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Introduction The Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) is a three-part series of examinations similar to the United States Medical Licensing Examination (USMLE) that osteopathic medical students must pass for medical licensure. Osteopathic students are not required to take the USMLE, but during the residency admission process, many emergency medicine (EM) residency programs will not consider osteopathic applicants who only take the COMLEX-USA. Therefore, we examined program-level characteristics between programs that accept the COMLEX-USA alone for osteopathic applicants and those that prefer the USMLE using free, publicly available online databases and residency program websites. Methods Emergency Medicine Residents' Association (EMRA) Match was the primary database used; however, missing exam preferences were supplemented from Fellowship and Residency Electronic Interactive Database Access (FREIDA) and individual program websites. Program characteristics were compared between EM residencies that accept the COMLEX-USA and those that prefer the USMLE using the Chi-square test for categorical variables and the Mann-Whitney test for interval variables. Results Two hundred sixty of the 278 EM programs in the dataset were included in the analyses. One hundred and seven programs reported preferring the USMLE, while 151 reported accepting the COMLEX-USA alone. Programs differed by the educational environment of the primary training site (p0.001), number of Standardized Letter(s) of Evaluation (SLOE) needed for an interview (p = 0.042), emergency department (ED) shift length (p = 0.021), former American Osteopathic Association accreditation (p0.001), percentage of osteopathic residents (p0.001), annual ED volume (p = 0.001), number of intern positions (p0.001), and number of elective weeks (p = 0.028). Conclusion EM residency programs that reported accepting the COMLEX-USA alone for osteopathic applicants differed from those that prefer the USMLE. Therefore, osteopathic medical students interested in EM should consider these differences when deciding whether to take the USMLE.

OBJECTIVE. This series of patients presented to the emergency department (ED) with abdominal pain, without the respiratory symptoms typical of coronavirus disease (COVID-19), and the abdominal radiologist was the first to suggest COVID-19 infection because of findings in the lung bases on CT of the abdomen. CONCLUSION. COVID-19 infection can present primarily with abdominal symptoms, and the abdominal radiologist must suggest the diagnosis when evaluating the lung bases for typical findings.

PURPOSE To evaluate how emergency medicine residency programs perceived and used Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI) total scores and videos during the Electronic Residency Application Service 2018 cycle. METHOD Study 1 (November 2017) used a program director survey to evaluate user reactions to the SVI following the first year of operational use. Study 2 (January 2018) analyzed program usage of SVI video responses using data collected through the AAMC Program Director's Workstation. RESULTS Results from the survey (125/175 programs; 71% response rate) and video usage analysis suggested programs viewed videos out of curiosity and to understand the range of SVI total scores. Programs were more likely to view videos for attendees of U.S. MD-granting medical schools and applicants with higher United States Medical Licensing Examination Step 1 scores, but there were no differences by gender or race/ethnicity. More than half of programs that did not use SVI total scores in their selection processes were unsure of how to incorporate them (36/58; 62%) and wanted additional research on utility (33/58; 57%). More than half of programs indicated being at least somewhat likely to use SVI total scores (55/97; 57%) and videos (52/99; 53%) in the future. CONCLUSIONS Program reactions on the utility and ease of use of SVI total scores were mixed. Survey results indicate programs used the SVI cautiously in their selection processes, consistent with AAMC recommendations. Future user surveys will help the AAMC gauge improvements in user acceptance and familiarity with the SVI.

Objectives Identification of patients with coronavirus disease 2019 (COVID‐19) at risk for deterioration after discharge from the emergency department (ED) remains a clinical challenge. Our objective was to develop a prediction model that identifies patients with COVID‐19 at risk for return and hospital admission within 30 days of ED discharge. Methods We performed a retrospective cohort study of discharged adult ED patients (n = 7529) with SARS‐CoV‐2 infection from 116 unique hospitals contributing to the National Registry of Suspected COVID‐19 in Emergency Care. The primary outcome was return hospital admission within 30 days. Models were developed using classification and regression tree (CART), gradient boosted machine (GBM), random forest (RF), and least absolute shrinkage and selection (LASSO) approaches. Results Among patients with COVID‐19 discharged from the ED on their index encounter, 571 (7.6%) returned for hospital admission within 30 days. The machine‐learning (ML) models (GBM, RF, and LASSO) performed similarly. The RF model yielded a test area under the receiver operating characteristic curve of 0.74 (95% confidence interval [CI], 0.71–0.78), with a sensitivity of 0.46 (95% CI, 0.39–0.54) and a specificity of 0.84 (95% CI, 0.82–0.85). Predictive variables, including lowest oxygen saturation, temperature, or history of hypertension, diabetes, hyperlipidemia, or obesity, were common to all ML models. Conclusions A predictive model identifying adult ED patients with COVID‐19 at risk for return for return hospital admission within 30 days is feasible. Ensemble/boot‐strapped classification methods (eg, GBM, RF, and LASSO) outperform the single‐tree CART method. Future efforts may focus on the application of ML models in the hospital setting to optimize the allocation of follow‐up resources.

OBJECTIVES: Evidence-based clinical practice guidelines (CPGs) for the treatment of pneumonia and sepsis have existed for many years with multiple studies suggesting improved patient outcomes. Despite their importance, little is known about variation in emergency department (ED) adherence to these CPGs. Our objectives were to estimate variation in ED adherence across CPGs for pneumonia and sepsis and identify patient, provider, and environmental factors associated with adherence. METHODS: This was a multicenter retrospective study using standard medical record review methods. The population consisted of consecutive adults hospitalized for pneumonia or sepsis (identified by discharge ICD-9 codes) at five Colorado hospitals (two academic, three community) who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. The outcome measured was ED adherence to the CPG (primary) and in-hospital mortality (secondary). Hierarchical generalized linear models were used for analysis. RESULTS: Among 827 patients, ED care was 57% adherence to CPGs with significant variation in adherence across CPGs (sepsis 50%, pneumonia 64%, p < 0.001). Patients were less likely to receive adherent care if they presented with chief complaints that were associated but not typical of the diagnosis (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4–0.8), received an ED diagnosis that was not specific to the CPG (associated diagnosis OR = 0.3 [95% CI = 0.2–0.5]; unrelated diagnosis OR = 0.4 [95% CI = 0.2–0.6]) or presented to a community hospital (OR = 0.6,95% CI = 0.4–0.9). ED CPG nonadherence was associated with higher in-hospital mortality (OR = 2.4, 95% CI = 1.2–4.8). CONCLUSION: Adherence to ED infectious CPGs for pneumonia and sepsis varies significantly across diseases and types of institutions with significant room for improvement, especially in light of a significant association with in-hospital mortality.

Purpose This study examined applicant reactions to the Association of American Medical Colleges Standardized Video Interview (SVI) during its first year of operational use in emergency medicine (EM) residency program selection to identify strategies to improve applicants' SVI experience and attitudes. Method Individuals who self-classified as EM applicants applying in the Electronic Residency Application Service 2018 cycle and who completed the SVI in summer 2017 were invited to participate in 2 surveys. Survey 1, which focused on procedural issues, was administered immediately after SVI completion. Survey 2, which focused on applicants' SVI experience, was administered in fall 2017, after SVI scores were released. Results The response rates for surveys 1 and 2 were 82.3% (2,906/3,532) and 58.7% (2,074/3,532), respectively. Applicant reactions varied by aspect of the SVI studied and their SVI total scores. Most applicants were satisfied with most procedural aspects of the SVI, but most applicants were not satisfied with the SVI overall or with their total SVI scores. About 20% to 30% of applicants had neutral opinions about most aspects of the SVI. Negative reactions to the SVI were stronger for applicants who scored lower on the SVI. Conclusions Applicants had generally negative reactions to the SVI. Most were skeptical of its ability to assess the target competencies and its potential to add value to the selection process. Applicant acceptance and appreciation of the SVI will be critical to the SVI's acceptance by the graduate medical education community.

Background and purpose: Fewer than 1 in 20 patients with acute ischemic stroke are treated with thrombolytic drugs, with threequarters of otherwise eligible patients being excluded secondary to delay in seeking medical treatment. Lack of symptom recognition may contribute to low treatment rates and is an important focus of public health education. The purpose of this study was to determine if an individual’s cumulative number of stroke risk factors correlated with their ability to identify stroke symptoms. Methods: We surveyed adults about their stroke risk factors and knowledge of stroke symptoms at grocery stores and malls in a medium-sized university town in the Midwestern US. Results: In total, 245 adults completed surveys. Self-reported risk factors included high blood pressure (25%), high cholesterol (22%), diabetes (12%), tobacco use (11%), alcohol use (7%), heart disease (7%), and prior stroke (3%). Cumulatively, 56% of respondents had no risk factors, 41% had 1� 3 risk factors, and 4% had 4� risk factors.When administered a six-point stroke symptom knowledge test, respondents with 4� risk factors were significantly less knowledgeable, receiving a mean score of 3.2, compared to those with 1� 3 risk factors, who scored a mean of 4.6. Those with four or more years of college were significantly more knowledgeable than those with only a high-school education, receiving mean scores of 4.6 and 3.9, respectively.There was no association between stroke knowledge and use of a primary care physician. Conclusions: Although it is known that individuals with more risk factors are more likely to have a stroke, in our study these respondents were less able to recognize stroke symptoms compared to respondents with fewer risk factors. Future public stroke awareness campaigns should be targeted toward those most at risk so they learn to recognize stroke symptoms and thus seek treatment in a timely manner.