Background Health care quality reviews are often thought to be of limited value as they react to human behavior rather than reflect varied processes throughout the healthcare system. Objective To evaluate if questioning ED physician reviewers as to whether they would have done something differently (WYHDSD) can be a useful marker to improve patient care processes in the emergency department. Methods Prospective data were collected on all patients presenting to an academic medical center ED with an annual census of 55,000 patients between November 2017 and November 2021. All cases who met the following standard criteria were identified for review by an electronic medical record system: 1) returned to the ED within 72 h and admitted on second visit; 2) admitted from the ED to the floor and then transferred to the ICU within 24 h; 3) expired within 24 h of ED arrival; or 4) were referred to the QA committee as the result of physician or patient complaints. Cases were randomly assigned to EM physicians not involved in the patient's care. After cases were reviewed using a structured electronic tool to assess for error and adverse events, reviewers were mandated to report whether they would have done anything differently (WYHDSD) in the management of the case. If a reviewer answered affirmatively, they were required to document specifics in a narrative format. Results During the study period, 6773 cases were reviewed. There were 815 cases where reviewers would have done something differently. In 297 cases, reviewers would have done something differently even though there were no near misses or adverse events found by standard QA reviews. Of those 297 cases, 261 of the WYHDSD responses were found to be due to 1 of the 5 following issues: communication, not acting on data acquired, not acquiring necessary information, systems issue/preventative measures, and knowledge gaps of clinicians. Conclusion Asking reviewers if they would have done something differently could potentially be a useful quality marker to improve patient care systems in the ED even in cases where reviewers did not identify errors or adverse events.

Importance:Urgent care (UC) centers have proliferated rapidly, yet research on how utilization has changed among older adults is limited. Objectives:To examine UC utilization among older adults and assess whether utilization rates varied by beneficiary sociodemographic and community characteristics. Design, Setting, and Participants:This cross-sectional study used data from a 20% national sample of fee-for-service Medicare beneficiaries aged 65 years or older using UC centers from January 1, 2012, to December 31, 2019. Statistical analysis was performed from May 1, 2021, to November 24, 2025. Main Outcome and Measures:Among Medicare beneficiaries aged 65 years or older, unadjusted UC visits were calculated by year from 2012 to 2019 overall and stratified by demographic characteristics, frailty, community rurality, Social Deprivation Index (SDI), and physician supply. Adjusted incidence rate ratios (IRRs) were calculated for UC visits in 2018 and 2019 using negative binomial models. Trends in the distribution of UC visits among the most frequent clinician specialty categories (primary care, emergency medicine, and advanced practice practitioners [APPs]) were examined using linear models. Results:There were 3 516 816 UC visits among 9 514 946 beneficiaries (mean [SD] age across visits, 75.2 [7.5] years; 63.4% women). UC visits increased from 47.7 to 117.2 per 1000 from 2012 to 2019 (9.0 [95% CI, 9.0-9.1] visits per 1000 per year). The growth in UC utilization was slowest for beneficiaries aged 85 years or older (4.0 [95% CI, 3.8-4.1] visits per 1000 per year), Medicaid-eligible beneficiaries (4.0 [95% CI, 3.9-4.2] visits per 1000 per year), those residing in communities that were rural (5.0 [95% CI, 4.8-5.2] visits per 1000 per year), thow who were disadvantaged (6.8 [95% CI, 6.0-7.6] visits per 1000 per year), and those with fewer physicians (7.2 [95% CI, 5.5-8.8] visits per 1000 per year). In 2018 and 2019, beneficiaries residing in rural communities had 45% lower adjusted UC utilization compared with urban communities (IRR, 0.55 [95% CI, 0.54-0.55]) and those residing in zip codes in the SDI fourth quartile had 23% lower adjusted UC utilization (IRR, 0.77 [95% CI, 0.77-0.78]) compared with those in the most advantaged quartile. The percentage of beneficiaries managed by APPs increased from 21.0% in 2012 to 50.8% in 2019. Conclusions and Relevance:In this cross-sectional analysis, UC utilization increased markedly among older adults, with a disproportionate concentration in urban, less-disadvantaged communities. The distribution of clinician training and specialty also changed, with APPs delivering care for more than half of UC visits among older adults in 2019. These findings highlight the evolving patterns of acute care delivery for this growing population and the need for additional evidence on how these trends are associated with patient-centered outcomes and the efficiency of care.

Urgent care centers play an increasingly vital role in the health care landscape as demand for timely and episodic care rises because of primary care shortages and crowded emergency departments (EDs). Urgent care centers serve as a critical bridge between primary and emergency care, but significant variability exists in their scope of practice, staffing, equipment, and available services. This variation leads to corresponding differences in the types of patient illnesses, injuries, acuity, and complexity that an individual urgent care center can appropriately evaluate and treat. Some urgent care centers can manage only very minor illnesses (eg, simple lacerations and uncomplicated pharyngitis), whereas others have staffing and resources (eg, advanced laboratory testing and imaging) necessary to manage more complex illnesses (eg, abdominal pain and minor head trauma in patients taking anticoagulation therapies). Additionally, the training and specialty of urgent care providers varies, including physicians trained in internal medicine, family practice, and emergency medicine, as well as nurse practitioners and physician assistants. Emergency physicians, in particular, are positioned to enhance the ability of urgent care centers to manage a broad spectrum of clinical presentations, reduce unnecessary ED transfers, and improve care quality and efficiency. Despite these important differences in staffing and capabilities, there is a striking lack of research and data about the position and effect of urgent care centers on the health care system in general, as well as the ability to offload crowded EDs in particular. We hypothesize that in order to optimally study the role of urgent care centers in the health care system, there is a need to categorize and study the different types of urgent care centers based on their individual capabilities and the populations that they each serve. To provide a framework for this type of study, this paper proposes a 5-tier model of urgent care capability based on clinical and operational factors, including provider qualifications, diagnostic testing capabilities, hours of operation, and integration with larger health systems. This is a system that differentiates urgent care centers based on capabilities into discrete tiers with a goal to optimize the study of which model will optimally fill the needs of acute, unscheduled care while supporting health system efficiency.

Error is often difficult to define. The objective of this study was to determine reliability of EM physician quality reviews in detecting medical error. Retrospective data were collected in an academic ED, with an annual census of 57,000, from 11/2012-11/2024. Cases reviewed were 1) returns to ED <72 h and admitted; 2) admissions from the ED to the floor and transferred to the ICU <24 h; 3) expired <24 h of ED arrival; 4) referred for QA review from provider or patient complaints. All cases were randomly assigned to a QA-trained EM physician not involved in the patient's care. Reviewers used an 8-point Likert scale to assess whether an error occurred, categorized as either definite, possible, judgment call, or no error. To help quantify level of agreement, random cases were assigned to at least 2 reviewers, with agreement assessed using Cohen's Kappa. Reviewer agreement was categorized into complete agreement, slight discordance, and higher levels of discordance with and without weights. Of 19,200 reviews, 1845 had 2 reviewers (9.6 %). There was moderate agreement when using a Likert scale with weights, (Kappa = 0.43[0.39-0.44]) and a grouped scale with weights, Kappa of 0.44 (0.38-0.47 when Likert ratings were grouped into no error (1), possible (2), probable(3), and definite (4-8). When comparing complete agreement between reviewer as to the likelihood of error, agreement diminished. When reviewers agreed on the presence of an error, they disagreed on its severity, both in weighted and unweighted analyses. Reviewers tended to agree when an error was an error. These findings underscore the need for standardized error classification frameworks to ensure reliability of reviews.

This letter, signed by over 50 academic chairs of emergency medicine, urges the ACGME to reconsider a proposed mandate requiring all emergency medicine residency programs to adopt a four-year training model. The authors argue that current three-year programs are supported by data demonstrating equivalent educational and clinical outcomes compared to four-year formats. They criticize the flawed survey methodology underpinning the proposal, note the loss of milestone-based training flexibility, and highlight the lack of added scholarly or clinical value in the fourth year. The letter also outlines negative consequences for fellowship participation, workforce development, trainee debt, and diversity. The signatories advocate for maintaining the current flexible training model to preserve excellence, equity, and innovation in emergency medicine education.

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients—actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

Rising length of stay and inpatient boarding in emergency departments have directly affected patient satisfaction and nearly all provider-to-patient care metrics. Prior studies suggest that ED observation has significant clinical and financial benefits including decreasing hospitalization and length of stay. ED observation is one method long employed to shorten ED length of stay and to free up inpatient beds, yet many patients continue to be admitted to the hospital with an average hospital length of stay of only one day. The objectives of this study were to evaluate whether vigorous tracking and provider reviews of one day hospital admits affected the utilization of ED observation and whether this correlated with significant change in rates of admission from observation status. Between September 2020 and May 2021, in a tertiary care hospital with an annual ED volume of 55,0000, chart reviews of 24-h inpatient discharges were initiated by two senior EM faculty to determine perceived suitability for ED observation. Non-punitive email reviews were then initiated with ED attending providers in order to encourage evaluation of whether these patients would have benefitted from being placed into observation. We then analyzed ED observation patient volumes and subsequent admission rates to the hospital from ED observation and compared these numbers to baseline ED observation volume and admission rates between September 2018 and May 2019. A total of 1448 reviews were conducted on 24-h discharges which correlated with an increase in utilization of ED observation from 11.77% (95% CI [11.62, 12.31]) of total ED volume in our control period to 14.21% (95% CI [13.84, 14.58]) during the study period. We found that the overall admission rate from ED observation increased from 20.12% (95% CI [18.97, 21.26]) baseline to 23.80% (95% CI [22.60, 25.00]) during the same time periods. Our data suggest that increasing the total number of patients placed into observation by 21% correlated with a relative increase in admission rates from ED observation by 18%. This would suggest that our efforts to potentially include more patients into our observation program led to a significant increase in subsequent admission rates. There is likely a balance that must be struck between under- and over-utilization of ED observation, and expanding ED observation may be an effective solution to hospital boarding and ED overcrowding.

A collection of portraits of M & amacr;ori, painted in Nelson in the early 1840s by English-born Isaac Coates, was rediscovered in 2005 at the Pitt Rivers Museum, Oxford. The subjects include Ng & amacr;ti Toa rangatira (chief) Te Rauparaha, and while others remain unidentified, the collection-the subject of a 2012 publication-is recognised as an invaluable historical record. It represents a wide range of M & amacr;ori society, at a time of widespread disruption and demographic change. It is likely the collection entered the Pitt Rivers between 1887 and 1902, a period of British imperial expansion when Indigenous material was being amassed and fitted into European notions of social development. The Pitt Rivers, whose extensive M & amacr;ori and Pacific holdings include its Cook-Voyage Collections, has recently carried out major changes to displays which reinforced stereotypical attitudes towards Indigenous cultures. More broadly, museums are now recognising the part colonialism played in the formation of their collections. This has resulted in a number of instances of repatriation, as in the return of stolen M & amacr;ori and Moriori ancestral remains to Te Papa Tongarewa Museum of New Zealand in 2022. Discussions continue, as on such well-known cases as the Parthenon marbles, held in the British Museum, and Benin objects resulting from a British punitive expedition in 1897 and now held in a large number of institutions worldwide

Background Error in emergency medicine remains common and difficult to identify. Objective To evaluate if questioning emergency physician reviewers as to whether or not they would have done something differently (Would you have done something differently? [WYHDSD]) can be a useful marker to identify error. Methods Prospective data were collected on all patients presenting to an academic emergency department (ED) between 2017 and 2021. All cases who met the following criteria were identified: 1) returned to ED within 72 h and admitted; 2) transferred to intensive care unit from floor within 24 h of admission; 3) expired within 24 h of arrival; or 4) patient or provider complaint. Cases were randomly assigned to emergency physicians and reviewed using an electronic tool to assess for error and adverse events. Reviewers were then mandated to answer WYHDSD in the management of the case. Results During the study period, 6672 cases were reviewed. Of the 5857 cases where reviewers would not have done something differently, 5847 cases were found to have no error. The question WYHDSD had a sensitivity of 97.4% in predicting error and a negative predictive value of 99.8%. Conclusion There was a significantly higher rate of near misses, adverse events, and errors attributable to an adverse event in cases where the reviewer would have done something differently (WHDSD) compared with cases where they would not. Therefore, asking reviewers if they WHDSD could potentially be used as a marker to identify error and improve patient care in the ED.

Emergency department (ED) crowding poses significant operational challenges to hospitals. One strategy to address these issues is the implementation of an ED observation (EDO) unit. EDO involves placing patients in observation status after their initial evaluation, allowing for continued assessment, treatment, and the determination of a safe disposition. This paper provides a comprehensive guide for ED leaders on the implementation of ED observation in their departments. It includes a checklist summarizing key implementation points, operational and financial considerations, staffing and location planning, patient selection, clinical care protocols, documentation and communication processes, securing buy-in from stakeholders, and outcome measurement. The guide also highlights the updated billing codes based on the 2023 updated Current Procedural Terminology (CPT) guidelines. Successful implementation of an EDO program has shown benefits such as improved patient flow, enhanced revenue generation, reduced costs, and comparable clinical outcomes. This guide aims to equip ED leaders with the necessary knowledge and tools to implement and manage an effective ED observation program in their departments, ultimately improving the overall efficiency of emergency care delivery.

Background: There is a paucity of data looking at resident error or contrasting errors and adverse events among residents and attendings. This type of data could be vital in developing and enhancing educational curricula Objectives: Using an integrated, readily accessible electronic error reporting system the objective of this study is to compare the frequency and types of error and adverse events attributed to emergency medicine residents with those attributed to emergency medicine attendings.Methods: Individual events were classified into errors and/or adverse events, and were attributed to one of three groups-residents only, attendings only, or both (if the event had both resident and attending involvement). Error and adverse events were also classified into five different categories of events-systems, documentation, diagnostic, procedural and treatment. The proportion of error events were compared between the residents only and the attendings only group using a one-sample test of proportions. Categorical variables were compared using Fisher's exact test.Results: Of a total of 115 observed events over the 11-month data collection period, 96 (83.4%) were errors. A majority of these errors, 40 (41.7%), were attributed to both residents and attendings, 20 (20.8%) were attributed to residents only, and 36 (37.5%) were attributed to attendings only. Of the 19 adverse events, 14 (73.7%) were attributed to both residents and attendings, and 5 (26.3%) adverse events were attributed to attendings only. No adverse events were attributed solely to residents (Table 1). Excluding events attributed to both residents and attendings, there was a significant difference between the proportion of errors attributed to attendings only (64.3%, CI: 50.6, 76.0), and residents only (35.7%, CI: 24.0, 49.0), p = 0.03. (Table 2). There was no significant difference between the residents only and the attendings only group in the distribution of errors and adverse events (Fisher's exact, p = 0.162). (Table 2). There was no statistically significant difference between the two groups in errors that did not result in adverse events and the rate of errors proceeding to adverse events (Fisher's exact, p = 0.15). (Table 3). There was no statistically significant difference between the two groups in the distribution of the types of errors and adverse events (Fisher's exact, p = 0.09). Treatment related errors were the most common error types, for both the attending and the resident groups. Conclusions: Resident error, somewhat expectedly, is most commonly related to treatment interventions, and rarely is due to an individual resident mistake. Resident error instead seems to reflect concomitant error on the part of the attending. Error, in general as well as adverse events, are more likely to be attributed to an attending alone rather than to a resident.(c) 2022 Elsevier Inc. All rights reserved.

Altered mental status (AMS) is frequently associated with poor outcomes across a wide spectrum of conditions including infections. This study aims to identify whether AMS in emergency department (ED) patients with COVID-19 is independently associated with in-hospital mortality. This was a retrospective multicenter cohort study. We included all patients with a positive SARS-CoV-2 PCR within 2 weeks of presentation, who were admitted from the ED of three hospitals in the greater Boston area between March and August 2020. The primary covariate of interest was ED AMS at ED arrival and the primary outcome was in-hospital mortality. The ED charts were abstracted for demographics, comorbid conditions, symptoms, laboratory testing, and radiology testing along with in-hospital outcomes. AMS was defined by documentation of changes in mental status from baseline. We used logistic regression modeling with backwards elimination to determine an adjusted estimate for the independent association of AMS with mortality. We included 824 visits with 51% male, a mean age was 67.1 (SD 17.0) and 153 (18.6%) had AMS. There were 132 deaths for an overall mortality rate of 16.1%. Patients with AMS had in-hospital mortality of 38.2% (95% CI 30.4%-46.4%), compared to 11.1% (8.8%-13.7%) for patients without AMS (p<0.0001). After adjusting for potential confounders, visits by patients with AMS during their stay at the ED had 3.1 (95% CI, 2.1-5.9) times the odds of death compared to those without AMS. Among patients with COVID-19, AMS in the ED was associated with three-fold increase in mortality compared to patients without AMS.

BACKGROUND:The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs).METHODS:The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education.RESULTS:Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills.CONCLUSIONS:APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

In the midst of the coronavirus pandemic, the chronic issue of police brutality directed toward Black Americans reached a tipping in late May with the brutal murder of George Floyd. The social response raised equity and justice awareness, kickstarting one of the largest movements in U.S. history. A national dialogue on systemic racism as a public health concern has reemerged. Though traditionally viewed as taboo within academic medicine, the dialogue surrounding racial inequality is unavoidable.

AbstractIntroductionThe evaluation of peer‐reviewed cases for error is key to quality assurance (QA) in emergency medicine, but defining error to ensure reviewer agreement and reproducibility remains elusive. The objective of this study was to create a consensus‐based set of rules to systematically identify medical errors.MethodsThis is a prospective, observational study of all cases presented for peer review at an urban, tertiary care, academic medical center emergency department (ED) quality assurance (QA) committee between October 13, 2015, and September 14, 2016. Our hospital uses an electronic system enabling staff to self‐identify QA issues for subsequent review. In addition, physician or patient complaints, 72‐hour returns with admission, death within 24 hours, floor transfers to ICU < 24 hours, and morbidity and mortality conference cases are automatic triggers for review. Trained reviewers not involved in the patient's care use a structured 8‐point Likert scale to assess for error and preventable or non‐preventable adverse events. Cases where reviewers perceived a need for additional treatment, or that caused patient harm, are referred to a 20‐member committee of emergency department leadership, attendings, residents, and nurses for consensus review. For this study, “rules” were proposed by the reviewers identifying the error and validated by consensus during each meeting. The committee then decided if a rule had been broken (error) or not broken (judgment call). If an error could not be phrased in terms of a rule broken, then it would not be considered an error. The rules were then evaluated by 2 reviewers and organized by theme into categories to determine common errors in emergency medicine.ResultsWe identified 108 episodes of rules broken in 103 cases within a database of 920 QA reviewed cases. In cases where a rule was broken and therefore an error was scored, the following 5 major themes emerged: (1) not acquiring necessary information (eg, not completing a relevant physical exam), N = 33 (31%); (2) not acting on data that were acquired (eg, abnormal vital signs or labs), N = 25 (23%); (3) knowledge gaps by clinicians (eg, not knowing to reduce a hernia), N = 16 (15%); (4) communication gaps (eg, discharge instructions), N = 17 (16%); and (5) systems issues (eg, improper patient registration), N = 17 (16%).ConclusionThe development of consensus‐based rules may result in a more standardized and practical definition of error in emergency medicine to be used as a QA tool and a basis for research. The most common type of rule broken was not acquiring necessary information. A rule‐based definition of medical error in emergency medicine may identify key areas for risk reduction strategies, help standardize medical QA, and improve patient care and physician education.

Background: Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings. Methods: All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed. Results: 350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p < 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p < 0.001). Conclusions: There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings showincreased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience. (c) 2019 Elsevier Inc. All rights reserved.

Burnout is a work-related condition. Although stress may be a part of emergency medicine, excessive levels of chronic stress can lead to maladaptive behaviors and burnout. Burnout can lead to decreased physician longevity and performance and poorer patient outcomes. The first step is recognizing burnout in providers. Efforts can then be made to identify modifiable or unnecessary sources of stress to help reduce chronic stress and burnout. Solutions should be found to eliminate or ameliorate individual-level and system-level sources of stress.