Zolpidem was associated with a tendency towards reduced responsiveness in patients with persistent vegetative states. There were no objective changes on positron emission tomography suggestive of an associated increase in cerebral blood flow with zolpidem. It would appear that zolpidem does not offer a beneficial effect in this setting.

Study Objectives: The United States is in the midst of an opioid epidemic. Of more than 42,000 opioid deaths in 2016, 40% were related to prescription medications. Emergency department (ED) visit prescriptions may provide the initial exposure for many patients who subsequently misuse or develop opioid use disorder (OUD). Physician prescribing patterns can vary extensively, however ED physicians are among the top 5 opioid prescribers in all medical specialties in almost all age groups. It is well documented that a larger quantity of tablets or prolonged prescription duration is associated with increased risk of chronic opioid use. Electronic health records (EHR) allow for implementation of active and passive interventions that may influence provider behavior, specifically the ability to set prescription preferences on the departmental level. We tested the hypothesis that decreasing the number of pills in our ED prescribing preference settings would decrease the duration of prescriptions and number of tablets for opioid medications prescribed by our providers.Methods: A pre-post study design was performed between 4/1/17 and 4/30/18 using all opioid prescriptions made through EPIC Corporation's 2015 ASAP EHR module in 2 EDs. Prior to the intervention, which occurred on 1/28/18, opioid prescriptions had the EHR default prescription settings, which varied in number of pills and durations. Using the CDC guidelines for opioid prescribing, all opioid entries were given defaults under 50 milligram morphine equivalents per day and supplies were only for 3-days. Opioid prescriptions, their dosages and total pills dispensed were abstracted using the institutional reporting software Qlik. Our outcome measures were rates of prescription attributes that were consistent with CDC guidelines. Chi-square and Mann Whitney test were used to determine statistical significance.Results: During the study period, there were 78,416 discharged patients, of whom 731 (0.093%) received opioid prescriptions. 503 (69%) of these prescriptions were for >3 days of therapy. Comparing the pre period to the post period there was a reduction in the median number of all opioid prescriptions per month (56 [IQR, 49.9-62.2] to 47 [IQR,[45][46][47][48][49], p ¼ 0.014). There was also a reduction in the proportion of prescriptions lasting >3 days (80% [95% CI, 76.5-83.1%] to 19.3% [95% CI, 13.2-27.1%], p<0.001), as well as a reduction in median number of pills dispensed (12 [IQR,[8][9][10][11][12][13][14][15][16] to 8 [IQR, 6-10], p<0.001).When isolating the 3 months pre and post intervention there was no difference in the median number of overall opioid prescriptions. However, there was a reduction in proportion of prescriptions lasting >3 days (70 .5% [95% CI, 62.6-77.4%] to 19.3% [95% CI, 13.2-27.1%], p<0.001), as well as the median number of pills dispensed (11 [IQR,.5] to 8 [IQR, 6-10] p<0.001).Conclusions: Modification of departmental EHR prescription preference settings can substantially alter prescribing patterns for opioid prescriptions in the ED. ...

Background Emergency medicine (EM) residency programs want to employ a selection process that will rank best possible applicants for admission into the specialty. Objective We tested if application data are associated with resident performance using EM milestone assessments. We hypothesized that a weak correlation would exist between some selection factors and milestone outcomes. Methods Utilizing data from 5 collaborating residency programs, a secondary analysis was performed on residents trained from 2013 to 2018. Factors in the model were gender, underrepresented in medicine status, United States Medical Licensing Examination Step 1 and 2 Clinical Knowledge (CK), Alpha Omega Alpha (AOA), grades (EM, medicine, surgery, pediatrics), advanced degree, Standardized Letter of Evaluation global assessment, rank list position, and controls for year assessed and program. The primary outcomes were milestone level achieved in the core competencies. Multivariate linear regression models were fitted for each of the 23 competencies with comparisons made between each model's results. Results For the most part, academic performance in medical school (Step 1, 2 CK, grades, AOA) was not associated with residency clinical performance on milestones. Isolated correlations were found between specific milestones (eg, higher surgical grade increased wound care score), but most had no correlation with residency performance. Conclusions Our study did not find consistent, meaningful correlations between the most common selection factors and milestones at any point in training. This may indicate our current selection process cannot consistently identify the medical students who are most likely to be high performers as residents.

IntroductionAs patients become increasingly involved in their medical care, physician-patient communication gains importance. A previous study showed that physician self-disclosure (SD) of personal information by primary care providers decreased patient rating of the provider communication skills.ObjectiveThe objective of this study was to explore the incidence and impact of emergency department (ED) provider self-disclosure on patients’ rating of provider communication skills.MethodsA survey was administered to 520 adult patients or parents of pediatric patients in a large tertiary care ED during the summer of 2014. The instrument asked patients whether the provider self-disclosed and subsequently asked patients to rate providers’ communication skills. We compared patients’ ratings of communication measurements between encounters where self-disclosure occurred to those where it did not.ResultsPatients reported provider SD in 18.9% of interactions. Provider SD was associated with more positive patient perception of provider communication skills (p<0.05), more positive ratings of provider rapport (p<0.05) and higher satisfaction with provider communication (p<0.05). Patients who noted SD scored their providers’ communication skills as “excellent” (63.4%) compared to patients without self-disclosure (47.1%). Patients reported that they would like to hear about their providers’ experiences with a similar chief complaint (64.4% of patients), their providers’ education (49%), family (33%), personal life (21%) or an injury/ailment unlike their own (18%). Patients responded that providers self-disclose to make patients comfortable/at ease and to build rapport.ConclusionProvider self-disclosure in the ED is common and is associated with higher ratings of provider communication, rapport, and patient satisfaction.

Objective This study seeks to evaluate the test characteristics of D‐dimer for pulmonary embolism (PE) in patients with a concurrent diagnosis of COVID‐19. We hypothesized that the sensitivity of D‐dimer for PE at current institutional cut points would be similar to those without COVID‐19. Methods This is a multicenter retrospective observational cohort study across five urban and suburban EDs in the same health care system. The electronic health record was queried for all computed tomography pulmonary angiography (CTPA) studies from December 1, 2019, to October 22, 2020. All ED patients who underwent CTPA had D‐dimer and COVID‐19 testing completed in a single encounter were included in the study. Baseline demographics were obtained. Test characteristics of D‐dimer for PE were calculated for patients with and without COVID‐19. Additionally, receiver operator characteristics (ROC) curves were constructed for two different D‐dimer assays. Results There were 1158 patient encounters that met criteria for analysis. Performance of D‐dimer testing for PE was similar between COVID‐19–positive and –negative patients. In COVID‐19–positive patients, the sensitivity was 100% (95% confidence interval [CI] = 87.6%–100%), specificity was 11.9% (95% CI = 7.9%–17.1%), and negative predictive value (NPV) was 100%. In COVID‐19–negative patients the sensitivity was 97.6% (95% CI = 91.5%–99.7%), specificity was 14.4% (95% CI = 12.1%–17%), and NPV was 98.3% (95% CI = 93.8%–99.6%). For assay 1 the area under the curve (AUC) for COVID‐19–positive patients was 0.76 (95% CI = 0.68–0.83), and for COVID‐19–negative patients, 0.73 (95% CI = 0.69–0.77). For assay 2, AUC for COVID‐19–positive patients was 0.85 (95% CI = 0.77–0.92), and for COVID‐19–negative patients, 0.80 (95% CI = 0.77–0.84). Inspection of the ROC curve for assay 1 revealed that 100% sensitivity was maintained up to a threshold of 0.67 FEU (fibrinogen equivalent units; from 0.50 FEU) with an increase in specificity to 29% (from 18.7%), and for assay 2, 100% sensitivity was maintained up to a threshold of 662 D‐dimer units (DDU; from 230 DDU) with an increased specificity to 59% (from 6.1%). Conclusion Results from this multicenter retrospective study did not find a significant difference in sensitivity of D‐dimer for PE due to concomitant COVID‐19 infection. Further study is required to determine if PE can safely be excluded based on D‐dimer results alone in patients with suspected or proven COVID‐19 or if adjusted D‐dimer levels could have a role in management.

IntroductionSince the creation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction (PS) scores, patient experience (PE) has become a metric that can profoundly affect the fiscal balance of hospital systems, reputation of entire departments and welfare of individual physicians. While government and hospital mandates demonstrate the prominence of PE as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PE in categorical emergency medicine (EM) residencies.MethodsThis was a prospective survey analysis of the Council of Emergency Medicine Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department, and questions regarding the presence and types of PS evaluative data and PE education they provide.ResultsWe obtained 168 responses from 139 individual residencies, representing 72% of all categorical EM residencies. This survey found that only 27% of responding residencies provide PS data to their residents. Of those programs, 61% offer simulation scores, 39% provide third-party attending data on cases with resident participation, 37% provide third-party acquired data specifically about residents and 37% provide internally acquired quantitative data.Only 35% of residencies reported having any organized PE curricula. Of the programs that provide an organized PE curriculum, most offer multiple modalities; 96% provide didactic lectures, 49% small group sessions, 47% simulation sessions and 27% specifically use standardized patient encounters in their simulation sessions.ConclusionThe majority of categorical EM residencies do not provide either PS data or any organized PE curriculum. Those that do use a heterogeneous set of data collection modalities and educational techniques. American Osteopathic Association and Accreditation Council for Graduate Medical Education residencies show no significant differences in their resident PS data provision or formal curricula. Further work is needed to improve education given the high stakes of PS scores in the emergency physician’s career.

IntroductionClinician educators are often asked to perform consultations for colleagues. Invitations to consult and advise others on local problems can help foster great collaborations between centers, and allows for an exchange of ideas between programs. In this article, the authors identify and summarize several key papers to assist emerging clinician educators with the consultation process.MethodsA consensus-building process was used to generate a list of key papers that describe the importance and significance of educational consulting, informed by social media sources. A three-round voting methodology, akin to a Delphi study, determined the most impactful papers from the larger list.ResultsSummaries of the five most highly rated papers on education consultation are presented in this paper. These papers were determined by a mixed group of junior and senior faculty members, who have summarized these papers with respect to their relevance for their peer groups.ConclusionFive key papers on the educational consultation process are presented in this paper. These papers offer background and perspective to help junior faculty gain a grasp of consultation processes.

Cerebral air embolism is a known complication from a myriad of iatrogenic causes. This case describes a 60-year-old female presenting from hemodialysis with altered mental status, bilateral homonymous hemianopia, and repetitive speech. A noncontrast head CT revealed air in the vein of Galen and the deep cerebral veins of the left thalamus and occipital sulcus, a complication from air being introduced into the patient via improper flushing of dialysis tubing. The retrograde flow of air bubbles in the upright patient during dialysis was likely responsible for the air embolus lodging in the cerebral vasculature. This patient was transferred to receive hyperbaric therapy, whereupon the patient survived with residual attention and spatial deficits.