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

Point-of-care Echocardiogram as the Key to Rapid Diagnosis of a Unique Presentation of Dyspnea: A Case Report

Introduction: Dyspnea is commonly evaluated in the emergency department (ED).The differential diagnosis is broad. Due to the large volume of dyspneic patients evaluated, emergency physicians (EP) will encounter uncommon diagnoses. Early, liberal application of point-of-care ultrasound (POCUS) may decrease diagnostic error and improve care for these patients.Case Report: We report a 48-year-old male presenting to the ED with cough and progressively worsening dyspnea for 11 months after multiple healthcare visits. Using POCUS, the EP was immediately able to diagnose a severe dilated cardiomyopathy (DCM) with left ventricular thrombus.Conclusion: Given that non-ischemic DCM is one of the most common etiologies of heart failure, often presenting with respiratory symptoms, POCUS is key to rapid diagnosis and, along with modalities such as electrocardiography and chest radiograph, should be standard practice in the workup of dyspnea, regardless of age or comorbidities

Coexistence of Substance Abuse among Emergency Department Patients Presenting with Suicidal Ideation

Background. Patients who are suicidal commonly seek care in the emergency department (ED). Few studies have examined the coexistence between suicidal ideation, substance abuse, and psychiatric diagnosis. Objectives. This study sought to determine how often suicidal ED patients have coexisting substance abuse and psychiatric diagnosis in addition to describing the characteristics of target population. Methods. In this retrospective cohort study, chart reviews were conducted of patients over 12 with suicidal ideation who presented to an academic ED from October 2016 to March 2017. Data abstracted included gender, age, insurance, prior psychiatric diagnoses, substances abused, presence of a suicide attempt, prior suicidality, number of ED visits in the prior year, and disposition. Both descriptive and inferential statistics were calculated. Results. There were 427 patient visits to the ED for suicidality during the study period, of which 54% were male, with a mean age of 34 years. Most patients (92%) had a psychiatric diagnosis, most commonly depression (67%). More than one psychiatric diagnosis was reported in 51% of patients, while 8% had no reported underlying psychiatric diagnosis. Substance abuse was reported in 58% of patients, including marijuana (42%) and opioids (41%). Polysubstance abuse was reported in 42%. Approximately half of the patients had three or more ED visits in the previous 12 months. Most patients were insured by Medicaid (51%), while 59% were admitted for inpatient treatment. Conclusion. Substance abuse and psychiatric diagnosis were reported frequently among patients presenting to the ED with suicidal ideation, often involving more than one substance/diagnosis. Future studies should be aimed at evaluating the relationship between these conditions and determining how to better care for this population

Transitioning to Pass/Fail USMLE Step 1: Will Students from Less Prominent Schools be Adversely Impacted?

Background: In January 2022, USMLE Step 1 scoring will be pass/fail (P/F). Although this change aims to decrease applicant stress, it will impact the way EM program directors (PDs) review applications. Little research exists on how the transition will impact applicants.Objectives: The purpose of this study was to determine if a change in Step 1 scoring will affect the likelihood to interview (LTI) an applicant. We hypothesized that transitioning to P/F scoring may negatively impact the LTI for students from less prominent schools.Methods: A survey of mock residency applications from strong, fair, and poor applicants was distributed to EM PDs via the CORD list serve. Respondents rated the LTI of applicants on a 5-point Likert scale. Applications from allopathic (MD), osteopathic (DO), and international medical graduates (IMG) were included. School prominence was determined by the 2020 US News & World Report rankings. Survey respondents were randomized to review applications with either numeric or P/F scores. Independent sample t-tests were calculated in SPSS 23.0 to compare mean ratings for applications based on scored or P/F scenarios for MD, DO, and IMG groups separately. This study was approved by the institutional review board at the study site.Results: Of 149 responses, poor performing MD students from highly prominent schools had a higher LTI with P/F scoring than poor performing students from less prominent schools (2.03 vs. 1.55, p < .01). For strong and fair performing MD students, no significant difference in LTI existed amongst high and less prominent schools with P/F scoring (Table 1). Strong DO (p<.01) and IMG (p<.001) applicants had higher LTI with P/F, while fair DO (p<.01) and IMG (p<.001) applicants had higher LTI with a numeric score (Table 2).Conclusions: When only P/F scoring is reported, poor performing students from low prominence schools have a significantly lower LTI than poor performing peers from high prominence schools.27 The Impact of Medical Education Fellowships on the Careers of Graduate

Does the Medical Student Performance Evaluation Change the Decision to Invite Residency Applicants?

Introduction: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone.  Methods: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant’s likelihood to receive an invitation to interview.  Results: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications – 48 total            (5.5 %, p< 0.01) – with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no). Conclusion: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD’s focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation