Real-Time Identification of Serious Infection in Geriatric Patients Using Clinical Information System Surveillance

To develop and characterize an automated syndromic surveillance mechanism for early identification of older emergency department (ED) patients with possible life-threatening infection. DESIGN : Prospective, consecutive-enrollment, single-site observational study. SETTING : A large university medical center with an annual ED census of 75,273. PARTICIPANTS : Patients aged 70 and older admitted to the ED and having two or more systemic inflammatory response syndrome (SIRS) criteria during their ED stay. MEASUREMENTS : A search algorithm was developed to screen the census of the ED through its clinical information system. A study coordinator confirmed all patients electronically identified as having a probable infectious explanation for their visit. RESULTS : Infection accounted for 28% of ED and 34% of final hospital diagnoses. Identification using the software tool alone carried a 1.63 relative risk of infection (95% confidence interval CI=1.09–2.44) compared with other ED patients sufficiently ill to require admission. Follow-up confirmation by a study coordinator increased the risk to 3.06 (95% CI=2.11–4.44). The sensitivity of the strategy overall was modest (14%), but patients identified were likely to have an infectious diagnosis (specificity=98%). The most common SIRS criterion triggering the electronic notification was the combination of tachycardia and tachypnea. CONCLUSION : A simple clinical informatics algorithm can detect infection in elderly patients in real time with high specificity. The utility of this tool for research and clinical care may be substantial.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66036/1/j.1532-5415.2008.02094.x.pd

Coping with COVID-19: medical students as strong and responsible stewards of their education

Abstract Background Due to the COVID-19 pandemic, clinical rotations at the University of Michigan Medical School (UMMS) were suspended on March 17, 2020, per the Association of American Medical Colleges’ recommendations. No alternative curriculum existed to fill the educational void for clinical students. The traditional approach to curriculum development was not feasible during the pandemic as faculty were redeployed to clinical care, and the immediate need for continued learning necessitated a new model. Approach One student developed an outline for an online course on pandemics based on peer-to-peer conversations regarding learners’ interests and needs, and she proposed that students author the content given the immediate need for a curriculum. Fifteen student volunteers developed content to fill knowledge gaps, and expert faculty reviewers confirmed that the student authors had successfully curated a comprehensive curriculum. Evaluation The crowdsourced student content coalesced into a 40-hour curriculum required for all 371 clinical-level students at UMMS. This student-driven effort took just 17 days from outline to implementation, and the final product is a full course comprising five modules, multiple choice questions, discussion boards, and assignments. Learners were surveyed to gauge success, and 93% rated this content as relevant to all medical students. Reflection The successful implementation of this model for curriculum development, grounded in the Master Adaptive Learner framework, suggests that medical students can be entrusted as stewards of their own education. As we return to a post-pandemic “normal,” this approach could be applied to the maintenance and de novo development of future curricula.http://deepblue.lib.umich.edu/bitstream/2027.42/173952/1/40037_2021_Article_650.pd

Disparate Utilization of Urine Drug Screen Nationwide in the Evaluation of Acute Chest Pain

Introduction: Urine drug screens (UDS) have unproven clinical utility in emergency department (ED) chest pain presentations. A test with such limited clinical utility may exponentiate biases in care, but little is known about the epidemiology of UDS use for this indication. We hypothesized that UDS utilization varies nationally across race and gender.Methods: This was a retrospective observational analysis of adult ED visits for chest pain in the 2011–2019 National Hospital Ambulatory Medical Care Survey. We calculated the utilization of UDS across race/ethnicity and gender and then characterized predictors of use via adjusted logistic regression models.Results: We analyzed 13,567 adult chest pain visits, representative of 85.8 million visits nationally. Use of UDS occurred for 4.6% of visits (95% CI 3.9%-5.4%). White females underwent UDS at 3.3% of visits (95% CI 2.5%-4.2%), and Black females at 4.1% (95% CI 2.9%-5.2%). White males were tested at 5.8% of visits (95% CI 4.4%-7.2%), while Black males were tested at 9.3% of visits (95% CI 6.4%-12.2%). A multivariate logistic regression model including race, gender, and time period shows significantly increased odds of ordering UDS for Black patients (odds ratio [OR] 1.45 (95% CI 1.11-1.90, p = 0.007)) and male patients (OR 2.0 (95% CI 1.55-2.58, p < 0.001) as compared to White patients and female patients.Conclusion: We identified wide disparities in the utilization of UDS for the evaluation of chest pain. If UDS were used at the rate observed for White women, Black men would undergo nearly 50,000 fewer tests annually. Future research should weigh the potential of the UDS to magnify biases in care against the unproven clinical utility of the test

Cultural Humility Curriculum to Address Healthcare Disparities for Emergency Medicine Residents

Introduction: Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with resident-presented lectures would increase residents’ sense of cultural humility and ability to identify vulnerable populations.Methods: At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data.Results: A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P  < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar trend.Conclusion: This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making

Model for Developing Educational Research Productivity: The Medical Education Research Group

Introduction: Education research and scholarship are essential for promotion of faculty as well as dissemination of new educational practices. Educational faculty frequently spend the majority of their time on administrative and educational commitments and as a result educators often fall behind on scholarship and research. The objective of this educational advance is to promote scholarly productivity as a template for others to follow. Methods: We formed the Medical Education Research Group (MERG) of education leaders from our emergency medicine residency, fellowship, and clerkship programs, as well as residents with a focus on education. First, we incorporated scholarship into the required activities of our education missions by evaluating the impact of programmatic changes and then submitting the curricula or process as peer-reviewed work. Second, we worked as a team, sharing projects that led to improved motivation, accountability, and work completion. Third, our monthly meetings served as brainstorming sessions for new projects, research skill building, and tracking work completion. Lastly, we incorporated a work-study graduate student to assist with basic but time-consuming tasks of completing manuscripts.Results: The MERG group has been highly productive, achieving the following scholarship over a three-year period: 102 abstract presentations, 46 journal article publications, 13 MedEd Portal publications, 35 national didactic presentations and five faculty promotions to the next academic level.Conclusion: An intentional focus on scholarship has led to a collaborative group of educators successfully improving their scholarship through team productivity, which ultimately leads to faculty promotions and dissemination of innovations in education

Optimizing scalable, technology-supported behavioral interventions to prevent opioid misuse among adolescents and young adults in the emergency department: A randomized controlled trial protocol

Preventing opioid misuse and opioid use disorder is critical among at-risk adolescents and young adults (AYAs). An Emergency Department (ED) visit provides an opportunity for delivering interventions during a rapidly changing opioid landscape. This paper describes pilot data and the protocol for a 2 × 2 factorial randomized controlled trial testing efficacy of early interventions to reduce escalation of opioid (prescription or illicit) misuse among at-risk AYAs. Interventions are delivered using technology by health coaches. AYAs ages 16-30 in the ED screening positive for prescription opioid use (+ ≥ 1 risk factor) or opioid misuse will be stratified by risk severity, sex, and age group. Participants will be randomly assigned to a condition at intake, either a live video health coach-delivered single session or a control condition of an enhanced usual care (EUC) community resource brochure. They are also randomly assigned to one of two post-intake conditions: health coach-delivered portal-like messaging via web portal over 30 days or EUC delivered at 30 days post-intake. Thus, the trial has four groups: health coach-delivered session+portal, health coach-delivered session+EUC, EUC + portal, and EUC + EUC. Outcomes will be measured at 3-, 6-, and 12-months. The primary outcome is opioid misuse based on a modified Alcohol Smoking and Substance Involvement Screening Test. Secondary outcomes include other opioid outcomes (e.g., days of opioid misuse, overdose risk behaviors), other substance misuse and consequences, and impaired driving. This study is innovative by testing the efficacy of feasible and scalable technology-enabled interventions to reduce and prevent opioid misuse and opioid use disorder. Trial Registration:ClinicalTrials.gov University of Michigan HUM00177625 NCT Registration: NCT04550715