查(与直接喉镜检查相比)从27.4%增加到77.7%,差异为50.3% (95% CI 44.2%至56.4%)。只有46%的插管使用环状压力。医生的一次通过率为80.5%,不良率为0.2%。在插管患者中最常见的入院诊断是呼吸系统病因(27.8%)、神经系统原因(21.4%)和败血症(16.0%)。插管患者的全因死亡率在24小时(19.7%)、7天(29.4%)、30天(38.4%)和1年(45.4%)时较高。结论:在社区急诊科插管的医生与在学术一级创伤中心插管的医生有相似的一次通过成功率和失败率,尽管治疗的是全因死亡率很高的内科病人。在麻痹剂和插管方法的选择上发生了巨大的变化。
{"title":"Intubation Practices in Community Emergency Departments.","authors":"Jonathan Kei, Travis Eurick, Tom A Hauck","doi":"10.1016/j.annemergmed.2024.11.021","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.11.021","url":null,"abstract":"<p><strong>Study objective: </strong>This study analyzes emergency medicine airway management trends and outcomes among community emergency departments.</p><p><strong>Methods: </strong>A multicenter, retrospective chart review was conducted on 11,475 intubations from 15 different community emergency departments between January 1, 2015, and December 31, 2022. Data collected included patient's age, sex, rapid sequence intubation medications, use of cricoid pressure, method of intubation, number of attempts, admission diagnosis, and all-cause mortality rates.</p><p><strong>Results: </strong>Active cardiopulmonary resuscitation occurred in 11.4% of intubations. When rapid sequence intubation was employed, the most frequently used induction agents were etomidate (91.6%), propofol (4.3%), and ketamine (4.1%). From 2015 to 2022, the use of rocuronium (versus succinylcholine) increased from 33.9% to 61.9%, a difference of 28% (95% confidence interval [CI] 21.1% to 34.9%). During the same period, video laryngoscopy (versus direct laryngoscopy) increased from 27.4% to 77.7%, a difference of 50.3% (95% CI 44.2% to 56.4%). Only 46% of intubations used cricoid pressure. Physicians had a first-pass success rate of 80.5% and a failure rate of 0.2%. The most common documented admission diagnoses among intubated patients were respiratory etiologies (27.8%), neurologic causes (21.4%), and sepsis (16.0%). All-cause mortality rates were high for intubated patients at 24 hours (19.7%), 7 days (29.4%), 30 days (38.4%), and 1 year (45.4%).</p><p><strong>Conclusion: </strong>Physicians intubating in community emergency departments have similar rates of first-pass success and failure seen in academic Level-1 trauma centers despite treating medically sick patients with high all-cause mortality rates. Dramatic shifts in choice of paralytic and method for intubation were seen.</p>","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":" ","pages":""},"PeriodicalIF":5.0,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963678","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Skin Glue to Reduce Intravenous Catheter Failure in Children. 皮肤胶减少儿童静脉置管失败。
IF 5 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-09 DOI: 10.1016/j.annemergmed.2024.11.014
Owen Chauhan, Amy C Plint, Nick Barrowman, Natasha Wills-Ibarra, Tyrus Crawford, Mei Han, Maala Bhatt

Study objective: The peripheral intravenous catheter (IV) is the most common and painful invasive medical device in acute care settings. Our objective was to determine whether adding skin glue to secure IVs reduced catheter failure rate in children.

Methods: We conducted a randomized controlled trial in a tertiary-care pediatric emergency department (ED). ED patients younger than 18 years old with an IV who were anticipated to be admitted to hospital were eligible for enrollment. Children were randomized to receive standard IV securement with cloth-bordered transparent polyurethane dressing (control) or application of cyanoacrylate glue at the catheter insertion site in addition to standard securement (intervention). Participants were followed until device removal due to failure or physician order. The primary outcome was IV failure before the intended treatment course was complete. Patients who were randomized with primary outcome data were included in the intention-to-treat analysis.

Results: Of the 557 participants enrolled between December 2020 and April 2023, 278 (50%) and 279 (50%) were allocated to the glue and control groups, respectively. A total of 527 participants were included in the intention-to-treat analysis. Intravenous failure rates in the glue and control groups were 83 of 265 (31.3%) and 82 of 262 (31.3%), respectively. The odds of intravenous catheter failure were not different between groups (adjusted odds ratio 0.98; 95% confidence interval, 0.67 to 1.42). Time to device failure was similar between groups (hazard ratio 0.99; 95% confidence interval, 0.73 to 1.35).

Conclusions: This study found no benefit in using skin glue to secure IVs in the ED in children.

研究目的:外周静脉导管(IV)是急性护理环境中最常见和最痛苦的侵入性医疗器械。我们的目的是确定添加皮肤胶来固定静脉注射是否能降低儿童导管失败率。方法:我们在一家三级护理儿科急诊科(ED)进行了一项随机对照试验。年龄小于18岁且静脉注射的ED患者预计将住院,符合入选条件。儿童随机接受标准IV固定,布边透明聚氨酯敷料(对照组)或在导管插入部位应用氰基丙烯酸酯胶(干预)。参与者被跟踪直到装置因失败或医生的命令被移除。主要结果是在预期疗程完成前静脉输注失败。随机选取具有主要结局数据的患者纳入意向治疗分析。结果:在2020年12月至2023年4月期间入组的557名参与者中,分别有278名(50%)和279名(50%)被分配到胶水组和对照组。意向治疗分析共纳入527名参与者。胶水组和对照组的静脉失败率分别为83 / 265(31.3%)和82 / 262(31.3%)。两组间静脉导管失效的几率无显著差异(校正优势比0.98;95%置信区间,0.67 ~ 1.42)。两组间设备失效时间相似(风险比0.99;95%置信区间,0.73 ~ 1.35)。结论:本研究发现在儿童ED中使用皮胶固定静脉注射没有任何益处。
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引用次数: 0
Elderly Woman With Dizziness, Slurred Speech, and Dyspnea 老年妇女头晕,口齿不清,呼吸困难。
IF 5 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-01 DOI: 10.1016/j.annemergmed.2024.07.015
Jordan C. Sheehan MD
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引用次数: 0
Association Between Neuromuscular Blocking Agents and Outcomes of Emergency Tracheal Intubation: A Secondary Analysis of Randomized Trials 神经肌肉阻滞剂与紧急气管插管结果之间的关系:随机试验的二次分析。
IF 5 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-01 DOI: 10.1016/j.annemergmed.2024.08.509
Stephanie C. DeMasi MD , Wesley H. Self MD, MPH , Neil R. Aggarawal MD, MHSc , Michael D. April MD , Luke Andrea MD , Christopher R. Barnes MD , Jason Brainard MD , Veronika Blinder DO , Alon Dagan MD , Brian Driver MD , Kevin C. Doerschug MD , Ivor Douglas MD , Matthew Exline MD, MPH , Daniel G. Fein MD , John P. Gaillard MD , Sheetal Gandotra MD , Kevin W. Gibbs MD , Adit A. Ginde MD, MPH , Stephen J. Halliday MD, MSCI , Jin H. Han MD , Matthew W. Semler MD, MSc

Study objective

To examine the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt and severe complications during tracheal intubation of critically ill adults in an emergency department (ED) or ICU.

Methods

We performed a secondary analysis of data from 2 multicenter randomized trials in critically ill adults undergoing tracheal intubation in an ED or ICU. Using a generalized linear mixed-effects model with prespecified baseline covariates, we examined the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt (primary outcome) and severe complications during tracheal intubation (secondary outcome).

Results

Among the 2,440 patients in the trial data sets, 2,339 (95.9%) were included in the current analysis; 475 patients (20.3%) received succinylcholine and 1,864 patients (79.7%) received rocuronium. Successful intubation on the first attempt occurred in 375 patients (78.9%) who received succinylcholine and 1,510 patients (81.0%) who received rocuronium (an adjusted odds ratio of 0.87; 95% CI 0.65 to 1.15). Severe complications occurred in 67 patients (14.1%) who received succinylcholine and 456 patients (24.5%) who received rocuronium (adjusted odds ratio, 0.88; 95% CI 0.62 to 1.26).

Conclusion

Among critically ill adults undergoing tracheal intubation, the incidences of successful intubation on the first attempt and severe complications were not significantly different between patients who received succinylcholine and patients who received rocuronium.
研究目的:研究在急诊科(ED)或重症监护室对重症成人进行气管插管时,所使用的神经肌肉阻断剂(琥珀胆碱与罗库溴铵)与首次插管成功率和严重并发症发生率之间的关系。方法:我们对在急诊科或重症监护室对重症成人进行气管插管的两项多中心随机试验的数据进行了二次分析。我们使用带有预设基线协变量的广义线性混合效应模型,研究了所使用的神经肌肉阻断剂(琥珀胆碱与罗库溴铵)与首次尝试成功插管的发生率(主要结果)和气管插管期间严重并发症的发生率(次要结果)之间的关系。结果在试验数据集中的 2,440 名患者中,2,339 名(95.9%)纳入了本次分析;475 名患者(20.3%)接受了琥珀胆碱治疗,1,864 名患者(79.7%)接受了罗库溴铵治疗。375名接受琥珀胆碱治疗的患者(78.9%)和1,510名接受罗库溴铵治疗的患者(81.0%)首次尝试就成功插管(调整后的几率比为0.87;95% CI为0.65至1.15)。结论在接受气管插管的重症成人患者中,接受琥珀胆碱的患者和接受罗库洛宁的患者在首次插管成功率和严重并发症的发生率上没有显著差异。
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引用次数: 0
Knowing Ourselves: The Annals Effort to Achieve Insight 认识我们自己:年鉴努力实现洞察力。
IF 5 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-01 DOI: 10.1016/j.annemergmed.2024.11.001
Richelle J. Cooper MD, MSHS , David L. Schriger MD, MPH , Donald M. Yealy MD
{"title":"Knowing Ourselves: The Annals Effort to Achieve Insight","authors":"Richelle J. Cooper MD, MSHS ,&nbsp;David L. Schriger MD, MPH ,&nbsp;Donald M. Yealy MD","doi":"10.1016/j.annemergmed.2024.11.001","DOIUrl":"10.1016/j.annemergmed.2024.11.001","url":null,"abstract":"","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"85 1","pages":"Pages 1-3"},"PeriodicalIF":5.0,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142871131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Artificial Intelligence to Predict Billing Code Levels of Emergency Department Encounters 人工智能预测急诊科就诊者的计费代码级别。
IF 5 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2025-01-01 DOI: 10.1016/j.annemergmed.2024.07.011
Jacob Morey MD, MBA, Richard Winters MD, MBA, Derick Jones MD, MBA

Study objective

To use artificial intelligence (AI) to predict billing code levels for emergency department (ED) encounters.

Methods

We accessed ED encounters from our health system from January to September 2023. We developed an ensemble model using natural language processing and machine learning techniques to predict billing codes from clinical notes combined with clinical characteristics and orders. Explainable AI techniques were used to help determine the important model features. The main endpoint was to predict evaluation and management professional billing codes (levels 2 to 5 [Current Procedural Terminology codes 99282 to 99285] and critical care). Secondary endpoints included predicting professional billing codes at different decision boundary thresholds and generalizability of the model at other EDs.

Results

There were 321,893 adult ED encounters coded at levels 2 (<1%), 3 (5%), 4 (38%), 5 (51%), and critical care (5%). Model performance for professional billing code levels of 4 and 5 yielded area under the receiver operating characteristic curve values of 0.94 and 0.95, accuracy values of 0.80 and 0.92, and F1-scores of 0.79 and 0.91, respectively. At a 95% decision boundary threshold, level 5 predicted charts had a precision/positive predictive value of 0.99 and recall/sensitivity of 0.57. The most important features using Shapley Additive Explanations values were critical care note, number of orders, discharge disposition, cardiology, and psychiatry.

Conclusion

Currently available AI models accurately predict billing code levels for ED encounters based on clinical notes, clinical characteristics, and orders. This has the potential to automate coding of ED encounters and save administrative costs and time.
研究目的使用人工智能(AI)预测急诊科(ED)就诊的计费代码水平。方法我们从医疗系统中获取了 2023 年 1 月至 9 月的 ED 就诊记录。我们使用自然语言处理和机器学习技术开发了一个集合模型,以根据临床笔记结合临床特征和医嘱预测计费代码。可解释人工智能技术用于帮助确定重要的模型特征。主要终点是预测评估和管理专业计费代码(2 至 5 级[当前程序术语代码 99282 至 99285] 和重症监护)。次要终点包括预测不同决策边界阈值下的专业计费代码,以及该模型在其他急诊室的通用性。结果:共有 321,893 次成人急诊室就诊被编码为 2 级(<1%)、3 级(5%)、4 级(38%)、5 级(51%)和重症监护(5%)。专业计费代码级别为 4 和 5 的模型性能的接收者工作特征曲线下面积值分别为 0.94 和 0.95,准确度值分别为 0.80 和 0.92,F1 分数分别为 0.79 和 0.91。在 95% 的决策边界阈值下,第 5 级预测图表的精确度/阳性预测值为 0.99,召回率/灵敏度为 0.57。使用 Shapley Additive Explanations 值的最重要特征是重症护理记录、医嘱数量、出院处置、心脏病学和精神病学。这有可能实现急诊室就诊的自动编码,节省管理成本和时间。
{"title":"Artificial Intelligence to Predict Billing Code Levels of Emergency Department Encounters","authors":"Jacob Morey MD, MBA,&nbsp;Richard Winters MD, MBA,&nbsp;Derick Jones MD, MBA","doi":"10.1016/j.annemergmed.2024.07.011","DOIUrl":"10.1016/j.annemergmed.2024.07.011","url":null,"abstract":"<div><h3>Study objective</h3><div>To use artificial intelligence (AI) to predict billing code levels for emergency department (ED) encounters.</div></div><div><h3>Methods</h3><div>We accessed ED encounters from our health system from January to September 2023. We developed an ensemble model using natural language processing and machine learning techniques to predict billing codes from clinical notes combined with clinical characteristics and orders. Explainable AI techniques were used to help determine the important model features. The main endpoint was to predict evaluation and management professional billing codes (levels 2 to 5 [Current Procedural Terminology codes 99282 to 99285] and critical care). Secondary endpoints included predicting professional billing codes at different decision boundary thresholds and generalizability of the model at other EDs.</div></div><div><h3>Results</h3><div>There were 321,893 adult ED encounters coded at levels 2 (&lt;1%), 3 (5%), 4 (38%), 5 (51%), and critical care (5%). Model performance for professional billing code levels of 4 and 5 yielded area under the receiver operating characteristic curve values of 0.94 and 0.95, accuracy values of 0.80 and 0.92, and F1-scores of 0.79 and 0.91, respectively. At a 95% decision boundary threshold, level 5 predicted charts had a precision/positive predictive value of 0.99 and recall/sensitivity of 0.57. The most important features using Shapley Additive Explanations values were critical care note, number of orders, discharge disposition, cardiology, and psychiatry.</div></div><div><h3>Conclusion</h3><div>Currently available AI models accurately predict billing code levels for ED encounters based on clinical notes, clinical characteristics, and orders. This has the potential to automate coding of ED encounters and save administrative costs and time.</div></div>","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"85 1","pages":"Pages 63-73"},"PeriodicalIF":5.0,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142320978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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Annals of emergency medicine
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