Kathleen Wittels

United States emergency department visits for vaginal bleeding during early pregnancy, 1993-2003

OBJECTIVE The purpose of this study was to describe the epidemiology of emergency department (ED) visits for vaginal bleeding during early pregnancy (VBEP). STUDY DESIGN We analyzed data from the National Hospital Ambulatory Medical Care Survey, 1993-2003. Cases presented with a complaint of vaginal bleeding and had diagnoses consistent with presentation during early pregnancy. RESULTS Over the 11-year period, there were 5.4 million visits for VBEP, which represents 1.6% of all ED visits or almost 500,000 visits/year. ED visits for VBEP increased from 5.6-7.8 visits per 1000 US population (P for trend < .01). The population rates were highest in the 20-29 year age group. ED patients with VBEP were more likely to be black, Hispanic, and uninsured, as compared to women presenting for other reasons. CONCLUSION ED visits for VBEP are rising, particularly among younger and Hispanic women. Programs that ensure primary obstetric care would help decrease reliance on the ED for this important condition.

Emergency reversal of pentasaccharide anticoagulants: a systematic review of the literature

Objectives: To conduct a systematic review of the literature to answer the question: Has administration of recombinant activated factor VII (rFVIIa) or prothombin complex concentrate (PCC) or activated PCC (aPCC) been demonstrated to be effective in reversing pendasaccharide anticoagulants (PSAs)?

Use of a Computerized Forcing Function Improves Performance in Ordering Restraints

STUDY OBJECTIVE We evaluate the effect of a computerized order entry system forcing function on improving timely renewal of restraint orders. METHODS In this prospective study of 2 successive interventions, physicians received computerized reminders to renew or discontinue restraint orders before their expiration. The initial intervention allowed acknowledgement of this reminder without further consequence, changing at 6 months to deny computer access until addressed. We performed chart review on emergency department visits with restraint orders in 3 consecutive 6-month periods (A, B, C) separated by these 2 interventions, determining time to order renewal, number of restraint orders, renewal orders per hour in restraints, and time in restraints and evaluating variability in these values across study intervals. Statistical analysis for our primary outcome used the Mann-Whitney and variance ratio tests. RESULTS Median time to order renewal decreased in periods B and C versus A by 64 and 56 minutes, respectively, with variability in this measure decreasing across all periods. Mean number of restraint orders in periods B and C significantly increased versus those in A (1.46 to 1.89 to 2.34), with corresponding increases in variability. Mean renewal orders per hour in restraint significantly increased in period C versus A and B, from 0.08 to 0.23 to 0.89, with increasing variability across all periods. Decreases in median time spent in restraints observed in periods B and C versus A of 45 and 105 minutes, respectively, trended toward but did not achieve significance, with significantly decreasing variability compared with baseline. CONCLUSION The forcing function improved restraint reordering and variability in practice and may have contributed to nonsignificant reductions observed in time in restraint.

Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety

Introduction Morbidity and mortality conferences (M+M) are a traditional part of residency training and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective was to determine the goals, structure, and the prevalence of practices that foster strong safety cultures in the M+Ms of U.S. emergency medicine (EM) residency programs. Methods The authors conducted a national survey of U.S. EM residency program directors. The survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding; Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare Research & Quality Safety Culture survey. Results There was an 80% (151/188) response rate. The primary objectives of M+M were discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous case submission, with 10% (15/151) maintaining complete anonymity during the presentation and 21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of programs report regular debriefing with residents who have had their cases presented. Conclusion The structure and goals of M+Ms in EM residencies vary widely. Many programs lack features of M+M that promote a non-punitive response to error, such as anonymity. Other programs lack features that support strong safety cultures, such as following up on systems issues or reporting back to residents on improvements. Further research is warranted to determine if M+M structure is related to patient safety culture in residency programs.

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

Introduction Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. Methods We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. Results We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). Conclusion Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for students to learn this skill.

Emergency Medicine Morbidity and Mortality Conference and Culture of Safety: The Resident Perspective

Morbidity and mortality conference (M&M) is common in emergency medicine (EM) and an Accreditation Council for Graduate Medical Education (ACGME) requirement. We aimed to characterize the prevalence of elements of EM M&M conferences that foster a strong culture of safety.