Abstract Background Emergency physicians face considerable workflow challenges in the emergency department (ED) due to unpredictable work environments, frequent interruptions, and mounting documentation requirements, all of which contribute to substantial computer-based work. Excessive time away from direct patient care is increasingly viewed as detrimental to the quality of care, communication, and patient safety. Objective This study aimed to quantify and visualize how emergency physicians allocate their time during ED shifts, particularly the time spent on the computer. Methods This cross-sectional observational time-motion study was conducted in a high-volume, urban ED. We used the validated TimeCaT application to continuously track physician activities, including computer use, direct patient care, communication, and all other tasks carried out during the shift. Electronic health record event log data were queried to estimate physicians’ computer use after their scheduled shift. The main outcome was the proportion of time spent on each activity. The primary measure was the total minutes of computer use (during and after the shift) per scheduled hour of clinical work. Additionally, we generated data visualizations to illustrate ED workflow-sequencing, task switching, and between-shift variability. Results We observed 20 emergency physicians for one 8- to 9-hour clinical shift each, generating over 150.0 hours of real-time observation data quantifying physicians’ ED workflow. Physicians spent a median of 34.1% of their shift minutes using the computer (156.5, IQR 145.2-179.3 min) and 26.9% with patients (115.2, IQR 102.0-154.1 min). Other activities included 15.9% for verbal communication with staff (73.3, IQR 45.6-96.4 min), 9.5% phone use (41.4, IQR 33.4-59.2 min), 5.5% miscellaneous tasks (24.2, IQR 18.4-30.1 min), 3.9% personal time (16.8, IQR 9.9-25.4 min), 0.7% electrocardiogram review (3.8, IQR 1.4–5.0 min), and 0.4% other procedures (median 1.7, IQR 0.6-6.4 min). Electronic health record log analysis showed that physicians spent an additional median 1.3 (IQR 0.5‐2.6) hours using the computer after their scheduled shifts, for a combined 29.8 (IQR 25.6‐38.5) minutes on the computer per scheduled hour of their ED shift. Workflow visualizations showed frequent alternation among activity categories and noticeable variability in within-shift fragmentation across physicians. Conclusions Emergency physicians spent more than one-third of their ED shift working on the computer, which was more time than they spent with patients. They also spent 1 to 2 hours using the computer after their scheduled shift. These findings demonstrate the need for strategies to reduce unnecessary computer use during and after clinical shifts to enhance workflow efficiency and improve patient care.

Study objective To develop definitions of (1) diagnostic excellence and (2) missed diagnostic opportunity to guide research and quality/safety programs in the emergency department (ED). Methods We used a modified RAND/UCLA panel method, which is a modified Delphi panel that is designed to measure consensus among clinical experts. First, we identified existing definitions of diagnostic error and related terms and extracted conceptual components (eg, accuracy and timeliness). Second, we recruited 11 multidisciplinary panelists, selected for diversity in professional role, clinical setting, geography, and diagnostic error exposure. Third, panelists rated conceptual components on validity, relevance to the ED, and overall importance using a 1 to 9 scale. Conceptual components with final-round median ratings ≥7 on all dimensions were selected for inclusion in narrative definitions. Results Diagnostic excellence in the ED is “the use of optimal, evidence-based practice to attain an accurate and timely explanation about a patient’s condition based on the information available at the time and communicate that explanation to the patient/family. Diagnostic excellence is patient-centered and equitable. Diagnostic excellence includes avoidance of divergent practices. It leads to better choices in management, prevents missed opportunities, and reduces the risk of preventable patient harm.” A missed diagnostic opportunity is “a measurable divergence from optimal, evidence-based practice that may lead to: an inaccurate or delayed explanation of a patient’s condition, despite information available at the time, or a failure in shared communication related to the diagnosis with the patient/family. A missed diagnostic opportunity may lead to suboptimal management, preventable patient harm, or inequitable outcomes.” Conclusion Future work should study implementation of these definitions into ED diagnostic research and quality/safety programs.

PURPOSE:Obtaining accurate medication histories for older adults in the emergency department (ED) is essential but challenging due to operational barriers and incomplete electronic health records (EHRs). We implemented a stakeholder-engaged intervention integrating pharmacy technicians (pharm techs) to obtain triage medication histories (T-MHs) for ED patients aged 65 years or older. METHODS:Starting in June 2023, pharm techs collected T-MHs from patients awaiting clinician evaluation. The intervention was developed using literature review, EHR data analysis, and focus groups with ED clinicians, pharm techs, and pharmacists. We identified key chief complaint-medication interactions and designed ED workflows for T-MH implementation. RESULTS:Three high-impact chief complaint-medication interactions were identified: (1) trauma with anticoagulant use; (2) any complaint with recent medication changes or adherence concerns; and (3) any complaint while on antibiotics. We educated pharm techs about these chief complaint-medication interactions and asked them to notify ED clinicians about cases identified. T-MHs were obtained in 3,197 ED encounters (41.2%) before any medication order or disposition decision. Focus groups revealed that patients and their care partners generally agreed to participate in medication histories, but, contrary to expectations, efforts to date have had minimal impact on clinician awareness of prior-to-admission medications, prescribing decisions, and disposition decisions. CONCLUSION:Integrating pharm techs to obtain medication histories in the ED is feasible and acceptable, but further efforts are needed to optimize workflow integration and handoff processes to improve clinical impact and patient safety.

This study examines the patient- and hospital-level variation in time to initiation of inpatient management among patients admitted to general medical services.

Background and Objectives: Elderly trauma patients face unique physiological challenges that often lead to undertriage under the current guidelines. The present study aimed to develop machine-learning (ML)-based, age-specific triage guidelines to improve predictions for intensive care unit (ICU) admissions and in-hospital mortality. Materials and Methods: A total of 274,347 trauma cases transported via Emergency Medical System (EMS)-119 in Seoul (2020-2022) were analyzed. Physiological indicators (e.g., systolic blood pressure; saturation of partial pressure oxygen; and alert, verbal, pain, unresponsiveness scale) were incorporated. Bayesian optimization was used to fine-tuned models for sensitivity and specificity, emphasizing the F2 score to minimize undertriage. Results: Compared with the current guidelines, the alternative guidelines achieved superior sensitivity for ICU admissions (0.728 vs. 0.541) and in-hospital mortality (0.815 vs. 0.599). Subgroup analyses across injury severities, including traumatic brain and chest injuries, confirmed the enhanced performance of the alternative guidelines. Conclusions: ML-based, age-specific triage guidelines improve the sensitivity of triage decisions, reduce undertriage, and optimize elderly trauma care. Implementing these guidelines can significantly enhance patient outcomes and resource allocation in emergency settings.

Aims Accurate diagnoses contribute to the improvement of clinical workflows and the enhancement of patient care. Commercially available automated electrocardiogram (ECG) interpretation systems require manual review by physicians despite their widespread use. This study investigates the frequency and characteristics of the modifications from automated ECG reports in routine clinical practice. Methods and results We retrospectively analysed 159 630 ECGs from 2011 to 2023 and compared automated preliminary ECG reports generated by the GE Marquette™ 12SL ECG analysis programme with finalized reports by physicians. A modification was defined as any textual difference between the initial and final reports. Our analysis revealed that 31.3% of all ECG reports underwent some forms of modification by physicians. We analysed the frequency of 69 pre-defined ECG-related terms before and after physician review, categorizing modifications as unchanged, deleted, or newly added. Modifications were more frequent for ECGs performed during off-hours, in patients with higher ventricular rates and longer QRS durations. At the term-level, diagnoses such as ‘prolonged QT interval’ (newly added from 5.6% of original reports) and ‘electronic ventricular pacemaker’ (newly added from 3.6% of original reports) were frequently added by physicians, while diagnoses like ‘inferior infarct’ and ‘anterior infarct’ were frequently deleted from automated ECG reports (32.0% and 44.6% automated reports with these terms required removals). Conclusion This large-scale real-world study demonstrated the high frequency of physicians’ modification in automated ECG interpretation. The identified patterns of modifications highlight the limitations of current rule-based systems in handling complex cases and nuanced ECG findings.

Mushroom (amatoxin) poisoning from ingestion is a rare but life-threatening medical emergency characterized by gastrointestinal symptoms before progression to multisystem organ failure in severe cases. Many therapies of amatoxin intoxication have been described, including supportive care, medical therapies, detoxification strategies, and liver transplant. The evidence supporting these therapies remains limited due to the rarity of amatoxin poisoning and challenge of a timely diagnosis. We report a case of amatoxin poisoning in Los Angeles causing severe liver injury without acute liver failure treated successfully using medical therapies, gallbladder drainage, and plasma exchange.

BACKGROUND The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI. METHODS Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed. RESULTS Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours. CONCLUSION Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.

[This corrects the article DOI: 10.14309/crj.0000000000001246.].

Background There is a clinical need for therapeutics for COVID-19 patients with acute hypoxemic respiratory failure whose 60-day mortality remains at 30-50%. Aviptadil, a lung-protective neuropeptide, and remdesivir, a nucleotide prodrug of an adenosine analog, were compared with placebo among patients with COVID-19 acute hypoxaemic respiratory failure. Methods TESICO was a randomised trial of aviptadil and remdesivir versus placebo at 28 sites in the USA. Hospitalised adult patients were eligible for the study if they had acute hypoxaemic respiratory failure due to confirmed SARS-CoV-2 infection and were within 4 days of the onset of respiratory failure. Participants could be randomly assigned to both study treatments in a 2 x 2 factorial design or to just one of the agents. Participants were randomly assigned with a web-based application. For each site, randomisation was stratified by disease severity (high-flow nasal oxygen or non-invasive ventilation vs invasive mechanical ventilation or extracorporeal membrane oxygenation [ECMO]), and four strata were defined by remdesivir and aviptadil eligibility, as follows: (1) eligible for randomisation to aviptadil and remdesivir in the 2 x 2 factorial design; participants were equally randomly assigned (1:1:1:1) to intravenous aviptadil plus remdesivir, aviptadil plus remdesivir matched placebo, aviptadil matched placebo plus remdesvir, or aviptadil placebo plus remdesivir placebo; (2) eligible for randomisation to aviptadil only because remdesivir was started before randomisation; (3) eligible for randomisation to aviptadil only because remdesivir was contraindicated; and (4) eligible for randomisation to remdesivir only because aviptadil was contraindicated. For participants in strata 2-4, randomisation was 1:1 to the active agent or matched placebo. Aviptadil was administered as a daily 12-h infusion for 3 days, targeting 600 pmol/kg on infusion day 1, 1200 pmol/kg on day 2, and 1800 pmol/kg on day 3. Remdesivir was administered as a 200 mg loading dose, followed by 100 mg daily maintenance doses for up to a 10-day total course. For participants assigned to placebo for either agent, matched saline placebo was administered in identical volumes. For both treatment comparisons, the primary outcome, assessed at day 90, was a six-category ordinal outcome: (1) at home (defined as the type of residence before hospitalisation) and off oxygen (recovered) for at least 77 days, (2) at home and off oxygen for 49-76 days, (3) at home and off oxygen for 1-48 days, (4) not hospitalised but either on supplemental oxygen or not at home, (5) hospitalised or in hospice care, or (6) dead. Mortality up to day 90 was a key secondary outcome. The independent data and safety monitoring board recommended stopping the aviptadil trial on May 25, 2022, for futility. On June 9, 2022, the sponsor stopped the trial of remdesivir due to slow enrolment. The trial is registered with ClinicalTrials.gov, NCT04843761. Findings Between April 21, 2021, and May 24, 2022, we enrolled 473 participants in the study. For the aviptadil comparison, 471 participants were randomly assigned to aviptadil or matched placebo. The modified intention-to-treat population comprised 461 participants who received at least a partial infusion of aviptadil (231 participants) or aviptadil matched placebo (230 participants). For the remdesivir comparison, 87 participants were randomly assigned to remdesivir or matched placebo and all received some infusion of remdesivir (44 participants) or remdesivir matched placebo (43 participants). 85 participants were included in the modified intention-to-treat analyses for both agents (ie, those enrolled in the 2 x 2 factorial). For the aviptadil versus placebo comparison, the median age was 57 years (IQR 46-66), 178 (39%) of 461 participants were female, and 246 (53%) were Black, Hispanic, Asian or other (vs 215 [47%] White participants). 431 (94%) of 461 participants were in an intensive care unit at baseline, with 271 (59%) receiving high-flow nasal oxygen or non-invasive ventiliation, 185 (40%) receiving invasive mechanical ventilation, and five (1%) receiving ECMO. The odds ratio (OR) for being in a better category of the primary efficacy endpoint for aviptadil versus placebo at day 90, from a model stratified by baseline disease severity, was 1 & BULL;11 (95% CI 0 & BULL;80-1 & BULL;55; p=0 & BULL;54). Up to day 90, 86 participants in the aviptadil group and 83 in the placebo group died. The cumulative percentage who died up to day 90 was 38% in the aviptadil group and 36% in the placebo group (hazard ratio 1 & BULL;04, 95% CI 0 & BULL;77-1 & BULL;41; p=0 & BULL;78). The primary safety outcome of death, serious adverse events, organ failure, serious infection, or grade 3 or 4 adverse events up to day 5 occurred in 146 (63%) of 231 patients in the aviptadil group compared with 129 (56%) of 230 participants in the placebo group (OR 1 & BULL;40, 95% CI 0 & BULL;94-2 & BULL;08; p=0 & BULL;10).

Background: eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR.Methods: The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome.Results: From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs.Conclusion: We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.

Introduction Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses. Methods and analysis This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients’ patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids. Ethics and dissemination This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public. Trial registration number NCT04509115 .

Objectives Manufacturer recalls and altered supply chains during the coronavirus disease 2019 (COVID-19) pandemic caused a nationwide shortage of blue-top tubes (BTTs). Most non-point-of-care coagulation tests use these tubes, leaving laboratories and health care facilities in short supply. The Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center implemented interventions to conserve supply without sacrificing patient safety. Methods In a retrospective quality improvement analysis, we examined coagulation testing and BTT utilization over the 3-month interval during which our interventions were applied. Our study assessed the interventions' effectiveness by evaluating changes in BTT utilization, coagulation testing volume, and patient impact. Results Average daily use (ADU) of BTT before and after the intervention were 476 and 403, respectively-a 15.2% reduction. Notably, the Emergency Department had a reduction in ADU of 43.3%. Average daily volumes of coagulation assays performed decreased from 949 to 783-a 17.5% reduction. No adverse events from the Pharmacy Department were identified during the study period. Conclusions Interventions resulting in significant reductions were in divisions with effective management and supervision. Success in navigating the BTT shortage stemmed from timely announcements, action, and effective communication. Our recommendations established more effective coagulation assay utilization, decreased overall BTT use, and prevented patients with coagulopathic disorders from experiencing adverse consequences.

Abstract Objectives Manufacturer recalls and altered supply chains during the coronavirus disease 2019 (COVID-19) pandemic caused a nationwide shortage of blue-top tubes (BTTs). Most non–point-of-care coagulation tests use these tubes, leaving laboratories and health care facilities in short supply. The Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center implemented interventions to conserve supply without sacrificing patient safety. Methods In a retrospective quality improvement analysis, we examined coagulation testing and BTT utilization over the 3-month interval during which our interventions were applied. Our study assessed the interventions’ effectiveness by evaluating changes in BTT utilization, coagulation testing volume, and patient impact. Results Average daily use (ADU) of BTT before and after the intervention were 476 and 403, respectively—a 15.2% reduction. Notably, the Emergency Department had a reduction in ADU of 43.3%. Average daily volumes of coagulation assays performed decreased from 949 to 783—a 17.5% reduction. No adverse events from the Pharmacy Department were identified during the study period. Conclusions Interventions resulting in significant reductions were in divisions with effective management and supervision. Success in navigating the BTT shortage stemmed from timely announcements, action, and effective communication. Our recommendations established more effective coagulation assay utilization, decreased overall BTT use, and prevented patients with coagulopathic disorders from experiencing adverse consequences.

Emergency department (ED) psychiatrists face the consequential decision to pursue involuntary inpatient psychiatric admission. Research on the relationship between patient characteristics and the decision to pursue involuntary psychiatric admission is limited. Using data from 2017 to 2018 at an urban Los Angeles hospital, we used generalized linear mixed effects models to compare patients who were involuntarily admitted to inpatient psychiatry to patients who were discharged from the ED. Of 2,448 patients included in the study, 1,217 (49.7%) were involuntarily admitted to inpatient psychiatry and 1,231 (50.3%) were discharged. After controlling for sociodemographic characteristics, admitted patients were more likely to have been brought in by police, have had an organized suicide plan or recent attempt, physical signs of harm, psychosis, depression or hopelessness, lack social support, have diagnoses of schizophrenia or bipolar disorder, and be administered injectable psychotropic medications. Stimulant use, a diagnosis of anxiety or developmental disorders, and recent medical ED utilization were associated with discharge. Psychiatrists pursued involuntarily psychiatric hospitalization based on factors potentially indicative of dangerousness, leaving patients, particularly those with recent substance use, without immediate access to treatment. Policies should focus on increasing follow up to high quality, voluntary outpatient mental health care.

Introduction: Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient. Case Series: Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED. Conclusion: Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.

IntroductionEDs are often the first line of contact with individuals infected with COVID-19 and play a key role in triage. However, there is currently little specific guidance for deciding when patients with COVID-19 require hospitalisation and when they may be safely observed as an outpatient.MethodsIn this retrospective study, we characterised all patients with COVID-19 discharged home from EDs in our US multisite healthcare system from March 2020 to August 2020, focusing on individuals who returned within 2 weeks and required hospital admission. We restricted analyses to first-encounter data that do not depend on laboratory or imaging diagnostics in order to inform point-of-care assessments in resource-limited environments. Vitals and comorbidities were extracted from the electronic health record. We performed ordinal logistic regression analyses to identify predictors of inpatient admission, intensive care and intubation.ResultsOf n=923 patients who were COVID-19 positive discharged from the ED, n=107 (11.6%) returned within 2 weeks and were admitted. In a multivariable-adjusted model including n=788 patients with complete risk factor information, history of hypertension increased odds of hospitalisation and severe illness by 1.92-fold (95% CI 1.07 to 3.41), diabetes by 2.20-fold (1.18 to 4.02), chronic lung disease by 2.21-fold (1.22 to 3.92) and fever by 2.89-fold (1.71 to 4.82). Having at least two of these risk factors increased the odds of future hospitalisation by 6.68-fold (3.54 to 12.70). Patients with hypertension, diabetes, chronic lung disease or fever had significantly longer hospital stays (median 5.92 days, 3.08–10.95 vs 3.21, 1.10–5.75, p<0.01) with numerically higher but not significantly different rates of intensive care unit admission (27.02% vs 14.30%, p=0.27) and intubation (12.16% vs 7.14%, p=0.71).DiscussionPatients infected with COVID-19 may appear clinically safe for home convalescence. However, those with hypertension, diabetes, chronic lung disease and fever may in fact be only ‘pseudo-safe’ and are most at risk for subsequent hospitalisation with more severe illness and longer hospital stays.

Background: Interruptions are recognized as potentially harmful to safety and efficiency, and are especially prevalent in the emergency department (ED) setting. Policies urging immediate review of all electrocardiograms (ECGs) may lead to numerous and frequent interruptions. Objective: We assessed the role of ECG review as a source of ED interruptions to characterize a potential target for interventions. Methods: We analyzed emergency physician time use during the course of a clinical shift using a time-and-motion design. A research assistant observed a convenience sample of shifts, observing and logging transitions between different tasks using an electronic device. Instances of ECG review were tallied, with start and ending times of ECG review recorded to the nearest second. An ECG review was considered an interruption if the immediate prior and subsequent tasks were the same. Results: Twenty shifts were observed for a total of 149 h. There were 211 ECG reviews, (mean rate 1.4 per hour), with more frequent review among physicians staffing a zone with higher-acuity patients (2.8 per hour), where clustering of multiple ECG reviews in succession was more common. Seventy-five percent of ECG reviews required < 30 s. Of all 211 ECG reviews, 102 (48%) were an interruption. The tasks most frequently interrupted were electronic medical record system use (68 of 102, 67%) and communicating with ED staff in person (18 of 102, 18%). Conclusions: Review of ECGs was a substantial driver of interruptions for emergency physicians. Interventions to integrate ECG review more naturally into physician workflow may improve patient safety by reducing these interruptions. (C) 2020 Elsevier Inc. All rights reserved.

Introduction: During protests following the death of George Floyd, kinetic impact projectiles (KIP) were used by law enforcement as a method of crowd control. We describe the injuries seen at a single Level 1 trauma center in Los Angeles over a two-day period of protests to add to the collective understanding of the public health ramifications of crowd-control weapons used in the setting of protests. Case Series: We reviewed the emergency department visits of 14 patients who presented to our facility due to injuries sustained from KIPs over a 48-hour period during civil protests after the death of George Floyd. Conclusion: Less lethal weapons can cause significant injuries and may not be appropriate for the purposes of crowd control, especially when used outside of established guidelines.

Objective:There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID-19) infection who are not hospitalized. The study objective was to assess 30-day outcomes (ED revisit, admission, ICU admission, and death) for low-risk patients discharged after ED evaluation for COVID-19.Methods:This was a retrospective cohort study of patients triaged to a COVID-19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well-appearing with few comorbidities. Data were collected from review of medical records and phone follow-up, and the analysis was descriptive.Results:Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow-up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3-7, range 1-17). There were no known deaths.Conclusions:A minority of low-risk patients with suspected COVID-19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well-appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.