BACKGROUND:Patients presenting to the Emergency Department (ED) with chest pain who have an indeterminate (detectable to mildly elevated) troponin are often evaluated with tests that use ionizing radiation. We hypothesized that patients initially evaluated with stress cardiac magnetic resonance (CMR) imaging receive less ionizing radiation through one year of follow-up than those initially evaluated with invasive angiography. METHODS:We conducted a secondary analysis of the CMR-IMPACT trial, which randomized adult patients at 4 U.S. sites (9/2013-7/2018) with a contemporary troponin of 0.006-1.0 ng/mL to either CMR imaging or invasive angiography. Cumulative radiation exposure from coronary computed tomography angiography, nuclear medicine stress imaging, cardiac catheterization, and percutaneous coronary intervention was assessed from index through one year using validated radiation dose estimates. Radiation doses at index and one year were compared between arms using linear regression adjusted for the stratification factors of initial troponin and known coronary artery disease in both intention-to-treat (ITT) and per-protocol (PP) populations. RESULTS:During the study period, 312 patients were enrolled, with 156 randomized to each arm (CMR vs. invasive angiography). In the ITT analysis, patients in the CMR arm had less radiation exposure at index compared to patients in the invasive angiography arm (4.7 ± 5.7 mSv vs. 7.8 ± 5.8 mSv; p < 0.001). The difference in radiation exposure at one year was 7.5 ± 10.9 mSv vs. 9.5 ± 8.4 mSv (p = 0.06). In the PP analysis, patients receiving CMR (N = 102) had less radiation exposure than those receiving invasive angiography (N = 104) at index (3.5 ± 5.1 mSv vs. 9.3 ± 3.7 mSv; p < 0.001) and one year (5.8 ± 10.9 mSv vs. 11.2 ± 8.1 mSv; p < 0.001). CONCLUSION:CMR was associated with decreased radiation exposure compared to invasive angiography.

Introduction: Burnout is well known as a prevalent hazard in emergency medicine (EM) careers, but the literature is less clear about what specific work-related factors actually contribute to wellness and burnout among academic EM faculty. Objectives: 1) To explore themes and specific concerns that contribute to faculty wellness in an academic emergency department, in a qualitative fashion. 2) To determine whether these themes and concerns changed appreciably in the time of the COVID-19 pandemic. Methods: EM faculty members at an academic institution were invited to participate in the study, including an on-line survey and a structured interview. Survey results were analyzed using descriptive statistics, interviews were coded and analyzed in qualitative fashion with frequency of themes as the primary outcome. Results: 33 of 40 EM faculty members at one institution participated in interviews with the study team. Twenty-four returned Maslach Burnout Inventory (MBI) and Areas of Worklife surveys, with 5 of the 24 registering as burned out by standard definitions. In qualitative analysis of the interviews, the most common negative themes were psychological stress, balancing work and family life, negative perceptions of non-departmental administration and certain aspects of clinical work. The most common positive themes included positive views of departmental leadership, teamwork among colleagues, trainees and others, and self-worth derived from doing the work of EM. Themes before and during the COVID-19 pandemic were similar, with an increase in positive comments related to patient care during the COVID-era (p = 0.02). Conclusion: Among one group of EM faculty, positive drivers of wellness were primarily relational in nature, including working in teams to care for patients and carry out the various missions of academic EM. Negative drivers were consistent with previous work in burnout among medical professionals, to include stress, tensions between work and family obligations, and conflicts in the care and work environments.

Background: The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway clinical decision support tool was designed to assist emergency department providers with chest pain risk stratification. Prior studies have demonstrated its safety and ability to reduce hospitalizations. However, cost effectiveness data is lacking. We performed a cost effectiveness analysis of the HEART Pathway compared with Standard Care. Hypothesis: The value of the HEART Pathway exceeds that of Standard Care as measured by cost effectiveness. Methods: A pre-planned economic analysis of the HEART Pathway Implementation Study was conducted. This prospective interrupted time-series accrued adults with possible acute coronary syndrome from 3 sites (11/2013-1/2016). The construct for the current analysis was a 1000-member Cohort (Deterministic) Markov model with two different time periods - one with a cycle length of 30 days run over the course of 1 year and one with a cycle length of 1 year run over the course of 10 years. Transition probabilities were obtained from patient encounter data from the original trial. A smaller subset of patients had direct costs available from the hospital perspective, including resources consumed and professional fees. Results: The HEART pathway and Standard Care cohorts included 3713 and 4761 patients with costing data respectively available for 140 and 139 patients. In both the 1-year and 10-year models, the HEART pathway had reduced costs and increased quality adjusted life years (QALYs) compared to Standard Care, making the HEART pathway strongly dominant in terms of cost effectiveness. Accordingly, an incremental cost effectiveness ratio is not defined. From the Markov models, mean cost per patient was projected to be lower for the HEART Pathway compared to Standard Care at 1 year ($6,225.31 versus $8,138.06) and at 10 years ($11,107.00 versus $13,322.76). Also, QALYs for the HEART Pathway were superior to Standard Care at 1 year (10.43 versus 10.20) and 10 years (7.73 versus 7.40). Conclusions: Compared to Standard Care, the HEART pathway was strongly dominant in terms of cost effectiveness using Markov modeling with 1-year and 10-year termination points.

INTRODUCTION The American College of Graduate Medical Education (ACGME) defines 18 "key procedures" as requirements in emergency medicine (EM) residency programs. The post-graduate year-1 (PGY-1) curriculum provides an early foundation for EM trainees to gain procedural experience, but traditional PGY-1 rotations may not provide robust procedural opportunities. Our objective was to replace a traditional orthopedic rotation with a 4-week rotation that emphasized EM procedure acquisition and comprehension. Although all residents met ACGME procedural requirements before the curricular modification, the purpose of this month was to increase overall procedure numbers. The block contained dedicated procedure shifts in the emergency department as well as an asynchronous, self-directed learning course. We sought to compare the number of procedures performed by PGY-1 residents during their orthopedic rotation (the year before implementation), to the number of procedures performed during their procedure rotation (the year after implementation). METHODS The total number of procedures performed and logged by PGY-1 residents during the traditional orthopedic rotation (during the year prior to implementation of the new procedure rotation) were compared to the total number of procedures by the first class to undergo the new procedure rotation the following year. Thirty resident logs were reviewed (15 per class). Data were analyzed using SAS NPAR1WAY; Z < 0.05 was considered significant. RESULTS When compared to the orthopedic rotation, the procedure rotation had statistically significant higher numbers of procedures per resident (22, standard deviation [SD] 12, vs 11.4, SD 7.6; Z = 0.0177). A wide variety of nonorthopedic procedures accounted for the increased numbers, (13.6, SD 10.3, vs 0.9, SD 0.9; Z < 0.001). While the average number of orthopedic procedures was slightly less on the procedure rotation, there was no statistical difference (orthopedic rotation 10.13, procedure rotation 8.26; Z = 0.4605). Notably, fewer procedures were performed when 2 residents were on the procedure rotation at the same time (21 vs 10.1). CONCLUSION This analysis demonstrated a larger number and a wider variety of procedures performed by PGY-1 residents during a dedicated procedure rotation compared to a traditional orthopedic rotation. Furthermore, exposure to orthopedic procedures did not decline significantly. Limitations of the study include a modest number of subjects. Data may be limited by the consistency of procedure logging by individual residents. Further studies may assess procedural competency after PGY-1 year of training.

OBJECTIVE This study aims to examine the existing perceptions and social media practices of nurses in a large academic medical center. BACKGROUND Limited data are available about the perceptions and social media practices among healthcare providers. An understanding of the social networking landscape within the nursing profession is necessary to inform policy and develop effective guidelines. METHODS This was a single-center prospective observational study involving nurses at a large academic medical center. Nurses completed an anonymous questionnaire regarding their personal use and perceptions of social media in the context of clinical medicine. RESULTS A total of 397 nurses participated in the study survey. Overall, 87% of participants reported using a general social media account currently. Increasing age was associated with decreasing frequency of social media use. CONCLUSION Social media usage is common among nurses. Social media perceptions and practices among nurses vary considerably. Well-informed policy and targeted education are needed to guide social media use among healthcare workers.

OBJECTIVE This study aims to examine the existing perceptions and social media practices of nurses in a large academic medical center. BACKGROUND Limited data are available about the perceptions and social media practices among healthcare providers. An understanding of the social networking landscape within the nursing profession is necessary to inform policy and develop effective guidelines. METHODS This was a single-center prospective observational study involving nurses at a large academic medical center. Nurses completed an anonymous questionnaire regarding their personal use and perceptions of social media in the context of clinical medicine. RESULTS A total of 397 nurses participated in the study survey. Overall, 87% of participants reported using a general social media account currently. Increasing age was associated with decreasing frequency of social media use. CONCLUSION Social media usage is common among nurses. Social media perceptions and practices among nurses vary considerably. Well-informed policy and targeted education are needed to guide social media use among healthcare workers.

Anchor-based, end-of-shift ratings are commonly used to conduct performance assessments of resident physicians. These performance evaluations often include narrative assessments, such as solicited or “free-text” commentary. Although narrative commentary can help to create a more detailed and specific assessment of performance, there are limited data describing the effects of narrative commentary on the global assessment process. This single-group, observational study examined the effect of narrative comments on global performance assessments. A subgroup of the clinical competency committee, blinded to resident identity, assigned a single, consensus-based performance score (1–6) to each resident based solely on end-of-shift milestone scores. De-identified narrative comments from end-of-shift evaluations were then included and the process was repeated. We compared milestone-only scores to milestone plus narrative commentary scores using a nonparametric sign test. During the study period, 953 end-of-shift evaluations were submitted on 41 residents. Of these, 535 evaluations included free-text narrative comments. In 17 of the 41 observations, performance scores changed after the addition of narrative comments. In two cases, scores decreased with the addition of free-text commentary. In 15 cases, scores increased. The frequency of net positive change was significant ( p = .0023). The addition of narrative commentary to anchor-based ratings significantly influenced the global performance assessment of Emergency Medicine residents by a committee of educators. Descriptive commentary collected at the end of shift may inform more meaningful appraisal of a resident’s progress in a milestone-based paradigm. The authors recommend clinical training programs collect unstructured narrative impressions of residents’ performance from supervising faculty.

Background: In the absence of vaccines and established treatments, nonpharmaceutical interventions (NPIs) are fundamental tools to control coronavirus disease (COVID-19) transmission. NPIs require public interest to be successful. In the United States, there is a lack of published research on the factors that influence public interest in COVID-19. Using Google Trends, we examined the US level of public interest in COVID-19 and how it correlated to testing and with other countries. Objective: The aim of this study was to determine how public interest in COVID-19 in the United States changed over time and the key factors that drove this change, such as testing. US public interest in COVID-19 was compared to that in countries that have been more successful in their containment and mitigation strategies. Methods: In this retrospective study, Google Trends was used to analyze the volume of internet searches within the United States relating to COVID-19, focusing on dates between December 31, 2019, and March 24, 2020. The volume of internet searches related to COVID-19 was compared to that in other countries. Results: Throughout January and February 2020, there was limited search interest in COVID-19 within the United States. Interest declined for the first 21 days of February. A similar decline was seen in geographical regions that were later found to be experiencing undetected community transmission in February. Between March 9 and March 12, 2020, there was a rapid rise in search interest. This rise in search interest was positively correlated with the rise of positive tests for SARS-CoV-2 (6.3, 95% CI -2.9 to 9.7; P<.001). Within the United States, it took 52 days for search interest to rise substantially after the first positive case; in countries with more successful outbreak control, search interest rose in less than 15 days. Conclusions: Containment and mitigation strategies require public interest to be successful. The initial level of COVID-19 public interest in the United States was limited and even decreased during a time when containment and mitigation strategies were being established. A lack of public interest in COVID-19 existed in the United States when containment and mitigation policies were in place. Based on our analysis, it is clear that US policy makers need to develop novel methods of communicating COVID-19 public health initiatives.

BACKGROUND:Residency applicants feel increasing pressure to maximize their chances of successfully matching into the program of their choice, and are applying to more programs than ever before.OBJECTIVE:In this narrative review, we examined the most common and highly rated factors used to select applicants for interviews. We also examined the literature surrounding those factors to illuminate the advantages and disadvantages of using them as differentiating elements in interviewee selection.METHODS:Using the 2018 NRMP Program Director Survey as a framework, we examined the last 10 years of literature to ascertain how residency directors are using these common factors to grant residency interviews, and whether these factors are predictive of success in residency.RESULTS:Residency program directors identified 12 factors that contribute substantially to the decision to invite applicants for interviews. Although United States Medical Licensing Examination (USMLE) Step 1 is often used as a comparative factor, most studies do not demonstrate its predictive value for resident performance, except in the case of test failure. We also found that structured letters of recommendation from within a specialty carry increased benefit when compared with generic letters. Failing USMLE Step 1 or 2 and unprofessional behavior predicted lower performance in residency.CONCLUSIONS:We found that the evidence basis for the factors most commonly used by residency directors is decidedly mixed in terms of predicting success in residency and beyond. Given these limitations, program directors should be skeptical of making summative decisions based on any one factor.

Background Although the concept of medical specialty competitiveness may seem intuitive, there are very little existing empirical data on the determinants of specialty competitiveness in USA. An understanding of the determinants of specialty competitiveness may inform career choices among students and their advisors. Specialty competitiveness correlates with availability and appeal. Methods This narrative review examines 2019 National Resident Matching Program (NRMP) data and the existing literature to define the determinants of specialty competitiveness. A statistical analysis of key elements of the 2019 NRMP data was performed. Results Using US senior applicant fill rate as a measure of competitiveness, medical specialty competitiveness follows general principles of supply and demand. The demand, or appeal, of a specialty correlates with several factors, including salary, prestige and lifestyle. Salary correlates strongly with US senior fill rate (r=0.78, p=0.001). Relatively few positions are available for the most competitive specialties in the NRMP match. The negative correlation between US senior fill rate and position availability is also strong (r=−0.85; p<0.0001). Conclusion A ‘competitive specialty’ correlates strongly with high earnings potential and limited position availability. In an ideal world, a student’s pursuit of a medical specialty should be guided by interest, qualifications and ability to succeed in that field. However, students must contend with the realities of competition created by the residency matching system.

The objective of the Intern Passport (IP) curriculum was to implement a structured orientation for incoming interns that effectively defined and distinguished various personnel and assets within the emergency department (ED). The method of training was an on-the-job orientation that required interns to obtain “stamps” (signatures) on their passports during visits to eight “countries” (specialists) within the ED. Topics covered during the visit included introductions, tasks and capabilities, expectations, and pearls and pitfalls. Interns obtained stamps after spending 30-minute orientation visits with each country during the first four-week rotation of internship. The ED countries visited were Adult Nursing, Pediatric Nursing, Orthopedics Technician, Respiratory Therapy, Pharmacy, Psychiatry, Observation, and Radiology. Effectiveness was assessed by participant completion of an optional anonymous retrospective survey. The IP was a beneficial addition to our intern orientation curriculum. It effectively defined and distinguished various personnel and assets within the ED.

BACKGROUND:Remediation of the struggling resident is a universal phenomenon, and the majority of program directors will remediate at least 1 resident during their tenure.OBJECTIVE:The goal of this project was to create a standardized template for program directors to use at all stages of remediation.METHODS:Between 2017 and 2018, the Council of Residency Directors in Emergency Medicine (CORD-EM) Remediation Committee searched for best practices in the medical literature and compiled a survey that was e-mailed to the CORD-EM listserv. After reviewing all information, a standardized remediation contract was created, reviewed by legal counsel, and distributed to members.RESULTS:Forty-two percent (110 of 263) of program directors or assistant program directors on the CORD-EM listserv answered the initial survey and provided guidance on current remediation practices. The committee created formal and informal standard remediation contracts as both fillable templates and alterable documents. These were reviewed by CORD-EM general legal counsel and approved by the CORD-EM Board of Directors for distribution. The project took approximately 20 hours to complete over 8 months and involved a cost of $480 for legal fees.CONCLUSIONS:With program director input and legal counsel review, the CORD-EM Remediation Committee produced standardized remediation contracts, which can be used by all emergency medicine programs after comparison to local institutional policy and local legal review. This process was feasible and can be replicated by other specialties.

Some percentage of residents and fellows across all specialties require remediation during training. Graduate medical education leaders must navigate remediation steps to optimize resident learning and acquisition of skills, preserve patient safety, and maintain the standards of the specialty.1–3 Standardized approaches to performance management are available for program leaders to achieve favorable remediation results.4–9 In 2015–2016, 1110 of 129 720 (0.86%) residents left or did not successfully complete their training program, including 843 residents who withdrew, 249 who were dismissed, and 18 who did not successfully complete training.10 The potential legal implications of successful and unsuccessful remediation are often overlooked. An understanding of the legal landscape surrounding the remediation process is important to protecting stakeholders, including trainees.A systematic approach to remediation with the use of consistent language is important, as is agreement on terminology by all parties. Remediation is any additional training, supervision, or assistance above what is typical for training in the specialty.6 Two levels of remediation are widely accepted: informal and formal.7 Informal remediation is directed at improving performance and is part of clinical education for a subset of learners. It is generally managed by the program and typically is not reported in future performance reports for the trainee. Formal remediation is based on a decision that the performance or conduct of a learner falls short of program requirements. This may include unsuccessful efforts of informal remediation. Unsuccessful formal remediation has potential long-standing consequences that include further remediation, non-promotion, probation, and even dismissal. Formal remediation may be reported on future reference letters for a trainee, even when completed successfully. Designated Institutional Official notification should occur in all cases of formal remediation and may be advisable with informal remediation in some cases.Probation constitutes a kind of last chance for a trainee to correct unacceptable conduct or performance. When making a decision to place a trainee on probation, program leaders should review their institutional policies to confirm their understanding of institutional due process policies for trainees. It is key to note that a program's responsibility to remediate a trainee's performance does not supersede its duty to protect patients from potential harm.11 Therefore, dismissal, nonrenewal of contract, and/or non-reappointment may be necessary if probation fails, or if egregious conduct occurs. Probation status is generally reported on future letters of reference and to licensing boards and employers.To preserve the standards of a medical specialty, programs must be prepared to withhold credentials from those who are unable to meet minimum acceptable criteria.11,12 Annually, a small number of trainees complete their program but are deemed to have not met the criteria of successful entry into unsupervised practice or recommendation for eligibility for the board certification examination in the specialty or subspecialty.Residents and fellows are in a unique position as they are hospital employees and learners simultaneously. They are expected to perform day-to-day patient care tasks required of them, and, concurrently, they are expected to demonstrate progression in their educational curriculum. Training programs must prepare learners for unsupervised practice after graduation. Human resources policies often do not adequately address the complexities of this unique employee/learner situation.When a program identifies that a trainee has deficiencies in knowledge, clinical skills, professionalism, or another competency, it has a responsibility to intervene and remediate. If remediation is unsuccessful, removal of the trainee from the training program may be indicated. Disciplinary interventions and negative educational assessments during training may affect attainment of professional goals and future employment. Legal questions can arise from both successful and unsuccessful remediation.A resident's claim to residency training is legally viewed as a “property interest deserving of appropriate due process before it is removed.”13 To protect trainees from capricious or arbitrary removal, the Accreditation Council for Graduate Medical Education (ACGME) institutional requirements specify that sponsoring institutions must have a policy that provides residents and fellows with due process upon suspension, nonrenewal, non-promotion, or dismissal. The sponsoring institution must provide the resident or fellow with written notice of intent when contract renewal or promotion is withheld.14 The ACGME Common Program Requirements charge the program director with ensuring compliance with mandates for trainees to raise a grievance and have the benefit of due process.15Remediation and disciplinary action should follow institutional due process, and the course of this should be documented in detail.12,16 Trainees should be given notice of deficiencies, an opportunity to review the evidence, and a chance to advocate for themselves.13,17 Trainees may avail themselves of institutional appeals processes. However, medical education programs are afforded considerable discretion regarding disciplinary intervention, and a formal hearing is not required by law.17 Courts have long recognized the qualification and discretion of universities to settle academic issues.18 Collaboration among the resident, program director, Clinical Competency Committee, Designated Institutional Official, human resources, and legal counsel is necessary at the latter stages of performance management (remediation, probation, dismissal).If evaluative comments are made without malice and are restricted to objective appraisals of performance, legal action will likely be unsuccessful. Case law supports educators' critical evaluation of a trainee's performance and abilities. Such negative comments are protected from libel action because they are a recognized component of academic evaluation, and the learner gives implied consent to be evaluated when enrolling in an educational program. Furthermore, the Kraft v William decision upholds the dissemination of this information within an educational institution. When faculty share evaluative comments with institutional stakeholders, such intraschool publication is protected from defamation claims by the common interest privilege of faculty and by the implied consent of the learner.19 This privilege was later qualified to include only communications made without malice.20It is unlikely for a trainee to recover damages after an educational record containing negative reports is shared with outside parties in good faith. Unprofessional conduct and other problematic behaviors in medical school are associated with subsequent disciplinary action by state medical boards.21–23 State licensing boards and hospital credentialing departments issue increasingly detailed inquiries about graduates' disciplinary histories.24 Educators are bound by an ethical obligation and professional duty to truthfully report formal remediation and/or probation (when solicited) on future letters of reference, licensing forms, and credentialing documents. Such reporting can affect a trainee's future career and employment eligibility. Legal action could potentially be sought by the trainee if he or she believes the probation status was unwarranted and/or inaccurate, or the disclosure of his or her status was improper. To defend a claim of unwarranted probation, the use of clear and consistent language is important during performance management. Written notification by the program and acknowledgment by the trainee that future reporting will occur, as well as contemporaneous documentation of such, are also crucial.24 There is no legal precedent to date that restricts a program's good faith disclosure of disciplinary action on a licensing or credentialing inquiry. When disclosing negative disciplinary events about a trainee to inquiring parties, it is prudent to seek legal counsel to confirm appropriate scope and phrasing of such disclosures. State medical boards often require institutions to report adverse actions that result in changes to a physician's staff privileges. Program leaders should consult their state licensing boards to ensure compliance with mandatory reporting. Unsolicited disclosure of a resident's disciplinary history to outside parties without a legitimate interest is not protected and should be avoided.12 When a medical school issued negative statements about a student to the Association of American Medical Colleges, a US Court of Appeals considered them to be stigmatizing and potentially restricting to the student's freedom to pursue other medical education opportunities.17While unsuccessful remediation resulting in dismissal poses possible liability, institutions are generally on solid legal ground. Courts have determined that no distinction exists between postgraduate continuing education programs and degree-granting institutions requiring successful achievement of program goals before granting a certificate.19 A sponsoring institution, therefore, is not in breach of contract if it withholds a certificate from a trainee who does not complete work satisfactorily. Courts have also recognized educators' ability to determine eligibility of trainees for credentials, as well as their prerogative to withhold certificates when performance criteria are not met.16,19 When dismissal decisions are made with just cause, and in accordance with institutional policy, programs and institutions may reasonably expect them to be upheld.11,12,16A resident contract may require the capitulation of the institutional appeals process upon resignation. A trainee may be tempted to resign in an effort to avoid formal dismissal or disciplinary action. While this option may be attractive to both the trainee and the program because it expedites closure of the matter, programs should be wary of allowing resignations when unethical or egregious conduct has occurred. The purpose of providing truthful information to outside parties is to protect future employers' patients. Allowing resignation before a disciplinary record is established impedes that purpose. In instances of personal hardship or changes of career interest, resignation is often the most appropriate action.Faculty and the sponsoring institution have an obligation to supervise trainees and ensure patient safety, and they can be held liable in cases of negligent injury caused by a resident or fellow during training.11,12,25 The ethical and legal obligation to prevent harm to patients may necessitate dismissal of poorly performing trainees. However, delivery of substandard medical care is not required for dismissal, and it is not necessary for a program to wait until injury occurs before terminating the clinical privileges of a trainee.26Successful completion of a training program implies that the graduate is competent to practice in that field of medicine, and to our knowledge there is no published case law to suggest that a program can be held liable for injuries caused by a graduate who ultimately completed the program. Courts have upheld educational institutions' authority in determining certification eligibility, and they have been reluctant to recognize a complaint of educational malpractice in the litigation of medical malpractice claims.27,28Courts have refused to recognize the tort of educational malpractice, and current case law does not provide sufficient grounds for legal action against training programs or sponsoring institutions for educational malpractice.12,25,29–44If a trainee exhibits concerning behavior stemming from a personal matter or a medical condition, deliberate steps must be taken to protect the individual and his or her patients. Generally, program directors and faculty should limit their evaluations to objective clinical performance and should not attempt to diagnose a medical condition. However, if a direct threat is perceived, based on medical knowledge or objective evidence, the trainee should be relieved of clinical responsibilities. An administrative leave of absence may be helpful to collect information and strategize appropriate next steps.According to the US Equal Employment Opportunity Commission, if an employer has a reasonable belief that an employee's ability to perform essential job-related duties is impaired, or that the employee poses a direct threat due to a medical condition, the employer may make disability-related inquiries and/or require the employee to submit to a medical examination.45 While a resident cannot be forced to seek treatment, securing appropriate treatment to maintain fitness for duty is that individual's responsibility.24 A program may require a trainee to be determined fit for duty by a medical professional before returning to clinical duty.When a disability is discovered during training, programs should protect the resident by collaborating with institutional officials familiar with the Americans with Disabilities Act. The trainee (employee) usually initiates the request for accommodation; however, if the disability is obvious or apparent, the employer has a duty to explore reasonable accommodations. If a trainee discloses a disability and requests accommodation, the program should initiate an interactive process to identify a reasonable accommodation.Job restructuring, modified scheduling, and reassignment are considered reasonable accommodations in many work environments.45 However, these alterations can present considerable challenges in residency training settings. An employer does not need to provide accommodation if this causes undue hardship. Factors that determine hardship include the cost and nature of the accommodation, as well as the type, structure, and function of the employer's operation.45 Program leadership must determine if the requested accommodation is compatible with the educational requirements of that program, which often reflect the demands of that medical specialty. Institutional officials should be consulted when a trainee's circumstances require consideration of the Americans with Disabilities Act.Standardized, effective performance management is important to optimize medical trainee success and maximize patient safety. Familiarity with the legal implications of remediation and adherence to institutional due process enable training programs and sponsoring institutions to protect programs, trainees, and their current and future patients (see summary box).

Objective The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. Methods Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests. Results A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36). Conclusions The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.

Objectives: The HEART Pathway combines a decision aid and serial contemporary cardiac troponin I (cTnI) measures to achieve >99% sensitivity for major adverse cardiac events (MACE) at 30 days and early discharge rates >20%. However, the impact of integrating high-sensitivity troponin (hs-cTn) measures into the HEART Pathway has yet to be determined. In this analysis we compare test characteristics of the HEART Pathway using hs-cTnI, hs-cTnT, or cTnI.Design & methods: A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. Each patient was risk stratified by the cTn-HEART Pathway (Siemens TnI-Ultra at 0- and 3-h) and a hs-cTnHEART Pathway using hs-cTnI (Abbott) or hs-cTnT (Roche) at 3-h. The early discharge rate, sensitivity, specificity, and negative predictive value (NPV) for MACE (death, myocardial infarction, or coronary revascularization) at 30 days were calculated.Results: hs-cTnI measures were available on 133 patients. MACE occurred in 11/133 (8%) of these patients. Test characteristics for the HEART Pathway using serial cTnI vs 3 hour hs-cTnI were the same: sensitivity (100%, 95%CI: 72-100%), specificity (49%, 95%CI: 40-58%), NPV (100%, 95%Cl: 94-100%), and early discharge rate (45%, 95%CI: 37-54%). The HEART Pathway using hs-cTnT missed one MACE event (myocardial infarction): sensitivity (91%, 95%CI: 59-100%), specificity (48%, 95%Cl: 39-57%), NPV (98%, 95%Cl: 91-100%), and early discharge rate (45%, 95%Cl: 37-54%).Conclusions: There was no difference in the test characteristics of the HEART Pathway whether using cTnI or hs-cTnI, with both achieving 100% sensitivity and NPV. Use of hs-cTnT with the HEART Pathway was associated with one missed MACE. (C) 2017 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Introduction: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported. Methods and Results: We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period. Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group. Conclusions: Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings. (C) 2016 Elsevier Inc. All rights reserved.

BACKGROUND The no objective testing rule (NOTR) is a decision aid designed to safely identify emergency department (ED) patients with chest pain who do not require objective testing for coronary artery disease. OBJECTIVES The objective was to validate the NOTR in a cohort of U.S. ED patients with acute chest pain and compare its performance to the HEART Pathway. METHODS A secondary analysis of 282 participants enrolled in the HEART Pathway randomized controlled trial was conducted. Each patient was classified as low risk or at risk by the NOTR. Sensitivity for major adverse cardiac events (MACE) at 30 days was calculated in the entire study population. NOTR and HEART Pathways were compared among patients randomized to the HEART Pathway in the parent trial using McNemar's test and the net reclassification improvement (NRI). RESULTS Major adverse cardiac events occurred in 22/282 (7.8%) participants, including no deaths, 16/282 (5.6%) with myocardial infarction (MI), and 6/282 (2.1%) with coronary revascularization without MI. NOTR was 100% (95% confidence interval [CI] = 84.6%-100%) sensitive for MACE and identified 78/282 patients (27.7%, 95% = CI 22.5-33.3%) as low risk. In the HEART Pathway arm (n = 141), both NOTR and HEART Pathway identified all patients with MACE as at risk. Compared to NOTR, the HEART Pathway was able to correctly reclassify 27 patients without MACE as low risk, yielding a NRI of 20.8% (95% CI = 11.3%-30.2%). CONCLUSIONS Within a U.S. cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR.

Introduction: Since 1978, the National Residency Matching Program (NRMP) has published data demonstrating characteristics of applicants who have matched into their preferred specialty in the NRMP main residency match.These data have been published approximately every two years.There is limited information about trends within these published data for students matching into emergency medicine (EM).Our objective was to investigate and describe trends in NRMP data to include the following: the ratio of applicants to available EM positions; United State Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (compared to the national means); number of programs ranked; and Alpha Omega Alpha Honor Medical Society (AOA) membership among U.S. seniors matching into EM.Methods: This was a retrospective observational review of NRMP data published between 2007 and 2016.We analyzed the data using analysis of variance (ANOVA) or Kruskal-Wallis testing, and Fischer's exact or chi-squared testing, as appropriate to determine statistical significance. Results:The ratio of applicants to available EM positions remained essentially stable from 2007 to 2014 but did increase slightly in 2016.We observed a net upward trend in overall Step 1 and Step 2 scores for EM applicants.However, this did not outpace the national trend increase in Step 1 and 2 scores overall.There was an increase in the mean number of programs ranked by EM applicants over the years studied from 7.8 (SD4.2) to 9.2 (SD5.0,p<0.001), driven predominantly by the cohort of U.S. students successful in the match.Among time intervals, there was a difference in the number of EM applicants with AOA membership (p=0.043)due to a drop in the number of AOA students in 2011.No sustained statistical trend in AOA membership was identified over the seven-year period studied. Conclusion:NRMP data demonstrate trends among EM applicants that are similar to national trends in other specialties for USMLE board scores, and a modest increase in number of programs ranked.AOA membership was largely stable.EM does not appear to have become more competitive relative to other specialties or previous years in these categories.

Audience: Medical Students, Interns, Residents, Fellows and Attending Physicians. Introduction: Most residents graduate residency without having the opportunity to perform emergency cricothyrotomy in a real failed airway scenario. Simulation training is therefore often utilized to fulfill residents’ procedural education. Animal tracheas are common models, but there is difficulty maintaining the unattached trachea in appropriate alignment and exposure. This manuscript outlines the materials and steps to reproduce a realistic, reusable cricothyrotomy simulation model and utilize it in training. Methods: Supplies from a local hardware store plus beginner woodworking skills and tools were used to build a pig trachea holding device. This simulation model has been used by the site’s Emergency Medicine residents as a tool for procedural airway training since 2011. Results: The pig trachea simulation model has become a reusable, favorable tool and permanent part of resident skills training sessions, which are held at the beginning of every academic year. A survey was administered which revealed that the model was easy to use, was a good simulation, and improved residents’ comfort level performing a cricothyrotomy. Conclusion: The inexpensive, reusable surgical airway model using a pig trachea holder and cadaveric skin is a useful, high fidelity procedural training tool. It has successfully fulfilled trainees’ need to practice this rare but potentially life-saving procedure.