Search

Evaluate the impact of positive oral contrast material (POCM) for non-traumatic abdominal pain on diagnostic confidence, diagnostic rate, and ED throughput.ED oral contrast guidelines were changed to limit use of POCM. A total of 2,690 abdominopelvic CT exams performed for non-traumatic abdominal pain were prospectively evaluated for diagnostic confidence (5-point scale at 20% increments; 5 = 80-100% confidence) during a 24-month period. Impact on ED metrics including time from CT order to exam, preliminary read, ED length of stay (LOS), and repeat CT scan within 7 days was assessed. A subset of cases (n = 729) was evaluated for diagnostic rate. Data were collected at 2 time points, 6 and 24 months following the change.A total of 38 reviewers were participated (28 trainees, 10 staff). 1238 exams (46%) were done with POCM, 1452 (54%) were performed without POCM. For examinations with POCM, 80% of exams received a diagnostic confidence score of 5 (mean, 4.78 ± 0.43; 99% ≥ 4), whereas 60% of exams without POCM received a score of 5 (mean, 4.51 ± 0.70; 92% ≥ 4; p .001). Trainees scored 1,523 exams (57%, 722 + POCM, 801 -POCM) and showed even lower diagnostic confidence in cases without PCOM compared with faculty (mean, 4.43 ± 0.68 vs. 4.59 ± 0.71; p 0.001). Diagnostic rate in a randomly selected subset of exams (n = 729) was 54.2% in the POCM group versus 56.1% without POCM (p 0.655). CT order to exam time decreased by 31 min, order to preliminary read decreased by 33 min, and ED LOS decreased by 30 min (approximately 8% of total LOS) in the group without POCM compared to those with POCM (p 0.001 for all). 205 patients had a repeat scan within 7 days, 74 (36%) had IV contrast only, 131 (64%) had both IV and oral contrast on initial exam. Findings were consistent both over a 6-month evaluation period as well as the full 24-month study period.Limiting use of POCM in the ED for non-traumatic abdominal pain improved ED throughput but impaired diagnostic confidence, particularly in trainees; however, it did not significantly impact diagnostic rates nor proportion of repeat CT exams.

Introduction SARS-CoV-2, a novel coronavirus, manifests as a respiratory syndrome (COVID-19) and is the cause of an ongoing pandemic. The response to COVID-19 in the United States has been hampered by an overall lack of diagnostic testing capacity. To address uncertainty about ongoing levels of SARS-CoV-2 community transmission early in the pandemic, we aimed to develop a surveillance tool using readily available emergency department (ED) operations data extracted from the electronic health record (EHR). This involved optimizing the identification of acute respiratory infection (ARI)-related encounters and then comparing metrics for these encounters before and after the confirmation of SARS-CoV-2 community transmission. Methods We performed an observational study using operational EHR data from two Midwest EDs with a combined annual census of over 80,000. Data were collected three weeks before and after the first confirmed case of local SARS-CoV-2 community transmission. To optimize capture of ARI cases, we compared various metrics including chief complaint, discharge diagnoses, and ARI-related orders. Operational metrics for ARI cases, including volume, pathogen identification, and illness severity, were compared between the preand post-community transmission timeframes using chi-square tests of independence. Results Compared to our combined definition of ARI, chief complaint, discharge diagnoses, and isolation orders individually identified less than half of the cases. Respiratory pathogen testing was the top performing individual ARI definition but still only identified 72.2% of cases. From the pre to post periods, we observed significant increases in ED volumes due to ARI and ARI cases without identified pathogen. Conclusion Certain methods for identifying ARI cases in the ED may be inadequate and multiple criteria should be used to optimize capture. In the absence of widely available SARS-CoV-2 testing, operational metrics for ARI-related encounters, especially the proportion of cases involving negative pathogen testing, are useful indicators for active surveillance of potential COVID-19 related ED visits.

Author(s): Kraut, Aaron; Tillman, David; Barclay-Buchanan, Ciara; Hess, Jamie; Hamedani, Azita; Jennett, Brian; Cordoba, Saby; Westergaard, Mary | Abstract: ABSTRACT: Audience: The continuous residency improvement committee (CRIC) innovation is designed for residency program leadership and residency program coordinators. Introduction: The Accreditation Council for Graduate Medical Education (ACGME) requires residency- training programs to perform ongoing self-study in order to maintain accreditation status and to engage in continuous program improvement.1 Standard evaluation constructs for self-study often fail to capture input from non-traditional stakeholders and do not always result in actionable recommendations for program improvement. We developed the CRIC process to address the need for a user-friendly evaluation construct that yields actionable recommendations for programmatic improvement from a variety of stakeholders and aligns with the ACGME-prescribed continuous self-study process. Objectives: The purpose of this innovation was to develop a novel approach to continuous program evaluation and improvement using a multisource feedback design to improve resident satisfaction with the program’s responsiveness to feedback while addressing the ACGME mandate for self-study. Methods: A committee of rotating reviewers systematically evaluates resident educational rotations over a 12-month period. Reviews focused on obtaining input from both traditional and non-traditional stakeholders in a multisource model in order to document and address deficiencies identified within the rotations. Topics: ACGME self-study, 360-evaluation, program evaluation, program evaluation committee.

Hernia is defined as an abnormal protrusion of an organ or tissue through a pathologic defect in its surrounding wall. Overall, hernia is common and is generally believed to be a benign condition associated with some morbidity, although it is not thought to be associated with significant mortality. Between 2001 and 2010, 2.3 million inpatient abdominal hernia repairs were performed in the United States, of which 567,000 were performed emergently. In some cases, a hernia can be a deadly condition. In 2002, hernia was listed as the cause of death for 1,595 US citizens. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of hernia. Figures show anatomic locations of the various abdominal wall, groin, lumbar, and pelvic floor hernias; a direct inguinal hernia; an indirect inguinal hernia; point-of-care sonograms showing a ventral wall hernia and an abdominal wall hernia; and the differential diagnosis of an abdominal mass based on anatomic location. Tables list risk factors for the development of inguinal hernia, sex-based differences in inguinal hernia development, risk factors for the development of incisional hernia, factors to consider when assessing the patient for a hernia, and factors associated with the highest rates of incarceration in patients with groin hernia. Key words: emergent hernia, hernia incarceration, incisional hernia, inguinal hernia, strangulated hernia This review contains 6 highly rendered figures, 5 tables, and 66 references.