Background and study aims  Most patients with upper gastrointestinal bleeding (UGIB) are hospitalized. Risk-stratifying UGIB with scoring tools may decrease avoidable admissions, thereby reducing the cost of care. We sought to describe how frequently low-risk UGIB patients present to urban emergency departments (ED) and the proportion who are admitted to examine how incorporating risk scores into decision support might diminish healthcare utilization in this population. Patients and methods  This is a retrospective cohort study of ED patients presenting from 2009 – 2013 to three urban hospitals that do not use electronic UGIB decision support. We used ED disposition diagnosis codes (ICD-9) to identify patients followed by manual chart review for verification and additional data collection. Patients with a Glasgow Blatchford Score (GBS) of 0 were classified as low risk. We also surveyed ED physicians at these hospitals to assess their beliefs about UGIB decision support. Results  Over the study period, 66 patients (13.2 per year) presented to the ED with low-risk UGIB. Of these, 10 patients (15.2 %) were admitted and none required endoscopic hemostasis. Most survey respondents (55.6 %, n = 20) were aware of UGIB risk scores but a minority (19.4 %, n = 7) used one. Conclusions  Low-risk UGIB patients infrequently present to the ED and only a minority are admitted. Despite advocacy to incorporate decision support into routine clinical care, ED physicians independently identified low risk patients. There is insufficient evidence to suggest the magnitude of this problem is large enough to warrant implementation of decision support for low risk UGIB.

Purpose:The Interprofessional Educational (IPE) Clinic at Duke is a clinical experience that has allowed an interprofessional team, including health professions students, to care for patients in the emergency department (ED) since 2015. COVID-19 presented fundamental challenges to the structure of this experience, such as student restrictions on attending clinical experiences and limitations on the number of providers in a patient room, which necessitated a transition from face-to-face encounters to virtual ones. Materials and Methods: As a result, two virtual experiences were implemented; one was based in the ED with in-person faculty and patients with virtual learners and one staffed by ambulatory providers engaging in telehealth clinics. These experiences sought to provide an interprofessional clinical experience for students while following appropriate safety guidelines. Surveys were distributed to students post-clinic to gather student demographics and their feedback regarding the experience. Additionally, faculty preceptors provided insight into the experience, especially regarding logistics and infrastructure. Results: The virtual experiences successfully allowed teams of students to participate remotely in aspects of care including history taking, physical assessments, and medical decision-making. Additionally, the virtual care team structure allowed for senior students to mentor junior learners and for faculty members to provide point of care feedback. Students gained practical experience in telehealth that included logistics and challenges of providing virtual care and appreciating how technological barriers such as lack of access to internetconnected devices can be a source of disparity. Conclusion:The COVID-19 pandemic required the reconfiguration of an in-person clinical experience to a virtual experience and this pivot was well received by students and faculty. The lessons learned can be generalizable to other professional schools who may be seeking to develop an interprofessional clinical experience and are exploring telehealth options.

Objective Limited data exist describing possible delays in patient transfer from the emergency department (ED) as a result of language barriers and the effects of interpretation services. We described the differences in ED length of stay (LOS) before intensive care unit (ICU) arrival and mortality based on availability of telephone or in‐person interpretation services. Methods Using an ICU database from an urban academic tertiary care hospital, ED patients entering the ICU were divided into groups based on primary language and available interpretation services (in‐person vs telephone). Non‐parametric tests were used to compare ED LOS and mortality between groups. Results Among 22,422 included encounters, English was recorded as the primary language for 51% of patients (11,427), and 9% of patients (2042) had a primary language other than English. Language was not documented for 40% of patients (8953). Among encounters with patients with non‐English primary languages, in‐person interpretation was available for 63% (1278) and telephone interpretation was available for 37% (764). In the English‐language group, median ED LOS was 292 minutes (interquartile range [IQR], 205–412) compared with 309 minutes (IQR, 214–453) for patients speaking languages with in‐person interpretation available and 327 minutes (IQR, 225–463) for patients speaking languages with telephone interpretation available. Mortality was higher among patients with telephone (15%) or in‐person (11%) interpretation available compared with patients who primarily spoke English (9%). Conclusions Patients with primary languages other than English who were critically ill spent a median of 17 to 35 more minutes in the ED before ICU arrival and experienced higher mortality rates compared with patients who spoke English as a primary language.

Background Observation of student skills is essential for accurate assessment of entrustment and competence. Time spent directly observing students in patient care must balance with the need to serve adequate numbers of patients and, in some instances, revenue generation. Clinical education may also be hampered by a negative learning climate. The authors created a Direct Observation Clinical Experience with feedback iN real Time (DOCENT) clinic with patients from the Emergency Department (ED) to provide care for low-acuity patients while observing student care to determine the best location for the clinic and interprofessional education opportunities. Methods Patient number, chief complaints, estimated severity of illness (ESI), and use of radiology resources were logged. ESI, length of stay (LOS), and satisfaction were monitored for non-inferiority to ED patients. Student evaluations collected information on amount of direct observation, quality of feedback, learning climate and both peer-to-peer and interprofessional teaching. Results Musculoskeletal (MSK) complaints were the most common category of complaints. Patient LOS in DOCENT was shorter than for ED patients (mean 4.5 vs. 6.4 hours, p < 0.0001). DOCENT patient satisfaction was higher than ED patient satisfaction. Patients with higher ESI could be seen when the clinic was located closer to the ED. Over 90% of students reported receiving constructive and reinforcing feedback and 100% reported a positive learning climate. Conclusions Creation of a DOCENT clinic in the ED provided an enriched student experience without compromising patient care. The high rates of MSK complaints provided great opportunity for interprofessional collaboration with physical therapy.

Background Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration. Methods An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked. Results Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016–June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students. Conclusions Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.