EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

The burden of complications associated with peripheral intravenous use is underevaluated, in part, due to the broad use, inconsistent coding, and lack of mandatory reporting of these devices. This study aimed to analyze the clinical and economic impact of peripheral intravenous–related complications on hospitalized patients. This analysis of Premier Perspective® Database US hospital discharge records included admissions occurring between July 1, 2013 and June 30, 2015 for pneumonia, chronic obstructive pulmonary disease, myocardial infarction, congestive heart failure, chronic kidney disease, diabetes with complications, and major trauma (hip, spinal, cranial fractures). Admissions were assumed to include a peripheral intravenous. Admissions involving surgery, dialysis, or central venous lines were excluded. Multivariable analyses compared inpatient length of stay, cost, admission to intensive care unit, and discharge status of patients with versus without peripheral intravenous–related complications (bloodstream infection, cellulitis, thrombophlebitis, other infection, or extravasation). Models were conducted separately for congestive heart failure, chronic obstructive pulmonary disease, diabetes with complications, and overall (all 7 diagnoses) and adjusted for demographics, comorbidities, and hospital characteristics. We identified 588 375 qualifying admissions: mean (SD), age 66.1 (20.6) years; 52.4% female; and 95.2% urgent/emergent admissions. Overall, 1.76% of patients (n = 10 354) had peripheral intravenous–related complications. In adjusted analyses between patients with versus without peripheral intravenous complications, the mean (95% confidence interval) inpatient length of stay was 5.9 (5.8-6.0) days versus 3.9 (3.9-3.9) days; mean hospitalization cost was $10 895 ($10 738-$11 052) versus $7009 ($6988-$7031). Patients with complications were less likely to be discharged home versus those without (62.4% [58.6%-66.1%] vs 77.6% [74.6%-80.5%]) and were more likely to have died (3.6% [2.9%-4.2%] vs 0.7% [0.6%-0.9%]). Models restricted to single admitting diagnosis were consistent with overall results. Patients with peripheral intravenous–related complications have longer length of stay, higher costs, and greater risk of death than patients without such complications; this is true across diagnosis groups of interest. Future research should focus on reducing these complications to improve clinical and economic outcomes.

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Care provision and benchmarking for patients with ST-elevation myocardial infarction (STEMI) have focused on streamlining time between initial hospital presentation and opening of theinfarct-related artery. In a Boston-area regional system already characterized by expedited advanced life support (ALS) dispatch and paramedic performance of prehospital electrocardiogram (EKG), a critical pathway was designed that allows for helicopter dispatch based on ground ALS providers' STEMI diagnosis. The pathway dictates that as soon as ALS crews make the diagnosis of STEMI from their 12-lead EKG, they will contact Boston MedFlight (BMF) and a helicopter will be immediately dispatched to the participating community hospital (Lawrence General Hospital [LGH]). Based on historical and predicted time patterns, it is expected that BMF will arrive at LGH soon after the ALS ambulance delivers the patient to the LGH emergency department (ED). The patient will then undergo BMF transport from the ED into central Boston with direct transfer into an awaiting cardiac catheterization suite (ie, bypassing the receiving hospital ED). The pathway minimizes the delay between patient arrival at LGH and BMF arrival for transport to the catheterization laboratory. It is hoped that implementation of the critical pathway will allow the region's patients with STEMI to achieve coronary arterial patency within 90 minutes of LGH presentation. If the pathway proves effective, it can serve as a model for other regions and programs with similar clinical and logistic situations and advance the concept of "diagnosis-to-balloon" time.

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Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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Study Objectives: Awake intubations are commonly performed in the OR for high-risk airways and include the use of topical anesthesia often augmented by lowerdose sedative agents. The rate of use of "awake" techniques, indications, devices employed, and outcomes are not known in ED populations. We sought to describe the current spectrum of awake intubation practices in the ED setting and report success rates, devices used, and rescue techniques in this population.Methods: We analyzed data from the National Emergency Airway Registry (NEAR), a multicenter prospective observational registry of 25 community and academic emergency departments. Patients with an awake intubation attempt, defined by use of topical airway anesthesia, between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with clusteradjusted 95% confidence intervals (CIs).Results: Of 19,071 discrete patient encounters, an awake technique was used on first attempt in 82 (0.4%) patients. The median patient age was 59 years (IQR 46-67) and 27 (33%) were female. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications. Emergency physicians performed 90% of first attempts. The most common initial devices were a flexible endoscope (78%) followed by the GlideScope video laryngoscope (7%). A nasal route was used in 56 (68%) cases. A combination of sedative and topical medications were used in 42 (51%) cases, while topical anesthesia alone was used in 40 (49%) cases. The most common sedative used was ketamine (41%). The first-attempt success rate for all awake intubations was 85% (95% CI [76%-95%]). Nasal first attempts were successful in 91% (95% CI [80%-97%]) versus 73% of oral first attempts (95% CI [52%-88%]). Success with flexible endoscopes via nasal and oral routes was 93% (95% CI ) and 50%, (95% CI [19%-81%]), respectively. Rigid video laryngoscopes via oral route were successful in 8 of 9 patients (89%, 95% CI [45%-100%]). First-attempt success among those receiving only topical agents was 90% (95% CI [70%-98%]); among those with topical plus sedative agent use first-attempt success was 81% (95% CI [64%-92%]). The most common device used for rescue technique was a flexible endoscope, which was used in 5 of 12 cases (47%). Hypoxia was the most common adverse event and occurred in 10 cases (12%). One patient required a rescue surgical airway. Ultimate success was 100%.Conclusion: Awake intubations in the ED are uncommon and are done most often in patients with airway swelling or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Nasal and oral routes with flexible and rigid video laryngoscopic equipment were used. Rescue cricothyroidotomy was performed once.