Resident Academic Day 2021

Carolinas Medical Center Department of Emergency Medicine

Resident Academic Day

June 17, 2021

Resident Academic Day 2021

CMC Department of Emergency Medicine Thursday, June 17, 2021 Medical Education Building • 3rd Floor Conference Room

Schedule 8:00 am

Welcome & Introductions

Mike Gibbs, MD, and Mike Runyon, MD

8:10 am

2021 Resident Academic Day Address

8:30 am

Chelsea Rushnell, MD – Impact of Post-hospital Discharge Visits by Community Paramedics on Outpatient Follow-up in a Transition Clinic

8:45 am

Joseph Blackwell, MD – Frequency of Successful Bougie Placement through the iGelTM Supraglottic Airway

9:00 am

William Bost, MD – Echocardiography Predictors of Acute Clinical Deterioration After Pulmonary Embolism

9:15 am

Elissabeth Hagler, MD – Disparities in COVID Outcomes

Jeffrey Kline, MD

---------------------------------------- Break @ 9:30 am ----------------------------------------------9:45 am

Alexandria Holmes, MD – Implementation of Airway Checklist in Community, Academic Adult Emergency Department

10:00 am

Jacob Leedekerken, MD – Efficacy of Performing Erector Spinae Planar and Serratus Anterior Planar Blocks for Rib Fractures in the Emergency Department

10:15 am

Claire Milam, MD – Physical Injury from Intimate Partner Violence (IPV) during the COVID-19 Pandemic, a Subset Analysis

10:30 am

Elizabeth Olson, MD – Emergency Department Use of Reusable Elastomeric Respirators During the COVID-19 Pandemic

10:45 am

Jennifer Pallansch, MD – COVID-19 effects on Resource Utilization by Victims of Intimate Partner, Violence, Sexual Assault, and Child Abuse ------------------------------------- Break @ 11:00 am -----------------------------------------------

11:15 am

Gabriela Rivera-Camacho, MD – Subpopulation Analysis of the Atrium-Modified HEART Pathway in Emergency Department Patients Presenting with Symptoms Suggestive of Acute Coronary Syndrome

11:30 am

Victoria Serven, MD – Multicenter Analysis to Assess Risk of Major Adverse Cardiac Events in Patients Undergoing High-Sensitivity Troponin Testing in the Emergency Department

11:45 am

Brian Shreve, MD – Impact of Post-hospital Discharge Visits by Community Paramedics on Hospital Readmission

12:00 pm

Tyler Siekmann, MD – Operational Impact of the Atrium-Modified HEART Pathway in Emergency Department Patients Presenting with Symptoms Suggestive of Acute Coronary Syndrome

12:15 pm

Alyssa Thomas, MD – Added Prognostic Value of Right Ventricular Assessment for Low-risk Pulmonary Embolism

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Resident Academic Day 2021 CMC Department of Emergency Medicine Visiting Professor

Jeffrey Kline, MD Dr. Jeffrey Kline received his MD from the Medical College of Virginia, and then did an emergency medicine residency followed by a research fellowship the Carolinas Medical Center. He now serves as Associate Chair of Research and Brooks Bock Chair of Emergency Medicine at Wayne State University School of Medicine. He is the present Editor In Chief of Academic Emergency Medicine.

His diagnostic research interests focuses on the diagnosis and treatment of venous thromboembolism in the emergency care setting and mentoring physician-scientists in emergency care. What he does best is grow heirloom tomatoes.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Impact of Post-hospital Discharge Visits by Community Paramedics on Outpatient Follow-up in a Transition Clinic Chelsea Wilson, MD1, S. Tyler Constantine, MD1, Stephanie Murphy MD2, Brian Shreve, MD1 1Department

of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, North Carolina 2Internal Medicine Hospitalist, Atrium Health, Charlotte, North Carolina

Background: Mobile integrated health (MIH) and community paramedicine (CP) programs are a service provided by local emergency medical services (EMS) and hospital systems. There is limited research published regarding their benefit, with available research focused on reduction of cost in the healthcare system, readmissions, and 911 calls for EMS systems. In our model, MIH/CP services are tied to multidisciplinary follow-up at a transition clinic which provides post-discharge care for thirty days after hospital discharge. For adult patients who were enrolled in transition services following hospital discharge, we hypothesize an initial home visit by MIH/CP paramedics is associated with increased attendance at the first scheduled outpatient visit as well as any future visits in the transition clinic.

Methods: This is a retrospective study of 316 cases. All patients had CP visits scheduled within 72 hours of discharge. Patients in the “CP Well Check” group completed at least one CP well check home visit after hospital discharge. Patients in the “No CP Well Check” group did not complete this visit. The primary outcome was the rate of attendance at the transition clinic.

Results: The primary outcome analysis included 316 patients. Of these, 219 patients (69%) had a CP well check and 97 patients (31%) did not have a CP well check. Of the 219 CP well check patients 153 (70%) attending the first transition clinic appointment, as compared to only 24 of the 97 (25%) patients that did not have a CP well check visit resulting in a 45% risk difference (CI 95%; 33.9%-54.8%). Relative risk was 2.8 for attendance at the clinic after receiving a CP well check (CI 95%; 2.0–4.1, p <0.0001).

The relative risk for follow-up at any future transition clinic was 1.9 (CI 95%; 1.5–2.5, p <0.0001).

Conclusion: In our system, a post-discharge visit by our MIH/CP team was correlated with statistically significant higher attendance at the first visit in our transition clinic and any future transition clinic visits after hospital discharge.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Frequency of Successful Bougie Placement through the iGelTM Supraglottic Airway S. Tyler Constantine, MD, Joseph Blackwell, MD, and Michael Gibbs, MD

Background: Airway management during a cardiac arrest remains a hot topic in emergency medicine. Current practice at our institution is to utilize an iGel™ supraglottic device during the arrest and exchange it for an endotracheal tube once return of spontaneous circulation has been achieved. The goal of this study was to determine if a gum elastic bougie could be inserted blindly through the iGel™ and visualized in the trachea.

Methods: Proceduralists were instructed on how to perform this and all signed a waiver of consent. Basic procedure was to insert the gum elastic bougie with the angled-tip end first, remove the iGel™ over the bougie, perform laryngoscopy via usual technique (video or direct) to confirm placement of the bougie in the trachea. If the bougie is in the trachea, intubate using an ETT over the bougie. If the bougie is not in the trachea, or there is uncertainty, intubate using usual ETI technique.

Results: The initial goal of 50 subjects was aborted prematurely due to procedure failure. Out of the thirteen total subjects, eleven were aborted prior to passing a bougie completely through the iGel™, one bougie was seen in the esophagus, and one was successfully visualized in the trachea. Most of the aborted attempts were cut short due to an inability to pass the bougie through the iGel™ itself.

Conclusions: This raises significant concerns regarding the ability to blindly insert an endotracheal tube through an iGel™ as a means of establishing a definitive airway.

Further areas research could include utilization of alternative techniques for establishing a definitive airway through an iGel™ SGA, such as a disposable fiberoptic scope.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Echocardiography Predictors of Acute Clinical Deterioration After Pulmonary Embolism Anthony J. Weekes MD, MSc1 Denise N. Fraga, MD, MPA1, Vitaliy Belyshev MD1, William Bost MD,1 Christopher A. Gardner MD, Joseph Rigdon PhD2, Nathaniel S. O’Connell PhD2 1 Department

of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, North Carolina 28203.

2Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston Salem North Carolina Background: Recommendations on echocardiography and laboratory measurements to predict deterioration events within days of pulmonary embolism (PE) are lacking. The primary objective was to determine right ventricle (RV) echocardiographic and laboratory measurements and their association with clinical outcomes within 5 days. Our secondary objective was to develop a prediction model for clinical deterioration, investigate its performance, and assess potential for clinical utility.

Methods: We prospectively enrolled regional emergency department PE patients with suspected abnormal RV and subsequent echocardiography measurements. The primary outcome was the occurrence of death or a predefined deterioration event within 5 days.

The secondary outcome was the primary outcome plus major bleeding, recurrence of venous-thromboembolism, or subsequent hospitalization within 30 days. Outcome group measurements were compared using t-test. We assembled logistic regression and random forest models. For prognostic performance, we used receiver operating curve analysis for both models and Delong’s test.

Results: Of 331 patients, 115 (34.7%) experienced the primary outcome.

Echocardiographic indices of RV size and systolic function differences were significant between outcome groups. Many RV predictor variables were among the top 25 predictors. Mean area under the curve (AUC) for prediction in the test dataset for the two models were 0.81 and 0.78. The AUC difference between models was insignificant p= 0.65 (0.5 classification threshold).

Conclusion: Echocardiography RV measurements were significantly different between 5-day outcome groups and outside of normal ranges. Accurate prognostic models were developed (adjustable to different classification thresholds), which may be clinically useful when augmented with a larger database.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Disparities in COVID Outcomes Elissabeth Hagler, MD, Denise N. Fraga MD MPA, Anthony J. Weekes MD, MSc; Shane Ali, MD; Melanie Hogg, MS, CCRA

Background: Health disparities have been identified in several aspects of medicine.

Black patients have been identified to have worse COVID-19 related outcomes than white patients in recent literature. The primary objective of this study is to identify if similar disparities in disease severity and mortality between black and white COVID-19 patients exists in the Charlotte Metro-region.

Methods: This was a retrospective, observational, cohort study at 18 Regional Atrium Health Emergency Departments. Data was analyzed from patients who visited the Emergency Department between March 17 2020 to July 23 2020. Information collected included patient demographics, vital signs, past medical history, and markers of disease severity, including new diagnoses, level of respiratory support, interventions, and mortality. We performed a univariate analysis of hospitalized Covid-19 positive patients stratified by black or white for co-existing conditions, initial emergency department vital signs, emergency department and hospitalization interventions, and acute and long-term outcomes, including mortality.

Results: A total of 2,434 patients were tested between March 17 and July 23, 2020, of which 1663 patients tested positive for COVID-19 (68.3%) and 771 patients tested negative (31.6%). Among this patient population, the mean age was 44 years, predominantly female (51.8%), and were predominantly white (43.1%). Race and insurance were statistically significant between COVID positive and COVID negative patients. Obesity (42.4%), Coronary artery disease (4.0%), cancer (4.0%), were statistically more common comorbidities among the COVID-19 positive group. Black COVID-19 positive patients were more likely to have diabetes (27%), asthma (12.2%), end stage-renal disease (2.9%), chronic kidney disease (10%), Human Immunodeficiency Virus (2%), and obesity (55%). There was no difference between black and white COVID positive patients in hospitalization and ED interventions. There was a statistically significant difference in mortality, with a higher mortality among white patients. Other acute outcomes, including acute respiratory distress syndrome, renal failure, myocarditis, seizures, hepatic injury, were similar between both groups.

Additionally, long term outcomes, including thromboembolism and neurological sequelae was similar between the groups.

Conclusion: Our analysis found a higher prevalence of COVID among black patients than white patients. COVID positivity was 67.8% in black patients in our population, in comparison to 21% in North Carolina.1 In our patient population, there was a more significant comorbid disease burden among black patients in comparison to white patients, similar to other studies. There was no difference in morbidity between black and white patients, including acute respiratory distress syndrome, new renal failure, new neurological sequelae, thromboembolism. Contrary to the Centers for Disease Control and Prevention published data on North Carolina, white patients were more likely to die of COVID.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Implementation of Airway Checklist in Community, Academic Adult Emergency Department Alexandria Holmes, MD; Robert Dalton Cox, MD; David Pearson, MD; Daniella James, MSN, RN, AGCNS-BC; Samantha Siegler, RN

Objective: Checklists have been employed in various fields of medicine to improve practice and standardization of care. Although there are guidelines providers follow to maximize safety and success of emergency intubation, standardized checklists for airway management are not widely used, and there is little literature specifically on utility in the emergency setting. As there is currently no standardization of evidencebased airway procedure being followed in our emergency department (ED), we sought to develop an airway checklist to standardize and improve the processes surrounding intubation in the adult setting.

Methods: The checklist was created by a group of identified stakeholders, and the process was implemented through educational video. Checklist use was monitored and tracked, and its effect on teammate attitudes surrounding intubation was assessed by surveys with Likert scale responses.

Results: A pre-survey was distributed with an educational video, with a total of 133 responses. Between December 2020 and March 2021, 220 intubations occurred in the adult ED: 165 medical, 55 trauma. 48 checklists were completed (approximately 21% use). Least completed areas of the checklist included hitting record on the CMac, endtidal CO2 monitoring, ABG/VBG reminder, and proper disposal/cleaning of equipment.

The checklists were able to identify several equipment issues, particularly with the CMac video laryngoscope and end tidal monitoring devices. The post implementation survey had a total of 81 responses. With implementation, there was a significant change in teammate attitudes towards overall success and preparedness for medical intubations, as well as RSI dosage communication. There was no significant change associated with trauma intubation attitudes. There was an increase in provider awareness of post-intubation ventilator settings.

Conclusion: Checklist implementation was preliminarily successful in this first iteration of quality cycle. As project continues, recommend continued fine-tuning for maximum efficiency, wider accessibility of checklist, and further education on goals of checklist and appropriate vs inappropriate scenarios in which to utilize.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Efficacy of Performing Erector Spinae Planar and Serratus Anterior Planar Blocks for Rib Fractures in the Emergency Department Jacob Leedekerken, MD; Denise Fraga, MD, MPA; Vivek Tayal, MD; Keegan Bradley, MD

Objective: The objectives of our study were to determine if emergency department (ED) providers were capable of performing regional blocks for rib fractures after receiving one hands-on training session; develop and implement an ED protocol for ESP and SAP blocks; and collect data on block outcomes.

Methods: This was a 16–month two phase prospective study with initial phase comprised of hands-on training and implementation of a protocol to perform an ESP or SAP block on patients >18 years who presented to the ED with 2+ rib fractures. Pre/post-tests and surveys were conducted to determine provider competency, block comfort level, and perceived block efficacy. Outcome data collected from blocks performed included block type, performer training level, and complications. In phase 2, patient pain scores, incentive spirometer (IS) volumes, cough scores, and morphine equivalents (MEs) were determined within the first 12 hours of the block. The blocks were performed with 0.5% ropivacaine and a total volume of 30cc with a technique previously described in the anesthesia literature.

Results: Thirty-one ED providers attended the hands-on session and completed the pre-and post-tests/surveys. Twenty-five providers completed the 12-week posttest/survey. Provider pre- vs post-test knowledge assessment scores increased from a mean of 68.3% to 87.4%. Performers’ comfort level increased from 1.61 (pre-test) to 3.68 (12-week post-test) with 5 being most comfortable. Performers’ perception of block effectiveness had a mean of 4.32 out of 5. 31 plane blocks, 97% being ESP blocks, were performed after protocol implementation with no complications reported. Median pain scores decreased and IS volumes (cc) increased at pre-block, 0.5-1hr, 4-6hr, and 1012hr time intervals with the respective values: 10, 5, 6.5, and 6.5 for pain and 500, 1000, 1000, and 1000 for IS (p<0.001). Cough scores and MEs at above-mentioned time intervals did not show a clinically or statistically significant change.

Conclusion: ESP and SAP blocks are safe and feasible procedures for an ED’s multimodal pain strategy for rib fractures. Although our study observed an improvement in pain scores and IS volumes after performing the blocks, the ME impact was less notable compared to previously published studies.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Physical Injury from Intimate Partner Violence (IPV) during the COVID-19 Pandemic, a Subset Analysis Claire Milam, MD, Jessica Salzman, MD, Kathryn Kopec, DO

Background: Intimate Partner Violence (IPV) is a prevalent issue, affecting one in three women globally.2 During the COVID-19 pandemic, there were many concerns and indications that risk factors as well as IPV itself increased.6-17 The purpose of our study was to investigate injuries sustained as well as the surrounding circumstances and sequelae of patients who were evaluated by the hospital’s advocacy team for IPV, Domestic Violence Healthcare Project (DVHP), during the stay-at-home order period of the pandemic and the same time frame pre-pandemic.

Methods: This was a multicenter retrospective observational cohort study that compared patient charts. A total of 41 charts were reviewed from March and April of 2019 and 32 charts were reviewed during the same months in 2020. A standardized form was used to extrapolate data and statistical analysis was achieved by standard t-test and chi squared comparison tools.

Results: Demographic data was not statistically different between 2019 and 2020. The most reported mechanisms of assault were strangulation and struck with fists. There was a statistically significant increase in strangulation assaults, with 16 (39%) patients in 2020 and 20 (63%) in 2020 (p=0.0497), a 38% increase. There was also a statistically significant increase in identified fractures on radiographic imaging, from 3 (10%) in 2019 to 6 (35%) in 2020 (p=0.02). Otherwise, there was a general increase in injuries per patient (3.4 ± 3.0 to 3.5 ± 2.6, p=0.91) and positive radiographic findings from 5 (16%) in 2019 to 10 (38%) in 2020 (p=0.06).

Conclusions: Our findings, specifically the increase in strangulation assaults and identified fractures, suggest an escalation in violence during the COVID-19 pandemic stay-at-home order. There needs to be dedicated resources for this at-risk population during times of natural disaster or states of emergency.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Emergency Department Use of Reusable Elastomeric Respirators During the COVID-19 Pandemic Olson, E.G.; Fraga, D.; Griggs, C.; Allen, B.K.

Objectives: To evaluate the acceptability of an elastomeric respirator program in the emergency department setting, focusing on healthcare worker perception of comfort, protection, and ease of communication compared against disposable N95 masks.

Methods: Between April 1, 2020, and January 1, 2021, we enrolled 108 healthcare workers at Atrium Health Carolinas Medical Center’s Emergency Department. They were given access to surgical masks and disposable N95-level particulate filtering respirators as well as a supply of reusable elastomeric respirators. Healthcare workers were surveyed on their experiences and opinions on elastomeric respirators compared to other forms of respiratory protection.

Results: Reusable elastomeric respirator size correlated with biologic sex. HCWs found elastomeric respirators more comfortable than other particulate-filtering masks, with the greatest discomfort in the nasal area while wearing half-face elastomeric masks and disposable N95 masks. HCWs reported wounds or skin breakdown on the forehead, nose, cheek, chin, and ears while wearing various masks, but these were less frequently reported with elastomeric respirators than disposable N95 masks. Some HCWs used personal care items to augment fit or protect their skin, with similar usage regardless of mask type. Fewer than one quarter of HCWs chose to wear the full-face respirator, but those who did rated it easiest to breathe in, second only to surgical masks. HCWs perceived the greatest protection while wearing elastomeric masks, especially during higher-risk situations. However, HCWs experienced more difficulty communicating while wearing elastomeric masks, specifically while speaking on the telephone, answering calls over the EMS radio, speaking with teammates, and speaking with patients. HCWs preferred surgical masks overall, but preferred half-face reusable elastomeric masks over other particulate-filtering masks.

Conclusion: Elastomeric respirators were well-accepted among HCW in the emergency department setting. Drawbacks include difficulty communicating and subjective increase in respiratory effort for some wearers.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

COVID-19 Effects on Resource Utilization by Victims of Intimate Partner Violence, Sexual Assault, and Child Abuse Jennifer Pallansch, MD1, Claire Milam, MD2, Kendra Ham, MD3, Patricia Morgan4, MD, Jessica Salzman, MD5, Kathryn Kopec, DO6, Margaret Lewis, MD7

Introduction: Key measures in preventing spread of the COVID-19 virus are social distancing and stay-at-home mandates. As described during prior natural disasters, these measures along with other stressors have the potential to increase incidences of intimate partner violence (IPV), sexual assault, and child maltreatment. Emergency Medicine as a specialty is uniquely poised to identify trends in violence and guide future disaster planning for at-risk populations.

Methods: We performed a retrospective review of county police dispatches, Emergency Department (ED) visits, Sexual Assault Nurse Examiner (SANE) consults, Domestic Violence Healthcare Project (DVHP) advocacy team consults, and Child Protection team consults at a large, tertiary, Level I trauma center. ICD-10 codes specific to IPV, sexual assault, and child maltreatment were queried from March to October in 2020 compared to 2019. Similarly, the number of consults performed by SANE, DVHP, and our Child Protection team were collected. All ED visits and consultations were compared to total ED visits for the reviewed time period. Finally, the total number of calls and referrals to two community resources, a child advocacy center and resource call line for victims were recorded during this timeframe.

Results: We found increases in police dispatches in 2020 for interpersonal violence and assault by 266 reports (p =0.03). In our hospital, we saw proportional increases in the percentage of ED visits for IPV and child maltreatment during the study timeframe by 40% (p=.03) and 38.4% (p=.03) respectively. A higher percentage of ED patients required DVHP and SANE services. Of note, only the proportional increases in DVHP consults in the first three months were statistically significant, increasing by 19.8% (p=.03). Fewer calls and referrals were made to our child advocacy center and resource call line, decreasing by 99 referrals and 252 calls respectively.

Conclusion: Despite decreased ED volumes throughout the pandemic, the percentage of visits and hospital resource utilization related to IPV, child maltreatment, and sexual assault increased following the initiation of stay-at-home orders. Additionally, community resources were under-utilized during this time. Further research is needed to address rising rates of interpersonal violence during disasters such as the COVID-19 pandemic.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Subpopulation Analysis of the Atrium-Modified HEART Pathway in Emergency Department Patients Presenting with Symptoms Suggestive of Acute Coronary Syndrome Gabriela Rivera-Camacho, MD; David Pearson, MD, MS, MBA; Victoria Serven, MD; Tyler Siekmann, MD; Kamala Swayampakala, PhD; Eric Schmidt, MD; Matthew Sullivan, MD

Background: The HEART score has been validated to risk stratify ED patients who are likely to suffer from a major cardiac adverse event (MACE) within six weeks of presentation to the ED2. Despite its high utilization in many EDs, there is limited data of validation among subpopulations. At our institution, we currently utilize the Atrium Modified Heart (AM-HEART) Score which uses clear descriptors to each classification.

Methods: We conducted a multi-center retrospective electronic medical record review involving patients who presented to the ED with symptoms concerning for acute coronary syndrome (ACS) from December 12, 2019, to January 26, 2020, in nineteen facilities. The study included patients ≥ age 18 who presented to participating EDs with symptoms concerning for ACS and diagnosed with chest pain, unstable angina, acute myocardial infarction, or NSTEMI upon ED disposition who had a HEART Score calculation and one high-sensitivity troponin. Patients without a completed HEART Score, age < 18, or patients diagnosed with STEMI were excluded. We analyzed how the AM-HEART Score performs to detecting the possibility of a MACE among subpopulations including gender, race, ethnicity, and medical history.

Results: Of the 6,398, 3,526 (55.1%) were females and 2,872 males (44.9%), 3,758 White (58,7%), 2,263 Black (35.4%), 74 Asian (1.2%), 14 Native American (0.2%), 289 others (4.5%), 444 Hispanic (6.9%), and 5,866 non-Hispanic (91.7%). When comparing females and males the sensitivities were and the 92.6% (75.7 – 99.1 95% CI) vs 89.5% (75.2 – 97.1 95% CI) and the specificities were 48.6% (47.0 – 50.0 95% CI) vs 43.8% (41.2 – 45.7 95% CI). The positive predictive values (PPV) (1.37 vs. 2.1) and negative predictive values (NPV) (99.99 vs 99.7) revealed no significant differences. When comparing Black patients and White patients the sensitivities were 87.5% (61.2 – 98.5 95% CI) vs 91.8 (80.4 – 97.7 95% CI) and the specificities were 52.0% (49.9 – 54.1 95% CI) vs 41.1% (39.5 – 42.7 95% CI), the PPV (1.3 vs 2.02) and NPV (99.8 vs 99.7) revealed no differences. When comparing Hispanic patients and non-Hispanic patients the specificities were 65.4% (60.7 – 69.8 95% CI) vs 45.1% (43.7 – 46.4 95% CI), the PPV (1.3 vs 1.73) revealed no differences.

Conclusion: The AM-HEART Score performed similarly with regards to gender, race, and ethnicity.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Multicenter Analysis to Assess Risk of Major Adverse Cardiac Events in Patients Undergoing High-Sensitivity Troponin Testing in the Emergency Department Victoria Serven MD, Kamala Swayampakala PhD, Christy Lesassier RN, David Pearson MD

Background: High-sensitivity troponin (hs-trop) testing strategies have been shown to effectively identify patients with suspected acute coronary syndrome (ACS) at very low risk for 30-day major adverse cardiac events (MACE). These strategies include single, serial, and delta troponins. However, the optimal testing strategy remains unclear. The aim of this study was to assess 30-day MACE for patients who entered the HEART Pathway and underwent testing with high sensitivity troponin I assays within Atrium Health’s EDs to identify patient populations that can safely be discharged home.

Method: This was a multicenter retrospective cohort study conducted between July 27, 2020 and January 31, 2021 that included adult (≥18 years old) ED patients who presented with suspected ACS and had a HEART Pathway completed. The Beckman Coulter high-sensitivity troponin I assay was utilized with gender-specific cut-offs (Female <12 ng/L, male< 20 ng/L) and a limit of quantification of 6 ng/L. The primary outcome was performance of an index hs-trop <6ng/L as a predictor for 30-day MACE. The secondary outcome utilized the 0 and 1-hour algorithm to examine the performance of a delta value <4 as a predictor of 30-day MACE. Results: 6,398 patients were enrolled, 65 (1%) of which had MACE. Of these, 4,664 patients had an index troponin of <6 ng/L. Twelve of these patients experienced MACE yielding an incidence rate of 0.26% (95% CI 0.05%-0.29%) and NPV of 99.85% (95% CI 99.7%-99.99%). 1,150 patients had a normal gender-specific index troponin, 21 experienced MACE; incidence rate of 1.83% (95%CI 1.05%-2.60%), NPV 99.30% (95% CI 98.3-99.99%). 4,171 patients had a delta troponin <4, of which 31 had a MACE; incidence rate of 0.74% (95% CI 0.48% - 1.00%), NPV 99.67% (95% CI 99.4%-99.96%).

Conclusion: In this multi-center analysis, an index troponin of <6 ng/L demonstrated a very low risk of 30-day MACE.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Impact of Post-Hospital Discharge Visits by Community Paramedics on Hospital Readmission Brian Shreve, MD, S. Tyler Constantine, MD

Background: Mobile integrated health (MIH) and community paramedicine (CP) programs are a service provided by local emergency medical services (EMS) and hospital systems. There is limited published research regarding their benefit, with available research focused on reduction of hospital readmissions, costs to the healthcare system, and 911 calls for EMS systems. In our model, MIH/CP services are tied to multidisciplinary follow-up at a transition clinic. For adult patients who were enrolled in transition services following hospital discharge, we hypothesize an initial home visit by MIH/CP paramedics is associated with increased attendance at the first scheduled outpatient visit in the transition clinic.

Methods: This is a retrospective study of 316 cases. Patients in the “CP Well Check” group received one CP well check home visit after hospital discharge. Patients in the “No CP Well Check” group did not receive this visit. The primary outcome was the rate of attendance at the transition clinic. The secondary outcome was hospital readmission within 30 days of discharge.

Results: The primary outcome analysis included 316 patients. Of these, 219 patients (69%) had a CP well check and 97 patients (31%) did not have a CP well check.

Relative risk was 2.8 for attendance at the clinic after receiving a CP well check (CI 95%; 2.0–4.1, p <0.0001). The relative risk for follow-up at any future transition clinic was 1.9 (CI 95%; 1.5–2.5, p <0.0001). Forty (18.3%) with a CP well check were readmitted within 30 days. Thirty-two patients (33%) without a CP well check required readmission for a risk difference of -14.7% (CI 95%; -25.7 to -4.5). Relative risk was 0.55 (CI 95%; 0.37– 0.83, p = 0.04), with less patients requiring readmission after a CP well check.

Conclusions: In our system, a post-discharge visit by our MIH/CP team was correlated with higher attendance at our transition clinic after hospital discharge. Our intervention was also associated with lower rates of hospital readmission.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Operational Impact of the Atrium-Modified HEART Pathway in Emergency Department Patients Presenting with Symptoms Suggestive of Acute Coronary Syndrome Tyler Siekmann, MD1; Kamala Swayampakala, PhD2; David Pearson, MD3 1Atrium

2Sanger

Health Carolinas Medical Center, Charlotte, NC Heart and Vascular Institute- CORE, Atrium Health, Charlotte, NC

Background: The Atrium Health regional health system has historically utilized the CHSM-HEART score to risk stratify patients presenting to the ED with chest pain or other ACS mimics. Beginning in late 2019, a new tool known as the Atrium-Modified (AM)-HEART score was deployed to provide more objective categorization of history and EKG findings while also integrating a new high-sensitivity troponin assay. We sought to determine the impact of the AM-HEART score on ED operational metrics such as ED length-of-stay (LOS) and hospital admission rates while also ensuring the tool could safely identify low-risk patients appropriate for discharge.

Methods: This multi-center retrospective cohort analysis included patients who presented to an Atrium Health ED with symptoms suggestive of ACS and a completed CHSM- or AM-HEART Score. The pre-implementation (March-December 2019) and post-implementation (July 2020-April 2021) cohorts were compared and separated by a 6-month wash-in period. Data was collected via query of the Atrium Health EMR and several ancillary databases. Primary outcome measures included ED LOS, ED discharge rates, hospital LOS for admitted patients and 30-day MACE rates.

Results: 12,315 and 6398 patients were included in the pre- and post-implementation cohorts respectively. Pre- vs. post-implementation ED length-of-stay times were 253.7 vs. 251 minutes (p=0.3522); ED discharge rates were 55.7% vs. 56.6% respectively (p=0.0001). For admitted patients, hospital length-of-stay times were 1.24 days vs.

1.38 days (p<0.0001). Rates of repeat ED visits within 30 days (11.3% vs. 11.6%, p=0.6030) and non-index visit hospitalizations within 30 days (5.5% vs. 6.0%, p=0.1580) had no statistical difference. Rates of 30-day MACE were unchanged (0.8% vs. 1.0%, p=0.1399).

Conclusion: This multi-center cohort study suggests the AM-HEART score has no effect on ED LOS but does allow increased rates of ED discharges without increasing 30-day ED return visits or hospitalizations. There were no significant differences in 30day MACE rates.

CMC Department of Emergency Medicine

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Resident Academic Day 2021

Added Prognostic Value of Right Ventricular Assessments for Low-risk Pulmonary Embolism Jaron D. Raper MD,1 Alyssa M. Thomas, MD, MPH,2 Kathryn Lupez, MD,3 Carly A. Cox MD,4 Dasia Esener, MD, MS,5 Jeremy S. Boyd, MD,6 Jason T Nomura, MD,7 Jillian Davison, MD,8 Patrick M. Ockerse, MD,9 Stephen Leech, MD,8 Jakea Johnson, MPH6, Eric Abrams, MD,5 Kathleen Murphy7, Christopher Kelly MD9, Joseph Rigdon PhD10, Nathaniel S. O’ Connell PhD10Anthony J. Weekes MD, MSc2* 1 Department

of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama 2 Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina 28203. Carolinas Medical Center is the central site of the Pulmonary Embolism Short Term Outcomes Registry (PESCOR) consortium.

3 Department of Emergency Medicine, Tufts Medical Center, Boston, Massachusetts 4 Emergency Medicine of Idaho 5 Department of Emergency Medicine Kaiser Permanente, San Diego 6 Department of Emergency Medicine, Vanderbilt University Medical Center 7 Department of Emergency Medicine, Christiana Care 8 Department of Emergency Medicine Orlando Health 9 Division of Emergency Medicine, University of Utah Hospital 10 Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston Salem North Carolina, USA Background: The presence of right ventricle abnormalities is important in stratifying the severity of pulmonary embolism (PE). Disposition decisions are influenced by concerns about early deterioration. PE prognostic models, like the simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcomes.

Our first objective was to determine if RV assessment variables add prediction accuracy for deterioration within 5-days in patients classified as low-risk by sPESI. Second objective was to determine the prognostic importance of RV assessments compared to other variables and to each other.

Methods: We identified low-risk sPESI patients from a prospective PE registry that included RV assessments (imaging and laboratory). We developed random forest [RF] models; full (with RV variables) and reduced (without RV variables), reported variable importance plots from full RF and log odds from logistic regression models Results: From 1736 patients, 611(35.2%) were ‘low-risk’ by sPESI and 75 (12.3%) experiencing early outcome. Proportions with abnormal RV by computed tomography, echocardiography, troponin, and natriuretic peptide were 26.2%, 20.6% 17.7% and 23.1% respectively. For deterioration, full and reduced prognostic models’ area under receiver operating curve were 0.80 (95% CI 0.77, 0.82) and 0.71 (95% CI 0.68, 0.73) respectively. By RF model, RV assessments were the top four in the variable importance plot; by regression model, echocardiography and computed tomography significantly increased predicted probability of deterioration.

Conclusions: RV assessments improved prognostic model accuracy versus models without RV assessments and were the top predictors of deterioration with echocardiography being ranked first.

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Resident Academic Day 2021 CMC Department of Emergency Medicine Graduates’ Destinations - Chief Residents

Chelsea Rushnell, MD

Victoria Serven, MD

Apollo MD Charlotte, NC

US Navy at Naval Medical Center Portsmouth, VA

Brian Shreve, MD

Tyler Siekmann, MD Apollo MD Charlotte, NC

EMS Fellowship Wake Forest Winston-Salem, NC

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Resident Academic Day 2021 CMC Department of Emergency Medicine Graduates’ Destinations - Residents

Joseph Blackwell, MD

William Bost, MD

Elissabeth Hagler, MD

Alexandria Holmes, MD

EMS Fellowship Carolinas Medical Center Charlotte, NC

Memorial Regional Medical Center Mechanicville, VA

Carolinas Emergency Physicians Cleveland, NC

Prisma Health Upstate Greenville, SC

Jacob Leedekerken, MD

Claire Milam, MD

Elizabeth Olson, MD

Jennifer Pallansch, MD

Georgia Emergency Department Services Atlanta, GA

Global Health Fellowship MUSC Charleston, SC

PEM Fellowship Carolinas Medical Center Charlotte, NC

Ultrasound Fellowship Eskenazi Hospital Indianapolis, IN

Gabriela RiveraCamacho, MD Ultrasound Fellowship Carolinas Medical Center Charlotte, NC

Alyssa Thomas, MD Houston Methodist Baytown Emergency Department Houston, TX

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Resident Academic Day 2021 CMC Department of Emergency Medicine Resident Award Recipients JOHN A. MARX OUTSTANDING SENIOR RESIDENT AWARD 1994 1995 1996 1996 1997 1998 1999 1999 2000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Jeffrey A. Kline, MD John T. DiPasquale, MD Craig A. Meek, MD Daniel M. Roberts, MD David A. Caro, MD Sean R. Sue, MD Joanne Oaks, MD Jennifer Isenhour, MD Tony Seupaul, MD Frances Eizember, MD Brent Myers, MD Alan E. Jones, MD Jennifer Gehring, MD Bret Nicks, MD Jim Fiechtl, MD Benjamin Davis, MD Gretchen Roe, MD Danielle Turner-Lawrence, MD Bijal Shah, MD Mike Puskarich, MD Liza Rosenman, MD Mike Koehler, MD Jackie Davis, MD Katharine Modisett, MD Daniel Troha, MD Kathryn West, MD Blake Johnson, MD Jaron Raper, MD and Carly A. Cox MD Kathryn Lupez, MD Jessica Hoglund, MD

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Resident Academic Day 2021 CMC Department of Emergency Medicine Resident Award Recipients DARREN BEAN OUTSTANDING TEACHING BY A RESIDENT AWARD 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Simong S. Youmans, MD Bruce B. Marshall, MD Joel L. Moll, MD Tony Yuan, MD Chris Thomson, MD Alan Heffner, MD Desiree La Charite, MD Darren Bean, MD, and Nael Hasan, MD Charles Staples, MD Josh Simmons, MD Dave French, MD Keith Pochick, MD Richard Graham, MD JoAnna Leuck, MD Harland Hayes, MD Shiloh Gilbert, MD Dustin Calhoun, MD Brittany Murray, MD Katie Sprinkel, MD Jonathan Bronner, MD Karina Reyner, MD Joshua Robertson, MD Catherine Lounsbury, MD Enola Okonkwo, MD Russell Trigonis, MD Robert Kregg Laundon, MD

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Resident Academic Day 2021 CMC Department of Emergency Medicine Resident Award Recipients OUTSTANDING RESIDENT RESEARCH ACHIEVEMENT AWARD 1994 1995 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Jeffrey A. Kline, MD David W. Templeton, MD Tamara M. Ardans, MD Andrew D. Perron, MD Kirk Mahon, MD Mark Courtney, MD Chris Moore, MD Alan E. Jones, MD Mike Runyon, MD Michael T. Fitch, MD, PhD Lyn Aborn, MD Christopher Crean, MD Patrick O’Malley, MD, and Melinda Threlkeld, MD Danielle Turner-Lawrence, MD John Garrett, MD, and Anne Daul, MD Mike Puskarich, MD, and Maria Glenn, MD Dustin Calhoun, MD Daren Beam, MD, and Omayra Marrero, MD James Cao, MD Greg Zahn, MD, and Andrew Wyman, MD Daniel Troha, MD Angela Johnson, MD and Gregory Thacker, MD Blake Johnson, MD Adeline Dozois, MD Kathryn Lupez, MD Jessica Hoglund, MD

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Resident Academic Day 2021 CMC Department of Emergency Medicine Faculty Award Recipients OUTSTANDING ACADEMICIAN - Faculty Award 2004 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Chris Tomazewski, MD Andrew Asimos, MD Lee Garvey, MD Mike Runyon, MD Jeff Kline, MD Sean Fox, MD Randy Cordle, MD Catherine Wares, MD David Callaway, MD Mike Runyon, MD David Pearson, MD Anthony Weekes, MD Anthony Weekes, MD Maria Pelucio, MD Kathryn Kopec, DO

EXEMPLAR - Faculty Award 2008 2009 2010 2012 2013 2014 2015 2016 2017 2018 2019 2020

Dave Pearson, MD Andrew Asimos, MD Jennifer Isenhour, MD Vivek Tayal, MD JP McBryde, MD Anthony Weekes, MD Mike Gibbs, MD Lee Garvey, MD Chris Griggs, MD David Callaway, MD Erin Noste, MD Jessica Salzman, MD

OUTSTANDING TEACHER - Faculty Award 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Jayne Batts, MD Vivek Tayal, MD Michael Roshon, MD John Marx, MD Vivek Tayal, MD JP McBryde, MD William Tsai, MD Jeffrey Hyland, MD Sean Fox, MD Jayme Woodson, MD

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2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Emily MacNeill, MD Randy Cordle, MD Mike Gibbs, MD Andrew Asimos, MD Sean Fox, MD Tyson Cook, MD Danielle Dragoo, MD Dalton Cox, MD Kathryn West, MD Denise Fraga, MD

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Resident Academic Day 2021 CMC Department of Emergency Medicine Visiting Professors: 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Judd E. Hollander, MD – University of Pennsylvania William H. Cordell, MD, Professor – Indiana University Frank Counselman, MD – Eastern Virginia Medical School Jill Baren, MD – University of Pennsylvania School of Medicine James L. Scott, MD – George Washington University Michael Gibbs, MD – Maine Medical Center James Hoestra, MD – Wake Forest University Katherine L. Heilpern, MD – Emory University School of Medicine Charles B. Cairns, MD, Professor & Chair – UNC Chapel Hill William Barsan, MD, Professor & Chair– University of Michigan Medical School Edward C. Jaunch, MD, MS , PACEP, FAHA – Medical University of South Carolina Andrew D. Perron, MD, FACEP, FACSM – Maine Medical Center Tony Seupaul, MD, Professor & Chair – University of Arkansas for Medical Science Alan Jones, MD – University of Mississippi Medical Center Jeffrey W. Runge, MD FACEP Joe Lex, MD, FACEP, MAAEM, FIFEM – Temple University School of Medicine David Mark Courtney, MD, MSCI - Feinberg School of Medicine at Northwestern Leon L. Haley Jr., MD, MHSA, FACEP – University of Florida Health Jacksonville “Tony” Seupaul, MD - Professor and Chair - University of Arkansas Malika Fair, MD, MPH, FACEP – The George Washington University

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