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Objectives The study of preventable deaths is essential to trauma research for measuring service quality and highlighting avenues for improving care and as a performance indicator. However, variations in the terminology and methodology of studies on preventable prehospital trauma death limit the comparability and wider application of data. The objective of this study was to describe the heterogeneity in terminology and methodology. Methods We performed a systematic literature review and report this using the PRISMA guidelines. Searches were conducted using PubMed (including Medline), Ovid, and Embase databases. Studies, with a full text available in English published between 1990 and 2015, meeting the following inclusion criteria were included: analysis of 1) deaths from trauma, 2) occurring in the prehospital phase of care, and 3) application of criteria to ascertain whether deaths were preventable. One author screened database results for relevance by title and abstract. The full text of identified papers was reviewed for inclusion. The reference list of included papers was screened for studies not identified by the database search. Data were extracted on predefined core elements relating to preventability reporting and definitions using a standardized form. Results Twenty-seven studies meeting the inclusion criteria were identified: 12 studies used two categories to assess the preventability of death while 15 used three categories. Fifteen variations in the terminology of these categories and combination with death descriptors were found. Eleven different approaches were used in defining what constituted a preventable death. Twenty-one included survivability of injuries as a criterion. Methods used to determine survivability differed and eight variations in parameters for categorization of deaths were used. Nineteen used panel review in determining preventability with six implementing panel blinding. Panel composition varied greatly by expertise of personnel. Separation of prehospital deaths differed with 10 separating those dead at scene ( DAS) and dead on arrival, three excluding those DAS, three excluding deaths prior to EMS arrival, and 11 not separating prehospital deaths. Conclusions The heterogeneity in methodology, terminology, and definitions of 'preventable' between studies render data incomparable. To facilitate common understanding, comparability, and analysis, a commonly agreed ontology by the prehospital research community is required. [ABSTRACT FROM AUTHOR]

Background: Due to the acuity and time‐sensitive needs of their clinical condition, patients presenting with certain emergent pathologies may lack capacity to provide meaningful prospective informed consent to participate in clinical research. For these reasons, these populations have often been excluded from research investigations. To mitigate this, regulations allowing exception from informed consent (EFIC; 21 CFR 50.24) or waiver of informed consent (WIC; 45 CFR 46.101) were developed in 1996. The purpose of this study was to identify trends in the utilization of EFIC and WIC in emergency research. We also sought to describe the disclosure of necessary prestudy regulatory requirements and justification for the use of EFIC/WIC as reported in completed EFIC/WIC clinical trials. Methods: This study is a review of 20 years of published trials using EFIC or WIC as the primary method of patient consent. Studies were identified using a MEDLINE search; ClinicalTrials.gov; queries to emergency and resuscitation researchers, research directors, department chairs, and principal investigators of acute care research networks; clinical review papers; and a query of the Federal Drug Administration (FDA) docket. All eligible studies were reviewed by three investigators and study data of interest were abstracted. Data are presented descriptively. Results: We identified 45 potentially eligible studies; 11 were ongoing (with no data yet available), four were completed (with no publications or data available), and two did not use EFIC or WIC. Of the remaining 28 studies, 24 (86%) used EFIC and four used WIC. The most common pathologies under study were cardiac arrest (10), hemorrhagic shock (six), and traumatic brain injury (five). Completion of the prestudy regulatory requirements was reported as follows: FDA investigational new drug/investigational device exemption application (for FDA regulated studies; 14, 50%), community consultation (13, 46%), public disclosure (10, 36%), and opt‐out procedures if requested by the institutional review board (seven, 25%). The justification of the need for the use of EFIC or WIC in the reported clinical trial, as defined as mention of at least one of the eight established criteria, was described in the text of 13 (46%) publications. Conclusions: Since their implementation in 1996, the EFIC/WIC regulations have allowed progress in research aimed at determining optimal care for devastating life‐threatening conditions. However, consistent and rigorous report of regulatory prestudy requirements and justification of the use of EFIC/WIC is lacking in clinical trial publications or on websites such as ClinicalTrials.gov. Since research without consent is an ethically sensitive issue and not widely understood, better justification of its needs within the presentation of the research itself may educate the general medical community and also reduce concerns about whether or not the regulations are being properly applied. [ABSTRACT FROM AUTHOR]

Conflicts of interest ( COIs) are common in the practice of emergency medicine and may be present in the areas of clinical practice, relations with industry, expert witness testimony, medical education, research, and organizations. A COI occurs when there is dissonance between a primary interest and another interest. The concept of professionalism in medicine places the patient as the primary interest in any interaction with a physician. We contend that patient welfare is the ultimate interest in the entire enterprise of medicine. Recognition and management of potential, real, and perceived COIs is essential to the ethical practice of emergency medicine. This paper discusses how to recognize, address, and manage them. [ABSTRACT FROM AUTHOR]

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 ( PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision. [ABSTRACT FROM AUTHOR]

The integrity of the research enterprise is of the utmost importance for the advancement of safe and effective medical practice for patients and for maintaining the public trust in health care. Academic societies and editors of journals are key participants in guarding scientific integrity. Avoiding and preventing plagiarism helps to preserve the scientific integrity of professional presentations and publications. The Society for Academic Emergency Medicine ( SAEM) Ethics Committee discusses current issues in scientific publishing integrity and provides a guideline to avoid plagiarism in SAEM presentations and publications. [ABSTRACT FROM AUTHOR]

Objectives The objective was to develop and evaluate an early sepsis detection score for the prehospital setting. Methods A retrospective analysis of consecutive patients who were admitted by emergency medical services ( EMS) to the emergency department of the Jena University Hospital was performed. Because potential predictors for sepsis should be based on consensus criteria, the following parameters were extracted from the EMS protocol for further analysis: temperature, heart rate ( HR), respiratory rate ( RR), oxygen saturation (SaO2), Glasgow Coma Scale score, blood glucose, and systolic blood pressure ( sBP). Potential predictors were stratified based on inspection of Loess graphs. Backward model selection was performed to select risk factors for the final model. The Prehospital Early Sepsis Detection ( PRESEP) score was calculated as the sum of simplified regression weights. Its predictive validity was compared to the Modified Early Warning Score ( MEWS), the Robson screening tool, and the BAS 90-30-90. Results A total of 375 patients were included in the derivation sample; 93 (24.8%) of these had sepsis, including 60 patients with severe sepsis and 12 patients with septic shock. Backward model selection identified temperature, HR, RR, SaO2, and sBP for inclusion in the PRESEP score. Simplified weights were as follows: temperature > 38°C = 4, temperature < 36°C = 1, HR > 90 beats/min = 2, RR > 22 breaths/min = 1, SaO2 < 92% = 2, and sBP < 90 mm Hg = 2. The cutoff value for a possible existing septic disease based on maximum Youden's index was ≥4 (sensitivity 0.85, specificity 0.86, positive predictive value [ PPV] 0.66, and negative predictive value [ NPV] 0.95). The area under the receiver operating characteristic curve ( AUC) of the PRESEP score was 0.93 (95% confidence interval [ CI] = 0.89 to 0.96) and was larger than the AUC of the MEWS (0.93 vs. 0.77, p < 0.001). The PRESEP score surpassed MEWS and BAS 90-60-90 for sensitivity (0.74 and 0.62, respectively), specificity (0.75 and 0.83), PPV (0.45 and 0.51), and NPV (0.91 and 0.89). The Robson screening tool had a higher sensitivity and NPV (0.95 and 0.97), but its specificity and PPV were lower (0.43 and 0.32). Conclusions The PRESEP score could be a valuable tool for identifying septic patients in the prehospital setting in the case of suspected infection. It should be prospectively validated. [ABSTRACT FROM AUTHOR]

All academic medical specialties have the obligation to continuously create new knowledge that will improve patient care and outcomes. Emergency medicine (EM) is no exception. Since its origins over 50 years ago, EM has struggled to fulfill its research mission. EM ranks last among clinical specialties in the percentage of medical school faculty who are National Institutes of Health (NIH)‐funded principal investigators (PIs; 1.7%) and the percentage of medical school departments with NIH‐funded PIs (33%). Although there has been a steady increase in the number of NIH‐funded projects and total NIH dollars, the slowing growth in the number of NIH‐funded PIs and lack of growth in the number of EM departments with NIH‐funded PIs is cause for concern. In response, the Association of Academic Chairs of Emergency Medicine (AACEM) Research Task Force proposes a set of 2030 strategic goals for the EM research enterprise that are based on sustaining historic growth rates in NIH funding. These goals have been endorsed by the AACEM Executive Committee and the boards of Society for Academic Emergency Medicine (SAEM), American College of Emergency Physicians (ACEP), and American Academy of Emergency Medicine (AAEM). The 2030 strategic goals include 200 NIH‐funded projects led by 150 EM PIs in at least 50 EM departments with over $100M in annual funding resulting in over 3% of EM faculty being NIH‐funded PIs. Achieving these goals will require a targeted series of focused strategies to increase the number of EM faculty who are competitive for NIH funding. This requires a coordinated, intentional effort with investments at the national, departmental, and individual levels. These efforts are ideally led by medical school department chairs, who can create the culture and provide the resources needed to be successful. The specialty of EM has the obligation to improve the health of the public and to fulfill its research mission. [ABSTRACT FROM AUTHOR]

Objective: Emergency medicine clinicians are excellent at identifying and treating physical trauma as a chief complaint, but are often unaware of patients' previous experiences of trauma. The purpose of this study was to describe emergency department (ED) patients' lifetime experiences of trauma. Methods: The investigative team used framework analysis to examine 1,282 participants' open‐ended responses to the Vera Institute's Trafficking Victim Identification Tool questions. Of these, 204 participants were found to have experienced at least one form of trauma; none of these participants were assessed positive for a human trafficking experience. Results: From 204 participants, 343 instances of trauma were recorded and analyzed. Of the 204 patient‐participants who reported trauma, 96 experienced one form of trauma and 108 experienced two or more. Three major themes emerged: work trauma (experiences of trauma originating in the workplace), coercion (being manipulated into activities), and trauma connections (some forms of trauma were commonly experienced with other kinds of trauma). A fourth, less prominent, theme was disclosure as witness (participants witnessing trauma). Conclusion: ED patients have experienced many forms of lifetime trauma and, in this study, were willing to share about their experiences while in the acute care setting. Given the common experience of trauma among the ED patients in this investigation, more work is needed to examine if and how trauma‐informed care principles should be employed in the ED. Additionally, the ED may be an underutilized data source for researchers seeking participants with experiences of trauma and/or a point of connection for trauma survivors to be linked to trauma care services. [ABSTRACT FROM AUTHOR]

In the article, the authors present their study which examined the explicit and implicit biases among pediatric emergency department (ED) physicians in the U.S. based on race, ethnicity and weight. Also cited are the possible correlation of physicians' demographics and their racial, ethnic and weight biases, and the results like the reduced implicit bias by overweight or obese physicians against Hispanic individuals.

Background: Hospital‐affiliated freestanding emergency departments (FREDs) are rapidly proliferating in some states and have been the subject of recent policy debate. As FREDs' role in acute care delivery is expanding in certain regions, little is known about the quality of care that they provide for their sickest patients. Our aim was to compare timeliness of emergent care at FREDs and hospital‐based EDs (HEDs) for patient visits with selected high‐acuity and time‐sensitive conditions. Methods: We performed a retrospective observational analysis of adult patient visit data from 19 FREDs and five HEDs from one health system over a 1‐year period. Median times to events and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated via Cox regression. Results: The median time to electrocardiogram for visits with chest pain was 10 minutes at FREDs and 9 minutes at HEDs (HR = 0.91 [CI = 0.87 to 0.96]). Time to cardiac catheterization lab for visits with ST‐segment elevation myocardial infarction (STEMI) was 78 minutes at FREDs, inclusive of transfer time, and 31 minutes at HEDs (HR = 0.41 [CI = 0.24 to 0.71]). Time to computed tomography for visits with stroke was 37 minutes at FREDs and 29 minutes at HEDs (HR = 0.42 [CI = 0.31 to 0.58]). Among visits with sepsis, FREDs had longer times to lactate collection (HR = 0.41 [CI = 0.30 to 0.56]), blood culture collection (HR = 0.24 [CI = 0.11 to 0.51]), and antibiotic administration (HR = 0.61 [CI = 0.26 to 1.42]). Beta agonists were administered for visits with asthma exacerbations in 24 minutes at FREDs and 44 minutes at HEDs (HR = 2.50 [CI = 2.34 to 2.68]), with similar times for anticholinergic and corticosteroid administration. Conclusions: Freestanding EDs provided more timely care than HEDs for visits with asthma exacerbation and less timely care for acute chest pain, stroke, and sepsis, although absolute differences were small. Even though STEMI patients at FREDs required transfer for catheterization, they tended to receive care in line with national guidelines. [ABSTRACT FROM AUTHOR]

The novel coronavirus, or COVID‐19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID‐19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi‐institutional (New York–Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID‐19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID‐19 cases with respiratory symptoms. [ABSTRACT FROM AUTHOR]

Background: We sought to develop a claims‐based definition of unscheduled care to describe the use and role of the emergency department (ED) in providing unscheduled care to vulnerable older adult populations. Methods: This study was a cross‐sectional analysis of national 20% sample of Medicare beneficiaries included in the 2012 Chronic Condition Warehouse data set. We measured three outcomes: the number of ED visits per 1,000 Medicare beneficiaries, the proportion of all unscheduled ED and office‐based visits occurring in the ED and the number of ED and non‐ED unscheduled visits adjusting for risk factors. Each outcome was estimated for vulnerable subpopulations of Medicare beneficiaries with multiple chronic conditions (MCCs), dual eligibility, hospice enrollment, and skilled nursing facility use. Results: A total of 10,717,786 Medicare beneficiaries were included with 33,696,461 potentially unscheduled care visits of which 5,192,235 (15%) occurred in the ED, 364,334 (1.1%) in facility‐based urgent care, and 31,570,113 (84%) in ambulatory office settings. In regression analyses each subpopulation was more likely to visit the ED for unscheduled care services than the reference population of Medicare beneficiaries ages 65 to 80. Dual‐eligible beneficiaries demonstrated higher ED visit rates and lower non‐ED visit rates for unscheduled care. The subpopulation with MCCs uses both the ED and the non‐ED setting for unscheduled care more so than any other group. Conclusions: Medicare beneficiaries, particularly vulnerable subpopulations, disproportionately visit the ED in comparison to physician offices for unscheduled care. Efforts to improve care coordination, measure quality, or reform payment to influence ED visitation should acknowledge these patterns and the unique availability of acute care services in the ED. [ABSTRACT FROM AUTHOR]

Background: Emergency providers (EPs) are uniquely placed to advocate for firearm safety and have been shown to be at risk of exposure to firearms in the emergency department (ED). We sought to characterize EPs' knowledge of firearms, frequency of encountering firearms in the ED and level of confidence with safely removing firearms from patient care settings. Methods: This was a survey study of EPs representing medical centers in 22 states. A 15‐item questionnaire was e‐mailed to all EPs at all included institutions. Questions pertained to EPs' knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions with p‐values and conducted association analyses among survey items. Results: Of 2,192 survey recipients, 1,074 (49.0%) completed the survey. A total of 635 (59.1%) reported encountering firearms in the ED or its immediate environment at least once per year, and 582 (54.2%) were not confident in their ability to safely handle a firearm found in a patient's possession. Frequency of handling firearms was significantly higher in states in the top quartile for firearm ownership, with 21.5% of respondents reporting handling firearms daily or weekly, compared to 10.9% in bottom‐quartile states. Level of firearms training also differed significantly: 42.1% of respondents in top‐quartile states reported formal training compared to 33.0% in bottom‐quartile states. Increased regional firearm ownership rates were associated with decreased rates of feeling unsafe at work. Conclusions: The majority of surveyed EPs reported little experience with handling firearms. Firearm experience was associated with comfort with managing firearms found in patients' possession. Regional differences were found regarding personal firearm experience and perceptions of workplace safety, both of which were associated with regional variations in firearm ownership. Despite this, no regional differences were found in encountering firearms in or around the ED. EPs may benefit from training on safely handling firearms. [ABSTRACT FROM AUTHOR]

Background: Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end‐of‐life discussions. Methods: Prospective cohorts of >65‐year‐old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose‐trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow‐up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in‐hospital death was the secondary outcome. Results: A total of 1,182 patients, with median age 76 to 80 years (IRE‐AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7–8.6) versus 5.7 (95% CI = 5.1–6.2) and Irish mean of 7.7 (95% CI = 6.9–8.5) versus 5.7 (95% CI = 5.1–6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver‐operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short‐term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in‐hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. Conclusions: The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short‐term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end‐of‐life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation. [ABSTRACT FROM AUTHOR]

Objective: The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. Methods: Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE—cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests. Results: A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low‐risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%–100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac‐related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36). Conclusions: The HEART Pathway had a 100% NPV for 1‐year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1‐year objective testing was not significant. [ABSTRACT FROM AUTHOR]

Background: In 2014, the state of Maryland (MD) moved away from fee‐for‐service payments and into a global budget revenue (GBR) structure where hospitals have a fixed revenue target, independent of patient volume or services provided. We assess the effects of GBR adoption on emergency department (ED) admission decisions among adult encounters. Methods: We used hospital medical record and billing data from adult ED encounters from January 1, 2011, through December 31, 2015, with four MD hospitals and two District of Columbia (DC) hospitals within the same health system. We performed difference‐in‐differences analysis and calculated the effects of the GBR model on ED admission rates (inpatient and observation) using hospital fixed‐effect regression adjusted for patient, hospital, and community factors. We also examined changes in the distribution of acuity among ED admissions with GBR adoption. Results: The study sample included 1,492,953 ED encounters with a mean ED admission rate of 20.5%. The ED admission rate difference pre‐ and post‐GBR was –1.14% (95% confidence interval [CI] = –0.89 to –1.40) for MD hospitals and –0.04% (95% CI = –0.24 to 0.32) for DC hospitals with a difference‐in‐differences result of –1.10% (95% CI = –1.34 to –0.86). This change was attributable to a –3.3% (95% CI = –3.54 to –3.08) decline in inpatient admissions and 2.7% (95% CI = 2.53 to 2.79) increase in observation admissions. Declines in admissions were observed primarily among mild‐to‐moderate severity of illness encounters with a low risk of mortality. Conclusions: Within the same health system, implementation of global budgeting in MD hospitals was associated with a decline in ED admissions—particularly lower‐acuity admissions—compared to DC hospitals that remained under fee‐for‐service payments. [ABSTRACT FROM AUTHOR]

In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration‐Pediatric Emergency Medicine in Non‐Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) visits provide an opportunity for hepatitis C virus (HCV) screening for patients who otherwise might not be tested. We report on a novel nontargeted, opt‐out HCV screening and linkage‐to‐care (LTC) program implemented in an urban ED. Methods: This is a descriptive analysis from 3 months (November 2016–January 2017) of a nontargeted, opt‐out ED HCV screening and LTC program among patients at least 13 years old undergoing phlebotomy for clinical purposes. A multipurpose best practice advisory (BPA) alerted providers to the program and generated order labels. For patients who authorized testing, specimens were drawn in the ED for HCV antibody (Ab) and reflex confirmatory RNA tests. Public health navigators attempted to contact RNA‐positive patients and arrange outpatient visits. Results: HCV Ab tests were performed on 3,808 patients, a 6,950% increase from preprogram. The proportion of HCV Ab test positivity was 13.2% (504/3,808, 95% confidence interval [CI] = 12.2%–14.3%) and of those 97.8% (493/504) had a follow‐up RNA test performed. A total of 292 were confirmed positive for active infection, for an overall RNA positivity rate of 7.7% (95% CI = 6.8%–8.5%). Of those with active infection, 155 (53%) were outside the Centers for Disease Control and Prevention birth cohort for increased risk for HCV including 46 (15.8%, 95% CI = 11.8%–20.4%) who also did not report injection drug use. Linkage attempts were documented on 223 (76.4%) patients and appointments were scheduled for 102 (38% of attempted). Sixty‐six patients attended their LTC visit (22.5% of all RNA‐positive patients, 30% of linkage‐eligible patients). Conclusions: Nontargeted opt‐out HCV testing can be successfully implemented in an ED setting. A number of patients diagnosed were outside traditional risk groups. Once diagnosed, an ED population may be difficult to engage in care, but a structured interdisciplinary program can successfully link patients to HCV care. [ABSTRACT FROM AUTHOR]

Abstract: Background and Objectives: Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients’ perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients’ desired level of involvement and what barriers and facilitators patients find most relevant to their experience. Methods: We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three‐person coding team. Emergent themes were identified, discussed, and organized. Results: Twenty‐nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self‐efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians’ good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care. Conclusions: This exploration of ED patients’ perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population. [ABSTRACT FROM AUTHOR]

Abstract: Objective: We compare case mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital‐based emergency departments (H‐EDs). Methods: Data from 74 FSEDs (2013–2015) in Texas and Colorado were compared to H‐ED data from the 2013–2014 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g., payer and case mix) were found between patients that use FSEDs compared to H‐EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, nonambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED LOS and as well as hospital admission rates and resource utilization rates in the IPW‐weighted samples. Results: Before balancing, FSEDs saw more young adults (age 25–44) and fewer older adults (age 45–64) than H‐EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H‐ED patients. Hospital admission rates were 37% lower overall (95% confidence interval = –51% to –23%) in FSEDs and varied considerably by primary discharge diagnosis. X‐ray and electrocardiogram use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, computed tomography scans, and laboratory tests). Conclusion: In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to < 65 years, privately insured, and nonambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H‐ED over FSEDs. [ABSTRACT FROM AUTHOR]

Abstract: Background: More than 30 million children are cared for across 5,000 U.S. emergency departments (EDs) each year. Most of these EDs are not facilities designed and operated solely for children. A Web‐based survey provided a national and state‐by‐state assessment of pediatric readiness and noted a national average score was 69 on a 100‐point scale. This survey noted wide variations in ED readiness with scores ranging from 61 in low‐pediatric‐volume EDs to 90 in the high‐pediatric‐volume EDs. Additionally, the mean score at the state level ranged from 57 (Wyoming) to 83 (Florida) and for individual EDs ranged from 22 to 100. The majority of prior efforts made to improve pediatric readiness have involved providing Web‐based resources and online toolkits. This article reports on the first year of a program that aimed to improve pediatric readiness across community hospitals in our state through in situ simulation‐based assessment facilitated by our academic medical center. The primary aim was to improve the pediatric readiness scores in the 10 participating hospitals. The secondary aim was to explore the correlation of simulation‐based performance of hospital teams with pediatric readiness scores. Methods: This interventional study measured the Pediatric Readiness Survey (PRS) prior to and after implementation of an improvement program. This program consisted of three components: 1) in situ simulations, 2) report‐outs, and 3) access to online pediatric readiness resources and content experts. The simulations were conducted in situ (in the ED resuscitation bay) by multiprofessional teams of doctors, nurses, respiratory therapists, and technicians. Simulations and debriefings were facilitated by an expert team from a pediatric academic medical center. Three scenarios were conducted for all teams and include: a 6‐month‐old with respiratory failure, an 8‐year‐old with diabetic ketoacidosis (DKA), and a 6‐month‐old with supraventricular tachycardia (SVT). A performance score was calculated for each scenario. The improvement of PRS was compared before and after the simulation program. The correlation of the simulation performance of each hospital and the PRS was calculated. Results: Forty‐one multiprofessional teams from 10 EDs in Indiana participated in the study, five were of medium pediatric volume and five were medium‐ to high‐volume EDs. The PRS significantly improved from the first to the second on‐site verification assessment (58.4 ± 4.8 to 74.7 ± 2.9, p = 0.009). Total adherence scores to scenario guidelines were 54.7, 56.4, and 62.4% in the respiratory failure, DKA, and SVT scenarios, respectively. We found no correlation between simulation performance and PRS scores. Medium ED pediatric volume significantly predicted higher PRS scores compared to medium‐high pediatric ED volume (β = 8.7; confidence interval = 0.72–16.8, p = 0.034). Conclusions: Our collaborative improvement program that involved simulation was associated with improvement in pediatric readiness scores in 10 EDs participating statewide. Future work will focus on further expanding of the network and establishing a national model for pediatric readiness improvement. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: All residency programs in the United States are required to report their residents' progress on the milestones to the Accreditation Council for Graduate Medical Education (ACGME) biannually. Since the development and institution of this competency‐based assessment framework, residency programs have been attempting to ascertain the best ways to assess resident performance on these metrics. Simulation was recommended by the ACGME as one method of assessment for many of the milestone subcompetencies. We developed three simulation scenarios with scenario‐specific milestone‐based assessment tools. We aimed to gather validity evidence for this tool. Methods: We conducted a prospective observational study to investigate the validity evidence for three mannequin‐based simulation scenarios for assessing individual residents on emergency medicine (EM) milestones. The subcompetencies (i.e., patient care [PC]1, PC2, PC3) included were identified via a modified Delphi technique using a group of experienced EM simulationists. The scenario‐specific checklist (CL) items were designed based on the individual milestone items within each EM subcompetency chosen for assessment and reviewed by experienced EM simulationists. Two independent live raters who were EM faculty at the respective study sites scored each scenario following brief rater training. The inter‐rater reliability (IRR) of the assessment tool was determined by measuring intraclass correlation coefficient (ICC) for the sum of the CL items as well as the global rating scales (GRSs) for each scenario. Comparing GRS and CL scores between various postgraduate year (PGY) levels was performed with analysis of variance. Results: Eight subcompetencies were chosen to assess with three simulation cases, using 118 subjects. Evidence of test content, internal structure, response process, and relations with other variables were found. The ICCs for the sum of the CL items and the GRSs were >0.8 for all cases, with one exception (clinical management GRS = 0.74 in sepsis case). The sum of CL items and GRSs (p < 0.05) discriminated between PGY levels on all cases. However, when the specific CL items were mapped back to milestones in various proficiency levels, the milestones in the higher proficiency levels (level 3 [L3] and 4 [L4]) did not often discriminate between various PGY levels. L3 milestone items discriminated between PGY levels on five of 12 occasions they were assessed, and L4 items discriminated only two of 12 times they were assessed. Conclusion: Three simulation cases with scenario‐specific assessment tools allowed evaluation of EM residents on proficiency L1 to L4 within eight of the EM milestone subcompetencies. Evidence of test content, internal structure, response process, and relations with other variables were found. Good to excellent IRR and the ability to discriminate between various PGY levels was found for both the sum of CL items and the GRSs. However, there was a lack of a positive relationship between advancing PGY level and the completion of higher‐level milestone items (L3 and L4). [ABSTRACT FROM AUTHOR]

Background Anxiety and depression rates among emergency department ( ED) patients are substantially higher than those in the general population. Additionally, those with mental health issues often have difficulty accessing care. Unfortunately, issues of anxiety and depression are frequently not addressed in the ED due to competing care priorities. This may lead to increased burden and overcrowding in EDs. Objective This study related anxiety and depression with ED utilization and perceived barriers to care. Methods To limit the impact of insurance coverage on ED utilization and access to care, a convenience sample of adults 45 to 85 years of age in the ED were surveyed. The Generalized Anxiety Disorder 7 and Patient Health Questionnaire 9 were used to measure anxiety and depression. Results A total of 251 subjects were enrolled. Severe anxiety was observed in 10% of patients, while moderately severe or severe depression was observed in 12%. Patients who were both severely anxious and depressed visited the ED nearly twice as often as nonanxious and nondepressed patients. The majority of patients cited at least one moderate barrier to care, and greater anxiety and depression scores were related to greater perceived barriers to care. Perceived barriers to care were more than three times higher among patients who were both anxious and depressed compared to those in patients who were neither depressed nor anxious and twice as high as in those who were either depressed or anxious (p < 0.001). Conclusion Patients identified with internalizing mental health concerns utilize the ED at elevated rates while also reporting the greatest difficulties accessing care. These findings highlight the need for ED interventions aimed at identifying patient mental health concerns, as well as perceived barriers to care, to design interventions to effectively improve continuity of care. [ABSTRACT FROM AUTHOR]

Background Over 35 million alcohol-impaired ( AI) patients are cared for in emergency departments ( EDs) annually. Emergency physicians are charged with ensuring AI patients' safety by identifying resolution of alcohol-induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients. Objective The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack's Impairment Index ( HII score), in a busy urban ED. Methods A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both 'usual' and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated. Results A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients' visits. Conclusions The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations. [ABSTRACT FROM AUTHOR]

A letter from the authors of the article "Tropical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial" is presented.

Background Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care. Objective The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy. Methods A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2. Results Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post- ED discharge success. Phase 3 resulted in five questions for the proposed measure. Conclusions A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics. [ABSTRACT FROM AUTHOR]

Objectives The emergency department ( ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions. Methods We conducted uniprofessional focus groups and individual interviews using a phenomenologic approach with emergency medicine resident physicians, ED staff nurses, patient care technicians, and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method. Results We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: 1) ED healthcare workers provide high-quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; 2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; and 3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety. Conclusion The experience of ED staff members while caring for agitated patients is complex and multidimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment, and system levels. Future research is needed to determine applicability of our findings across institutions to build a comprehensive framework for ED agitated patient care. [ABSTRACT FROM AUTHOR]

The article discusses role of shared decision making (SDM) in health care wherein patients and clinicians work together to determine best health practice. Topics discussed include several ways to improve patients care such as treatment undergone trials, evidence based guidance, and quality performance; major key elements in implementing SDM in regular practice such as clarifying situation, informing patient and understanding patients insights; and also mentions several myths related to SDM.

Background Traditionally, emergency department ( ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft tissue infections ( SSTI). Management of an abscess requires incision and drainage, whereas cellulitis generally requires a course of antibiotics. Misdiagnosis often results in unnecessary invasive procedures, sedations (for incision and drainage in pediatric patients), or a return ED visit for failed antibiotic therapy. Objective The objective was to describe the operating characteristics of point-of-care ultrasound ( POCUS) compared to clinical examination in identifying abscesses in ED patients with SSTI. Methods We systematically searched Medline, Web of Science, EMBASE, CINAHL, and Cochrane Library databases from inception until May 2015. Trials comparing POCUS with clinical examination to identify abscesses when evaluating SSTI in the ED were included. Trials that included intraoral abscesses or abscess drainage in the operating room were excluded. The presence of an abscess was defined by drainage of pus. The absence of an abscess was defined as no pus drainage upon incision and drainage or resolution of SSTI without pus drainage at follow-up. Quality of trials was assessed using the QUADAS-2 tool. Operating characteristics were reported as sensitivity, specificity, positive likelihood ratio ( LR+), and negative likelihood ratio ( LR−), with their respective 95% confidence intervals ( CI). Summary measures were calculated by generating a hierarchical summary receiver operating characteristic ( HSROC) model. Results Of 3,203 references identified, six observational studies (four pediatric trials and two adult trials) with a total of 800 patients were included. Two trials compared clinical examination with clinical examination plus POCUS. The other four trials directly compared clinical examination to POCUS. The POCUS HSROC revealed a sensitivity of 97% (95% CI = 94% to 98%), specificity of 83% (95% CI = 75% to 88%), LR+ of 5.5 (95% CI = 3.7 to 8.2), and LR− of 0.04 (95% CI = 0.02 to 0.08). Conclusion Existing evidence indicates that POCUS is useful in identifying abscess in ED patients with SSTI. In cases where physical examination is equivocal, POCUS can assist physicians to distinguish abscess from cellulitis. [ABSTRACT FROM AUTHOR]

Background Variations in syncope management exist. Our objective was to identify the reasons for consultations and hospitalizations and outcomes among emergency department ( ED) syncope patients. Methods We conducted a prospective cohort study to enroll adult syncope patients at five EDs. We collected baseline characteristics, reasons for consultation and hospitalization, and hospital length of stay. Adjudicated 30-day serious adverse events ( SAEs) including death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, and procedural intervention. We used descriptive analysis. Results From 4,064 enrolled patients (mean ± SD age = 53.1 ± 23.2 years; 55.9% female), 3,255 (80.1%) were discharged directly by the ED physician. Of those with no SAEs identified in the ED ( n = 600), 42.8% of referrals and 46.5% of hospitalizations were for suspected arrhythmias, and 71.2% of patients hospitalized for arrhythmias had no cause identified. SAEs among groups were 9.7% in total, 2.5% discharged by ED physician, 3.4% discharged by consultant, 21.7% as inpatient, and 4.8% following discharge from hospital. The median hospital length of stay for suspected arrhythmias was 5 days (interquartile range = 3 to 8 days). Conclusion Cardiac syncope, particularly suspected arrhythmia, was the major reason for ED referrals and hospitalization. The majority of patients hospitalized for cardiac monitoring had no identified cause. An important number of patients suffered SAEs, particularly arrhythmias, outside the hospital. Development of a risk-stratification tool and out-of-hospital cardiac monitoring strategy should improve patient safety and save substantial resources. [ABSTRACT FROM AUTHOR]

Objectives Risk stratification of emergency department ( ED) patients with upper gastrointestinal bleeding ( UGIB) using preendoscopic risk scores can aid ED physicians in disposition decision-making. We conducted a systematic review to assess the predictive value of preendoscopic risk scores for 30-day serious adverse events. Methods We searched MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception to March 2015. We included studies involving adult ED UGIB patients evaluating preendoscopic risk scores and excluded reviews, case reports, and animal studies. The composite outcome included 30-day mortality, recurrent bleeding, and need for intervention. In two phases (screening and full review), two reviewers independently screened articles for inclusion and extracted patient-level data. The consensus data were used for analysis. We reported sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios with 95% confidence intervals. Results We identified 3,173 articles, of which 16 were included: three studied Glasgow Blatchford score ( GBS); one studied clinical Rockall score ( cRockall); two studied AIMS65; six compared GBS and cRockall; three compared GBS, a modification of the GBS, and cRockall; and one compared the GBS and AIMS65. Overall, the sensitivity and specificity of the GBS were 0.98 and 0.16, respectively; for the cRockall they were 0.93 and 0.24, respectively; and for the AIMS65 they were 0.79 and 0.61, respectively. The GBS with a cutoff point of 0 had a sensitivity of 0.99 and a specificity of 0.08. Conclusion The GBS with a cutoff point of 0 was superior over other cutoff points and risk scores for identifying low-risk patients but had a very low specificity. None of the risk scores identified by our systematic review were robust and, hence, cannot be recommended for use in clinical practice. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB. [ABSTRACT FROM AUTHOR]

Precision medicine is an emerging approach to disease treatment and prevention that considers variability in patient genes, environment, and lifestyle. However, little has been written about how such research impacts emergency care. Recent advances in analytical techniques have made it possible to characterize patients in a more comprehensive and sophisticated fashion at the molecular level, promising highly individualized diagnosis and treatment. Among these techniques are various systematic molecular phenotyping analyses (e.g., genomics, transcriptomics, proteomics, and metabolomics). Although a number of emergency physicians use such techniques in their research, widespread discussion of these approaches has been lacking in the emergency care literature and many emergency physicians may be unfamiliar with them. In this article, we briefly review the underpinnings of such studies, note how they already impact acute care, discuss areas in which they might soon be applied, and identify challenges in translation to the emergency department (ED). While such techniques hold much promise, it is unclear whether the obstacles to translating their findings to the ED will be overcome in the near future. Such obstacles include validation, cost, turnaround time, user interface, decision support, standardization, and adoption by end-users. [ABSTRACT FROM AUTHOR]

Background An abnormal chest X-ray ( CXR) inconsistent with simple bronchiolitis is found in 7%-23% of cases. Despite national guidelines stating 'current evidence does not support routine radiography in children with bronchiolitis'; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia. Objectives We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis. Methods We searched the medical literature from 1965 to June 2015 in PubMed/ EMBASE using the following PICO formulation of our clinical question, 'What characteristic(s) of history/physical examination (H&P) and vital signs ( VS) in a child with bronchiolitis should prompt the physician to order a CXR?': Patients-pediatric emergency department ( ED) patients (<2 years) with clinical bronchiolitis; Intervention-H&P and VS; Comparator-a CXR positive for airspace disease (+ CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome-operating characteristics of H&P and VS predicting an + CXR were calculated: sensitivity, specificity, and likelihood ratios ( LR+ or LR−). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool ( QUADAS-2). We created a test-treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection. Results We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a + CXR ranged from 7% to 23%. An oxygen saturation < 95% was the predictor with highest LR+ of 2.3 (95% confidence interval = 1.3 to 3.07) to predict a + CXR. None of the H&P and VS variables were found to have sufficiently low LR- to significantly decrease the pretest probability of finding a + CXR. Our test-treatment threshold model showed that hypoxia (O2 Sat < 95%) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O2 Sat < 95%) and respiratory failure requiring ventilatory support. Conclusion No single predictor of a + CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment. [ABSTRACT FROM AUTHOR]

Objective Fall-related visits to emergency departments ( EDs) are common among older individuals. We aimed to assess effectiveness of a healthcare intervention program for the management of elderly patients admitted to EDs after a fall. Methods Using a before-after observation method, we investigated ED healthcare staff practices related to fall-related injuries in 2010 (period 1) and 2012 (period 2) in 13 centers participating in the Northern French Alps Emergency Network. Following the identification of initial weaknesses, several information and training tools were introduced between the two periods to improve patient management. All individuals aged 75 years or over who presented to an ED after a fall were included in the study. We reviewed the completeness and quality of medical records during both periods and compared the rate of clinical-paraclinical check-ups performed, geriatric evaluation/assessment in the ED, and the 1-month recurrence of visits to the ED for the same reason. Results During period 1, a total of 2,425 falls were recorded, while 2,684 were reported in period 2. The 2012 medical charts contained significantly more information about risk factors than those of 2010. An electrocardiogram (64% vs. 53%; p < 0.001), biologic check-up (65% vs. 57%; p < 0.001), balance, orthostatic hypotension, and cognitive impairment tests were more often performed in 2012. There was no change in the hospitalization rate, although short-duration hospitalization in the ED was more frequent in 2012. Geriatrists were more often consulted by patients in 2012 (18% vs. 13%; p < 0.001) and more involved in ED evaluation and hospitalization. The intervention program had a beneficial impact on the fall recurrence rate ( n = 29 [3.6%] in period 1 and n = 17 [2.0%] in period 2; odds ratio = 0.52; p = 0.037), which significantly decreased between 2010 and 2012. Conclusions The intervention program was associated with a decrease of fall recurrence. Further efforts should be made in EDs to ensure a sustained level of satisfactory and long-lasting management of the elderly. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to compare anxiolysis with intranasal dexmedetomidine, an alpha-2 agonist, versus intranasal midazolam for pediatric laceration repairs. Methods We performed a double-blind, randomized controlled trial of 40 patients 1-5 years with lacerations requiring suture repair in an academic pediatric emergency department ( ED). Patients were randomized to receive either intranasal dexmedetomidine or intranasal midazolam. Our primary outcome measure was the anxiety score at the time of patient positioning for the laceration repair. We chose this time point to isolate the anxiolysis from the medications prior to intervention. Patient encounters were videotaped and scored for anxiety at multiple time points using the modified Yale Preoperative Anxiety Scale. The scale is 23.3-100 with higher scores indicating higher anxiety. We also evaluated these scores as a secondary outcome by dichotomizing them into anxious versus not anxious with a previously validated score cutoff. Results Of the 40 patients enrolled, 20 in the dexmedetomidine group and 18 in the midazolam group completed the study and were included in the analysis. The median age was 3.3 years (range = 1.0-5.4 years). The median baseline anxiety score was 48.3. The anxiety score at position for procedure for patients receiving dexmedetomidine was 9.2 points lower than those receiving midazolam (median difference = 9.2, 95% confidence interval = 5 to 13.3; median score for dexmedetomidine = 23.3, median score for midazolam = 36.3). The proportion of patients who were classified as not anxious at the position for procedure was significantly higher in the dexmedetomidine group (70%) versus the midazolam group (11%). The number needed to treat with dexmedetomidine instead of midazolam to obtain the result of a not anxious patient at this time point was 1.7 patients. There were also significantly more patients who were classified as not anxious at the time of wound washout in the dexmedetomidine group compared to the midazolam group (35% vs. 6%). Dexmedetomidine and midazolam performed similarly with respect to all other measures including anxiety at other time points, parental perceived anxiety, parent and proceduralist satisfaction, procedural success, complications, and time in the ED. There were no serious adverse events seen in either group. Conclusions Intranasal dexmedetomidine is an alternative anxiolytic medication to intranasal midazolam for pediatric laceration repairs, performing similarly in our study, except that patients who received dexmedetomidine had less anxiety at the time of positioning for procedure. [ABSTRACT FROM AUTHOR]

Objectives Patients report pain and discomfort with nasogastric tube ( NGT) intubation. We tested the hypothesis that premedication with midazolam alleviates pain during NGT placement in the emergency department ( ED) by > 13 on a 100-mm visual analog scale ( VAS). Methods We performed a double-blind randomized controlled pilot study, assigning ED patients requiring NGT placement to midazolam or placebo. All patients received intranasal cophenylcaine; additionally, they received an intravenous ( IV) dose of the study drug, either 2 mg of IV midazolam or saline control. Nurses placed NGTs while observed by research staff, who then interviewed subjects to determine the primary outcome of pain using a VAS. Additional data collected from patients and their nurses included discomfort during the procedure, difficulty of tube insertion, and complications. Results We enrolled 23 eligible patients and obtained complete data in all: 10 midazolam and 13 controls. We found a significant reduction in mean pain VAS score of −31 (95% confidence interval = −53 to −9 mm) with 2 mg of midazolam (mean ± SD = 52 ± 30 mm), compared to placebo (mean ± SD = 21 ± 18 mm), more than double the effect size considered clinically relevant. Treatment did not impact ease of placement and there were no serious adverse effects. Conclusions Premedication with 2 mg of IV midazolam reduces pain of NGT insertion in ED patients without the need for full procedural sedation. [ABSTRACT FROM AUTHOR]

Objective The objective was to evaluate the effect of an emergency clinician-initiated ' ED admission holding order set' on emergency department ( ED) treatment times and length of stay ( LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act ( PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone ( DDTPG) time, for admitted patients. Methods We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a 'non-value-added' activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior. Results The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [ IQR] = 295 to 543) and 395 ( IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 ( IQR = 21 to 431) and 316 ( IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 ( IQR = 150 to 306) and 200 ( IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 ( IQR = 58 to 138) and 92 ( IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 ( IQR = 112 to 261) and 178 ( IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 ( IQR = 129 to 316) and 202 ( IQR = 127 to 305) minutes following the intervention. Conclusions We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change. [ABSTRACT FROM AUTHOR]

Objectives The objective was to obtain a commitment to adopt a common set of definitions for emergency department ( ED) demographic, clinical process, and performance metrics among the ED Benchmarking Alliance ( EDBA), ED Operations Study Group ( EDOSG), and Academy of Academic Administrators of Emergency Medicine ( AAAEM) by 2017. Methods A retrospective cross-sectional analysis of available data from three ED operations benchmarking organizations supported a negotiation to use a set of common metrics with identical definitions. During a 1.5-day meeting-structured according to social change theories of information exchange, self-interest, and interdependence-common definitions were identified and negotiated using the EDBA's published definitions as a start for discussion. Methods of process analysis theory were used in the 8 weeks following the meeting to achieve official consensus on definitions. These two lists were submitted to the organizations' leadership for implementation approval. Results A total of 374 unique measures were identified, of which 57 (15%) were shared by at least two organizations. Fourteen (4%) were common to all three organizations. In addition to agreement on definitions for the 14 measures used by all three organizations, agreement was reached on universal definitions for 17 of the 57 measures shared by at least two organizations. The negotiation outcome was a list of 31 measures with universal definitions to be adopted by each organization by 2017. Conclusion The use of negotiation, social change, and process analysis theories achieved the adoption of universal definitions among the EDBA, EDOSG, and AAAEM. This will impact performance benchmarking for nearly half of US EDs. It initiates a formal commitment to utilize standardized metrics, and it transitions consistency in reporting ED operations metrics from consensus to implementation. This work advances our ability to more accurately characterize variation in ED care delivery models, resource utilization, and performance. In addition, it permits future aggregation of these three data sets, thus facilitating the creation of more robust ED operations research data sets unified by a universal language. Negotiation, social change, and process analysis principles can be used to advance the adoption of additional definitions. [ABSTRACT FROM AUTHOR]

Objective We aimed to evaluate the association between patient chief complaint and the time interval between patient rooming and resident physician self-assignment ('pickup time'). We hypothesized that significant variation in pickup time would exist based on chief complaint, thereby uncovering resident preferences in patient presentations. Methods A retrospective medical record review was performed on consecutive patients at a single, academic, university-based emergency department with over 50,000 visits per year. All patients who presented from August 1, 2012, to July 31, 2013, and were initially seen by a resident were included in the analysis. Patients were excluded if not seen primarily by a resident or if registered with a chief complaint associated with trauma team activation. Data were abstracted from the electronic health record ( EHR). The outcome measured was 'pickup time,' defined as the time interval between room assignment and resident self-assignment. We examined all complaints with >100 visits, with the remaining complaints included in the model in an 'other' category. A proportional hazards model was created to control for the following prespecified demographic and clinical factors: age, race, sex, arrival mode, admission vital signs, Emergency Severity Index code, waiting room time before rooming, and waiting room census at time of rooming. Results Of the 30,382 patients eligible for the study, the median time to pickup was 6 minutes (interquartile range = 2-15 minutes). After controlling for the above factors, we found systematic and significant variation in the pickup time by chief complaint, with the longest times for patients with complaints of abdominal problems, numbness/tingling, and vaginal bleeding and shortest times for patients with ankle injury, allergic reaction, and wrist injury. Conclusions A consistent variation in resident pickup time exists for common chief complaints. We suspect that this reflects residents preferentially choosing patients with simpler workups and less perceived diagnostic ambiguity. This work introduces pickup time as a metric that may be useful in the future to uncover and address potential physician bias. Further work is necessary to establish whether practice patterns in this study are carried beyond residency and persist among attendings in the community and how these patterns are shaped by the information presented via the EHR. [ABSTRACT FROM AUTHOR]

Objectives The objectives were to determine if nebulized albuterol causes an increase in the serum lactate level compared to placebo and, secondarily, to confirm that albuterol decreases serum potassium levels compared to placebo in patients with normokalemia. Methods This was a randomized, double-blind, placebo-controlled trial. Twenty-eight healthy adult volunteers were assigned to receive either 10 mg of nebulized albuterol or placebo (nebulized saline) over 1 hour. Serum lactate was measured prior to treatment and at 30 and 70 minutes after the start of treatment. Serum potassium level was measured prior to treatment and at 70 minutes. The primary outcome was the degree of change in lactate level. The secondary outcome was the degree of change in potassium level. Results In the 14 subjects who received albuterol, the mean increase in lactate was 0.77 mmol/L (95% confidence interval [ CI] = 0.52 to 1.02 mmol/L), and the mean decrease in potassium level was 0.5 mEq/L (95% CI = −0.72 to −0.28 mEq/L). Among the subjects who received placebo, the lactate level decreased by 0.15 mmol/L (95% CI = −0.39 to 0.09 mmol/L) and there was no change in potassium level at (0.0 mEq/L [95% CI = −0.21 to 0.21 mEq/L]). These differences are statistically significant (p < 0.0001 and p = 0.003, respectively). Conclusion Nebulized albuterol increases lactate levels and decreases potassium levels in healthy adults. [ABSTRACT FROM AUTHOR]

Objective The General Internal Medicine ( GIM) Care Transformation Initiative implemented at one of four teaching hospitals in the same city resulted in improved efficiency of in-hospital care. Whether it had beneficial effects upstream in the emergency department ( ED) is unclear. Methods Controlled before-after study of ED length of stay ( LOS) and crowding metrics for the intervention site ( n = 108,951 visits) compared to the three other teaching hospitals (controls, n = 300,930 visits). Our primary outcome was ED LOS for GIM patients but secondary outcomes included ED LOS for all adults and ED crowding metrics. Results The GIM Care Transformation was associated with an additional 2.8-hour reduction in median ED LOS (from 25.6 hours to 13.5 hours) over and above the 9.3-hour decline (from 30.6 hours to 21.3 hours) seen in the three control EDs for GIM patients who were hospitalized (p < 0.001). As less than one in 30 ED visits resulted in a GIM ward admission, the median ED LOS for all patients declined by 15 minutes (from 4.6 hours to 4.3 hours, p < 0.001) in the control hospitals and by 30 minutes (from 5.7 hours to 5.1 hours, p < 0.001) at the intervention hospital pre versus post (p = 0.04 for the 15-minute additional reduction, p < 0.001 for level change on interrupted time series). Other metrics of ED crowding improved by similar amounts at the intervention and control hospitals with no statistically significant differences. Conclusion Although the GIM Care Transformation Initiative was associated with substantial reductions in ED LOS for patients admitted to GIM wards at the intervention hospital, it resulted in only minor changes in overall ED LOS and no appreciable changes in ED crowding metrics. [ABSTRACT FROM AUTHOR]

Objective Delayed diagnosis of Kawasaki disease ( KD) may lead to serious cardiac complications. We sought to create and test the performance of a natural language processing ( NLP) tool, the KD- NLP, in the identification of emergency department ( ED) patients for whom the diagnosis of KD should be considered. Methods We developed an NLP tool that recognizes the KD diagnostic criteria based on standard clinical terms and medical word usage using 22 pediatric ED notes augmented by Unified Medical Language System vocabulary. With high suspicion for KD defined as fever and three or more KD clinical signs, KD- NLP was applied to 253 ED notes from children ultimately diagnosed with either KD or another febrile illness. We evaluated KD- NLP performance against ED notes manually reviewed by clinicians and compared the results to a simple keyword search. Results KD- NLP identified high-suspicion patients with a sensitivity of 93.6% and specificity of 77.5% compared to notes manually reviewed by clinicians. The tool outperformed a simple keyword search (sensitivity = 41.0%; specificity = 76.3%). Conclusions KD- NLP showed comparable performance to clinician manual chart review for identification of pediatric ED patients with a high suspicion for KD. This tool could be incorporated into the ED electronic health record system to alert providers to consider the diagnosis of KD. KD- NLP could serve as a model for decision support for other conditions in the ED. [ABSTRACT FROM AUTHOR]

Objectives Emergency departments ( EDs) commonly analyze cases of patients returning within 72 hours of initial ED discharge as potential opportunities for quality improvement. In this study, we tested the use of a health information exchange ( HIE) to improve identification of 72-hour return visits compared to individual hospitals' site-specific data. Methods We collected deidentified patient data over a 5-year study period from Healthix, an HIE in the New York metropolitan area. We measured site-specific 72-hour ED returns and compared these data to those obtained from a regional 31-site HIE (Healthix) and to those from a smaller, antecedent 11-site HIE. Although only ED visits were counted as index visits, either ED or inpatient revisits within 72 hours of the index visit were considered as early returns. Results A total of 12,669,657 patient encounters were analyzed across the 31 HIE EDs, including 6,352,829 encounters from the antecedent 11-site HIE. Site-specific 72-hour return visit rates ranged from 1.1% to 15.2% (median = 5.8%) among the individual 31 sites. When the larger HIE was used to identify return visits to any site, individual EDs had a 72-hour return frequency of 1.8% to 15.5% (median = 6.8%). HIE increased the identification ability of 72-hour ED return analyses by a mean of 11.16% (95% confidence interval = 11.10% to 11.22%) compared with site-specific (no HIE) analyses. Conclusion This analysis demonstrates incremental improvements in our ability to identify early ED returns using increasing levels of HIE data aggregation. Although intuitive, this has not been previously described using HIE. ED quality measurement and patient safety efforts may be aided by using HIE in 72-hour return analyses. [ABSTRACT FROM AUTHOR]

Background The Affordable Care Act initiated several care coordination programs tailored to reduce emergency department ( ED) use for Medicaid-enrolled frequent ED users. It is important to clarify from the patient's perspective why Medicaid enrollees who want to receive care coordination services to improve primary care utilization frequently use the ED. Methods We conducted a qualitative data analysis of patient summary reports obtained from Medicaid enrolled frequent ED users who agreed to participate in a randomized control trial ( RCT) evaluating the impact of patient navigation intervention compared with standard of care on ED use and hospital admissions. We defined frequent ED users as those who used the ED four to 18 times in the past year. The study was conducted at an urban, teaching hospital ED with approximately 90,000 visits per year. The research staff conducted interviews (~30-40 minutes), regarding the patient's medical history, reasons for ED visits, health care access issues, and social distresses. The aforementioned findings were summarized in a 1- to 2-page report and presented to the RCT's project team (social worker, emergency medicine physician, primary care physician, and patient navigators) on a weekly basis to further understand the needs of this patient population. A diverse team of researchers (program staff and physicians) coded all reports and reached consensus using reflexive team analysis. We reconciled differences in code interpretations and generated themes. Results One-hundred patients enrolled in the RCT from March 2013 to February 2014, and all 100 patient summary reports were evaluated. We identified three key themes associated with Medicaid enrollee frequent ED use: 1) negative personal experiences with the healthcare system, 2) challenges associated with having low socioeconomic status, and 3) significant chronic mental and physical disease burden. Conclusions Medicaid frequent ED users engaged in receiving patient navigation services with the goal to reduce ED use and hospital admissions describe barriers that go beyond timely primary care access issues. These include sociodeterminants of health, lack of trust in primary care providers, and healthcare system. [ABSTRACT FROM AUTHOR]

Objectives Prescription drug monitoring programs ( PDMPs) are underutilized, despite evidence showing that they may reduce the epidemic of opioid-related addiction, diversion, and overdose. We evaluated the usability of the Massachusetts ( MA) PDMP by emergency medicine providers ( EPs), as a system's usability may affect how often it is used. Methods This was a mixed-methods study of 17 EPs. We compared the time and number of clicks required to review one patient's record in the PDMP to three other commonly performed computer-based tasks in the emergency department ( ED: ordering a computed tomography [ CT] scan, writing a prescription, and searching a medication history service integrated within the electronic medical record [ EMR]). We performed semistructured interviews and analyzed participant comments and responses regarding their experience using the MA PDMP. Results The PDMP task took a longer time to complete (mean = 4.22 minutes) and greater number of mouse clicks to complete (mean = 50.3 clicks) than the three other tasks ( CT-pulmonary embolism = 1.42 minutes, 24.8 clicks; prescription = 1.30 minutes, 19.5 clicks; SureScripts = 1.45 minutes, 9.5 clicks). Qualitative analysis yielded four main themes about PDMP usability, three negative and one positive: 1) difficulty accessing the PDMP, 2) cumbersome acquiring patient medication history information within the PDMP, 3) nonintuitive display of patient medication history information within the PDMP, and 4) overall perceived value of the PDMP despite an inefficient interface. Conclusions The complicated processes of gaining access to, logging in, and using the MA PDMP are barriers to preventing its more frequent use. All states should evaluate the PDMP usability in multiple practice settings including the ED and work to improve provider enrollment, login procedures, patient information input, prescription data display, and ultimately, PDMP data integration into EMRs. [ABSTRACT FROM AUTHOR]

The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit ( OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine ( EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine ( SAEM) and the American College of Emergency Physicians ( ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored. [ABSTRACT FROM AUTHOR]

Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions. [ABSTRACT FROM AUTHOR]

Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging. [ABSTRACT FROM AUTHOR]

Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging. [ABSTRACT FROM AUTHOR]