Comparison of Direct Staffing Costs of Advanced Practice Providers and Residents in a High Acuity Area of a Community Emergency Department

Background: Resident physicians and advanced practice providers (APPs) both have roles in providing care within emergency departments (ED). While both bring unique skill sets and capabilities to the health care team, little is known about the comparative financial impact of APPs and residents in a community ED. The objective of this study was to compare direct staffing costs per relative value unit (RVU) generated of emergency medicine (EM) residents and APPs in a community ED setting. Methods: This was a retrospective, observational analysis of RVU productivity of resident physicians and APPs in the high acuity area of a community ED. Billing data was acquired to determine RVUs generated by both APPs and residents when supervised by an attending physician. Direct costs and hours worked were used to calculate RVUs/hour and direct costs/hour. Direct cost/RVU generated were calculated for the four specific groups of providers (PGY1, PGY2, PGY3, and APP). Results: During the study period, APPs generated 2.88 RVUs/hour. Residents generated 2.01, 3.00, and 3.49 RVUs/hour respectively from PGY1 to PGY3. When the RVU data was combined with scheduled hours and direct costs for both groups, APPs were found to cost $22.46 per RVU generated. The average cost of a resident throughout three years of residency training is approximately$12.38 per RVU generated. Conclusion: In a high acuity area of a community ED, EM residents generate more RVUs/hour than APPs after completion of their PGY1 year. Given the lower direct hourly cost of a resident compared with an APP, the direct cost of a resident to assist an attending to generate RVUs is less than that of their APP counterparts during all three years of training. This suggests that community hospitals should consider sponsoring EM residency positions over hiring APPs for use in the high acuity setting

Lower-Third Standardized Letters of Evaluation in Emergency Medicine: Does Gender Make a Difference in Match Outcome?

Objective The purpose of this study was to determine whether gender influences the likelihood of receiving a lowerthird global assessment (GA) on the standardized letter of evaluation (SLOE) submitted as part of the emergency medicine (EM) application process as well as the impact of gender on ultimate match outcomes for applicants receiving a lower-third GA ranking. Our hypothesis was that female applicants with a lowerthird GA ranking have a higher risk of not matching. Methods We conducted a retrospective cohort study evaluating U.S.-based allopathic applicants to a single EM residency program in the Mid-Atlantic region during the 2017-2018 and 2018-2019 match cycles. GA SLOE rankings and gender for all applicants were extracted and compared to the National Resident Matching Program (NRMP) data for each applicant on match outcome. Comparative analyses were conducted between gender and SLOE GA rankings in order to obtain an odds ratio (OR) of gender and match outcomes. Results A total of 2,017 SLOEs were reviewed from 798 applicants in the 2018 and 2019 EM match cycles. Overall, 716 (90%) applicants successfully matched in EM, with 82 (10%) applicants failing to match into EM; 277 students had at least one lower-third GA ranking. For all applicants, having at least one lower-third GA ranking was associated with a significant risk of not matching (OR: 0.20; 95% CI: 0.12-0.34). Of the 277 students with at least one lower-third GA ranking, 85 (31%) were female and 192 (69%) were male. Of the female applicants with a lower-third GA ranking, 15 (18%) failed to match in EM, and 39 (20%) of the males failed to match in EM. For applicants with a lower-third GA ranking, female gender alone was not associated with a significantly increased risk of not matching (OR: 1.18; 95% CI: 0.61-2.21). Conclusions Female applicants receive a lower-third GA ranking less frequently than their male counterparts. One or more lower-third rankings on the GA significantly reduced an applicant’s chances of matching into an EM program. For those with a lower-third GA ranking, female gender alone does not significantly increase the risk of not matching into EM

The “Ebb and Flow” of Documentation: Does the Transition Between Two Electronic Medical Records Systems Affect Emergency Department Efficiency?

Background: Electronic Medical Record (EMR) systems are electronic databases for compiling patient records. As healthcare networks expand, it is critical for providers to have access to patient data more broadly. As a result individual healthcare facilities must adjust to enterprise wide EMRs. Objective: This study examined the operational effects of transitioning from an Emergency Department (ED) specific EMR to an enterprise wide EMR by evaluating throughput metrics in a community ED. Methods: During a 6-month transition period (July-December 2017) in a community-based, academic ED located in North Central West Virginia, length of stay (LOS) and the following operational metrics were analyzed: door-to-provider times, door to disposition time, average LOS, left without treatment (LWOT) rates, and total ED volumes. These metrics were compared with the prior year’s same 6-month period to account for seasonal variability in patient pathology or ED volumes. Results: Overall, there was a statistically significant increase in the LOS measures, including door-to-provider time (p=0.0003), door to disposition time (p Conclusion: An ED-specific EMR to enterprise wide EMR transition in a community ED had a negative effect on the overall efficiency of the emergency department

Kicking against the PRCs - a domesticated transposase antagonises silencing mediated by polycomb group proteins and is an accessory component of polycomb repressive complex 2

The Polycomb group (PcG) and trithorax group (trxG) genes play crucial roles in development by regulating expression of homeotic and other genes controlling cell fate. Both groups catalyse modifications of chromatin, particularly histone methylation, leading to epigenetic changes that affect gene activity. The trxG antagonizes the function of PcG genes by activating PcG target genes, and consequently trxG mutants suppress PcG mutant phenotypes. We previously identified the ANTAGONIST OF LIKE HETEROCHROMATIN PROTEIN1 (ALP1) gene as a genetic suppressor of mutants in the Arabidopsis PcG gene LIKE HETEROCHROMATIN PROTEIN1 (LHP1). Here, we show that ALP1 interacts genetically with several other PcG and trxG components and that it antagonizes PcG silencing. Transcriptional profiling reveals that when PcG activity is compromised numerous target genes are hyper-activated in seedlings and that in most cases this requires ALP1. Furthermore, when PcG activity is present ALP1 is needed for full activation of several floral homeotic genes that are repressed by the PcG. Strikingly, ALP1 does not encode a known chromatin protein but rather a protein related to PIF/Harbinger class transposases. Phylogenetic analysis indicates that ALP1 is broadly conserved in land plants and likely lost transposase activity and acquired a novel function during angiosperm evolution. Consistent with this, immunoprecipitation and mass spectrometry (IP-MS) show that ALP1 associates, in vivo, with core components of POLYCOMB REPRESSIVE COMPLEX 2 (PRC2), a widely conserved PcG protein complex which functions as a H3K27me3 histone methyltransferase. Furthermore, in reciprocal pulldowns using the histone methyltransferase CURLY LEAF (CLF), we identify not only ALP1 and the core PRC2 components but also plant-specific accessory components including EMBRYONIC FLOWER 1 (EMF1), a transcriptional repressor previously associated with PRC1-like complexes. Taken together our data suggest that ALP1 inhibits PcG silencing by blocking the interaction of the core PRC2 with accessory components that promote its HMTase activity or its role in inhibiting transcription. ALP1 is the first example of a domesticated transposase acquiring a novel function as a PcG component. The antagonistic interaction of a modified transposase with the PcG machinery is novel and may have arisen as a means for the cognate transposon to evade host surveillance or for the host to exploit features of the transposition machinery beneficial for epigenetic regulation of gene activity.Fil: Liang, Shih Chieh. University of Edinburgh; Reino UnidoFil: Hartwig, Ben. Max Planck Institute for Plant Breeding Research; AlemaniaFil: Perera, Pumi. University of Edinburgh; Reino UnidoFil: Mora Garcia, Santiago. Fundación Instituto Leloir; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones Bioquimicas de Buenos Aires; ArgentinaFil: de Leau, Erica. University of Edinburgh; Reino UnidoFil: Thornton, Harry. University of Edinburgh; Reino UnidoFil: Lima de Alves, Flavia. University of Edinburgh; Reino UnidoFil: Rapsilber, Juri. University of Edinburgh; Reino UnidoFil: Yang, Suxin. University of Edinburgh; Reino UnidoFil: James, Geo Velikkakam. Max Planck Institute for Plant Breeding Research; AlemaniaFil: Schneeberger, Korbinian. Max Planck Institute for Plant Breeding Research; AlemaniaFil: Finnegan, E. Jean. University of Edinburgh; Reino UnidoFil: Turck, Franziska. Max Planck Institute for Plant Breeding Research; AlemaniaFil: Goodrich, Justin. Mc Gill University; Canad

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management

Audience: The targeted audience for this simulation is Emergency Medicine (EM) residents. Medicalstudents, advanced practice providers, and staff physicians could all also find educational merit in thisscenario.Background: Cardiovascular disease is the leading cause of death in the United States according to the CDC.1Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a priorhistory of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encounteredin the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of thosepatients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardialinfarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patientspresenting with chest pain, regardless of the acute care or emergency setting.Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary orquaternary medical center with 24-hour catheterization laboratory availability. For patients presenting withelectrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergocardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patientsliving in rural areas have a cardiac catheterization-capable facility available to them within a 60-minutedriving radius, making it difficult for those patients to undergo cardiac catheterization within the desired timeframe.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities tolearn about and deploy thrombolytic agents during residency training, graduating EM residents may beunfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physiciansby 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Althoughhistorically EM graduates have not selected rural areas for practice, with only approximately 8% ofemergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceivedsaturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With thesechanging practice dynamics in mind, this simulation provides the opportunity for residents and medicalstudents to experience the management of a STEMI in the rural setting, with a focus upon the indications,contraindications, dosing, and disposition of a patient receiving thrombolytics.Educational Objectives: By the end of this simulation, learners will be able to:1. Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural settingwithout timely access to cardiac catheterization.2. Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefitsand risks of thrombolysis.3. Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.4. Arrange for transfer to a tertiary care center following completion of thrombolysis.Educational Methods: This scenario is a simulated encounter in a rural emergency department settingrequiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits ofthrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher levelof care.Research Methods: The educational content of this simulation as a teaching instrument was evaluated bythe learner utilizing an internally developed survey after case completion. This survey was reviewed forprecision of language and assessment of learning objectives by our simulation faculty and other members ofour West Virginia University Emergency Medicine Department of Medical Education. The learner was askedto specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale,where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before andafter the scenario as well as their comfort with having a shared decision-making conversation with patientswith regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparingthem for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = nothelpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity tocomment directly on any aspect of the simulation.Results: Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% responserate. Overall, the feedback received regarding the simulation was positive. There was a low average comfortlevel with administering thrombolytics and having a shared decision-making conversation regardingadministering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective commentsregarding the simulation were universally positive.Discussion: The management of STEMI in the rural emergency department differs significantly from theenvironment in which many EM residents train. As a leading cause of death in the United States, STEMImanagement is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despitemany graduates ultimately working in rural emergency departments. This simulation sought to provide arealistic patient encounter to promote familiarity and comfort in the identification, patient discussion andexecution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effectivevia learner survey completion