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  Differences within a health system: imaging use for suspected pediatric appendicitis

  Nafisa Bhuiyan, Ryan Nierstedt, Michelle Jankowski, Shanna Jones, and Aveh Bastani

  Publication Date: 5-2-2022

  INTRODUCTION
  Ultrasound (US) is the first line imaging used for suspected pediatric appendicitis. However, following equivocal US findings and its lower negative predictive value for ruling out appendicitis, Computed Tomography (CT) imaging is often performed in children. This study investigates the differences in imaging utilization between a community hospital (Beaumont Troy) and a children’s ED hospital (Beaumont Royal Oak), making it the first study to evaluate suspected pediatric appendicitis in Beaumont Health System. It also aims to further characterize differences in patient outcomes such as surgery, length of hospital stay, complications of appendicitis, and highlight the need to reduce unnecessary CT use due to its radiation exposure.

  METHODS
  Following IRB approval, this retrospective mixed-methods chart review analyzed patients ages 4-17, who initially received an abdominal US in the ED for abdominal pain associated with suspected appendicitis between January 1st, 2016 – January 1st, 2019 in Beaumont Troy and Royal Oak hospitals. Variables of interests were compared between hospitals using unequal variance two sample t-test, Chi-Square, and Fisher Exact tests. Pathology reports determined a definitive diagnosis of appendicitis.

  RESULTS
  In the ED, 1,672 patients (1113 from Royal Oak, 559 from Troy) were suspected to have appendicitis. The community hospital performed significantly more CT imaging (P=0.0007), had longer length of stay in the ED (P

  CONCLUSIONS
  This study confirmed our prediction and prior studies showing the community hospital utilizing more CT imaging for suspected appendicitis than the children’s hospital, despite no difference in surgical interventions or complication rates at the community hospital. Further investigation is necessary to decrease reliance on CT imaging after equivocal US findings in Beaumont Health System.

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  Evaluation of Implementing ‘Team Strategies and Tools to Enhance Performance and Patient Safety’ in a Community Emergency Department

  Bryson Caskey, Shanna Jones, Sarah Berry, Heather Harris, David Donaldson, and Aveh Bastani

  Publication Date: 5-2-2022

  This study sought to provide an initial evaluation of implementing the program ‘Team Strategies and Tools to Enhance Performance and Patient Safety’ (TeamSTEPPS) in the William Beaumont Troy Emergency Department (ED). TeamSTEPPS integrates teamwork into medical practice by developing tools and strategies within leadership, situation monitoring, mutual support, and communication to increase team performance in order to improve quality, safety, and efficiency of healthcare1,2 (figure 1). It was implemented in the Troy Beaumont ED in 2017. This study was designed to determine if the program is achieving desired outcomes, identify areas for improvement, and add to the limited fund of data on the effectiveness of TeamSTEPPS in community ED’s3-5.

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  Journal Club in the Pre-Clinical Years During Medical School

  Kristin Cuadra and Steven Joseph

  Publication Date: 5-2-2022

  INTRODUCTION
  Traditionally, journal clubs have been conducted within graduate medical programs to help integrate evidence-based learning. This study will be focused on beginning to integrate journal club into the pre-clinical years while implementing successful techniques used in past journal clubs. Our hypothesis is that, with a structured review instrument in place to help students analyze clinical articles, students will be able to benefit from monthly journal clubs and fully grasp concepts taught in these pre-clinical years. Overall, the results will contribute significantly in determining the efficacy of journal club and whether or not it can be a valuable tool in medical education.

  METHODS
  This was a prospective study that consisted of 14 2nd year medical students from August 2020 to April 2021. Each month, a one-hour journal club was held virtually over Zoom, where students used a structured review instrument to discuss and analyze journal articles. Journal club articles correlated with the pre-clinical curriculum at OUWB. At the end of April 2021, all 14 students were asked to complete a 10-question survey determining whether or not the monthly journal clubs were helpful in providing them with a better understanding of organ system material. Descriptive statistics was used to analyze the survey responses.

  RESULTS
  All 14 students either “strongly agreed” or “agreed somewhat” when asked if their pre-clinical education benefited from the monthly journal clubs as well as when asked if integrated journal clubs would benefit their future education in residency.

  CONCLUSIONS
  The results support the hypothesis that medical students would benefit from integrating journal club into the pre-clinical curriculum. Students felt that journal club positively impacted their education and was applicable in order to start practicing evidence-based medicine. Further studies may demonstrate whether journal club can improve clinical performance throughout medical school.

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  Differences in Small Bowel Obstruction Outcomes in an Academic vs Community Hospital.

  Kelly Fahey, Aveh Bastani, Shanna Jones, and Philip Kilanowski-Doroh

  Publication Date: 5-2-2022

  Small bowel obstruction: blockage in small intestine. Adhesions are the most common cause. Accounts for 300,000 hospitalizations in the US annually, and 20% of emergency surgical procedures in patients with abdominal pain. High morbidity and mortality. Average hospital stay of 8 days. 30-day readmission rate of 16%. In-hospital mortality rate of 3%. Costly diagnosis: more than $2 billion spent on admissions for adhesion-related disease in the United States. Clinical presentation: variable, includes abdominal pain, vomiting, constipation, nausea, and abdominal distention. Management. Operative: important if signs of ischemia, peritonitis, or strangulation. Conservative: includes bowel rest, nasogastric decompression, serial examinations, and a water-soluble contrast challenge. Majority of patients (65-80%) with SBO due to adhesions can be successfully managed with non-operative treatment. Wide institutional variation exists with respect to the decision on admitting service. Aim and Objective To understand the differences in admitting service (medicine or surgery) in patients with SBO on morbidity and length of stay in a large academic hospital vs a community hospital.

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  A Multimodal Approach to Reducing Opioid Administration in the Emergency Department

  Eddie Ford, Vito Rocco, Shanna Jones, and Patrick Karabon

  Publication Date: 5-2-2022

  INTRODUCTION
  The United States is battling a deadly epidemic against opioid abuse and misuse, which began as a result of pharmaceutical companies purposely downplaying the addictive potential of their opioid medications. In 2016, a Colorado health care system developed a groundbreaking alternative to opioids (ALTO) protocol for acute pain relief in the Emergency Department (ED). This protocol was adapted and implemented in the Beaumont Troy ED and is the focus of this current study. The primary goal of this study is to characterize the impact of the ALTO protocol on the rate of opioid and non-opioid administration in the ED for acute pain relief.

  
  METHODS
  A retrospective chart review of ED admission/discharge data and medication administration data for adult patients was completed for the control cohort (pre-ALTO) and ALTO intervention group during the study period of April 2018 – August 2019. To ensure accurate comparison of medications used, a standardizing procedure of calculating morphine equivalent units (MEUs) was utilized. Variables were statically analyzed and presented through a log-linear regression model and monthly percentage change (MPC) over time.

  
  RESULTS
  During the study period, the rate of MEUs administered decreased by 1.05% per month MPC = -1.05%, P = 0.0018. Compared to the control group, ALTOs administered increased on average by 2.36% per month MPC = 2.36%, P =

  
  CONCLUSIONS
  The results support the hypothesis that the ALTO protocol would lead to a reduction in the rate of opioids used for acute pain relief while also increasing the rate of ALTOs used for acute pain relief in the ED. This research will contribute to the production of universally accepted and preferred non-opioid pain reduction protocols in order to limit future opioid misuse and abuse.

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  Prehospital Use of Ketamine in the Pediatric Population

  Ashima Goyal, Revelle Gappy, Remle Crowe, John Frawley, Nai-Wei Chen, and Robert Swor

  Publication Date: 1-2022

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  The Current State of Diagnostic Error Education in U.S. Medical Schools

  Dakota Hall, Sandra LaBlance, and Brett Todd

  Publication Date: 5-2-2022

  INTRODUCTION
  Diagnostic error has been identified by the Institute of Medicine as a major cause of patient harm. Despite recent focus on the importance of diagnostic error, little is known about how medical schools are educating future physicians, specifically, the extent to which it is taught. We aimed to investigate the current state of diagnostic error education in U.S. medical schools.

  METHODS
  We conducted an anonymous survey of deans of medical education at U.S. M.D. and D.O. medical schools utilizing Qualtrics, which was distributed in February 2021 and resent on two occasions through a listserv known to reach U.S. medical school faculty. The survey asked questions concerning diagnostic error education at that school, including whether or not it was taught, details about the curriculum if taught, and questions about obstacles if not taught.

  RESULTS
  47 out of a potential 192 deans of medical education responded to the survey. Of those that responded, 93.6% were M.D. schools, and 6.4% were D.O. schools. 83.7% of schools teach diagnostic error, while 16.3% schools do not. 68.0% of schools teach diagnostic error during both the preclinical and clinical years, 28.0% teach it during only the preclinical years, and 4.0% teach it during only the clinical years. Small-group discussions are the most commonly used format for teaching diagnostic error, utilized by 87.5% of schools. Other teaching formats used include didactic lectures (79.2%), online educational modules (41.7%), workshops (33.3%), simulation (33.3%), and flipped classroom (29.2%).

  CONCLUSIONS
  To our knowledge, this is the first study investigating diagnostic error education in U.S. medical schools. The results suggest that the majority of U.S. medical schools do teach diagnostic error in their curriculum, and that it is more commonly taught in the preclinical years using small-group discussions. Future research should investigate the effects of diagnostic error education in medical school on patient outcomes.

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  The Impact of medical scribes on emergency physician diagnostic testing and diagnosis charting

  Lucas Nelson and Brett R. Todd

  Publication Date: 5-2-2022

  INTRODUCTION
  Since the widespread adoption of electronic medical records (EMRs), medical scribes have been increasingly utilized in emergency department (ED) settings to offload the documentation burden of emergency physicians (EPs). Scribes have been shown to increase EP productivity and satisfaction; however, little is known about their effects on the EP’s diagnostic process. We aimed to assess what effect, if any, scribes have on EP diagnostic test ordering and their documentation of differential diagnoses.

  METHODS
  We conducted a retrospective cohort study utilizing a chart review to compare diagnostic practices of EPs working both with and without scribes. We analyzed the number of laboratory and radiologic diagnostic studies ordered per encounter as well as characteristics of differential diagnosis documentation.

  RESULTS
  Scribes did not affect laboratory studies ordered per encounter (mean 6.31 by scribes vs. 7.35 by EPs, difference -1.04; 95% confidence interval [CI] -2.34 to 0.26) or radiologic studies ordered per encounter (mean 1.49 by scribes vs. 1.39 by EPs, difference 0.10; 95% CI -0.15 to 0.35). Scribes did not affect the frequency of documenting a differential diagnosis or the number of diagnoses considered in each differential, but they were associated with higher word counts in EP differentials (mean 72.29 by scribes vs. 50.00 by EPs, mean difference 22.79; 95% CI 6.77 to 38.81).

  CONCLUSIONS
  Scribe use does not appear to affect EP diagnostic test ordering but may have a small effect on their documentation of differential diagnoses.

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  Imaging for suspected pediatric appendicitis: Can ultrasound alone be trusted?

  Ryan Nierstedt, Nafisa Bhuiyan, Michelle Jankowski, Lauren DeSantis, Aveh Bastani, and Shanna Jones

  Publication Date: 5-2-2022

  INTRODUCTION
  Diagnosis of pediatric appendicitis relies on a combination of laboratory results, diagnostic imaging, and clinician judgement. However, the necessity of CT imaging has been questioned given radiation exposure. Therefore, ultrasound imaging has become a useful diagnostic tool, yet its sensitivity in identifying appendicitis is often lower in comparison to CT. This study aims to determine the sensitivity of US imaging for pediatric appendicitis and if differences exist in the diagnosis of appendicitis utilizing both CT and ultrasound or ultrasound alone.

  METHODS
  After obtaining IRB approval, patients 4-17 years of age who received an abdominal ultrasound and/or additional abdominal CT imaging at Beaumont Royal Oak and Troy emergency departments between January 1st, 2016 and January 1st, 2019 were reviewed. Radiology reports were reviewed to determine if the appendix was visualized, and if a diagnosis positive or negative for appendicitis was made. Comparisons between imaging modalities were done using Fisher's Exact tests and sensitivity of predicting appendicitis between imaging cohorts were computed using reviewed pathology reports, when present, as the gold standard for appendicitis.

  RESULTS
  1,672 patients were included in our cohort (1,113 from Royal Oak, 559 from Troy). 77% of patients with suspected appendicitis only received an ultrasound, while 23% underwent additional CT imaging. Of the 1,672 patients imaged for appendicitis, 384 received an appendectomy (23%). For positive ultrasound tests, there was no difference in the rates of appendicitis in those who received CT imaging and ultrasound when compared to those who received ultrasound alone (p>0.99). The sensitivity in determining appendicitis using ultrasound alone was 0.95 for Royal Oak and 0.93 for Troy.

  CONCLUSIONS
  While the diagnosis of appendicitis in the pediatric population is multifaceted and should be individualized to each patient, our data demonstrates that a positive ultrasound finding alone may be sufficient for diagnosis without further CT imaging.

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  Risk Factors Affecting Delayed Diagnosis of Adult Acute Appendicitis

  Nicholas W. Prewitt and Brett R. Todd

  Publication Date: 5-2-2022

  INTRODUCTION
  The diagnosis of appendicitis is time-sensitive and delays increase the risk of morbidity and mortality through complications, including perforation, gangrene, and abscess formation. Nearly all cases of appendicitis are diagnosed in and admitted through the emergency department (ED). Therefore, improvements in the time to diagnosis of acute appendicitis in the ED may improve patient outcomes. However, it currently remains unclear what factors contribute to prolonged diagnostic times of appendicitis. This study aimed to determine if demographic, environmental, or provider-related factors result in delays in the diagnosis of adult acute appendicitis in the ED.

  METHODS
  We conducted a retrospective cohort study to evaluate the causes of variability in diagnosis times of acute appendicitis utilizing chart review methodology. Charts were pulled from Epic for all patients diagnosed with acute appendicitis, 18 years and older, and from the Beaumont Hospital, Royal Oak ED in the time period of 2016 to 2018. Variables collected include age, race, sex, primary language, time of day, day of week, time of year, mode of arrival, referral to ED, return ED visit, and the provider experience. Time to diagnosis was defined as the time from ED arrival to diagnosis of appendicitis by radiologist read. Data was analyzed using a univariate generalized linear model.

  RESULTS
  907 patients met the inclusion criteria. Average time to diagnosis was significantly lower in white patients than nonwhite patients (3.96 versus 4.30 hours; p = 0.005) and in males than females (3.74 versus 4.32 hours; p < 0.001).

  CONCLUSIONS
  Female and nonwhite patients experience a prolonged time to diagnosis of acute appendicitis. This may reflect confusion with pelvic pathology in females and possibly the effects of implicit bias in healthcare workers. ED providers should be cognizant of these discrepancies in order to avoid increased morbidity and mortality in these population of patients with acute appendicitis.

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  Cardiac Arrest Patient Length of Stay and Survival in Michigan Hospitals

  Jaemin Song, David A. Berger, James H. Paxton, Joseph B. Miller, Joshua Reynolds, Nai-Wei Chen, and Robert Swor

  Publication Date: 5-2-2022

  INTRODUCTION
  Current guidelines recommend deferring prognostic decisions for at least 72 hours following admission after Out of Hospital cardiac arrest (OHCA). Most non-survivors experience withdrawal of life-sustaining therapy (WLST), and early WLST may adversely impact survival. We sought to characterize the hospital length of stay (LOS) and timing of Do Not Resuscitate (DNR) orders (as surrogates for WLST) to assess their relationship to survival following cardiac arrest.

  METHODS
  We performed a retrospective cohort study of probabilistically linked cardiac arrest registries (Cardiac Arrest Registry to Enhance Survival (CARES) and Michigan Inpatient Database (MIDB) from 2014 to 2017.

  RESULTS
  We included 3644 patients from 38 hospitals with >30 patients. The patients' mean age was 62.4 years and were predominately male (59.3%). LOS ≤ 3 days (ORadj = 0.11) and early DNR (ORadj = 0.02) were inversely associated with survival to discharge. There was a non-significant inverse association between hospital rates of LOS ≤ 3 days and survival (p = 0.11) and Early DNR and survival (p = 0.83). In the multilevel model, using median odd ratios to assess variation in LOS ≤ 3 days and survival, patient characteristics contributed more to variability in survival than between-hospital variation. However, between-hospital variation contributed more to variability than patient characteristics in the provision of early DNR orders.

  CONCLUSIONS
  We observed that LOS ≤ 3 days for post-arrest patients was negatively associated with survival, with both patient characteristics and between-hospital variation associated with outcomes. However, between-hospital variation appears to be more highly associated with the provision of early DNR orders than patient characteristics. Further work is needed to assess variation in early DNR orders and their impact on patient survival.

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  Ventricular assist device association in improving outcomes in patients resuscitated from out of hospital cardiac arrest

  Julie Tram, Andrew Pressman, Nai-Wei Chen, David Berger, Joseph Miller, Robert Welch, Joshua Reynolds, James Pribble, Robert Swor, and CARES Surveillance Group

  Publication Date: 5-2-2022

  INTRODUCTION
  There has been continued debate on the efficacy of ventricular assist devices (VAD) on improving survival outcomes in post cardiac arrest patients.
  The objective of this study is to assess whether the use of VAD is associated with improved survival outcome in patients resuscitated from out-of-hospital cardiac arrest in Michigan.

  METHODS
  We matched cardiac arrest cases from 2014-2017 in the Michigan CARES Registry (CARES) and the Michigan Inpatient Database (MIDB) using probabilistic linkage.VAD are defined as either IABP or Impella device identified using ICD-9 or 10 procedure codes. Multilevel, multivariable regression analyses were employed to evaluate the impact of device use on survival, adjusting for variables normally predictive of cardiac arrest survival (age, location, witnessed, shockable rhythm).

  RESULTS
  A total of 3,790 CARES cases were matched with MIDB of which 183 (4.8%) received IABP, 50 (1.3%) Impella, and 1,131 (29.8%) survived to discharge. VAD use was associated with improved survival to discharge (OR=2.07, 95% CI 1.55, 2.77). IABP were used more frequently and associated with an improved outcome (OR=2.16, 95%CI 1.59, 2.93) compared to Impella (OR=1.72, 95% CI 0.96, 3.06). In a multivariable model, however, VAD was no longer associated with an improved outcome (aOR =0.95, 95% CI 0.69, 1.31). In the subset of patients with cardiogenic shock (n=725) we identified an improved survival with VAD (OR= 1.84 95% CI 1.24, 2.73). IABP use was more frequent and associated with an improved outcome (OR=1.98, 95% CI 1.32, 2.98). After adjusting for patient characteristics, VAD increased odds of improved outcome by 14% but was not statistically significant (aOR = 1.14, 95% CI 0.74, 1.77 ).

  CONCLUSIONS
  Although limited by low frequency of use, VAD or IABP alone was associated with improved outcomes for post arrest care. However, in a multivariable analysis, VAD use was not associated with an independent improvement in post arrest survival.

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  Assessing Geriatric Patients in the Emergency Department Using A New Trauma Protocol

  Benjamin Travers, Ali Beydoun, Patrick Karabon, Shanna Jones, Michael Opsommer, Aveh Bastani, and David Donaldson

  Publication Date: 5-2-2022

  INTRODUCTION
  The Level III trauma protocol was implemented to reduce time to diagnosis and treatment for elderly patients (defined as patients aged > 65 who are taking anticoagulant/antiplatelet agents) presenting in the ED with a potential head injury after a fall. In 2017, approximately 11.4% of the patients triaged by the new Level III trauma protocol had an intracranial bleed, which is a population that had previously been overlooked as they have a low index of suspicion for an intracranial bleed. This study sought to determine if the recent implementation of the Level III trauma protocol in the Troy Beaumont Emergency Department (ED) has led to better health outcomes for this population.

  METHODS
  The researchers retrospectively reviewed the charts of patients who met the inclusion criteria and had an intracranial bleed on computed tomography (CT). The patients were split into two groups based on if they were triaged before (N = 12) or after (N = 56) the level III trauma protocol was implemented. Time spent in the ED and patient centered health outcomes were collected and t-test analyses were completed to compare the pre and post level III trauma protocol groups.

  RESULTS
  The average time from arrival in the ED to CT (2.37 hours) and time spent in the ED (ED LOS) (4.72 hours) for the pre-level III trauma group were significantly longer than the average time to CT (0.64 hours) and ED LOS (2.55 hours) for the post-level III trauma group (p < 0.01). There was insufficient evidence to conclude that there was any difference in health outcomes between the pre and post Level III trauma groups (p > 0.05).

  CONCLUSIONS
  This suggests that the Level III trauma protocol reduces the time to diagnosis, treatment, and ED LOS for the high-risk elderly population with an intracranial bleed without negatively impacting health outcomes.

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  Outcomes for Patients with Congestive Heart Failure and Chronic Kidney Disease Receiving Fluid Resuscitation for Severe Sepsis or Septic Shock

  Melany Wiczorek, Ronny Otero, Steven Knight, Kaitlin Ziadeh, James Blumline, and Zachary Rollins

  Publication Date: 5-2-2022

  INTRODUCTION
  Sepsis core measures are an integral part of sepsis treatment. Current fluid administration guidelines consist of administering at least 30cc/kg of intravenous fluids (IVF) per ideal body weight (IBW) within the first three hours of sepsis diagnosis regardless of pre-existing comorbidities at risk for fluid overload. This study aims to evaluate the outcomes of patients with a history of congestive heart failure (CHF) and/or chronic kidney disease (CKD) who receive fluid resuscitation for the management of severe sepsis or septic shock.

  METHODS
  We performed a retrospective case-control study of Emergency Department patients treated for severe sepsis or septic shock. We identified subjects with a history of CHF or CKD (at-risk group [AR]) and a sample of patients without a history of CHF/ CKD (control group). We performed a structured chart review recording demographics, fluids received, airway interventions required, and outcome. Logistic regression analysis was used to compare the association between the amount of IV fluids received and the outcomes of interest.

  RESULTS
  Our cohort consisted of 745 patients with a history of CHF and/or CKD (AR group) and 570 patients without a history of CHF and/or CKD (control group). Overall patients in the AR group received less IVFs than the control group at 24 hours. There was a significant association between receipt of >30cc/kg of IVF in the AR group at 3hrs and 6hrs from ED arrival and the need for BiPAP. There was no statistically significant association between receipt of >30 cc/kg of IVF in the AR group compared to the control group in terms of in-hospital mortality.

  CONCLUSIONS
  We identified a significant association of >30 cc/kg IVF administration and the need for Bi-PAP in AR patients. We identified higher in-hospital mortality in the AR group, but this was not associated with the amount of IVF resuscitation received.