An operationally implementable predictive model has been developed to forecast the number of COVID-19 infections in the patient population, hospital floor and ICU censuses, ventilator and related supply chain demand. The model is intended for clinical, operational, financial and supply chain leaders and executives of a comprehensive healthcare system responsible for making decisions that depend on epidemiological contingencies. This paper describes the model that was implemented at NorthShore University HealthSystem and is applicable to any communicable disease whose risk of reinfection for the duration of the pandemic is negligible.

Background: The global healthcare burden of COVID-19 continues to rise. There is currently limited information regarding the disease progression and the need for hospitalizations in patients who present to the Emergency Department (ED) with minimal or no symptoms. Objectives: This study identifies bounceback rates and timeframes for patients who return to the ED due to COVID-19 after initial discharge on the date of testing. Methods: Using the NorthShore University Health System's (NSUHS) Enterprise Data Warehouse (EDW), we conducted a retrospective cohort analysis of patients who were tested positive for COVID-19 and were discharged home on the date of testing. A one-month follow-up period was included to ensure the capture of disease progression. Results: Of 1883 positive cases with initially mild symptoms, 14.6% returned to the ED for complaints related to COVID-19. 56.9% of the mildly symptomatic bounceback patients were discharged on the return visit while 39.5% were admitted to the floor and 3.6% to the ICU. Of the 1120 positive cases with no initial symptoms, only four returned to the ED (0.26%) and only one patient was admitted. Median initial testing occurred on day 3 (2-5.6) of illness, and median ED bounceback occurred on day 9 (6.3-12.7). Our statistical model was unable to identify risk factors for ED bouncebacks. Conclusion: COVID-19 patients diagnosed with mild symptoms on initial presentation have a 14.6% rate of bounceback due to progression of illness. Published by Elsevier Inc.

The publication of the Institute of Medicine’s report “To Err is Human” in 1999 served as a call to arms for medical educators to address patient safety issues. Simulation has been proposed as a method that can help identify errors, uncover system and provider vulnerabilities, and promote the practice of safe behaviors. Models and mannequins have allowed a safe space for deliberate practice of procedures. Practicing low frequency, high acuity cases in the simulation lab can improve provider confidence and skills. Additionally, in situ simulation—where a standardized patient or portable mannequin is placed within the work setting and the simulation case is conducted in the typical care area-- has been utilized to train interdisciplinary teams in the environment where clinical care is actually delivered. Effective teamwork is essential for the safe practice of medicine and in situ simulation lends itself well to identify and address failures of communication within teams. While much of the existing research has shown that simulation training improves confidence, communication, and teamwork, demonstrating improved patient safety outcomes has proved elusive. More research is necessary and we hope this chapter will identify areas where further progress simulation research can be conducted to improve patient safety in the emergency department (ED).

To reduce emergency department (ED) chest pain observation and admission rates, a multidisciplinary task force designed and implemented a triage protocol using quantitative symptom scoring (HEART score) and biomarkers for myocardial damage. High-sensitivity troponin-T (hs-TnT) has been shown to be an effective tool in diagnosing patients with suspected acute coronary syndrome (ACS) in the ED.1 2 The protocol risk stratified patients by HEART score and hs-TnT into low risk (HEART score 0–3 and normal hs-TnT in two separate measurements in 2-hour intervals), intermediate risk (HEART score 4–6 and hs-TnT <100 ng/L) and high risk (HEART score ≥7 or hs-TnT ≥100 ng/L).2 3 Normal values of hs-TnT were defined according to the manufacturer labelling of sex-specific 99th percentile from healthy reference population (females <14 ng/L; males <22 ng/L). By the protocol, patients with low risk for ACS can be discharged with close follow-up. Patient with high risk for ACS would be admitted to the hospital for further workup while those with intermediate risk were to undergo same, or next day, cardiovascular imaging with subsequent decision to admit or discharge home. The protocol was implemented in March 2019. The COVID-19 …

Objective: Combating Coronavirus 2019 has stretched hospital resources to the extreme. In an effort to cohort personnel and equipment, NorthShore University HealthSystem (NSUHS) designated Glenbrook Hospital (GBH) as our “COVID hospital”, which became public knowledge on April 6, 2020. We hypothesize that with this public declaration our emergency department (ED) total volumes and COVID-19 related visits would be affected.Methods: We performed a retrospective analysis of our total ED volumes and COVID-19 related ED visits from March 12, 2020 until April 30, 2020. The pre public declaration timeframe of March 12-April 5, 2020 acted as our control whereas the post-public declaration acted as the testing group (April 6-April 30, 2020). NSUHS four primary hospitals were included in the analysis. We ran a chi-squared analysis on both groups to determine if there was statistical significance.Results: Both total ED volumes and COVID-19 related ED visits, when comparing pre VS post-public declaration of GBH as the “COVID hospital”, showed statistical significance (p < .001). Three of the four hospitals had a decrease in total ED volumes, whereas the COVID-19 related ED visits increased at two hospitals and decreased at the others.Conclusions: Our results support our hypothesis that after the public declaration of Glenbrook Hospital as the “COVID hospital”, patients’ decision making regarding which ED to visit was significantly affected. Certain limitations, including socioeconomic status and a small geographical footprint of NSUHS, may have affected our results. Further work should be done to reproduce these results to ensure replication.

AEM Education and TrainingVolume 4, Issue S1 p. S140-S142 Commentary And Perspective Structural Competency: What Is It, Why Do We Need It, and What Does the Structurally Competent Emergency Physician Look Like? Ernest E. Wang MD, FACEP, Corresponding Author Ernest E. Wang MD, FACEP [email protected] [email protected] orcid.org/0000-0001-8312-2553 NorthShore University HealthSystem, Evanston, IL Address for correspondence and reprints: Ernest E. Wang MD, FACEP; e-mails: [email protected]; [email protected]Search for more papers by this author Ernest E. Wang MD, FACEP, Corresponding Author Ernest E. Wang MD, FACEP [email protected] [email protected] orcid.org/0000-0001-8312-2553 NorthShore University HealthSystem, Evanston, IL Address for correspondence and reprints: Ernest E. Wang MD, FACEP; e-mails: [email protected]; [email protected]Search for more papers by this author First published: 24 November 2019 https://doi.org/10.1002/aet2.10415Citations: 1 Related articles appear on pages S88. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Salhi BA, Tsai JW, Druck J, Ward-Gaines J, White MH, Lopez BL. Toward structural competency in emergency medical education. Acad Emerg Med 2020; 27. 2Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med 2014; 103: 126–33. Citing Literature Volume4, IssueS1Special Issue: Proceedings from the 2019 Society for Academic Emergency Medicine Annual MeetingFebruary 2020Pages S140-S142 ReferencesRelatedInformation

ObjectiveThe objective was to compare attending emergency physician (EP) time spent on direct and indirect patient care activities in emergency departments (EDs) with and without emergency medicine (EM) residents. MethodsWe performed an observational, time-motion study on 25 EPs who worked in a community-academic ED and a nonacademic community ED. Two observations of each EP were performed at each site. Average time spent per 240-minute observation on main-category activities are illustrated in percentages. We report descriptive statistics (median and interquartile ranges) for the number of minutes EPs spent per subcategory activity, in total and per patient. We performed a Wilcoxon two-sample test to assess differences between time spent across two EDs. ResultsThe 25 observed EPs executed 34,358 tasks in the two EDs. At the community-academic ED, EPs spent 14.2% of their time supervising EM residents. Supervision activities included data presentation, medical decision making, and treatment. The time spent on supervision was offset by a decrease in time spent by EPs on indirect patient care (specifically communication and electronic health record work) at the community academic ED compared to the nonacademic community ED. There was no statistical difference with respect to direct patient care time expenditure between the two EDs. There was a nonstatistically significant difference in attending patient load between sites. ConclusionsEPs in our study spent 14.2% of their time (8.5 minutes/hour) supervising residents. The time spent supervising residents was largely offset by time savings related to indirect patient care activities rather than compromising direct patient care.

The aim of this study was to assess the effect of a dynamic electronic cognitive aid with embedded clinical decision support (dCA) versus a static cognitive aid (sCA) tool. Anesthesia residents in clinical anesthesia years 2 and 3 were recruited to participate. Each subject was randomized to one of two groups and performed an identical simulated clinical scenario. The primary outcome was task checklist performance with a secondary outcome of performance using the Anesthesia Non-technical skills (ANTS) scoring system. 34 residents were recruited to participate in the study. 19 residents were randomized to the sCA group and 15 to the dCA group. Overall inter-rater agreement for total checklist, malignant hyperthermia, hyperkalemia and ventricular fibrillation was 98.9%, 97.8%, 99.5% and 99.5% respectively with similar Kappa coefficient. Inter-rater agreement for ANTS partial ratings, however, was only 53.5% with a similar Kappa of 0.15. Mean performance was statistically higher in the dCA group versus the sCA group for total check list performance (15.70 ± 1.93 vs 12.95 ± 2.16, p < 0.0001). The difference in performance between dCA and sCA is most notable in dose-dependent related checklist items (4.60 ± 1.3 vs 1.89 ± 1.23, p < 0.0001), while the performance score for dose-independent checklist items was similar between the two groups (p = 0.8908). ANTS ratings did not differ between groups. In conclusion, we evaluated the use of a sCA versus a dCA with embedded decision support in a simulated environment. The dCA group was found to perform more checklist items correctly.

Summary Statement In 2014, the six allopathic emergency medicine (EM) residency programs in Chicago established an annual, citywide, simulation-based assessment of all postgraduate year 2 EM residents. The cases and corresponding assessment tools were designed by the simulation directors from each of the participating sites. All assessment tools include critical actions that map directly to numerous EM milestones in 11 different subcompetencies. The 2-hour assessments provide opportunities for residents to lead resuscitations of critically ill patients and demonstrate procedural skills, using mannequins and task trainers respectively. More than 80 residents participate annually and their assessment experiences are essentially identical across testing sites. The assessments are completed electronically and comparative performance data are immediately available to program directors.

The HEART score has been prospectively validated to risk stratify emergency department (ED) patients with chest pain. We implemented a mandatory HEART score calculation into the electronic health record (EHR): 1) to determine the impact of the HEART score on ED chest pain observation rates, and 2) to evaluate the effect of an EHR hard-stop on HEART score documentation. We examined ED chest pain dispositions across an integrated 4-hospital health care system for all patients who presented with chest pain or had non-specific chest pain diagnoses (“Other chest pain”; “Chest pain, unspecified”; “Precordial pain”; “Intercostal pain”) as a final diagnosis from March 2017 through May 2018. All patients were required to have a calculated HEART score by the treating physician prior to discharge or admission after the initial “Go-Live” date in March 2017. Subsequent EHR hard-stops were implemented June 2017 (for admissions) and August 2017 (for discharges). Patients with scores of 0-3 could be considered for ED discharge, scores of 4-6 were admitted as observation status, and scores >=7 were appropriate for full inpatient status admission. Data abstraction from the EHR were used to calculate the percentage of patients discharged, placed in observation, and admitted as an inpatient. A total of 4,198 patients who met the inclusion criteria presented to the ED between March 2017 and May 2018. Observation rates after HEART score implementation have decreased by 8.7% (51.8% down to 43.1%). This decline is due to both higher number of ED discharges and full inpatient admissions. Emergency physician disposition demonstrated significant concordance with initial HEART score. Patients with a low score (0-3) were discharged at a significantly higher rate (p<0.001), patients with a medium score (4-6) were admitted to observation status at a significantly higher rate (p<0.001), and patients with a high HEART score were admitted as inpatient status at a significantly higher rate (p<0.001). There was no statistically significant change in 30-day mortality (p-value=0.957). Implementation of a mandatory HEART score calculation in ED chest pain patients reduces ED observation admission rates with no change in 30-day mortality.

BACKGROUND Although many studies have illustrated the discomfort that resident physicians feel when discussing end-of-life (EOL) issues with their patients, fewer studies have addressed interventions to directly increase medical resident proficiency and comfort in conducting these discussions and for translating these beliefs into a formal advance care plan. OBJECTIVES We report on an innovative curriculum conducted at The University of Chicago (NorthShore) internal medicine residency to improve residents' proficiency and comfort in leading outpatient advance care planning (ACP) discussions. METHODS Four educational components were executed. First, residents completed an on-line module introducing ACP and guiding residents to complete their own ACP. Second, residents attended a didactic "How To" lecture given by physicians with expertise in ACP that emphasized ACP communication tools and a video demonstration. Third, residents completed a video-recorded simulation-based ACP discussion with a standardized patient. Finally, residents conducted an ACP outpatient encounter with one of their continuity clinic patients. Expert preceptors directly observed, evaluated, and provided feedback to residents during both patient encounters. Residents were surveyed before and immediately after the curriculum using a nine-variable questionnaire, which assessed the resident's training and comfort with ACP. RESULTS Sixteen second year residents completed the curriculum and surveys. Precurriculum and post-curriculum mean change on a Likert scale of 1 (uncomfortable) to 5 (very comfortable) was compared using paired t-tests. Results demonstrated statistically significant improvements in the following comfort level variables: eliciting understanding of health and prognosis (pre 3.63 vs. post 4.38, p = 0.035), discussing EOL care based on patient values (pre 3.50 vs. post 4.38, p = 0.008), specifically discussing EOL care based on patient values in the outpatient setting (pre 2.75 vs. post 4.31, p = 0.001) and initiating an advance directive and medical power of attorney (pre 2.56 vs. post 4.19, p < 0.001). CONCLUSION A multimodality curriculum including self-directed learning, lectures, and practice with simulated and actual outpatients with active reflection and feedback is effective in improving resident comfort level and formal training in ACP. Further research is needed to understand whether these interventions will translate into an increased frequency of discussions with patients about ACP after residency training.

Introduction According to the Accreditation Council for Graduate Medical Education emergency medicine requirements established before the popularity of video laryngoscopy (VL) use, 35 intubations are necessary for graduation. Our study aimed to establish a mastery-learning model for a skill set very different (VL) from direct laryngoscopy (DL) and to determine the number of attempts needed to achieve mastery with VL. Methods With the use of a randomized, controlled crossover study design, two learner groups underwent baseline testing intubating a mannequin using VL. Afterward, the intervention group received a mastery training intervention. After training, learners were required to repeat the procedure until achievement of 100% on the checklist for two consecutive attempts was achieved. After 3 months, both groups returned for retesting, and the control group received the same mastery training as the intervention group. Both groups returned for final testing after another 3 months. Results The intervention arm had an improvement in performance versus the control arm at 3 months of total time (P < 0.05). Both groups had an improvement within their groups’ checklist scores at 3 months after training (P < 0.05), and within the intervention arm, this effect was sustained at 6 months (P < 0.05). There was no significant difference in the mean required attempts to demonstrate mastery (overall, 2.5; intervention, 2.75; control 2.25; P = 0.28). Conclusions Simulation-based mastery-learning produces skill enhancement with VL that is resistant to decay across 6 months. Furthermore, although a small number of attempts are needed to achieve mastery, clinical experience did not substitute as a proxy for skill acquisition. This mastery-learning model provides skill sets that are not otherwise obtained in the clinical curriculum in a 3-month period.

Traumatic brain injury (TBI) is one of the leading causes of injury-related death. In the United States alone, an estimated 1.7 million people sustain a TBI each year, and approximately 5.3 million people live with a TBI-related disability. The direct medical costs and indirect costs such as lost productivity of TBIs totaled an estimated $76.5 billion in the U.S. in the year 2000. Improving the limited treatment options for this condition remains challenging. However, recent reports from interdisciplinary working groups (consisting primarily of neurologists, neurosurgeons, neuropsychologists, and biostatisticians) have stated that to improve TBI treatment, important methodological lessons from the past must be taken into account in future clinical research. An evaluation of the neuroprotection intervention studies conducted over the last 30 years has indicated that a limited understanding of the underlying biological concepts and methodological design flaws are the major reasons for the failure of pharmacological agents to demonstrate efficacy. Cerebrolysin is a parenterally-administered neuro-peptide preparation that acts in a manner similar to endogenous neurotrophic factors. Cerebrolysin has a favorable adverse effect profile, and several meta-analyses have suggested that Cerebrolysin is beneficial as a dementia treatment. CAPTAIN is a randomized, double-blind, placebo-controlled, multi-center, multinational trial of the effects of Cerebrolysin on neuroprotection and neurorecovery after TBI using a multidimensional ensemble of outcome scales. The CAPTAIN trial will be the first TBI trial with a 'true' multidimensional approach based on full outcome scales, while avoiding prior weaknesses, such as loss of information through "dichotomization," or unrealistic assumptions such as "normal distribution."

OBJECTIVE:To characterize complication and failure rates and outcomes of patients who underwent cranioplasty with polyetheretherketone (PEEK) and titanium implants and to compare complication and failure rates between the 2 implants.METHODS:A retrospective cohort study of patients who underwent cranioplasty with PEEK patient-specific implant (PEEK Optima-LT) and preformed titanium mesh at the National Neuroscience Institute, Singapore, between January 2001 and February 2012 was performed. Data related to initial decompressive craniectomy and cranioplasty, associated complications after cranioplasty, and indication for revision or removal of implants were collected. Cranioplasty failure was defined as revision or removal of a patient's implant.RESULTS:Overall complication rates for PEEK and titanium cranioplasty were 25.0% and 27.8%, respectively. The combined complication rate was 27.3%. A trend toward increase in exposed implant in titanium cranioplasty compared with PEEK cranioplasty was observed (P = 0.074). There were 3 of 24 (12.5%) cranioplasty failures with PEEK, and 27 of 108 (25%) cranioplasty failures with titanium (P = 0.129). Previous deep infection in patients after decompressive craniectomy was associated with cranioplasty complications (odds ratio, 23.3; confidence interval, 3.00-180.5; P = 0.003) and failure (odds ratio, 22.5; confidence interval, 2.82-179.0; P = 0.003).CONCLUSIONS:The findings from this study highlight that cranioplasty is associated with significant complications, including the necessity for reoperation. It is hoped that the information in this study will provide better understanding of the risks associated with PEEK and titanium cranioplasty and contribute to decision making by the clinician and patient.

Thrombosis of the inferior vena cava due to compression of the inferior vena cava by a hepatic haematoma is seemingly rare. We present a case of a 56-year-old female with a hepatic haematoma after blunt trauma that caused this type of compression. The constriction resulted in the formation of an inferior vena cava thrombus, and considering the contraindication to anticoagulation, we placed a retrievable inferior vena cava filter under standard fluoroscopy. This case stresses the need for systematic investigation of the abdomen, especially after a blunt trauma, which can cause compression of the inferior vena cava. Furthermore, inferior vena cava thrombosis should be considered in patients with compression of the inferior vena cava due to hepatic haematoma.

Simulation-based training and assessment have gained traction in medical education, though their usefulness to preclinical students remains unclear. Our objectives were to determine (1) the feasibility of a simulation module for teaching students with little or no previous experience in managing undifferentiated, acutely ill patients and (2) its impact on students’ knowledge and attitudes about critical care.