Abstract 256: Discharging Low-risk Pulmonary Embolism From An Emergency Room

Background and Objectives: Patients with PE are traditionally admitted on parenteral agents, despite increasing literature that sPESI negative patients can be safely discharged from the ED. Our quality improvement initiative is focused on outpatient treatment for ED-diagnosed pulmonary emboli (OTPE) and our objective is to assess LOS, readmissions and to describe findings of our follow-up phone calls.

Methods: This is an actively enrolling prospective study from 7/2020 at a single site with >500 PE cases per year with a PE Response Team (PERT). All ED PE patients are screened for OTPE. Exclusion criteria include sPESI ≥ 1, ESC high or intermediate, bleeding ≤ 30 days, hemoglobin < 8, platelet < 50,000, pregnancy, prior VTE, concomitant COVID-19, recent major surgery and social factors. Patients identified are discussed with PERT and ED physicians. If agreed upon, patients are discharged on DOAC with follow-up within one week. Patients receive calls on days 3, 7, and 30 from the OTPE team to assess AE relating to the DOAC or PE. LOS metrics are reported as mean with standard deviations, and readmissions are reported as percentages.

Results: Ninety-eight low-risk patients were identified, of which 50 were OTPE-eligible with mean age 44.5 ± 16.9 years of age and 58% female. When comparing OTPE to low-risk admissions, there are no differences in age (p=0.35) and sex (p=0.72). For OTPE, the follow-up calls on day 3, 7, and 30 revealed no patient reported recurrent VTE, major bleeding or death. There was a similar ED provider to disposition LOS (p=0.74). Low-risk admissions had a higher rate of readmission than OTPE (p=0.19).

Conclusion: Our OTPE process does not increase ED provider to disposition LOS, readmissions, or adverse outcomes. Future work will examine financial implications of OTPE and barriers to adoption of the process. As this is actively enrolling quality improvement initiative, we will continue to track post-implementation to optimize our process.

Quantifying pulmonary perfusion from noncontrast computed tomography

Purpose

Computed tomography (CT)‐derived ventilation methods compute respiratory induced volume changes as a surrogate for pulmonary ventilation. Currently, there are no known methods to derive perfusion information from noncontrast CT. We introduce a novel CT‐Perfusion (CT‐P) method for computing the magnitude mass changes apparent on dynamic noncontrast CT as a surrogate for pulmonary perfusion.

Methods

CT‐Perfusion is based on a mass conservation model which describes the unknown mass change as a linear combination of spatially corresponding inhale and exhale HU estimated voxel densities. CT‐P requires a deformable image registration (DIR) between the inhale/exhale lung CT pair, a preprocessing lung volume segmentation, and an estimate for the Jacobian of the DIR transformation. Given this information, the CT‐P image, which provides the magnitude mass change for each voxel within the lung volume, is formulated as the solution to a constrained linear least squares problem defined by a series of subregional mean magnitude mass change measurements. Similar to previous robust CT‐ventilation methods, the amount of uncertainty in a subregional sample mean measurement is related to measurement resolution and can be characterized with respect to a tolerance parameter τ. Spatial Spearman correlation between single photon emission CT perfusion (SPECT‐P) and the proposed CT‐P method was assessed in two patient cohorts via a parameter sweep of τ. The first cohort was comprised of 15 patients diagnosed with pulmonary embolism (PE) who had SPECT‐P and 4DCT imaging acquired within 24 h of PE diagnosis. The second cohort was comprised of 15 nonsmall cell lung cancer patients who had SPECT‐P and 4DCT images acquired prior to radiotherapy. For each test case, CT‐P images were computed for 30 different uncertainty parameter values, uniformly sampled from the range [0.01, 0.125], and the Spearman correlation between the SPECT‐P and the resulting CT‐P images were computed.

Results

The median correlations between CT‐P and SPECT‐P taken over all 30 test cases ranged between 0.49 and 0.57 across the parameter sweep. For the optimal tolerance τ = 0.0385, the CT‐P and SPECT‐P correlations across all 30 test cases ranged between 0.02 and 0.82. A one‐sample sign test was applied separately to the PE and lung cancer cohorts. A low Spearmen correlation of 15% was set as the null median value and two‐sided alternative was tested. The PE patients showed a median correlation of 0.57 (IQR = 0.305). One‐sample sign test was statistically significant with 96.5 % confidence interval: 0.20–0.63, P < 0.00001. Lung cancer patients had a median correlation of 0.57(IQR = 0.230). Again, a one‐sample sign test for median was statistically significant with 96.5 percent confidence interval: 0.45–0.71, P < 0.00001.

Conclusion

CT‐Perfusion is the first mechanistic model designed to quantify magnitude blood mass changes on noncontrast dynamic CT as a surrogate for pulmonary perfusion. While the reported correlations with SPECT‐P are promising, further investigation is required to determine the optimal CT acquisition protocol and numerical method implementation for CT‐P imaging.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021

Objectives

Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care.

Methods

Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables.

Results

Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points).

Conclusion

Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

SPRINT Through Tasks: A Novel Curriculum for Improving Resident Task Management in the Emergency Department

INTRODUCTION

The emergency department (ED) presents a challenging task-management environment to emergency medicine (EM) trainees. However, equipping residents with a tool to improve task switching (generically known as multitasking) could have positive impacts on patient care and physician emotional state. We designed a task-management tool and educational curriculum with the goal of improving emergency medicine resident task-switching ability.

METHODS

The task-management tool uses the acronym SPRINT: (1) stabilize critical patients, (2) perform procedures, (3) rack (see new patients in the chart rack), (4) in or out (reassess and disposition), (5) type it up (chart completion). These tasks and their order were decided on by two seasoned clinicians based on their years of experience in the ED. The SPRINT tool was taught to EM residents through a 1-hour curriculum consisting of an introductory video, a classroom-based workshop with multimedia didactics, and team learning with a card game simulating the use of the SPRINT tool on a shift. Residents were surveyed to evaluate their task-management confidence and perceived effectiveness of the curriculum.

RESULTS

A total of 34 EM residents participated in this training on the SPRINT tool. There was an improvement in resident confidence in task management, and residents reporting having a strategy for task prioritization 8 weeks after the workshop.

DISCUSSION

The SPRINT curriculum provides EM residents with a tool to manage the complex task-management environment of the ED. Further research in task-management education should focus on patient-oriented outcomes among physicians who have received this training.

An Emergency Medicine Milestone-Based Simulation Curriculum: Acute Ischemic Stroke

INTRODUCTION

The emergency medicine (EM) resident's ability to make independent decisions in the setting of acute ischemic stroke has been reduced as a result of the involvement of multidisciplinary teams. This simulation was created to give EM residents the opportunity to independently manage the early stages of ischemic stroke and its complications.

METHODS

A solo learner was presented with a 55-year-old male with complaints consistent with an acute stroke. The resident had to calculate stroke severity; coordinate hospital resources; discuss risks, benefits, and alternatives to thrombolysis; and deal with subsequent complications. The learner had to keep a broad differential for sudden change in mental status and consider alternative interventions. Strategies to decrease intracranial pressure needed to be implemented while obtaining neurosurgical consultation. Debriefing included discussion of expected actions in the context of the Accreditation Council for Graduate Medical Education (ACGME) milestones. Residents' review of their video performance added additional self-reflection.

RESULTS

A total of 69 PGY 3 EM residents independently participated in this simulation over a 5-year period. Thirty-two completed a postsimulation evaluation. Nearly all learners felt that this case reflected an actual patient encounter and increased their confidence in managing stroke. The milestone-based feedback tool was completed with all learners. Anticipated actions linked to Level 1 and 2 milestones were regularly achieved while acquisition of Level 3 and 4 actions varied.

DISCUSSION

Case actions were uniquely characterized by the ACGME milestones, which helped to delineate learners' knowledge gaps and provided concrete areas for improvement.

Monthly Progression of Emergency Medicine Resident Efficiency: What Can We Expect of Our Residents Throughout Training?

BACKGROUND

Developing the capacity for efficient patient care is essential during emergency medicine (EM) residency training. Previous studies have demonstrated that resident efficiency improves during each year of training.

OBJECTIVES

This study assessed the progression of EM resident efficiency monthly and sought to develop a model that describes this progression in terms of patients per hour (pts/h) weighted by month of training.

METHODS

We performed a retrospective review of EM resident efficiency as determined by pts/h using EM resident monthly patient logs from a postgraduate year (PGY) 1-3 EM training program. Mean pts/h and standard deviation (SDs) were calculated based on month of training. One-way analysis of variance compared year-to-year training. We formulated several linear regression models to describe this progression.

RESULTS

We analyzed 51 consecutive months of patient logs from 110 residents. The mean pts/h for PGY1 was 1.201 (n = 85, SD = 0.241), for PGY2 was 1.497 (n = 82, SD = 0.218), and for PGY3 was 1.676 (n = 80, SD = 0.224). Linear regression was used to describe patients seen per hour by the month of training. A significant regression was found with an R² of 0.437 and p < 0.000. Over 36 months of training, a resident's predicted pts/h is equal to 1.113 + (0.018 × month of training).

CONCLUSIONS

EM resident efficiency increases monthly, with most improvement occurring in the PGY1 year. Understanding this improvement may aid in resident performance evaluation and the understanding of predicted resident workflow.

Difficulty Breathing With a Rash: A Pediatric Simulation Case for Residents and Fellows

INTRODUCTION

The purpose of the case is to teach health care professionals to recognize Henoch-Schönlein purpura (HSP), including rare and serious complications. The case includes a review of epidemiology, classification, clinical manifestations, and treatment of HSP.

METHODS

Utilizing an adolescent simulation mannequin, we present the case of an 11-year-old female who presents to a pediatric emergency department with HSP and respiratory symptoms requiring intubation. This case reinforces the appearance of the characteristic rash and helps learners develop an algorithm for HSP management that includes the identification and management of abdominal pain associated with HSP, as well as the rare and serious complication of pulmonary vasculitis. We focus learners on managing severe respiratory distress in the HSP patient. Learners are assessed using standardized forms, and the learner outcome measurements include the recognition of HSP and successful management of abdominal pain and respiratory failure in this unique setting.

RESULTS

This module has been used with pediatric residents, emergency medicine residents, pediatric emergency medicine fellows, and pediatric emergency medicine nurse practitioners. Approximately 30 learners have completed this module during seven separate sessions. All learners felt the case provided the opportunity to identify HSP as well as to manage a serious and rare complication of the disease.

DISCUSSION

Overall, we have had positive feedback from the learners about this case, and it provides them the opportunity to see more rare complications during their training period. Learners leave the session with enhanced knowledge of HSP, as well as a review of respiratory failure and intubation.