Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and m... more Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level. This chest pain clinical pathway has undergone regular review and updates under a collaborative team of cardiologists, emergency department physicians, cardiac nurse practitioners, and other associated stakeholders in the treatment of patients presenting with chest pain. This review will discuss the key changes that our institutional chest pain algorithm has undergone over the last 2 decades and what the future holds for chest pain algorithms.
With a persistent trend of increasing emergency department (ED) volumes every year, services are ... more With a persistent trend of increasing emergency department (ED) volumes every year, services are intensifying. Thus, improving the timeliness of delivering emergency care should be a primary focus, both from an operational and from a research perspective. Much has been published on factors associated with delays in emergency care, and the next phase in this area of research will focus on exploring interventions to improve the timeliness of care. On June 1, 2011, Academic Emergency Medicine held a consensus conference titled "Interventions to Assure Quality in the Emergency Department." This article summarizes the findings of the breakout session that investigated interventions to improve the timeliness of emergency care. This article will explore the background on the concept of timeliness of emergency care, the current state of interventions that have been implemented to improve timeliness, and specific questions as a framework for a future research agenda.
Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency... more Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6-14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2-12.4%), contained at least one error. 41% (95% CI 3...
Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools... more Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools can support this process effectively, however. Our objective was to describe the relationship between clinical complexity, diagnostic uncertainty, fit with illness script and the content of case presentations by physicians. We observed the handoff of care for150 patients during eleven shift changes at a large urban emergency department (ED). Results indicate that as uncertainty about diagnosis and perceived illness script increased, more descriptive detail was conveyed to the incoming physicians. Physicians were concerned primarily with creating a shared mental model of a patient's clinical state and with describing the expected path to disposition rather than simply passing on data and findings. Electronic tools for ED handoffs should allow adjustment of structure and content to capture complexity and uncertainty appropriately without requiring extra effort for more routine cases t...
Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools... more Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools can support this process effectively, however. Our objective was to describe the relationship between clinical complexity, diagnostic uncertainty, fit with illness script and the content of case presentations by physicians. We observed the handoff of care for150 patients during eleven shift changes at a large urban emergency department (ED). Results indicate that as uncertainty about diagnosis and perceived illness script increased, more descriptive detail was conveyed to the incoming physicians. Physicians were concerned primarily with creating a shared mental model of a patient's clinical state and with describing the expected path to disposition rather than simply passing on data and findings. Electronic tools for ED handoffs should allow adjustment of structure and content to capture complexity and uncertainty appropriately without requiring extra effort for more routine cases t...
In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS... more In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which includes primary percutaneous intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2008, there have been changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. In particular, recent data on the novel antiplatelet agent prasugrel, dosing of clopidogrel after PCI, and interactions with clopidogrel and other medicines and substrates, which can lead to decreased platelet response to clopidogrel, have led us to update our ACS clinical pathway. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI, and provide rationale for the changes that we have made to our institutional protocol. ...
Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 2011
In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS... more In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which includes primary percutaneous intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2008, there have been changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. In particular, recent data on the novel antiplatelet agent prasugrel, dosing of clopidogrel after PCI, and interactions with clopidogrel and other medicines and substrates, which can lead to decreased platelet response to clopidogrel, have led us to update our ACS clinical pathway. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI, and provide rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care.
Residency applicants have the right to see letters of recommendation written on their behalf. It ... more Residency applicants have the right to see letters of recommendation written on their behalf. It is not known whether applicants are affected by waiving this right. Our multicenter study assessed how frequently residency applicants waived their FERPA rights to view their letters of recommendation, and whether this affected the ratings they were given by faculty. We reviewed all ERAS-submitted letters of recommendation to 14 ACGME-accredited programs in 2006-2007. We collected ERAS ID, program name, FERPA declaration, standardized letter of recommendation (SLOR) use, and SLOR Global Assessment ranking. The percentage of applicants who waived their FERPA rights was determined. Chi-square tests of independence assessed whether applicants' decision to waive their FERPA rights was associated with their SLOR Global Assessment. We examined 1776 applications containing 6424 letters of recommendations. Of 2736 letters that specified a Global Assessment, 2550 (93%) applicants waived their...
Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 2008
In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACS... more In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2003, there have been numerous changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.
Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and m... more Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level. This chest pain clinical pathway has undergone regular review and updates under a collaborative team of cardiologists, emergency department physicians, cardiac nurse practitioners, and other associated stakeholders in the treatment of patients presenting with chest pain. This review will discuss the key changes that our institutional chest pain algorithm has undergone over the last 2 decades and what the future holds for chest pain algorithms.
With a persistent trend of increasing emergency department (ED) volumes every year, services are ... more With a persistent trend of increasing emergency department (ED) volumes every year, services are intensifying. Thus, improving the timeliness of delivering emergency care should be a primary focus, both from an operational and from a research perspective. Much has been published on factors associated with delays in emergency care, and the next phase in this area of research will focus on exploring interventions to improve the timeliness of care. On June 1, 2011, Academic Emergency Medicine held a consensus conference titled "Interventions to Assure Quality in the Emergency Department." This article summarizes the findings of the breakout session that investigated interventions to improve the timeliness of emergency care. This article will explore the background on the concept of timeliness of emergency care, the current state of interventions that have been implemented to improve timeliness, and specific questions as a framework for a future research agenda.
Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency... more Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6-14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2-12.4%), contained at least one error. 41% (95% CI 3...
Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools... more Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools can support this process effectively, however. Our objective was to describe the relationship between clinical complexity, diagnostic uncertainty, fit with illness script and the content of case presentations by physicians. We observed the handoff of care for150 patients during eleven shift changes at a large urban emergency department (ED). Results indicate that as uncertainty about diagnosis and perceived illness script increased, more descriptive detail was conveyed to the incoming physicians. Physicians were concerned primarily with creating a shared mental model of a patient's clinical state and with describing the expected path to disposition rather than simply passing on data and findings. Electronic tools for ED handoffs should allow adjustment of structure and content to capture complexity and uncertainty appropriately without requiring extra effort for more routine cases t...
Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools... more Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools can support this process effectively, however. Our objective was to describe the relationship between clinical complexity, diagnostic uncertainty, fit with illness script and the content of case presentations by physicians. We observed the handoff of care for150 patients during eleven shift changes at a large urban emergency department (ED). Results indicate that as uncertainty about diagnosis and perceived illness script increased, more descriptive detail was conveyed to the incoming physicians. Physicians were concerned primarily with creating a shared mental model of a patient's clinical state and with describing the expected path to disposition rather than simply passing on data and findings. Electronic tools for ED handoffs should allow adjustment of structure and content to capture complexity and uncertainty appropriately without requiring extra effort for more routine cases t...
In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS... more In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which includes primary percutaneous intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2008, there have been changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. In particular, recent data on the novel antiplatelet agent prasugrel, dosing of clopidogrel after PCI, and interactions with clopidogrel and other medicines and substrates, which can lead to decreased platelet response to clopidogrel, have led us to update our ACS clinical pathway. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI, and provide rationale for the changes that we have made to our institutional protocol. ...
Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 2011
In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS... more In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which includes primary percutaneous intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2008, there have been changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. In particular, recent data on the novel antiplatelet agent prasugrel, dosing of clopidogrel after PCI, and interactions with clopidogrel and other medicines and substrates, which can lead to decreased platelet response to clopidogrel, have led us to update our ACS clinical pathway. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI, and provide rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care.
Residency applicants have the right to see letters of recommendation written on their behalf. It ... more Residency applicants have the right to see letters of recommendation written on their behalf. It is not known whether applicants are affected by waiving this right. Our multicenter study assessed how frequently residency applicants waived their FERPA rights to view their letters of recommendation, and whether this affected the ratings they were given by faculty. We reviewed all ERAS-submitted letters of recommendation to 14 ACGME-accredited programs in 2006-2007. We collected ERAS ID, program name, FERPA declaration, standardized letter of recommendation (SLOR) use, and SLOR Global Assessment ranking. The percentage of applicants who waived their FERPA rights was determined. Chi-square tests of independence assessed whether applicants' decision to waive their FERPA rights was associated with their SLOR Global Assessment. We examined 1776 applications containing 6424 letters of recommendations. Of 2736 letters that specified a Global Assessment, 2550 (93%) applicants waived their...
Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 2008
In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACS... more In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2003, there have been numerous changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.
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