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BACKGROUND: Recognition and diagnosis of concussion is increasing, but current research shows these patients are discharged from the emergency department (ED) with a wide variability of recommendations and instructions. OBJECTIVE: To assess the adequacy of documentation of discharge instructions given to patients discharged from the ED with concussions. METHODS: This was a quality-improvement study conducted at a University-based Level I trauma center. A chart review was performed on all patients discharged with closed head injury or concussion over a 1-year period. Chi-squared measures of association and Fisher's exact test were used to compare the proportion of patients receiving discharge instructions (printed or documented in the chart as discussed by the physician). Multivariable logistic regression was used to assess the relationship between whether the concussion was sport-related in relation to our primary outcomes. RESULTS: There were 1855 charts that met inclusion criteria. The physician documented discussion of concussion discharge instructions in 41% (95% confidence interval [CI] 39.2-43.7) and printed instructions were given in 71% (95% CI 69.1-73.2). Physicians documented discussion of instructions more often for sport-related vs. non-sport-related concussion (58% vs. 39%, p = 0.008) with an odds ratio (OR) of 2.1 (95% CI 1.6-2.8). Discharge instructions were given more often for sport-related injuries than those without sport-related injuries (85% vs. 69%, p = 0.047), with an OR of 2.2 (95% CI 1.6-3.1). Children were more likely to have had physician-documented discussion of instructions (56%, 95% CI 52.3-59.1 vs. 31%, 95% CI 28.0-33.6), printed discharge instructions (86%, 95% CI 83.2-88.1 vs. 61%, 95% CI 57.6-63.4), and return-to-play precautions given (11.2%, 95% CI 9.2-13.6 vs. 4.5%, 95% CI 3.4-5.9) compared with adults. CONCLUSIONS: Documentation of discharge instructions given to ED patients with concussions was inadequate, overall.

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BACKGROUND: A few studies suggest that an increasing clinical workload does not adversely affect quality of teaching in the Emergency Department (ED); however, the impact of clinical teaching on productivity is unknown. OBJECTIVES: The primary objective of this study was to determine whether there was a difference in relative value units (RVUs) billed by faculty members when an acting internship (AI) student is on shift. Secondary objectives include comparing RVUs billed by individual faculty members and in different locations. METHODS: A matched case-control study design was employed, comparing the RVUs generated during shifts with an Emergency Medicine (EM) AI (cases) to shifts without an AI (controls). Case shifts were matched with control shifts for individual faculty member, time (day, swing, night), location, and, whenever possible, day of the week. Outcome measures were gross, procedural, and critical care RVUs. RESULTS: There were 140 shifts worked by AI students during the study period; 18 were unmatchable, and 21 were night shifts that crossed two dates of service and were not included. There were 101 well-matched shift pairs retained for analysis. Gross, procedural, and critical care RVUs billed did not differ significantly in case vs. control shifts (53.60 vs. 53.47, p=0.95; 4.30 vs. 4.27, p=0.96; 3.36 vs. 3.41, respectively, p=0.94). This effect was consistent across sites and for all faculty members. CONCLUSIONS: An AI student had no adverse effect on overall, procedural, or critical care clinical billing in the academic ED. When matched with experienced educators, career-bound fourth-year students do not detract from clinical productivity.

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BACKGROUND: The Standardized Letter of Recommendation (SLOR) was developed in an attempt to standardize the evaluation of applicants to an emergency medicine (EM) residency. OBJECTIVE: Our aim was to determine whether the Global Assessment Score (GAS) and Likelihood of Matching Assessment (LOMA) of the SLOR for applicants applying to an EM residency are affected by the experience of the letter writer. We describe the distribution of GAS and LOMA grades and compare the GAS and LOMA scores to length of time an applicant knew the letter writer and number of EM rotations. METHODS: We conducted a retrospective review of all SLORs written for all applicants applying to three EM residency programs for the 2012 match. Median number of letters written the previous year were compared across the four GAS and LOMA scores using an equality of medians test and test for trend to see if higher scores on the GAS and LOMA were associated with less experienced letter writers. Distributions of the scores were determined and length of time a letter writer knew an applicant and number of EM rotations were compared with GAS and LOMA scores. RESULTS: There were 917 applicants representing 27.6% of the total applicant pool for the 2012 United States EM residency match and 1253 SLORs for GAS and 1246 for LOMA were analyzed. The highest scores on the GAS and LOMA were associated with the lowest median number of letters written the previous year (equality of medians test across groups, p < 0.001; test for trend, p < 0.001). Less than 3% received the lowest score for GAS and LOMA. Among letter writers that knew an applicant for more than 1 year, 45.3% gave a GAS score of "Outstanding" and 53.4% gave a LOMA of "Very Competitive" compared with 31.7% and 39.6%, respectively, if the letter writer knew them 1 year or less (p = 0.002; p = 0.005). Number of EM rotations was not associated with GAS and LOMA scores. CONCLUSIONS: SLORs written by less experienced letter writers were more likely to have a GAS of "Outstanding" (p < 0.001) and a LOMA of "Very Competitive" (p < 0.001) than more experienced letter writers. The overall distribution of GAS and LOMA was heavily weighted to the highest scores. The length of time a letter writer knew an applicant was significantly associated with GAS and LOMA scores.

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BACKGROUND: Emergency Department (ED) overcrowding is a national problem. Initiating orders in triage has been shown to decrease length of stay (LOS), however, nurse, physician assistant, and attending physician advanced triage have all been criticized. STUDY OBJECTIVES: Our primary objective was to show that Emergency Medicine resident-initiated advanced triage shortens patient LOS. Our secondary objective was to evaluate whether or not resident triage decreases the number of patients who left prior to medical screening (LPTMS). METHODS: This prospective interventional study was performed in a 42-bed, Level III trauma center, academic ED in the United States, with an annual census of approximately 41,000 patients. A junior or senior Emergency Medicine resident initiated orders on 16 weekdays for 6 h daily on patients presenting to triage. Patients evaluated during the 6-h period on other weekdays served as the control. The study was powered to detect a reduction in LOS of 45 min. Multivariable median regression was used to compare length of stay and Fisher's exact test to compare proportions. RESULTS: There were 1346 patients evaluated in the ED during the intervention time. Regression analysis showed a 37-min decrease in median LOS for patients on intervention days as compared to control days (p = 0.02). The proportion of patients who LPTMS was not statistically different (p = 0.7) for intervention days (96/1346, 7.13%) compared to control days (136/1810, 7.51%). CONCLUSIONS: Resident-initiated advanced triage is an effective method to decrease patient LOS, however, our effect size is smaller than predicted and did not significantly affect the percent of patients leaving before medical screening.

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OBJECTIVES: Serum lactate levels are a useful tool in monitoring critically ill patients, especially those who are septic. However, lactate levels are often not routinely drawn or rapidly available in some institutions. The objective of this study was to determine if a readily available anion gap (AG) could be used as a surrogate marker for abnormal lactate level in Emergency Department (ED) patients at risk for sepsis. METHODS: Prospective, observational cohort study of consecutive ED patients seen at an urban university tertiary care referral center with 46,000 annual ED visits. ED patients aged 18 years or older presenting with clinically suspected infection were eligible for enrollment if a serum chemistry and lactate levels were drawn during the ED visit. During the 9-month study period, 1419 patients were enrolled. The initial basic chemistry panels, calculated AG, and lactate levels drawn in the ED were collected. We defined, a priori, an AG > 12 and a lactate > 4 mmol/L to be abnormal. Analysis was performed with Student's t-test, operating characteristics with 95% confidence intervals, and logistic regression. RESULTS: The mean AG was 11.8 (SD 3.6) and the mean lactate was 2.1 (SD 1.3). For an AG > 12, the mean lactate was 2.9 (SD 1.7), compared with 1.8 (SD 0.8) for an AG < 12. The sensitivity of an elevated AG (> 12) in predicting elevated lactate levels (> 4 mmol/L) was 80% (72-87%) and the specificity was 69% (66-71%). Patients with a gap > 12 had a 7.3-fold (4.6-11.4) increased risk of having a lactate > 4 mmol/L. The area under the curve was 0.84. CONCLUSION: This study suggests that an elevated AG obtained in the ED is a moderately sensitive and specific means to detect elevated lactate levels in ED patients at risk for sepsis. This information may be somewhat helpful to Emergency Physicians to risk-stratify their patients to provide more aggressive early resuscitation.

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