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Study Design: Cross-sectional cohort study. Objectives: Cauda equina syndrome (CES) is a neurologic emergency, and delay in diagnosis can result in irreversible impairment. Our purpose was to determine the value of physical examination in diagnosis of CES in patients complaining of bladder and/or bowel complications in the emergency department. Methods: Adult patients at one tertiary academic medical center that endorsed bowel/bladder dysfunction, underwent a lumbar magnetic resonance imaging (MRI), and received an orthopedic spine surgery consultation from 2008 to 2017 were included. Patients consulted for trauma or tumor were excluded. A chart and imaging review was performed to collect demographic, physical examination, and treatment data. Sensitivity, specificity, and negative and positive predictive values were calculated, and fast-and-frugal decision trees (FFTs) were generated using R. Results: Of 142 eligible patients, 10 were diagnosed with CES. The sensitivity and specificity of the exam findings were highest for bulbocavernosus reflex (BCR) (100% and 100%), followed by rectal tone (80% and 86%), postvoid residual bladder (80% and 59%), and perianal sensation (60% and 68%). The positive predictive value was high for BCR (100%), but low for other findings (13% to 31%). However, negative predictive values were consistently high for all examinations (96% to 100%). Two FFTs utilizing combinations of voluntary rectal tone, perianal sensation, and BCR resulted in no false negatives. Conclusions: A combination of physical examination findings of lower sacral function is an effective means of ruling out CES and, with further study, may eliminate the need for MRI in many patients reporting back pain and bowel or bladder dysfunction.

Objective The objective was to conduct a pilot randomized controlled trial to assess the feasibility, logistics, and potential effect of monthly provider funnel plot feedback reports from Press Ganey data and semiannual face-to-face coaching sessions to improve patient satisfaction scores. Methods This was a pilot randomized controlled trial of 25 emergency medicine faculty providers in one urban academic emergency department. We enrolled full-time clinical faculty with at least 12 months of baseline Press Ganey data, who anticipated working in the ED for at least 12 additional months. Providers were randomized into intervention or control groups in a 1:1 ratio. The intervention group had an initial 20-minute meeting to introduce the funnel plot feedback tool and standardized feedback based on their baseline Press Ganey scores and then received a monthly e-mail with their individualized funnel plot depicting cumulative Press Ganey scores (compared to their baseline score and the mean score of all providers) for 12 months. The primary outcome was the difference in Press Ganey “doctor-overall” scores between treatment groups at 12 months. We used a weighted analysis of covariance model to analyze the study groups, accounting for variation in the number of surveys by provider and baseline scores. Results Of 36 eligible faculty, we enrolled 25 providers, 13 of whom were randomized to the intervention group and 12 to the control group. During the study period, there were 815 Press Ganey surveys returned, ranging from four to 71 surveys per provider. For the standardized overall doctor score over 12 months (primary outcome), there was no difference between the intervention and control groups (difference = 1.3 points, 95% confidence interval = –2.4 to 5.9, p = 0.47). Similarly, there was no difference between groups when evaluating the four categories of doctor-specific patient satisfaction scores from the Press Ganey survey (all p > 0.05). Conclusions In this pilot trial of monthly provider funnel plot Press Ganey feedback reports, there was no difference in patient satisfaction scores between the intervention and control groups after 12 months. While this study was not powered to detect outcome differences, we demonstrate the feasibility, logistics, and effect sizes that could be used to inform future definitive trials.

Introduction: Febrile neutropenia is a potentially life-threatening complication of chemotherapy in pediatric oncology patients. Prompt initiation of antibiotic therapy may minimize morbidity and mortality associated with this condition, and time to antibiotic (TTA) administration 80% of eligible patients in the pediatric emergency department. Methods: After collecting baseline data, we employed consecutive PDSA cycles to (i) reduce time to antibiotic order after patient arrival; (ii) expedite the preparation of antibiotic by pharmacy; and (iii) enable antibiotic ordering before patient arrival. Statistical process control methodologies were used for key outcome measures to compare pre-intervention, post-intervention, and maintenance periods. Results: Comparing pre-intervention and post-intervention years, mean TTA decreased from 64 to 53 minutes and the percentage of patients receiving antibiotics in

Background: AHA/ACC/ESC practice guidelines advise an ECG within 10 minutes for all patients with symptoms suggestive of ST-segment elevation myocardial infarction (STEMI). This facilitates early diagnosis and timely treatment. Earlier treatment, particularly percutaneous coronary intervention (PCI), has been associated with better clinical outcomes. Our objective was to quantify the impact of delayed screening on timely treatment and determine if there may be race, sex or presenting complaint disparities. Methods: We examined the association between time-to-first ECG (door-to-screening, or D2S) and time-to-PCI in a 3-center 1-year retrospective cohort study including all emergency department (ED) patients with acute STEMI per hospital discharge diagnosis who underwent catheterization for PCI. The primary outcome was door-to-balloon time (D2B) and the ED-centric secondary outcome was door-to-cath-lab arrival time (D2CAR). Results: Of 161,920 patients seen in the 3 EDs, 137 (0.08%) were diagnosed with STEMI. Of the 137, 75 (55%) underwent emergent PCI, and 31 (41%) of the ED STEMI PCI patients did not receive an ECG within 10 minutes. These 31 patients were more commonly female (55% vs. 19%, p=0.001), non-white (87% vs. 65%, p =0.028), and reported chest pain or shortness of breath less frequently (55% vs. 94%, p Conclusion: A significant proportion of ED patients with STEMI did not receive an ECG within 10 minutes of arrival resulting in a 2.2 fold increase in D2B time. They were more likely to be female, non-white, and with atypical chief complaints. Normalizing screening criteria for presentation diversity could improve more equitable access to timely STEMI treatment

Background Timely diagnosis of ST ‐segment elevation myocardial infarction ( STEMI ) in the emergency department ( ED ) is made solely by ECG . Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes. Methods and Results We examined STEMI screening performance in 7 ED s, with the missed case rate ( MCR ) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door‐to‐ ECG times for captured versus missed patients. The overall MCR for all 7 ED s was 12.8%. The lowest and highest MCR s were 3.4% and 32.6%, respectively. The mean difference in door‐to‐ ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMI s was 0.09%. ED s with the greatest informedness (sensitivity+specificity−1) demonstrated superior performance across all other screening measures. Conclusions The 29.2% difference in MCRs between the highest and lowest performing ED s demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across ED s and to understand variable performance.

Background Spinal epidural abscess (SEA) is a rare and life-threatening infection with increased incidence over the past two decades. Delays in diagnosis cause significant morbidity and mortality among patients. The objective of this study was to describe average time-to-imaging and frequencies of intervention, risk factors, and outcomes among patients with SEA presenting to an emergency department at a single academic health center in Portland, Oregon. Methods This retrospective cohort study reviewed data from patients with no prior history of SEAs at a single hospital from October 1, 2015 to April 1, 2018. We report measures of central tendency and frequencies of collected information. Results Of the 34 patients included, seven (20%) died or were discharged with plegia during the study period. Four others (11.8%) had motor weakness, and four (11.8%) patients had new bowel or bladder dysfunction at discharge. Those who died or were discharged with plegia (n = 7) had shorter mean time-to-imaging order (20.8 hours vs. 29.2 hours). Patients with a history of intravenous drug use had a longer mean time-to-imaging order (30.2 hours vs. 23.7 hours) vs. those without a history of intravenous drug use. Furthermore, only three (42.9%) of the seven patients who died or acquired plegia presented with the three symptom classic triad of SEA: (1) fever; (2) abnormal neurologic examination or symptoms; and (3) neck or back pain. Conclusion SEA is a potentially deadly infection requiring prompt identification and treatment. This research provides baseline data for potential quality improvement work at the study site. Future research should evaluate multi-center approaches for identifying and intervening to treat SEA, particularly among patients with a history of intravenous drug use. Disclosures All authors: No reported disclosures.

Significant delays occur in providing adequate pain relief for patients who present to the emergency department (ED) with extremity fractures. The median time to pain medication administration for patients presenting to our ED with extremity fractures was 72.5 minutes. We used a multidisciplinary approach to implement three improvement cycles with the goal of reducing the median time to pain medication by 15% over an eight month time period. First, we redesigned nursing triage and treatment processes. Second, we improved nursing documentation standardization to ensure accurate tracking of patients who declined pain medication. Third, through consensus building within our physician group, we implemented a department-wide standard of care to provide early pain relief for extremity fractures. Median time to pain medication for patients with an extremity fracture reduced significantly between the pre-and post-intervention periods (p=0.009). The average monthly median time to medication was 72.5 minutes (95% CI: 57.1 to 88.0) before the intervention (Jan 2013-Oct 2014) and 49.8 minutes (95% CI: 42.7 to 56.9) after the intervention (November 2014 to June 2016). In other words, monthly median time was 31% faster (22.7 minute difference) in the post intervention period. Implementing three key interventions reduced the time to pain medication for patients with extremity injuries. Since June 2016 the reductions in median time to medication have continued to improve.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. Introduction Advances in ST-segment elevation myocardial infarction (STEMI) management have involved improving the clinical processes connecting patients with timely emergency cardiovascular care. Screening upon emergency department (ED) arrival for an early ECG to diagnose STEMI, however, is not optimal for all patients. In addition, the degree to which timely screening and diagnosis are associated with improved time to intervention and postpercutaneous coronary intervention outcomes, under more contemporary practice conditions, is not known. Methods We present the methods for a retrospective multicentre cohort study anticipated to include 1220 patients across seven EDs to (1) evaluate the relationship between timely screening and diagnosis with treatment and postintervention clinical outcomes; (2) introduce novel measures for cross-facility performance comparisons of screening and diagnostic care team performance including: Door-to-screening, door-to-diagnosis and door-to-catheterisation laboratory arrival times and (3) describe the use of electronic health record data in tandem with an existing disease registry. Ethics and dissemination The completion of this study will provide critical feedback on the quality of screening and diagnostic performance within the contemporary STEMI care pathway that can be used to (1) improve emergency care delivery for patients with STEMI presenting to the ED, (2) present novel metrics for the comparison of screening and diagnostic care and (3) inform the development of screening and diagnostic support tools that could be translated to other care environments. We will disseminate our results via publication and quality performance data sharing with each site. Institutional ethics review approval was received prior to study initiation.

Introduction: Asynchronous online training has become an increasingly popular educational format in the new era of technology-based professional development. We sought to evaluate the impact of an online asynchronous training module on the ability of medical students and emergency medicine (EM) residents to detect electrocardiogram (ECG) abnormalities of an acute myocardial infarction (AMI). Methods: We developed an online ECG training and testing module on AMI, with emphasis on recognizing ST elevation myocardial infarction (MI) and early activation of cardiac catheterization resources. Study participants included senior medical students and EM residents at all post-graduate levels rotating in our emergency department (ED). Participants were given a baseline set of ECGs for interpretation. This was followed by a brief interactive online training module on normal ECGs as well as abnormal ECGs representing an acute MI. Participants then underwent a post-test with a set of ECGs in which they had to interpret and decide appropriate intervention including catheterization lab activation. Results: 148 students and 35 EM residents participated in this training in the 2012-2013 academic year. Students and EM residents showed significant improvements in recognizing ECG abnormalities after taking the asynchronous online training module. The mean score on the testing module for students improved from 5.9 (95% CI [5.7-6.1]) to 7.3 (95% CI [7.1-7.5]), with a mean difference of 1.4 (95% CI [1.12-1.68]) (p