BACKGROUND: Emergency medicine physicians experience the highest rates of burnout of any medical specialty, with emergency medicine residents being particularly likely to experience the phenomenon during their medical training. Much of the current research around burnout centers on the causes of and solutions for burnout, but less is known about what residents are already doing to cope with their symptoms. Therefore, the primary question addressed in this project is “What are the experiences of emergency medicine residents in recognizing, approaching, and recovering from burnout?” DESIGN: This study qualitatively explores themes relating to resilience and recovery from burnout using individual interviews with emergency medicine residents at four west coast training programs. All 2nd, 3rd, and 4th year EM residents were invited to complete an initial screening survey to collect demographics and basic information about their experiences with burnout. All survey participants were invited to schedule a virtual 60-minute interview based on a semi-structured interview guide. Interviewees were asked to share about their experiences with burnout during residency and how they have managed the challenges that burnout presents. ANALYSIS: The recorded interviews were transcribed, de-identified, and coded. We applied a grounded theory approach to develop theories based in the participants’ experience of the process of burnout, and a constructivist/interpretivist paradigm that assumes that understanding emerges from exploring the participant’s lived experience through interactive dialogue and co-created interpretation. At this stage in the research study, 15 interviews have been conducted, transcribed, and undergone preliminary coding. Following the conclusion of individual interviews (target ~20), we will host virtual focus groups to explore and validate study findings. EMERGING THEMES: Many residents express significant dissonance between the doctor they “hoped they would be” and their actual behavior based on their capacity to tolerate immensely stressful working conditions. Most residents agree that the intensity of their workload is integral to their education and future success as physicians, and that burnout in residency is not entirely preventable—however, there is a significant difference between participants who feel they have been able to reconcile or integrate their dissonant view of their hopes versus actual behavior, and those who are not able to manifest this reconciliation. Pending further analysis, results may include a proposed model of the stages of burnout in residency and the factors that make residents most likely to overcome their burnout prior to the conclusion of their training program.

Background and Objectives: Atrial fibrillation (AF) is responsible for up to a quarter of ischemic strokes, making treatment with urgent prophylactic oral anticoagulation (OAC) essential. AF is often first diagnosed in the emergency department (ED), providing an opportunity for initiating OAC to improve clinical outcomes. This analysis is part of an ongoing, mixed-methods, stepped-wedge trial to incorporate a clinical decision support (CDS) tool to increase uptake of OAC prescribing in the ED. Methods: Semi-structured interviews were conducted with eight ED physicians from one academic urban tertiary care (n=5) and one urban community hospital (n=3). The interview guide included physician experiences and attitudes towards providing stroke prevention, use of a CDS tool, and recall of a specific AF patient encounter. Interviews were recorded, transcribed verbatim, and de-identified. The study team developed a coding scheme and coded transcripts using Atlas.ti qualitative software. Coded exports were analyzed using an inductive, iterative, thematic approach through constant comparison methods. Results: Eligible physicians treated patients in the ED for new-onset AF, regardless of CDS tool use or OAC prescription. Most physicians were male (7, 87.5%), White (6, 75%), and from an academic, tertiary care hospital (5, 62.5%). Physicians reported several barriers to prescribing OACs to AF patients in the ED, including the difficulty of communicating the risk of untreated AF to patients, time limitations, and risk aversion. However, physicians reported that a CDS tool that calculates stroke risk, displays prescribing options, and visualizes risk change with OACs could aid patient communication and provide data-driven recommendations to support physician decisions. Further, combining bleeding and stroke risk stratification variables in one tool has the potential to streamline workflow, thus addressing time constraints. Conclusion: Preliminary findings highlight the barriers to prescribing OACs for AF in the ED and the opportunities a CDS tool presents to address them, adding to the knowledge base of the factors that affect CDS tool implementation and uptake. Results identify areas for quality improvement, contribute to the implementation science literature, and impact the practical application of a CDS tool for AF, which may facilitate OAC physician prescribing habits that impact clinical outcomes.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and often, first diagnosed in the emergency department (ED). AF increases the risk of stroke, which can be decreased by 64% if the appropriate oral anticoagulation (OAC) is prescribed. Unfortunately, many patients are not prescribed OAC for new AF. We investigate whether patient ethnicity, specifically Hispanic-Latino, affects OAC prescription. This retrospective chart review study included patients at an academic tertiary care center and a community hospital >17 years old with a primary ED diagnosis of AF or paroxysmal AF from January 2020-2022. Patients with valvular heart disease or high risk for bleeding were excluded. Trained chart reviewers manually abstracted electronic health record (EHR) data. Factors that may be predictive of OAC prescription were used to assess stroke and bleeding risk, including demographics, medication, disposition, EKG, comorbidities, vital signs, and ED management. An exploratory analysis was performed to evaluate the relationship between patient ethnicity and anticoagulation prescribing rates. The relationship was then tested for statistical significance with Fisher’s exact test. Among 363 patients that are over the age of 17 with a primary diagnosis of AF or paroxysmal AF in the ED, 5.79% (n=21) were Hispanic-Latino and 94.21% (n=342) were not. Providers prescribed or adjudicated stroke prophylaxis for 44.08% (n=160) patients, 6.88% (n=11) of which are Hispanic-Latino and 93.13% (n= 149) are non-Hispanic-Latino. 52.38% (n=11) of Hispanic-Latino patients were prescribed OAC, while 43.57% (n=149) of non-Hispanic-Latino patients were prescribed OAC. There was not a significant difference between prescribing rates in patients who are Hispanic-Latino vs non-Hispanic-Latino (p=0.50). Although prescribing rates were different between ethnic groups, we did not find a statistically significant difference in OAC prescribing for Hispanic-Latino patients and non-Hispanic-Latino patients. This exploratory analysis yielded interesting results and needs further investigation to explore factors that lead to prescribing OAC, such as communication barriers between the provider and patient, and if the two groups are disproportionately affected by those factors, or potential unconscious bias with more data collection.

Background: Optimal patient care requires consistent and active communication between emergency physicians (EPs) and emergency nurses (ENs). The emergency department (ED) is a setting where communication occurs often and with important consequences. This mixed methods study sought to determine how frequently communication led to adverse patient care events with a questionnaire, then qualitatively assess good and bad characteristics of communication between EPs and ENs using focus groups. Methods: EPs and ENs at four hospitals were surveyed using a unique questionnaire and then invited to participate in a guided interview using trained facilitators. The transcripts from the focus groups were anonymized and then analyzed for themes using an iterated code book. Results: 116 eligible ENs and EPs completed the initial questionnaire. Both disciplines noted that poor communication is common, adversely affects patient care and ED function, affects trust placed in the individual and the discipline as a whole, and that non-verbal communication behaviors affect team communication. In the focus groups, six themes emerged: 1) In-person communication was preferred, and physical layout and communication tools could be both beneficial and harmful to communication. 2) Core elements of desired professional communication include respect, closed-loop communication, and attention. 3) Poor communication begets poor communication. 4) Effective communication affects patient care beyond the individual patient or shift. 5) Gender and

gender dyads influence communication dynamics. 6) Techniques for effective communication can be taught. Conclusions: Emergency nurses and EPs across nine EDs described failures of communication as both common and significant to patient care. This study identified general characteristics and modalities of effective communication, complex factors influencing communication, including gender dynamics and type of care, and emphasized the whole-department impact of communication quality.

Background: On February 1, 2021, Oregon enacted ballot measure 110 to decriminalize the personal possession of controlled substances. The penalty for heroin possession was reduced from a misdemeanor to violation and felony to misdemeanor for possession of 1 g and 1–3 g, respectively. Many heroin users resort to "body stuffing," internal concealment of illicit drugs, to evade police detection or prosecution of possession. Ultimately, this dilemma places the "body stuffer" at risk of developing opioid toxicity leading to health care utilization and cost. The objective of this study is to describe the characteristics and determine the effect of measure 110 on heroin body stuffers in Oregon. Methods: This is a retrospective chart review of heroin body stuffers reported to a single poison center for the one-year before and one-year after the implementation of the measure (February 1, 2020–January 31, 2022). Inclusion criteria were cases with "heroin" in the "substance" data field. Exclusion criteria were non-human exposures, information cases, if the case did not describe the internal concealment of heroin for the purpose of avoiding drug possession prosecution, cases from outside of Oregon, and cases where the history of body stuffing was later retracted. All cases were reviewed by a single reviewer and the following data collected: age, sex, reported ingestion amount, disposition, and packaging type. Data is reported as a percentage of known values and the proportion of subjects in groups of dichotomous outcomes were compared using the Chi- square test. Results: 384 cases were reviewed and 204 met inclusion/exclusion criteria. There was no change in the number of cases in the one-year period before and the one-year period after the measure passing (102 v 102). The majority of patients ingested heroin orally (200/204; 98%) vs rectal concealment (4/204; 2%). In the post-implementation period, patients were more likely to ingest ≥3 g of heroin (45.9% v 28.4%, p 1⁄4 0.02), be discharged from the emergency department (51.0% v 33.7%, p <0.01), and less likely to sign out against medical advice (15.7% v 35.6%, p <0.01). Discussion: There was no difference in the number of heroin body stuffers reported to a single poison center before and after passing a law that decriminalized heroin possession. Additionally, patients in the post implementation period were more likely to conceal ≥3 g of heroin and more likely to be seen and treated in the ED without admission. We hypothesize that the effect of the measure allowed patients to more freely communicate the exposure amount with their health care providers. Limitations of the study include its retrospective nature, passive data collection of poison center record, and incomplete data. Conclusions: We found no difference in the number of heroin body stuffer cases in Oregon after the implementation of measure 110 to decriminalize personal drug possession.

Background: According to the annual report of the American Association of Poison Control Centers’ National Poison Data System, 18.2% out of the 6,199 exposures during pregnancy were intentional in 2020. Research Question: What are the characteristics of acute intentional exposures during pregnancy that were reported to the Toxicology Investigators Consortium (ToxIC) Core Registry between January 2014 – December 2021? Methods: This is a prospective analysis of all intentional overdoses in pregnant women identified from the ToxIC database from 2014-2021. We considered cases to be intentional if the patient expressed self-harm or suicidality. Each case was reviewed for age, exposure type, number of exposures, clinical signs and symptoms, and treatment. Age was further categorized into four groups: 10-19, 20-29, 30-39, and 40-49 years. Exclusions included age over fifty years and any false positive pregnancy tests. Categorical variables were compared using chi square tests. Results: Of the 13,316 cases of intentional exposures in women, 120 cases included pregnant patients. Six patients were excluded for age > 50 years and one patient had a false pregnancy test leaving 114 patients for analysis. In total, over-the-counter non-opioid analgesics were the most common class of ingestion (45.6%), followed by antidepressants (22.8%), and sedative-hypnotics/muscle relaxants (17.5%). The majority of pregnant patients were ages 20-29 (72.1%). More than a third of patients ingested more than one class of medication or agent. Patients aged 10-19 years were more likely to ingest four or more medications (p = 0.0002). About two-thirds of the patients developed signs and symptoms of

toxicity, with the majority developing CNS depression, followed by hypotension, and agitation. N-acetylcysteine, sodium bicarbonate, and naloxone were the most common antidotes administered. Conclusion: The majority of intentional drug exposure in pregnant women included non-opioid analgesics and sedative-hypnotics/muscle relaxants in women less than 29 years. Further studies should investigate the risks of fetal harm and outcomes in intentional overdoses during pregnancy.

Background and Objectives Atrial fibrillation (AF) is the most common arrhythmia in the emergency department (ED). AF increases the risk of stroke; thus, early initiation of oral anticoagulation (OAC) for at-risk patients at the initial ED visit is imperative. We examine the management and prescribing practices for ED patients with new-onset AF. Methods This was a retrospective chart review study, pre-implementation of a clinical decision support tool. Data was collected from three enrolling urban EDs—an academic tertiary care center and two community hospitals. Using the electronic health record (EHR), patients were included if they had a new primary diagnosis of AF or paroxysmal AF during an ED visit between January 2020 to January 2022 and >1yr of follow-up data, age >17 years, and no OAC (< 1yr) from ED visit. We excluded patients at high-bleeding risk (such as a history of valvular disease, pregnancy, severe liver or kidney disease, admitted to hospital, major surgery within 72 hours of ED visit, and recent brain, eye, or spinal cord injury). Eight trained chart reviewers abstracted the EHR data using a standardized chart abstraction guide. Data were analyzed using descriptive statistics. Associations between OAC prescribing by site and ED return were tested using Fisher's test. Results Of the 2,908 diagnosed with AF, 303 patients met the inclusion criteria (mean age 64, male 57% [n=172]). Of the included patients, 43% (n=129) were diagnosed with new-onset AF and 44% (n=134) with paroxysmal AF. Providers prescribed or adjusted stroke prophylaxis for 41% (n=125) of patients. The prescribing rate was significantly different at the three sites (p=0.004), 54% (n=48) at the academic site, 42% (n = 39) and 31% (n = 38) at the two community sites. Of the included patients, 21% (n=63) returned to the ED in the year following their initial visit, of which 88% (n=58) returned for recurrent AF and 11% (n=7) for a complication related to OAC. There was no significant association between an OAC prescription and ED returns visits (p=0.67). Conclusion In our pre-implementation data, the majority of patients did not receive an OAC, with a significantly lower rate in a community setting. An intervention, such as increased guidance using a CDS tool, may increase guideline adherence at different practice locations and improve the long-term clinical outcomes of AF patients.

Background and Objectives Oral anticoagulation (OAC) reduces stroke and mortality risk in patients with nonvalvular atrial fibrillation and flutter (AFF). The incidence of US emergency department (ED) OAC initiation is poorly understood, as are the appropriate actions following discharge. We examined stroke prophylaxis actions on, and shortly following, ED discharge of stroke-prone AFF patients in a large integrated healthcare delivery system. Methods This retrospective cohort study included ED encounters among adults with a primary diagnosis of nonvalvular AFF, high stroke risk (CHA2DS2- VASc ≥2), and no recent (< 90d) OAC from 21 community EDs between 2010-2017. Actions included OAC prescription by an ED or follow-up clinician or a referral to an anticoagulation management service < 14 days of discharge. We compared OAC action rates between groups with t- tests, and chi-square tests, and used ANOVA and Cramer’s V to estimate effect size. We used Poisson GEE models to estimate rates of OAC action, with confidence intervals (CIs) adjusted for repeated measures by clinician/facility/patient cluster and an exchangeable correlation structure. Results Among 9,603 eligible ED discharges, mean age was 73.1y (SD 11.4), 38% were female, and mean CHA2DS2-VASc was 3.5 (SD 1.5). From 2010 to 2017, OAC action increased significantly from 19.6% to 37.9%. In the adjusted model, encounters with females aged 75-84y were less likely to result in OAC action than encounters with males aged < 64y (estimate of mean: 23.9%, 95% CI 14.1-33.8%; 18.7%, 95% CI 13.4-23.0%, respectively). OAC action was associated with moderate stroke risk, with encounters with CHA2DS2-VASc 4 to 5 receiving OACs at rates 4.6% above (95% CI 2.4-6.9%) those with CHA2DS2-VASc 2-4. Absolute rates of OAC action in 2017 were 15.8% (95% CI 12.1-19.5%)

above those in 2010 in the adjusted model. Conclusion While OAC action increased over the 7-year study, there remains an opportunity for improvement as a majority of eligible patients in 2017 were not receiving appropriate OAC action. Additionally, female gender and those > 84y were less likely to receive appropriate action compared to men and those < 65y. The undertreatment of those > 84y suggests a misunderstanding of the net clinical benefit associated with OAC in the elderly. Furthermore, opportunities to address gender disparities exist as we seek to improve stroke prophylaxis in AFF patients discharged from the ED.

Background: All parts of the False Hellebore (Veratrum viride) plant (FH) contain toxic sodium channel activators called veratrum alkaloids. These toxins can produce nausea, vomiting, bradycardia, and hypotension. FH bears a morphologic resemblance to non-toxic wild ramps/leeks (Allium tricoccum), a member of the onion family. Case report: A 69-year-old male presented to the emergency department following unintentional ingestion of 2 to 3 leaves of FH after attempting to forage for wild ramps. Around two hours after ingestion, the patient developed nausea, vomiting, diarrhea, and bradycardia with a heart rate (HR) of 38. Initial blood pressure (BP) was 162/80. ECG showed ectopic atrial bradycardia, nonspecific intraventricular conduction delay, and abnormal inferior O waves. The patient received 0.5 mg atropine with improvement of HR to 80. Two hours later, the patient developed recurrent bradycardia (HR48) and new reported hypotension (BP not recorded). The patient was started on 3 mg/hr dopamine infusion and admitted to the intensive care unit (ICU). In the ICU, dopamine infusion was continued and he was treated symptomatically for ongoing nausea and vomiting with pantoprazole and ondansetron. Eleven hours after initial ingestion, the patient's BP had normalized (133/54), but he remained bradycardic (HR44). The patient remained in the ICU on a 3 mg/hr dopamine infusion for three days with persistent bradycardia and ongoing nausea, vomiting, and diarrhea. His symptoms resolved on hospital day three, with his HR reaching 80, and he was discharged home on hospital day four. Conclusion: Non-toxic wild ramps/leeks may be confused with toxic FH due to similar morphologic characteristics. Small ingestions of FH can result in significant toxicity for an unexperienced forager. Caution must be used when foraging, and toxic ingestions should be on the differential for patients with abnormal vital signs.

With the increased pressures on Emergency Departments, coupled with the decreasing number of available psychiatric beds in the United States, healthcare workers in both fields find themselves dismayed by the lengthening boarding of patients in acute mental health crisis. Patient in the Emergency Department with primary psychiatric illness with extended ED visits face multiple risks, including miscommunication that results in exacerbation of chronic medical conditions, or delays in medicolegal paperwork that unnecessarily prolong ED stays. We developed a multidisciplinary approach with physicians, nurses and pharmacists to try to reduce the medical errors associated with frequent handoffs without a primary daily hospital team for management. We identified several components of psychiatric care that appeared to be "high miss" areas, including medicolegal status, management of chronic medical conditions and restraint/seclusion orders. We surveyed our department to evaluate specific areas of concern, via email survey and GEMBA analysis. Initial data suggested that most people felt patients were getting all appropriate components of psychiatric care ~30% of the time. We obtained feedback from nursing staff, pharmacy and physicians to establish a checklist to help streamline sign-outs. We developed a mnemonic, "SHEDS" for sugar control, home medications, expiration time for restraints and seclusion, documentation verification, Social Work updates/ Psychiatry consult to identify key aspects of commonly missed yet critical components in the care of our psychiatric patients. We plan to perform post-intervention qualitative surveys and ethnographic data collection to assess for intervention effectiveness

Background Burnout is prevalent among emergency clinicians, and many of the same causes of burnout also reduce joy at work. The concept of “Joy Rounds (JR)” was introduced in neurology to combat burnout and enhance work satisfaction1. JR consists of asking team members, “what brought you joy today?” before starting rounds. Subjectively, JR were found to enhance connectedness and increase joy at work. Though other studies have examined burnout in emergency medicine, there is a paucity of data on interventions that enhance shift experience and team connectedness in the emergency department (ED). Our goal was to evaluate if JR, which we also termed Positivity Rounds, would positively impact “shift experience” and “team connectedness” for emergency clinicians. We hypothesized that it would positively impact both. Methods At an urban academic ED with an annual volume of 50,000 patients, clinicians were asked to voluntarily initiate JR before shift and share something that recently brought them joy. If clinicians did not perform JR, they simply continued with their shift. At the end of shift, team members completed an anonymous survey rating their “shift experience” and “team connectedness” on a 1-10 scale, with 1 being least favorable and 10 most favorable. The survey asked four questions: role in the ED, whether they completed JR, rating of shift experience, and rating of interactions with the ED team. Results All ED clinicians had the opportunity to participate. 66 surveys were collected from February-September 2022. 15% of respondents were medical students, 33% were residents, and 52% were attendings. 74% (N=49) of respondents completed JR and 26% (N=17) did not. For those who did not complete JR, “shift experience” was rated on average 7/10 compared to those who did complete JR for whom “shift experience” was rated 7.7/10 (p=0.013). For those who did not complete JR, “team connectedness” was rated 7.25/10, and for those who did complete JR, “team connectedness” was rated 8.9/10 (p=0.001). There were 22 subjective comments which were uniformly favorable and included “helped me connect to new people on my team” and “sets a positive tone for shift.” Discussion This study aimed to evaluate the impact of JR on shift experience and team connectedness in the ED. Participation in JR improves both the shift experience and team connectedness for ED clinicians in our study. Given the high rates of burn out experienced by ED clinicians, and the relationship between shift experience, team connectedness and burn out, instituting JR could have a positive impact on ED clinicians and could mitigate some of the contributors to burn out. Participating in JR is a form of mindfulness activity at the beginning of the shift that brings the team together to share their joyous moments of the day and set the ground for connectedness and teamwork. Conclusion Our study demonstrates that participation in JR improves shift experience and team connectedness for ED clinicians. JR may have a beneficial impact on joy in the workplace. Further studies are needed to determine if JR can have a positive effect across other specialties. Citations: Hutchison, K. The Joy of Joy Rounds. Neurology Insights. https://www.neurologyinsights.com/2018/09/04/the-joy-of-joy-rounds/ Acknowledgments: I would like to thank Jordan Taboada for his administrative support of this study.

Emergency Departments (ED) nationwide are experiencing unprecedented volumes, boarding and crowding which has led to a greater need to improve patient throughput to allay capacity struggles.1 Turnaround times for radiology including computed tomography (CT) scans and magnetic resonance imaging (MRI) scans contribute to delays in diagnosis, treatment and ultimately disposition.2 Delays in radiology results impact ED length-of-stay which can lead to poor patient outcomes and increased healthcare costs.3 Our previous vRAD request process centered on ad lib requests for vRAD reads by the ED clinician after an Oregon Health and Science Unviersity (OHSU) preliminary Radiology Resident read was provided. A vRAD read is requested prior to a discharge disposition because this is considered an attending level final read. The time between acquisition of an OHSU preliminary Radiology Resident report and ED clinician request for a vRAD read is highly variable and a source of delay, owing to lack of process automation. We have created an ED and Radiology Department workflow to streamline vRAD read acquisition, with intent to shorten overall turnaround times. In 2022, our department requested on average of 657.9 imaging studies per month. The average time from exam end to vRAD read was 93.2 minutes and time from vRAD request time to result time was 31.2 minutes. This equates suggests our currently average time from exam end to vRAD request time to be 62 minutes. We have revised our vRAD request process with aim to reduce the time between preliminary Radiology Resident read and vRAD request. Our main process change is to pre-identify patients likely to be discharged if imaging is negative for acute processes, and automatically send these studies to vRAD immediately after an OHSU preliminary Radiology Resident read is completed. To measure impact, our primary outcome metric is time-to-test by analyzing time from preliminary read to vRAD request time. Our secondary outcome will be examining time from exam end to vRAD read, time from vRAD request time to result time and time from exam end to vRAD request time. We are hopeful this innovative new process will have implications on radiology turnaround times with extrapolative applications to other health systems. Citations 1. Perotte R, Lewin GO, Tambe U, Galorenzo JB, Vawdrey DK, Akala OO, Makkar JS, Lin DJ, Mainieri L, Chang BC. Improving Emergency Department Flow: Reducing Turnaround Time for Emergent CT Scans. AMIA Annu Symp Proc. 2018 Dec 5;2018:897-906. PMID: 30815132; PMCID: PMC6371246. 2. Bartsch E, Shin S, Roberts S, MacMillan TE, Fralick M, Liu JJ, Tang T, Kwan JL, Weinerman A, Verma AA, Razak F, Lapointe-Shaw L. Imaging delays among medical inpatients in Toronto, Ontario: A cohort study. PLoS One. 2023 Feb 3;18(2):e0281327. doi: 10.1371/journal.pone.0281327. PMID: 36735736; PMCID: PMC9897551. 3. Cournane S, Conway R, Creagh D, Byrne DG, Sheehy N, Silke B. Radiology imaging delays as independent predictors of length of hospital stay for emergency medical admissions. Clin Radiol. 2016 Sep;71(9):912-8. doi: 10.1016/j.crad.2016.03.023. Epub 2016 Jul 7. PMID: 27210242.

Team-based communication is essential to the delivery of high-quality medical care in the emergency department (ED). With so many quick decisions that must be made to care for critically ill patients, well-established team dynamics and communication are essential in this environment. After reviewing multiple patient safety event reports indicating that communication issues among the care team had led to less-than-desirable outcomes, our quality improvement team brainstormed ways to improve communication among our physicians and nurses. One intervention we have employed is the Interdisciplinary Team Huddle Initiative. The Interdisciplinary Team Huddle Initiative (ITHI) aimed to add on-duty physician attendance at a daily huddle. This daily huddle occurs every morning within a designated department area and was traditionally attended only by nursing staff. The huddle intends to promote staff familiarity, share active concerns about operations that may affect the care we provide, and designate staffing roles. With the physician team joining the daily huddle, we hoped this would promote better communication among physicians and nursing staff, resulting in better team dynamics. We surveyed participants both pre-intervention (35 respondents) and post-intervention (19 respondents). Before the intervention, 46% either somewhat or strongly disagreed that they knew the daily issues impacting operations in our department. After the intervention,

48% of participants strongly or somewhat agreed that they knew the daily issues affecting ED operations. Before the intervention, 42% of participants either strongly or somewhat agreed that they were familiar with the nursing staff they would be working with that day. In comparison, after the intervention, only 26% either strongly or somewhat agreed they were familiar with the nursing staff they would be working with that day. From this study, our team learned that improving interdisciplinary teamwork in the emergency department will take time and a multifaceted approach. The feedback we received indicated that while attending the daily huddle was an excellent initial step, there were barriers to fostering teamwork based on this intervention alone. One obstacle we face is that many travel nurses are new to our system, so developing professional relationships and team continuity has been challenging. Other feedback indicated that demands on the time and attention of the clinical team sometimes made it difficult or impossible for them to attend the daily huddle. Some remedies to these issues will be the charge nurse regularly calling our physician lead into the huddle and ensuring extra time for introducing new team members. As nursing staffing stabilizes in the ED and with efforts to improve physician engagement and improvement, we will continue to obtain ongoing data to assess effectiveness.

ABSTRACT Study Objective: To utilize a Design Thinking framework to critically analyze Emergency Department sign out to improve quality and efficiency of this process. Methods: This was a mixed methods study of the process of sign out at a single center quaternary hospital in the Western U.S. Emergency Medicine Residents, Fellows and Faculty were interviewed to determine their impression of the existing sign out procedure. We used formal, informal interviewing techniques and direct observation to inform our understanding of the sign out process. We assessed this information through the lens of the Design Thinking framework to develop a problem statement. We performed a literature search using PubMed to give guidance on gold standard practice for sign out in the Emergency Department. This search yielded 11 articles with 7 included for final analysis based on relevance. We developed a template for a sign out note and a refined sign out procedure. We engaged end users to trial the process and garnered more formal and informal feedback. The new process was rolled out after an education process conducted by email and at a weekly Emergency Medicine residency conference. Results: Our analysis showed that the IPASS note structure had been validated as a tool to improve patient care transitions and decrease the risk of medical error. The initial brief was to “revamp the IPASS note template”, but in using a Design Thinking approach to better understanding the problem demonstrated that we have broader issues around our sign out “culture” and consistency between providers. The literature review discovered a previously published paper which outlined the change in sign out process at this institution and many of the problems uncovered during their mixed methods analysis had not been fixed by changing the IPASS note template. Conclusions: Using a Design Thinking approach to understand sign out processes at a large academic institution was an effective tool to explore problems. In better understanding the problem we can develop better solutions keeping the end user in mind at all stages of the development process.

Ambulance diversion is a common tool utilized by emergency departments (ED) to divert ambulance traffic when they are overwhelmed. While ambulance diversion does reduce overcrowding in a particular ED (1), it leads often leads to prolonged transport times (2), reduced EMS system efficiency and increased burden on EMS providers (3-4), and increased overcrowding at neighboring facilities (5). In 2022, representatives from the Portland Metro Five-County Emergency Medical System, the Oregon Association of Hospitals and Health Systems, county oversight agencies, and area hospitals met and developed a shared protocol to more effectively manage situations that would result in ambulance diversion. This protocol defined steps hospitals were to take to prevent the need to go on ambulance diversion and also limited when, how often, and for how long hospitals could be on ambulance divert. This protocol was trialed a total of 6 times over the course of 2022. We examined the effects this protocol had on an emergency department at a urban academic medical center that serves as a tertiary and quaternary care center for the region and primarily looked at eight measures; daily EMS arrivals, Door to Doc time, LWBS, admit LOS, discharge LOS, daily inbound transfers, ED boarder occupancy, and ED total occupancy. The results showed that during these trials the number of daily EMS arrivals, Door to Doc time, and daily inbound transfers all decreased while LWBS rate and admit/discharge LOS increased, likely due to increase in ED total and boarder occupancy. The next step is to review data since implementation, look at patient outcome measures mortality/morbidity, look at data from neighboring hospitals, and look at EMS measures like transportation and drop-off times.