Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department

BACKGROUND

Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians.

METHODS

Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa.

RESULTS

A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified.

CONCLUSION

Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group

Introduction

Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex‐based differences, including metrics such as door‐to‐room (DTR) and door‐to‐healthcare practitioner (DTP) times to look for potential signs of systemic bias.

Methods

We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min.

Results

A total of 106,011 adult visits to the ED were investigated. Female patients had 8‐min longer median length‐of‐stay (LOS) than males (P < 0.01). Females had longer DTR (2‐min median difference, P < 0.01), and longer DTP (5‐min median difference, P < 0.01). Females had longer median door‐to‐over‐the‐counter analgesia time (84 vs. 80, P = 0.58), door‐to‐advanced analgesia (95 vs. 84, P < 0.01), door‐to‐PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door‐to‐intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males.

Conclusion

Numerous statistically significant differences were identified in throughput and care measures—mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.

Prevalence and Categorization of Drug-Related Problems in the Emergency Department

BACKGROUND

Drug-related problems (DRPs) are common among patients seen in the emergency department (ED), but the true incidence is not clear.

OBJECTIVES

The primary objective of this study was to determine the prevalence of DRPs among patients seen in a U.S. ED. The secondary objective was to categorize these DRPs by problem type and by medication class.

METHODS

This was a prospective observational cohort study of a random sample of ED patients between December 2011 and March 2013. ED pharmacists screened randomly selected patients for the presence of a DRP contributing to the ED visit. Four independent auditors evaluated the results to achieve consensus for the presence or absence of DRPs and categorization of the DRPs.

RESULTS

Among 1039 patients screened for DRPs, 308 (29.6%) were found to have at least 1 DRP contributing to the ED visit. Among a total of 443 DRPs, the most commonly identified categories were adverse drug reaction (n = 193 [43.6%]), ineffective medication (n = 69 [15.6%]), and subtherapeutic dosage (n = 68 [15.3%]). The most commonly implicated drug classes were cardiovascular medications (n = 113 [26.5%]), anti-infective medications (n = 52 [12.2%]), and analgesic medications (n = 58 [13.6%]).

CONCLUSIONS

A substantial proportion of ED visits are associated in part or in total with DRPs. Adverse drug reactions and cardiovascular medications are the most common category and medication class implicated, respectively.

Taking the stage: a development programme for women speakers in emergency medicine

Female physicians in the USA achieve associate and full professor rank at numbers disparate to their representation within emergency medicine (EM). The authors describe a novel curriculum aimed at developing women speakers as a step on the journey towards academic recognition. In this pilot programme, four female physicians at a single academic emergency department participated in a year-long Speaker Development Programme (SDP), and all presented in at least one national EM conference at SDP completion. Participants reported improved speaking skills, confidence and drive to present externally. Elements to success were mentor engagement, encouragement by the departmental chair and creation of a growth and belonging mindset within the cohort. Future steps include creating a framework for maintaining the SDP beyond the pilot phase, such as ensuring access to curriculum materials, and retaining an experienced external mentor over time.

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions

INTRODUCTION

Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery.

METHODS

This observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by healthcare providers at an academic ED. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED healthcare providers.

RESULTS

Of 217 ED healthcare providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably for time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (p<0.001 for all comparisons). However, manual injection use was rated more favorably for risk of provider self-injury and patient cost (p<0.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector.

CONCLUSION

ED healthcare providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED.

Gender Distribution Among American Board of Medical Specialties Boards of Directors

Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.

A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department

BACKGROUND

Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines.

OBJECTIVE

To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence.

METHODS

A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated.

RESULTS

The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit.

CONCLUSIONS

Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.